Wednesday, March 31, 2004

An Activist Pediatrician is Opportunistic, Too.

As a Wednesday Special, I am suspending my usual rule against posting ad hominem attacks.

Articles on the Washington Post website become inaccessible after two weeks. As it happens, the author also posted a complete copy of the article I am writing about, so you can see it here after the WaPo copy goes underground. The author, Dr. Lawrence Diller, is an activist pediatrician who has made a fortune selling books that are critical of his colleagues.

Keeping Doctors in the Dark

By Lawrence Diller
Wednesday, March 24, 2004; Page A21

The Food and Drug Administration issued an official warning this week on the increased risks of suicidal tendencies when taking antidepressants such as Prozac. The makers of Prozac and of nearly every other major antidepressant used in this country (Paxil, Zoloft, Wellbutrin, Effexor, Celexa, Lexipro) will have to include a new warning on the package label. This action is the culmination of more than 10 years of efforts to bring to light potential dangers of these medications.

The new warning alerts doctors and patients that in the first days and weeks of treatment, side effects such as agitation, panic, irritability, insomnia and severe restlessness may occur, contributing to an overall increase in the risk of suicide. More than a decade ago similar concerns over Prozac were beaten down in U.S. courts by an onslaught of "expert" testimony of industry-sponsored researchers and legal arrangements that gagged victims and their families with large monetary settlements.

[...] It seems that only the trial lawyers have a vested economic interest in following up on medications. That's a costly post-marketing surveillance system, both to the society that absorbs the legal costs and to the people hurt by a medication, before enough publicity or economic pain is felt by the manufacturer to change the label or withdraw the drug. Nearly 80 percent of respondents to a poll on my Web site said they'd pay at least a 1 percent surcharge on their medications to fund independent, systematic follow-up on pharmaceuticals.

The FDA decision to issue its warning on antidepressants is a vindication, albeit a much delayed "bitter pill" to the families that lost a child to suicide as a result of taking what might have been no better than placebo treatment. How many more children must die from other questionable drugs before our government takes the necessary actions to "heal" the sick regulation of the pharmaceutical industry?

Go ahead and read the whole thing, if you want, but there is not much point; you get the picture from the first two and last two paragraphs. Of greater interest is the comparison between Doc Diller's article and one recently published on Reason online.

Suicide Watch

Why is the FDA scaring people about antidepressants?

Jacob Sullum
March 26, 2004

The pediatrician Lawrence Diller, writing in The Washington Post, says the Food and Drug Administration has issued "an official warning...on the increased risks of suicidal tendencies when taking antidepressants such as Prozac." This is probably how most Americans interpreted the FDA's recent public health advisory covering 10 antidepressants.

Yet the FDA emphasizes it "has not concluded that these drugs cause worsening depression or suicide." Despite more than a decade of publicity about the alleged suicide-triggering properties of Prozac and its cousins, the FDA says, "a causal role for antidepressants in inducing such behaviors has not been established."

It is therefore hard to understand why the FDA is requiring that manufacturers of these drugs add a conspicuous suicide warning to their labels. The warning advises health care providers to "carefully monitor patients receiving antidepressants for possible worsening of depression or suicidality, especially at the beginning of therapy or when the dose either increases or decreases." It says "health providers should be aware that worsening of symptoms could be due to the underlying disease or might be the result of drug therapy."

The FDA defends the warning by arguing that it makes sense to keep an eye on depressed patients even if there's no truth to the claim that antidepressants make people kill themselves. "We think this is good advice whether the drugs did it or not," an FDA official told The New York Times, "If someone commits suicide, it doesn't really matter whether it's the drug or the underlying disease. In either case, you need to pay attention."

Putting aside the issue of whether people who feel happier after taking antidepressants are suffering from an "underlying disease," this rationale is rather strange. By the same logic, the FDA could require a warning that a heart drug might raise the risk of myocardial infarction not because there was good evidence that it did but because people with heart disease should be closely monitored.

[...] This distinction does not really follow from a concern about suicide. Severely depressed patients are especially likely to kill themselves, meaning that not only the benefits but also the risks (if any) of taking antidepressants are higher for them. Conversely, mildly depressed people may enjoy less dramatic benefits, but any suicide risk also would be lower. It seems the controversy over antidepressants and suicide has become a cover for other, unarticulated concerns about the appropriate use of chemicals to tweak one's mood and personality.

Mr. Sullum has a good point in the concluding sentence. Unfortunately, he does not provide any evidence to back up his allegation that the "controversy over antidepressants and suicide has become a cover for other, unarticulated concerns about the appropriate use of chemicals to tweak one's mood and personality."

It probably is not possible to prove such a claim. After all, who really can know the motivations of another person? As it happens, we do have some ancillary information that suggests Mr. Sullum is correct in his allegation. I would add another allegation: that Doc Diller is not only an activist, he is an opportunistic activist who is making a ton of money by ignoring the scientific principles of medical practice, pandering to a market of other anti-psychiatry activists and unwary parents.

I personally don't care if other anti-psychiatry activists waste their money on his books. But I do object to him feeding on the fears of parents and fanning the flames of litigation.

I hasten to add that I cannot prove that he is doing these things. This is my opinion. But there are some facts to support these allegations. I hasten to add also that Mr. Sullum is hardly beyond reproach. He is the author of Saying Yes: In Defense of Drug Use. So he has a financial pony in this race, too.

I suppose if there were ever any hope of me making money off this blog, I could face the same accusations. But I assume most of my readers know the chances of that.

Back to the point. What is the evidence that Doc Diller is trying to make a buck, in a way that is unscrupulous? I did not quote the entire Sullum article, but in it, he points out that the "FDA's decisions are not supposed to be based on anecdotes, which are emotionally compelling but scientifically unreliable." This is one of the most fundamental principles of medical science. The literature is full of case reports of one or two patients who exhibited some unexpected drug response. These reports are posted just in case some kind of pattern emerges. Then, someone can justify doing a formal study to prove the point.

For example, I recall seeing, about ten years ago, a report about two patients with schizophrenia who got better after being given Pepcid for gastroesophageal reflux. Pepcid is an H2 blocker that does not cross the blood-brain barrier very well. So it was not expected to have any effect on the brain, much less having a salutary effect on schizophrenia. Did anything ever come of it? No. Just two anecdotal reports that are lost in the dustbin of letters to the editor in some obscure journal.

Another example: The premarketing studies of the antidepressant Remeron included three cases of neutropenia (low white blood cell count). This was dutifully reported in the package insert. The statistical analysis indicated that it was as likely as not to be a fluke. Was it? Yes. After the drug had been given to millions of people, no additional cases emerged.

It is important to recognize that this kind of thing happens all the time. If you do 20 independent lab tests on a patient, there is a 50% chance that one of them will be abnormal, even if there is nothing wrong with the patient. Part of the practice of medicine is learning to suspend judgment, to not draw any conclusions, based upon isolated observations. Surely Doc Diller knows this. Yet, look at what he has posted on his website:

I've been a doctor for twenty-seven years and thought I was pretty accustomed to the sad and difficult stories I heard about kids in my practice of behavioral pediatrics. Still I wasn't prepared for the tales of devastation and woe as I listened to parents and children speak earlier this week at the Food and Drug Administration meeting on the adverse effects of the anti-depressant drugs on children.

This is ridiculous. I spent six months in training, in a children's hospital, and I'm sure he has a lot more experience in pediatrics than I do. He has had to tell parents that their kid has cancer, or cystic fibrosis, or any of a number of awful things, hundreds of times. He has seen all kinds of "devastation and woe". It is his job to be able to withstand that with complete æquanimitas. He goes on:

The problem facing the FDA, though, is that many of these extreme acts could have been the product of the disorders these drugs were meant to treat. Yet only two parents of about forty personal witnesses spoke of the value of the medications. They also happen to be representatives of the National Alliance for the Mentally Ill (NAMI) which has close ties to the psychiatric establishment and drug industry.

I personally know several members of NAMI. The ones I know are among the kindest, most altruistic people on this planet. Yes, they do get grants from pharmaceutical companies. Although I cannot speak for the two parents that Doc Diller saw at the meeting, the NAMI members I know are serious advocates for patients, usually because they have family members who are afflicted with mental illness. To cast doubt upon their credibility because NAMI accepts corporate contributions is irresponsible. NAMI has a high rating among charitable organizations, and they publish openly their financial resources. See their 2003 annual report (162 KB PDF) for details. Notice that many of their large donors are insurance companies. Insurance companies have an interest in keeping costs low, so they tend to have an agenda opposite that of the pharmaceutical companies. Other large contributors to NAMI are philanthropic organizations, and there are many individuals and estates that make contributions. If he means to imply that NAMI is a shill for Big Pharma, he needs to find some actual evidence.

Now look at some excerpts from his presentation to the President's Council on Bioethics:

Just again, like all psychiatric diagnoses, there are no biological or psychological tests for ADHD, and more interesting to me is looking at the use of stimulants in America, and in the wide variation which points -- you don't know how many people have ADHD for sure, but you can be much more certain of who is using Ritalin, and we will find out in a short time why.

No tests? This is a summary of tests accepted as evidence by Purdue University when a student requests accommodations on the basis of ADHD:

The basic diagnostic instrument is the clinical interview. Commonly several other diagnostic instruments are used to provide a broader foundation of information upon which to base a diagnosis and to identify the student's functional status. The following information is provided for the purpose of reference for professionals using other assessment instruments.

The common functional areas and the frequently used diagnostic instruments for each are:

Cognitive Functioning – provides a wealth of information on how the student copes with a variety of verbal and visual/spatial tasks. Using one instrument: Wechsler Adult Intelligence Scale-III (WAIS-III) all subtests (as appropriate); or Woodcock Johnson Tests of Cognitive Ability-III.
Alternating and Divided Attention – provides information about mental flexibility (the ability to shift focus) and the ability to simultaneously attend to multiple demands. Using at least two instruments: Wisconsin Card Sort; Attentional Capacity Test (ACT); Paced Auditory Serial Addition Test (PASAT); Trail Making Tests, Parts A and B; or Kagen Matching Familiar Figure Test (KMFFT)

Target Focused –provides information about sustained and selective attention over time. Using one instrument: Tests of Variable Attention (TOVA); Connors’ Continuous Performance Test (CPT); or Gordon Diagnostic System (GDS).

Executive Functioning– provides information about problem solving methods, frustration levels, restlessness, and distractibility. Using at least two instruments: Halstead – Reitan Category Test; Porteus Maze Test; Tower of London (sequencing and planning); Stroop Neurological Screening Test (SNST); Wisconsin Card Sort; Rey-Osterrieth Complex Figure Task; or Letter Cancellation Task.
Memory Functioning– provides information about long term and short term memory. Using one instrument. Wechsler Memory Scale- III (WMS-III); California Verbal Learning Test (CVLT); or the Verbal and Nonverbal Selective Reminding Tests.
Self and Other Reports – provides information about functioning from questionnaires. Using two instruments (one from a significant other [parent or sibling completing the checklists as it pertains to the student] and the other from the student): Wender Utah Rating Scale (WURS); Barkley Self-Rating Symptom Checklist for ADHD Adults; Copeland System Checklist for Adult Attention Deficit Disorders; Connors’ Adult ADHD Rating Scales (CAARS); or Brown ADD Scales (Adult).

It is true that there is no single test that is conclusively diagnostic of ADHD. A trained, experienced psychologist has to do a battery of tests, conduct an interview, etc., but to say there are no tests is just plain wrong.

How good of a grasp of science does Doc Diller have? See this excerpt from one of my earlier posts; this is also from the December 12, 2002 presentation to the PCBE:

[...]it is a special pleasure and privilege to welcome Dr. Lawrence Diller to the council this afternoon. In an area in which there have been zealots and radicals on all sides, this is a man who has occupied the sober middle voice of moderation, and of care, and of proper concern.

Dr. Diller has occupied the sober middle, a good place for someone talking about a controlled substance. The man in the sober middle has this to say about the mechanism of action of methylphenidate:

Now, a little bit on the drugs themselves. The way that these stimulants work, is that they block dopamine receptor sites, and therefore increase the neurotransmitter at the synapse, and tagged dopamine seems to show up more at the pre-frontal cortex and the local cerruleus [sic] in the brain.

Now, compare this with the following text from Psychiatric News September 21, 2001 Volume 36 Number 18 p. 18: (The Psychiatric News article is a summary of the findings reported originally in The Journal of Neuroscience, 2001, 21:RC121:1-5.)

[...]Although methylphenidate has been prescribed for nearly 50 years, its mechanisms of action have been understood only poorly. A central nervous system stimulant, the drug is believed to block both the dopamine and norepinephrine transporters responsible for clearing the neurotransmitters out of the synapse after a signal has been transmitted from one neuron to the next, in the same way that an SSRI blocks the reuptake of serotonin.

Notice two things: 1) The mechanism of action of methylphenidate involves blockade of the dopamine reuptake transporters, not the dopamine receptors, and 2) The increased dopamine shows up in the striatum, not the prefrontal cortex. (The dopamine displaces the radioactive tracer from the receptors, so the treated patients show less radioactivity where there is more dopamine released.)

Dr. Diller may be sober, he may not be a zealot or a radical, but in his work helping to refine science policy for the President of the United States, he made two factual errors in one sentence.

Turning to his WaPo Opinion article, the last sentence of his opening paragraph is: "This [FDA announcement] action is the culmination of more than 10 years of efforts to bring to light potential dangers of these medications."

When I was in medical school, I was taught that it is important to monitor patients for suicide risk shortly after starting an antidepressant. That would have been in the early- to mid- 1980's. None of the medications mentioned in the FDA announcement had even been put on the market yet. The fact is, the risk he is talking about is not news. It just isn't. The fact that the FDA has issued a warning is news, but it does not represent new scientific knowledge. There are two points about this: First, the FDA is a government organization that serves a regulatory function. It is not fundamentally a scientific institution. Second, the FDA issues warnings almost every day. For example, they issued 37 medication warnings in February 2004. (If you want, you can sign up for e-mail alerts of these warnings.) We cannot know for sure what motivated Doc Diller to write about this one particular warning, but looking at his website, it is apparent that he has a particular interest in bashing psychotropic medication.

Further on in his Opinion article, he states. "It seems that only the trial lawyers have a vested economic interest in following up on medications." If this is true, why is it that the FDA issues such frequent warnings? Are we to believe that trial lawyers instigated all these warnings? No, the fact is, the FDA and the pharmaceutical industry are paying close attention to safety issues. Usually, they act on these issues when it appears to be appropriate. Yes, there have been some significant failures in the system, including some unconscionable cover-ups. But even Doc Diller has not established a case for the contention that there has been a cover-up of the possible link between antidepressants and suicide.

Dr. Diller wrote his Opinion piece and got it published in the Washington Post. I am sure this has attracted some attention to him, and his books, and his website; no doubt, he continues to profit from this. If only he would spend more time studying the science of medicine, he might be able to write something that actually is accurate and newsworthy.

At the Center of the Storm Over Bush And Science
---
Junk Science or Junk Logic?

There was an article in NYT by James Glanz, on March 30, 2004, entitled At the Center of the Storm Over Bush And Science. The article did not bring much new to the issue, but it did include some information about Dr. John H. Marburger III, President Bush's science adviser. This included some content from an interview with Dr. Marburger. I posted a comment in the NYT Forum: Join a Discussion on Science in the News.

Commentary on James Glanz's At the Center of the Storm Over Bush And Science, published: March 30, 2004:

Mr. Glanz brings a fresh perspective to the topic of the allegations of the Bush administration systematically suppressing, distorting, and misusing science. The background on Dr. Marburger is particularly interesting. For a collection of opinions on this, as well as a more detailed history, see:

http://corpus-callosum.blogspot.com/2004_01_01_corpus-callosum_archive.html#107533447761570611

and
http://corpus-callosum.blogspot.com/2004_02_01_corpus-callosum_archive.html#107663777074330170

as well as
http://corpus-callosum.blogspot.com/2004_02_01_corpus-callosum_archive.html#107699093373408572

One person replied:

norbertzangox - 11:14 AM ET March 31, 2004 (#4592 of 4594)

I read most of the text on the first of your links. What I found was standard issue liberal paranoia about anyone who works for an organization that actually produces anything. The article described the attempt of the CDC to replace good Democrats with "Individuals with known industry connections." That phraseology portrays persons who work for an industry as horned devils without exactly saying so, by using the description "known connections", which we normally reserve for descriptions of relationships that persons may have with the Mafia or drug dealers.

It is a well-worn and tiring technique for laying adverse impressions between the lines. Its usual purpose is to create negative feelings when the author lacks sufficient data to create a sound case for his poor opinion of the person he is describing.

About the claim that the article makes, ". . . EPA administrator for air and radiation, blocked studies of bipartisan clean air proposals because they would undercut support for President Bush's weaker Clear Skies initiative.", I ask, how does the claimant (Senator Edwards, whom we all know to be an impartial observer of the present administration) know that the bipartisan clean air proposal would undercut President Bush's plan if no one has doe the analysis? Why don't those who are so convinced that their plan is better do an analysis? Let them lay it out there so we all can assess it.

For believing that the rest of the issues constitute misinformation, it is necessary to believe that carbon dioxide is causing climate change and that the existing levels of pollutants in the air are harming health. There are perfectly logical and scientific reasons to dispute both contentions.

Carbon dioxide is not a pollutant. Anthropogenic emissions of carbon dioxide are not the cause of climate change. The sun is the more likely culprit, if culprit is even a proper adjective. All indications and observations from history and the present are that warmth is better than cold. Ice ages are murderous. The medieval warm period was a period of prosperity, good health and beneficial social change.

EPA health effects studies greatly overestimate the toxicity and danger of existing concentrations of air pollutants. Air pollution is not causing health problems in this country. In China perhaps, but not in the US.

I believe that the essay at http://www.greeningearthsociety.org/wca/2004/wca_ [...], presents a more insightful and interesting analysis of the ongoing debate about science and junk science. You might want to give it a look.

Mr. Norbertzangox is correct. The sun is the major factor in climate change. If there were no sun, the climate would remain stable for a really, really, long time. He is correct also, that the article portrayed those who work in lead-related industry as horned devils. Yes, this is an expression ("known connections") normally reserved for Mafia or drug dealers. However, the point of the article was not to impugn the persons who were appointed to the CDC's committee on lead toxicity. The point was to impugn the Bush administration.

As it happens, I am familiar with the Greening Earth Society's web site. The commentary on climate change includes the following:

Junk Science

In a city swept by major maelstroms, a smaller but not insignificant one swirling through our Nation's Capital concerns a purported Republican effort to employ something called “sound science” to loosen environmental regulations. What keeps this one spinning is pressure by Democrats to purportedly strengthen regulations using what they too deem to be “sound science.”

Sound science is science its proponents find to be agreeable. What they find scientifically disagreeable is labeled “junk science.” Sad to say, whenever you hear someone using the term “sound science” you'll hear a lot of the first word and not see very much of the second. [...]

Let's begin with a reality check. Science isn't the Simon Pure beast your grammar school teacher made it out to be. It's not even a particularly logical enterprise. Further complicating matters, today's sound science can become tomorrow's junk science. This is because scientists tend to work within what the great historian of science, Thomas Kuhn, called “paradigms” or overall belief systems. Kuhn first advanced this concept in a number of academic papers in the 1950s, and more comprehensively in his oft-quoted Structure of Scientific Revolutions, a book first published in 1962 and still a top seller on the topic.

A Band of Rebels

Kuhn notes that most scientists spend their lives working to shore up the reigning world-view and that those who disagree with it are by definition much fewer in number. The outsiders tend to find inconsistencies within the current paradigm. As a consequence, they tend be unpopular among their peers and are derided. But often they are more logical and (dadgummit) they frequently turn out to be right. The few eventually overwhelm the mass, but it happens against impressive resistance.

This model very neatly fits the evolution of climate change and global warming.[...]

This is a peculiar argument. Yes, Thomas Kuhn did point out that major shifts in scientific thinking start out with a small number of dissenters. But the argument appears to be that, since the the scientists who disagree with the theory -- that anthropogenic CO₂ is implicated as a cause of climate change -- are in the minority, they are likely to be correct.

This obviously is not a logically supportable conclusion. Another problem with the whole pro-CO₂ argument is this: while it is difficult to prove, conclusively, that anthropogenic CO₂ is the cause of global warming, that is not really the point. The point is this: can reducing the output anthropogenic CO₂ of reduce the impact of climate change? This really is a separate issue. Regardless of what caused what in the past, what we need to know is: what can change things for the better, in the future?

Tuesday, March 30, 2004

Suicides in the Military

Army sent mentally ill troops to Iraq

By Mark Benjamin
United Press International
Published 3/12/2004 5:53 PM
View printer-friendly version

WASHINGTON, March 12 (UPI) -- The Army appears to have "inappropriately" deployed soldiers to Iraq who already were diagnosed with mental problems, according to documents obtained by United Press International.

More than two dozen suicides by U.S. troops in Iraq, and hundreds of medical evacuations for psychiatric problems, have raised concerns about the mental health of soldiers in Operation Iraqi Freedom. An Army Medical Department after-action report obtained by UPI suggests that the Army sent some soldiers to war who were mentally unfit in the first place.

"Variability in predeployment screening guidelines for mental health issues may have resulted in some soldiers with mental health diagnoses being inappropriately deployed," the report said. That could "create the impression that some soldiers develop problems in theater, when, in some cases, they actually have pre-existing conditions."

The October 2003 report said the Army should consider quickly changing course to prevent deploying more soldiers with mental problems. In a massive troop rotation now under way, more than 100,000 troops are heading to the region.

"Perhaps stricter predeployment screening is required to keep at-risk soldier from deploying," the report said. That would help in "identifying soldiers that may become non-functional in theater due to mental health problems."

It says that idea, among others, "must be passed on in a timely manner since units will more than likely be deploying in the near future."

A number of veterans' advocates say signs of widespread mental problems among soldiers from Iraq shock them -- one in 10 soldiers evacuated from the war on terror to an Army hospital in Germany were sent solely for mental problems. The Pentagon says that number is not out of line. It also is investigating more than two dozen suicides in Iraq and Kuwait but says the rate is not alarmingly high.

Analysis: In a randomly selected group of people in the USA, out of 100,000 people, in one year, you would expect about 10.7 suicides. The Pentagon said that the number of suicides -- "more than two dozen" -- is "not alarmingly high." Looking at the most recent complete figures at NIMH Suicide Facts, and crunching a few numbers, and making some assumptions, we seen that among males ages 20-24, we would expect 20 suicides in a group of 100,000 in one year. (The assumption is that all of the deployed soldiers are male, and that all of those who killed themselves are male. Probably not exactly true, but close enough.) There are some factors we cannot quantify. Suicide risk is increased among those with ready access to firearms, those with a history of violence, those with substance abuse problems, and so forth. Although we can't quantify this, it seems reasonable to think that among male soldiers in a combat zone, an increased risk of 20% above baseline is reasonable. Therefore, 24 suicides is about what one would predict. Although I would love to say that the number of suicides is an indication that there is something wrong with the military, the numbers do not support that position.

Furthermore, efforts to predict suicide in individuals have not proven to be very accurate; and efforts to demonstrate reduction in suicide via suicide prevention programs largely have been futile. So it does not seem likely that the military has much chance of actually reducing the risk. Still, on humanitarian grounds, they should increase their screening and not deploy soldiers at risk. I doubt this would have a measurable impact on the suicide rate, but it easily could reduce the amount of chronic posttraumatic stress disorder and reduce the incidence of exacerbation of pre-existing serious mental illness.

My wife used to work with at-risk veterans. Her group consisted of about 50, mostly male, who had the most days in-hospital of all the veterans in the area. Two of her patients committed suicide over a period of several years (despite intensive case management and individualized treatment). Several of them had been sent into combat (mostly in Viet Nam) even though they clearly had been exhibiting signs of serious mental illness prior to deployment. I don't know if those two suicides could have been prevented, but I do think that those patients would not have had such severe illness if they had been screened out, and not sent to combat.

"Of All Our Enemies, the Most Real and Dangerous is Fear Itself."

There is a good essay in The American Prospect, by Jane Smiley and James Squires, publication date 4/1/2004. Go ahead and read the entire thing if you want; I am just going to point a few excerpts to make a point.

Fear Factor
Our hype-driven culture thrives on confusing reality with fantasy and on making us afraid

[...] The 2004 election could be stolen, too, as many of the weaknesses in the 2000 balloting process have gone uncorrected and some reforms, such as touch-screen and other computer-based election machines, have been shown to be unreliable and easily manipulated. But the real threat is not that Democrats or Republicans will steal a critical state again, or that another president will be appointed by the Supreme Court; it is the possibility that fear is being replaced in the political process by fear-mongering, employed in the high-tech world of instant communications by the skilled and unscrupulous mind manipulators of today's advertising culture. And the integrity of our political process is evaporating as quickly as the moral principles that once set us apart and made us a model for great nations of the world.

[...] It took nearly half a century for entertainment and advertising to overwhelm the institution of the free press, which used to function as America's public voice. And it took about the same length of time for the press's successor in that role -- television -- to change the process by which the human brain makes decisions.

Recent scientific advances that allow the mapping of brain activity suggest that children who grow up watching television receive and process information differently and more rapidly than their parents who did not. Not unlike muscle development, brain development varies with use, so the more different parts the brain employs, the more efficient it becomes. As a result, the audio-visual communication of information is more efficient when employed by those who have grown up watching television. As more and more people have used audio-visual communication over the years, and as technological sophistication has increased, the structure of capitalism has also changed. When television became the marketplace, people began to gather in front of the screen, ready for their brains to be washed. And no institution in society keeps up with moving targets as well as the American marketing industry.

[...] All presidents spend their first terms running for re-election, but the Bush administration has relied on the principles of advertising unceasingly, almost without recourse to any other mode of communication. And so far that's been its crowning achievement.

[...] Repeated terrorist alerts, new assessments of reinvigorated bin Laden minions, and resumption of the culture war leave little time for dull, irrelevant economic and social truth. So the Republican strategists' idea of the perfect presidential debate would be an image face-off: a doctored photograph of the probable-Democratic nominee, Senator John Kerry, attending an anti-war rally with Jane Fonda, in contrast to two 15-second film clips of the wartime president, one with him in a flight jacket aboard an aircraft carrier and the other of him leading "NASCAR dads" in prayer at the Daytona 500. The Democratic strategist, of course, prefers another juxtaposition of images: that of young war hero Kerry in combat gear moving through a Vietnam jungle while, to the sound of car-bomb explosions, a smirking Bush challenges terrorists to "bring it on" in Baghdad.

Of course, none of these images approaches the whole truth, which remains as elusive in our system and among our leaders as nobility and statesmanship. But in election 2004, they might be the closest the democracy can come to substantive debate in our current climate of fear. And this is why, back in another time, when images were slower and truth easier to find, an unquestionably great wartime president warned us that of all our enemies, the most real and dangerous is fear itself.

The essay makes a number of points, and in the process, bashes politicians left and right. The point I would like to emphasize is in their concluding paragraph: "of all our enemies, the most real and dangerous is fear itself."

Why is this so? Because fear, perhaps more than any other emotion, has the potential to derail a logical thought process. It is hard to think clearly when you are fearful. People who are afraid are easier to manipulate, because their capacity for logic fails them. This happens to have been the topic of my first and second posts.

Sunday, March 28, 2004

Another Exercise in Connecting the Otherwise Unconnected

A modest amount of blogbuzz was generated by the article in The New Republic, The Web Won't Topple Tyranny. I was poking around to see what people had to say about it. For reasons not entirely clear, I ended up seeing this post on Rodger Payne's blog.

Saturday, March 27, 2004

Draft
Some time ago, I referenced the basic "military math" that slows further implementation of the Bush Doctrine. Put simply, the US doesn't have a sufficiently large armed force to carry out additional Iraq-like invasions and occupations. Most of the force is already deployed somewhere important, and the rest is either training to deploy or resting from a recent deployment

Additionally, anecdotal evidence suggests that re-enlistment rates may be down as well, which will further limit the President's apparent aspirations.

Conscription, of course, could alter this equation -- though it would take awhile to draft and then train new (likely much less motivated) soldiers.

In any event, I recently read an interesting piece on AlterNet by Conner Freff Cochran suggesting that a draft is coming. Don't expect to hear the Republicans talking about this before the election.

Dr. Payne also provided information from the Selective Service Annual Performance Plan 2004. Part of this involves getting volunteer registrars in most if not all high schools, and to increase staffing at local draft boards. The Dept. of Defense went so far as to post a notice asking people to sign up to be board members for the Selective Service.

Curiously, the notice has been removed. Some foresighted people saved copies, such as this one at the Memory Hole:

Defense Department Deletes Notice About Draft Boards

>>> On 23 Sept 2003, the Defense Department Website called "Defend America" posted a notice for people to join local draft boards. "If a military draft becomes necessary," the notice explained, "approximately 2,000 Local and Appeal Boards throughout America would decide which young men, who submit a claim, receive deferments, postponements or exemptions from military service, based on Federal guidelines."

In early November, that notice started to receive media attention, with articles from the Associated Press, the Seattle Post-Intelligencer , the Oregonian, the Toronto Star, the BBC, and London Guardian (unsurprisingly, none of the major papers or networks in the US covered it).

In a familiar turn of events, the notice suddenly disappeared from the Website. (Thanks to LG for pointing this out.) We've mirrored the page and posted the text below.

Serve Your Community and the Nation
Become a Selective Service System Local Board Member

The Selective Service System wants to hear from men and women in the community who might be willing to serve as members of a local draft board.

Prospective Board Members must be citizens of the United States, at least 18 years old, and registered with the Selective Service (if male). Prospective Board Members may not be an employee of any law enforcement occupation, not be an active or retired member of the Armed Forces, and not have been convicted of any criminal offense.

Once identified as qualified candidates for appointment, prospective Board Members are recommended by the Governor and appointed by the Director of Selective Service, who acts on behalf of the President in making appointments. Each new member receives 12 hours of initial training after appointment, followed by 4 hours of annual training for as long as he or she remains in the position. They may serve as Board Members for up to 20 years, if desired.
Local Board Members are uncompensated volunteers who play an important community role closely connected with our Nation's defense. If a military draft becomes necessary, approximately 2,000 Local and Appeal Boards throughout America would decide which young men, who submit a claim, receive deferments, postponements or exemptions from military service, based on Federal guidelines.

Positions are available in many communities across the Nation. If you believe you meet the standards for Selective Service Board Membership, and wish to be considered for appointment please visit our web site at: http://www.sss.gov/fslocal.htm

Regarding the posting and subsequent removal of the notice, a spokesperson for the Selective Service System was quoted as saying:

"This not even remotely resembles efforts to kick it up a notch," said Dan Amon, a public affairs specialist for the Selective Service System.

He said the Selective Service routinely sought applicants to fill 11,000 slots on local draft boards nationwide to be ready if the draft ever were reinstated. The terms on these voluntary boards are for 20 years, and many are now expiring, he said.

"We're just going through a cycle," he said. He said when the information was posted on the Defense Department Web site, it raised some alarms. "We're not even quite sure how it got there," he said.

"We're not even quite sure how it got there." Right.

More information on the Selective Service program can be seen in the Vancouver paper here. This refers to two pieces of legislation, S 89 and HR 163, AKA the 'Universal National Service Act of 2003'. Thomas.loc.gov lists the currents status of the legislation as follows:

H.R.163
Title: To provide for the common defense by requiring that all young persons in the United States, including women, perform a period of military service or a period of civilian service in furtherance of the national defense and homeland security, and for other purposes.
Sponsor: Rep Rangel, Charles B. [NY-15] (introduced 1/7/2003) Cosponsors: 13
Related Bills: S.89
Latest Major Action: 2/3/2003 House committee/subcommittee actions. Status: Executive Comment Requested from DOD.

According to an article on AlterNet.Org, the Selective Service's current plan calls for a final report to be submitted to the President on March 31, 2005. If that happens, an actual draft lottery could be up and running by June 15,2005. That happens to be a little over a month after my son's 18th birthday. (In case you were wondering why I took the trouble to write this, which is a little off my usual subject matter.)

Blog commentary on this is universally negative, as far as I could tell. Conservative blogs such as the Evangelical Outpost and conservative sites such as CATO express concern that reinstating the draft could lower the quality of the military services. Hear the CATO commentary here (Realaudio link). Francis has a website named BushDraft.com that includes a collection of links about the draft. Another can be found at the Information Clearinghouse. Lisa Bralts-Kelly at Handbasket? meet Hell expresses a negative opinion here. Likewise, Tom at Livejournal/user/yesthattom is opposed to the draft. Kevin Brennan at Tilting at Windmills opines that the notion of reinstating the draft is an urban legend. This is based upon Rivka's post at Respectful of Otters. She raises some good points that would seem to suggest that the draft is not coming back anytime soon. She adds,

[...] it seems to me that we have enough to worry about with what Bush is actually doing. We can't afford to spare any outrage for things he's not doing."

This leaves us not knowing what the government is really up to. Perhaps they do not know themselves what they are up to. All this brings me back to where I started, which was the article called The Web Won't Topple Tyranny. It may not topple tyranny, but it will sure help us keep track of what is going on.

More on Suicide
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Facts, Opinions, Experience, and a little bit of Nonsense

In the NYT, there is an article by Gina Kolata, one of the best science writers in the business. The title is: Why Test Animals to Cure Human Depression? Ms. Kolata has picked up on the issue of antidepressants possibly causing suicide, and posed some interesting questions to some of the people who do research in the area of drug development.

OF MICE AND MEN

Why Test Animals to Cure Human Depression?

By GINA KOLATA

YOU might think if questions were raised about whether antidepressant drugs can make patients suicidal during the first few weeks of treatment, that scientists would turn to animal testing for further investigation.

After all, suicides are rare enough that there are no firm human data on whether the drugs can cause them. But you can do experiments with animals - examining their brains, giving them high doses of drugs - that you could never do with people.

That might seem like a reasonable course of action, especially after the Food and Drug Administration announced last week that it was so concerned about a possible, though very slight, suicide risk that it wants antidepressant drugs to carry warnings on their labels. But it turns out that animal experiments are not an option.

The reason, said Dr. Alan Schatzberg, chairman of the department of psychiatry and behavioral science at Stanford University's School of Medicine, is that "we don't have an animal model of depression."

[...]Those symptoms, he noted, involve the prefrontal cortex, a brain area not highly developed in animals. So, he asked, "How do you model it in an animal?"

[...] Some psychologists say they can make animals exhibit signs of depression by putting them in situations where they feel helpless to control their fate. "All this stuff about animals don't feel sad or hopeless, that's some huge leap," said Dr. Martin Seligman, director of the Positive Psychology Center at the University of Pennsylvania. He said that the only sign of depression that could not be elicited in animals was suicide.

What if, by chance, researchers stumbled on an animal test that predicted whether an antidepressant drug might prompt suicide as a rare side effect in people?

"We would immediately go back and test all of our drugs," Dr. Ruffolo said. If the animal tests indicated that the drugs were linked to suicide, he added, the company would use the test to search for other drugs that were not. [...]

Ms. Kolata points out that one of the difficulties in doing research on suicide is that it happens infrequently in the context of a research study. Suicide is the 11th leading cause of death in the USA, but that amounts to only 1.3% of all deaths per year. In 2001 there were 30,622 deaths by suicide (or that were ruled to be due to suicide) out of almost 300 million people. This means that, each year, about 0.01% of people will die via suicide.

After a suicide, the most important question is: why did the person do it? Obviously, it is very difficult to get the answer to that question, since you can't ask the only person who really knew. Suicide notes, when they are found, may not always give the real reason.

The only definitive way to study an aspect of human behavior is by doing a randomized, double-blind, controlled, prospective experiment. Nobody is going to do a study in which people are knowingly exposed to a risk of suicide, so there never will be a definitive study of the causes of suicide. For similar reasons, I think there never will be an animal model for suicide risk. If someone developed a putative animal model, it would only be useful if validated. In order to validate it, you would have to demonstrate that the behavior of the animals is correlated with the behavior of humans.

To complicate matters further, drugs can be associated with an increased suicide risk even if they are not psychiatric medications. Accutane and interferon have been associated with suicide, and they have no known direct psychotropic effects. As a result, it is difficult to postulate a model pathophysiology for suicide risk. Without an idea about how, on a molecular level, a drug could promote suicide, there is little basis for establishing an animal model.

The F.D.A., Antidepressants and Suicide Risk (3 Letters)

o the Editor:

Re "Regulators Want Antidepressants to List Warning" (front page, March 23):

There is much to be lost and little to be gained by the new Food and Drug Administration warning. It is true that there have been suicides by adults who happen to be taking antidepressants. But information about these suicides is based only on anecdotal reports, not scientific studies, and we know few details.

Do they involve people suffering from bipolar disorder who become manic when given antidepressants indiscriminately by general practitioners? Are these people using street drugs concomitantly and not telling their internists?

Unfortunately, the F.D.A. warning will scare many people away from taking a medication that would otherwise lead them to have happier and more rewarding lives. Rather than preventing suicides, this warning will create the risk of more suicides.

PETER KUDLER, M.D.
New York, March 23, 2004

To the Editor:

The Food and Drug Administration, with good intentions, has overreacted and opened the floodgates of fear and malpractice litigation ("Overprescribing Prompted Warning on Antidepressants," news article, March 24).

It would be ironic if this action caused patients to abruptly discontinue their medication out of fear and misunderstanding, which could trigger severe rebound depression, withdrawal and suicide.

Imagine the trial lawyers licking their chops ready to blame every suicide not on the disease but on the therapy. The F.D.A. has acted irresponsibly and foolishly.

MITCHEL L. GALISHOFF, M.D.
Valley, Ala., March 24, 2004

To the Editor:

The current brouhaha over antidepressants (front page, March 23) is another example of the medical profession's refusal to understand depression as a serious medical illness. Many internists dispense antidepressants to depressed patients and blithely instruct them to return in six months, as if they were treating a common allergy.

This practice is encouraged by managed care companies to rein in costs. Yet for the last 40 years, psychiatrists have known that depressed patients are at great risk for suicide in the earliest stages of recovery.

JUDITH EBENSTEIN, M.D.
Irvington, N.Y., March 24, 2004

See this post for a thoughtful, personal account of the appearance of suicidal thoughts after starting an antidepressant.

Category: Things found while looking for other things
Subcategory: WTF???

Do you suppose the FDA should put a warning label on feminists?

GOP Desperation Tactics

Found via Talking Points Memo, here is a link to an article about fundraising from blogs:

GOP criticizes Democratic House candidate's Internet fund-raising

Posted on Thu, Mar. 25, 2004
CHET BROKAW

Associated Press

PIERRE, S.D. - Republicans have accused Democratic U.S. House candidate Stephanie Herseth of maintaining a secret Web page to receive campaign donations raised from ads on liberal groups' Internet sites.

But a Herseth campaign official scoffed at the charge, saying the Web page is not secret and can be found easily with a standard search of the Internet.

Herseth faces Republican Larry Diedrich in a June 1 special election to fill the vacancy left when Bill Janklow resigned as South Dakota's lone member of the U.S. House.

Jason Glodt, executive director of the South Dakota Republican Party, said the Herseth campaign arranged the special Internet donation site to prevent most South Dakotans from knowing about Herseth's relationship with such liberal groups.

The Herseth Web page takes campaign donations from people directed there from Internet sites called "blogs," which are online bulletin boards that feature journals, opinionated articles and messages.

[...]

"I think the real point is you judge a person by the friends they keep, and look where she's focusing her fund-raising efforts," Glodt said. "Anybody can look at these blogs and the content, and realize the values they are promoting are completely contradictory to the South Dakota values she purports to represent."

Five comments: First, where do they get off saying that blogs feature "opinionated articles"?

Second, who cares if the blogs that carry the ads have content that is "contradictory to the South Dakota values she represents"? That is like criticizing a candidate who runs ads in a newspaper, when some of the articles in the newspaper are objectionable. Are we to infer that the opinions expressed in the blogs represent the opinions of the candidate?

Third, what good would a fundraising page be if it were secret? That would be like NPR stopping all broadcasting during their fund drive.

Fourth, if using the internet to solicit donations is so wrong, why does Larry Diedrich solicit donations on his main campaign site?

Fifth, is it true that most South Dakotans do not know about Herseth's backers? on the Daily Rebuplic web site, a newspaper in Mitchell, South Dakota, readers can leave comments. After an article on the campaign, a reader had this to say:

Reader Comments

Posted: Wednesday, March 17, 2004
Article comment by: Marcy Mattern

I really enjoyed the article about the upcoming congressional race. I would however like to see more information about Larry Dietrich. I wonder why you haven't reported that Ms. Herseth is being supported by Emily's List, NARAL and Planned Parenthood?

Perhaps Dietrich's campaign would be served better if he could come up with some substantive issues. Complaining about internet fundraising is a non-issue.

Another Problem with the Family Marriage Amendment
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Sex Isn't Black and White

Long ago, I was watching an episode of Leave It To Beaver. The show ran between 1957 and 1963, so I would have been five years old, at the most. The show was in black and white, as the illustration shows.

In one of the episodes, Ward Cleaver -- the father figure -- was lecturing to Beaver. The Beaver had done something morally ambiguous, and was trying to weasel his way out of being blamed for it. In response, Mr. Cleaver said something like: "Beaver, something is either right, or it is wrong, and that was wrong."

At the time, I recall thinking that some things really are not all that clear-cut. Later, I was peripherally involved in collecting data for a project that was supposed to define the boundaries of the various categories of anxiety disorders. I learned that trying to nail down a definition of a human trait is exceedingly difficult. The devil is in the details, and the more complex something is, the more details there are. And the more devils there are, too.

Stop and think of aspects of human biology, and try to think of one that illustrates a clear-cut, either-or dichotomy. Life vs. Death? Well, no, actually hospitals have to have lengthy guidelines to follow to decide if a patient is alive or dead. What about Male vs. Female?

Clearly, the notion of an absolute distinction between females and males is a core belief in every culture. Children are aware of this distinction even before they have any knowledge of procreation. We are so accustomed to being able to tell the difference between males and females that it does not even occur to us that there might be some situations in which gender assignment is less than obvious.

The Family Marriage Amendment would define a marriage as a union between one man and one woman. That would mean that men cannot marry men, and women cannot mary women. A very clear distinction.
Mr. Cleaver was aptly named. He could cut right to the heart of the matter. He could separate the meat from the bone, so to speak. And he always could tell right from wrong. Like I said, it was a black and white show.

But even Mr. Cleaver might not have such an easy time distinguishing female from male. Take the case of 21-hydroxylase deficiency. This is an hormonal disorder that causes a developing female fetus to produce too much male hormone. As a result, the baby looks like a male, even though it has two X chromosomes.

There are many other causes (eMedicine) of gender confusion. In some cases, it takes a team of doctors a fair amount of study to decide if a newborn is male or female. Sometimes not everyone on the team can agree.

Sometimes it seems as though nature always has another surprise waiting for us. Just when we think we have an absolutely clear way to distinguish females from males, nature tosses in another variation that we had not anticipated. Here is a description (from eMedicine) of the genetic basis for true hermaphroditism:

The most common karyotype is 46,XX, although mosaicism is common. A translocation of the gene coding for HY antigen from a Y chromosome to either an X chromosome or an autosome presumably explains the testicular material in a patient with a 46,XX karyotype. More problematic is how a true hermaphrodite with a 46,XY karyotype can have ovarian tissue, since two X chromosomes are believed to be necessary to normal ovarian development. Possibly, unidentified XX cell lines are present in these patients.

So it is possible that some individuals will have XY in some of their cells, and XX in others. Or they will have what appear to be two X chromosomes, but one of the X chromosomes has Y chromosome genes in it. So you can't distinguish males from females by looking at the chromosomes, with absolute reliability. For every rule, there will be an exception.

In fact, it is quite likely that there are many couples in the USA, in which one member of the couple looks entirely male, but is genetically female. Sometimes this is discovered during an infertility workup. Usually there are other symptoms that lead to the diagnosis earlier in life, but not always. Are we going to require that all couples in the USA undergo a complete genetic and endocrinological workup before they get a marriage license? Are we going to require the same of all couples already married, just to be sure that there aren't already some same-sex marriages? After all, either it is right, or it is wrong. And if it is wrong, it should be stopped. Right now.

Note: persons with some kind of ambiguous genitalia or hermaphroditism are called intersexuals. Society often is not nice to them. See Bodies Like Ours and Intersex Society of North America for more information. And try to be nice to people, all people, even if their very existence threatens your belief structure.

Saturday, March 27, 2004

Public Reply to Comment on Antidepressants and Suicide

Corpus Callosum comments by Haloscan

Thanks for the link. Just started the whole blogging thing and haven't decided whether I really need trackback.

I enjoyed your article. I have a close friend who is a pharm sales rep and we've have a lot of discussions about the use of anti-depressants (his field). Obviously I'm not an FDA fan for many reasons, and didn't go into a lot of the "evidence" I had researched on the net and gathered from my friend. However, somewhere in my archives is a longer rant about the issues regarding drugging children. While there are obviously instances where it may be appropriate, I think we should be more hesitant to prescribe these meds (and others) to children.

Anyway, thanks for the link. I've bookmarked your site - look forward to checking back on some of your stuff.
Norman | Email | Homepage | 03.27.04 - 9:13 pm | #

The topic of pediatric psychopharmacology is an important one, and as you point out, there are serious ethical issues involved. This is reviewed, from a perspective that is only slightly biased, in the book, Beyond Therapy, published by the President's Council on Bioethics.

One reason that pediatric psychopharmacology is important, from a public health standpoint, is that there is evidence in adults that treating depression today can make relapses less likely tomorrow. No one knows if treating persons with depression at a young age would make a difference in their longterm outcome. However, if that turns out to be true, we will be in a situation where we will have to pay very close attention to see if we can have a positive, long-term impact.

Major Depression is estimated to cost the country about $45 billion dollars a year. Most of this is due to lost productivity. (The reference is in one of my earlier articles). If comprehensive treatment of children could reduce this, it would make a high difference in the economy and it the quality of life for millions of people.

Of course, this does not make the ethical issues go away; it merely highlights the importance of considering all sides of the issue.

Regarding the second issue: TrackBack. I suppose you do not need it, and the fact is most people who have it do not seem to use it. It is a bit of a hassle to do the TrackBacks manually each time. I like it., though, because it makes it easier to do research on topics in the Blogosphere. Someday it all will be automated and it will be used much more.

When I write a serious essay and post it on my blog, I always do an informal blogosphere survey just to make sure that I have something to add to what is already out there. Comments, trackbacks, and blog search engines greatly facilitate this.

By the way, when I was researching for the Antidepressants and Suicide article, I used Waypath for the first time. It seemed to be better than some of the others (Bloglines, Blogdex) at finding pertinent articles on the 'net. It also makes a nice graph, if you want, showing the amount of "buzz" that certain topics create.

You just go to their Weblog Post Analysis form, then enter the permalink URL of a post that deals with the topic you are interested in. It returns a list of related articles.

One final comment. I appreciate the fact that you made your comment a reasonable one. Half the comments I get from people I don't know are needlessly inflammatory. I tried to add your blog to my aggregator, Bloglines, but it did not find an RSS or Atom feed. SInce you use Blogger, why not go to the settings page and turn on the Atom site feed? If you are really into it, you can then go to Atom2RSS and set up an RSS feed. Atom2RSS formats the RSS feed perfectly, unlike some of the others.

If you are trying to figure out how to do this kind of thing, sometimes you can go to a blog that has successfully implemented the feature you want, use the View menu on your browser to "View Source" and study the HTML code to see how the feature was implemented.

You can screw up your blog pretty badly doing this, so be sure to make a backup of your template.

Good luck.

Antidepressant Medication and Suicide
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A Meta-Review of the Blogosphere

There is concern that there could be a link between antidepressant drugs and suicidal thoughts and behavior. This is something that has generated a lot of commentary in the blogosphere:

I would like to take some time to pull together the recent medical information, news reports, and blogger commentary; then provide my own views on the subject. I conclude with some recommendations. If you already are familiar with this topic, just skip down to the recommendations.

Starting with the medical information, the Canadian Medical Association Journal has three articles of interest:

These articles are in the Commentary section. As such, they are not original, peer-reviewed research articles. I included them because the perspective of persons in Canada is likely to be different from that seen in the USA. They have a single-payer health system rum by the government. The effect of politics, finance, and lobbying will be different in Canada. See the bibliography in the CMAJ articles for links to the original research that has prompted all this buzz.

The FDA has issued reportss:

Not all of the recent scientific articles about antidepressants and suicide have concluded that there is a risk; some have indicated a reduction of risk::

There are many news articles and editorials; representative examples include:

From the blogosphere:

There are others, of course, but I could spend all day tracking them all down. I stopped when I got the impression that I was unlikely to find many more new ideas.

None of what I have to say will make any sense unless you have wither been following this topic closely, or you have read at least one good summary paper. If neither is true for you, I suggest you scan the article #2 in the first group: Antidepressants and adverse effects in young patients: uncovering the evidence.

Summary: drawing from the links above, and my persona experience, I would like to present a summary of all of this. It appears that the opinion in the blogosphere is split. Some persons feel that the suicide risk is an example of a cover-up, that it is a reason to not prescribe antidepressant, or that it is a reason to turn to alternative medicine instead of refined pharmaceutical. Many people express concern about the influence of financial concerns when it comes to marketing and regulating medications. Some express the belief that the FDA is being overly zealous in requiring warnings about suicide risk. Some people point out the difficulties of making sense of all the available information on the link between antidepressants and suicide. Most notable are the articles from The Toxicology Weblog (#1 above) and Blogcritics (#3). One commentator speculated that the FDA issued the warnings in order to help shield pharmaceutical companies from litigation (#14).

In an attempt to get a clear picture of how best to think about this topic, I thinks it is good to get a sense of the fact that what we are talking about is the probability that something bad could happen as a result of trying to make something good happen. It is important to recognize that, for persons with major depressive disorder, there is no risk-free option. That is, there is going to be a risk of suicide no matter what you do. All you can do is alter the probabilities.

For persons with MDD, there is a risk that they could commit suicide on and off medication, and that if on medication, that the suicide could be caused by the medication or by something else. Note that this is an oversimplification. In most cases, suicide is a complex event. There are multiple factors that lead to suicide in an individual, and in practice it is going to be very difficult to identify a singular cause. Despite that complication, it still is useful to enumerate the possible risk scenarios:

Person with MDD, off medication:

Risk of suicide due to disease
Risk of suicide unrelated to disease

Persons with MDD on medication:

Risk of suicide due to disease
Risk of suicide due to medication
Risk of suicide unrelated to disease or medication

Note that, in the unmedicated group, there will be a subpopulation of people who do kill themselves, who would not have done so if they had been on medication.   Keep in mind that the goal here is to minimize total risk, because it is the total risk that affects the patient's prognosis. Thus, if you do something to increase one risk, but also lower the risk in a different area, the total risk may go down. Thus, even if antidepressant use can increase suicide risk in some situations, it might lower the risk in other situations, with a new effect being that overall risk is lowered. Note also that that the risk of suicide due to antidepressant medication, in the unmedicated group, is zero (by definition). Therefore, if there are any suicides related to medication in the medicated group, the risk of suicide due to medication will not be zero.

Some commentators have wondered how it could be that we do not actually know the relative risk for these subpopulations. But think for a moment about what you would have to do to get really solid information. First of all, you would have to do a very large, randomized, placebo controlled study. To average out the effects of age, health care delivery system, geography, and other confounding variables, you would have to have a multi-site study, preferably including centers in several different countries. You would have to keep close track of thousands of people all over the world for at least several months; years would be better. You also would have to have some objective way to tell which suicides in the medicated group were due to the medication. It is not obvious that there is any way to do that.

Such a study would be enormously expensive. Pharmaceutical companies could sponsor it, but no one would accept the result uncritically in that case. It would have to be sponsored by the World Health Organization, NIMH, on some other neutral agency with deep pockets. Would this be the best use of the resources needed to conduct the study? Remember, if this study is done, that would mean resources would not be going toward understanding HIV, SARS, cancer, etc. Suicide is a fairly common cause of death, but it is not in the top ten causes. Therefore, it is not likely that the definitive study will be done anytime soon.

Therefore, we are left having to make important -- life changing -- treatment decisions, while we know full well that we do not have the information we need to accurately judge the relative risks of the treatment vs. no treatment.

One thing I noticed, especially in reading the blogs, magazine articles, and editorials, is that a lot of people have really strong feelings about the topic. In some cases, it appears that people equate the issue of suicide risk due to antidepressants with the global question of whether antidepressants are good or bad. This is somewhat like using the alleged breast cancer - abortion link as a proxy battleground for the pro-choice/pro-life debate. I submit that this fuzzy overgeneralization is not helpful.   It only confuses the issue.

There is another source of potential fuzzy thinking that should be clarified. Let us say that we do somehow find a way to quantify the pertinent relative risks. What would we do with the information. Remember, the relative risks are valid for large populations. They may or may not be applicable to any given individual.

Also, remember that the statistics could be used as a guide to develop public policy that is good for the population as a whole, but not necessarily to any given individual. A good example of this is pertussis vaccine. If everyone gets the vaccine, the population is better off. But some individuals will have serious reactions. Because there can be a difference between what is good for the group and what is good for the individual, we could end up seeing people promoting the wider use of antidepressants on public health grounds, while a separate group argues against it on for individual reasons. This is a kind of an argument that is difficult to resolve.

One thing that is apparent from the articles cited above is the there may bee an important difference in the relative risk for adults compared to children and adolescents. Most commentators agree that we need to be careful especially when it comes to treatment of children.   Unfortunately, there is a severe shortage of trained child psychiatrists. In the USA, there is a dearth of hospital beds for young persons with mental illness. Even when hospitalization is an option, it is difficult to keep the patient in the hospital for more than a few days.   Also, most children are limited in their capacity to understand what is happening to them, and to report problems when they should. For these reasons, we need to be especially careful about exposing children to medication that could have serious risks.

Some people have been critical of the FDA for its stance that in cannot render a definitive statement about the risk of antidepressant-related suicide risk. However, seeing that there is a tremendous amount of data, some of it contradictory, I think the FDA is correct to refrain from making a final pronouncement. Another criticism of the FDA has been that they do not have a lot of specific recommendations. WHile they do post several recommendations, they are all general tips that represent basic good medical practice. It is not clear that they are recommending anything other than a vague 'be careful' warning.

My recommendations: I would like to see a big multi-center study set up to try to resolve the question of possible antidepressant-induced suicide risk. If the study is done, regardless of whether it shows an increased or decreased risk, or no effect, it is likely to conclude with a recommendation for more careful attention to premarketing drug trials; publication of articles with negative results, just as prominently as those with positive results; and closer follow-up of persons treated with antidepressant medication. All of this will cost money, of course. There are some simple, practical things to do in the meantime:

If a patient calls to make an appointment for evaluation of depression, they can try to schedule two or three appointments all at once, at weekly intervals. The first would be for an evaluation, the subsequent ones would be for follow-up. In actual practice, it often is hard to schedule a follow-up appointment for just one week after the initial assessment. If you schedule both up front, you are sure to be able to get in within a week of starting medication.
Any patient who gets an Rx for an antidepressant should be instructed in how to make contact in emergencies. They also should prepare themselves mentally for the fact that, if there is a crisis, they may need to go to an emergency room or talk to an on-call doctor whom they do not know. No one likes to do this, but if one is prepared to face it if it comes up, it tends to go better.
Physicians should explain to patients that there are no risk-free options, and that the medication can have adverse effects. It is helpful to mention that adverse effects generally are reversible: they go away when the drug is stopped; and that most adverse effects can be treated easily. Akathisia, for example, responds to treatment with beta-blockers, benzodiazepines, or Periactin. Patients may fear that if they report adverse effects, they will be taken off the medication. This is not necessarily the case. They may fear that any adverse effect they have will be permanent. This misconception could lead to hopelessness and contribute to suicide risk.
If the person prescribing antidepressant medication does not plan to see the patient weekly, appointments should be offered with the clinic nurse, if in a primary care setting; or with a psychologist or other counselor, if in a mental health clinic. Even a scheduled phone call could help. Doctors should set aside time in their schedules for phone calls, and/or use a secure e-mail system. Some patients will send an update by fax to the doctor's office, with a note such as 'I just wanted you to know about this (possible adverse effect), please call me if this should be addressed.'
Insurance companies should not erect bureaucratic and financial barriers to appropriate evaluation and follow-up. They should not authorize just one visit when the patient or the doctor's office calls for preauthorization of services. They should automatically authorize two or three sessions, so that it will be more likely that proper follow-up will occur.
Accrediting agencies should monitor closeness of follow-up as an index of quality of care.
If patients have a known risk of suicide, their family and their treatment providers should ask them what would get in the way of their reaching out, should they become suicidal. Anticipating the barriers ahead of time often makes the barriers go away.
For mild depression, consider using psychotherapy and/or lifestyle modifications before trying medication.
If you do decide to take use antidepressants, use them properly. Use a med box to help guard against skipped doses. Do not take more than recommended. In most cases, do not stop suddenly. Be very careful about alcohol, nicotine, caffeine, illegal drugs, over-the counter medication, and herbal or alternative-medical products in combination with antidepressant medication.

Thursday, March 25, 2004

Creationism and Evolution
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The Topic That Will Not Die

Another essay by Phyllis Schlafly caught my attention. This time she wrote about the recent efforts of some persons to get schools to teach alternatives to evolution, which typically would be some variant of creationism or intelligent design. It seems that this is one of the more common topics in the Blogosphere. In an effort to find a fresh approach, something new to say, I decided to engage my spontaneity engine.

One of my favorite ways to pound out a quick essay is to use the compare-and-contrast structure. It's easy to do; the essay almost writes itself. But if what I want is a fresh approach, I can't use a hackneyed method. So what to do? First, read the essay by Schlafly, then poke around a bit using intuition, settle on something to compare and contrast the essay with, and figure out how to sprinkle in some observations of my own.

Ok, where did I last see a well-written post about evolution and creationism? Pharyngula is what comes to mind. Sometimes the first association is the best, so I go to Paul Myers' site. This time, I find an essay, not by Myers, but one he borrowed from The Botanical Society of America (BSA). (See the original context, here.) It turns out that Ed Brayton already wrote about the BSA essay, so there is no point in me just doing another review of the same piece. And Scientific American has posted 15 Answers to Creationist Nonsense, and Chris Cagle has addressed intelligent design, so there is no need for a simple refutation of the Schlafly article (which deals with creationism and intelligent design). But the comparison between the Schlafly article and the BSA article does appear to be a fresh perspective.

Now, with both sides of the brain engaged, and action potentials zinging back and forth along the corpus callosum, I can get to work.

The Schlafly essay was published on March 22, 2004, on Townhall.com. The title is: Ohio lesson plan pleases conservatives, irks apostles of Darwin. The comparator essay, Botanical Society of America's Statement on Evolution, was written by members of BSA and finalized on July 27, 2003. Admittedly, the comparison is not entirely fair. The BSA probably had a committee that went through several drafts of their Statement on Evolution. So theirs would be expected to be more polished. Still, Ms. Schlafly put hers up on the 'net, so she must think it is presentable.

She begins:

"Why is it important for scientists to critically analyze evolution?"

That's the first question in the "student reflection" portion of a controversial 22-page section called "Critical Analysis of Evolution," which is now part of Ohio's 547-page public school science curriculum.

How could anybody object to such an innocuous question?

The response to this is contained in the BSA essay. Note, however, that the BSA essay has been around for a long time. I cannot help but think that if Ms. Schlafly had done her homework, she would know that there is an answer to this. Not that she regularly reads the Botanical literature, but really, it is simply to find many good articles on the subject. Even though her question really is a rhetorical device, it is not very effective for this purpose if there is a good answer to it. From the BSA:

We are asked, "Why, in all fairness, don't we teach both explanations and let students decide?" The fairness argument implies that creationism is a scientifically valid alternative to evolution, and that is not true. Science is not about fairness, and all explanations are not equal. Some scientific explanations are highly speculative with little in the way of supporting evidence, and they will stand or fall based upon rigorous testing. The history of science is littered with discarded explanations, e.g., inheritance of acquired characters, but these weren't discarded because of public opinion or general popularity; each one earned that distinction by being scientifically falsified.

Now, back to Schlafly:

On Feb. 10, the Ohio State Board of Education approved the new curriculum by a vote of 13-5 after being persuaded by 22 Ohio scientists that the lesson plan promotes academic freedom and that it is good for students in 10th grade to have an inquiring mind about evolution.

This is an interesting way to mislead people. The format of her essay is similar to that of a newspaper report. But look at what she does: she starts out with some dry facts: "On Feb. 10, the Ohio State Board of Education approved the new curriculum by a vote of 13-5...", but then she slips in some opinion statements: "promotes academic freedom and that it is good for students in 10th grade to have an inquiring mind about evolution." Did she survey the Board to see if in fact those are things that the (unnamed) scientists persuaded them to believe? Or is this an untested hypothesis of hers, mentioned as another rhetorical device? A well-written article would not leave me with these questions. If she is reporting and not merely advancing her own opinion, she would do well to learn how to write like a scientist, are at least like a good reporter. BSA provides a good example of clarity:

[...] To test these hypotheses, plant biologists crossed einkorn and emmer wheats with goatgrasses, which produced sterile hybrids. These were treated to produce a spontaneous doubling of the chromosome number, and as predicted, the correct crosses artificially produced both the emmer and breadwheat species. No one saw the evolution of these wheat species, but logical predictions about what happened were tested by recreating likely circumstances.

I realize that the clarity is diminished somewhat by taking the quote out of context, but the idea here is that an effective essay contains an indication of how the conclusions were derived.

Again, back to Schlafly:

There is nothing religious about creationism, or even about intelligent design, in the new Ohio standards. What is controversial is giving students the opportunity to question evolution; it's the inquiry-and-debate aspect that some people find so threatening.

I've got news for her. People do not become professional academicians if they find inquiry and debate to be threatening. Again, she posits an hypothesis with absolutely no support. I suppose it is true that "some people" find inquiry and debate to be threatening, but she implies that it is the opponents of creationism who have this reaction. Can she provide an example of one proponent of evolution who is opposed to inquiry and debate? Every scientist I know would love to have school children engage in both activities more often. (As a matter of fact, I invite any creationist on the planet to debate my 11th-grade son, who just won the State Mock Trial competition.) Getting back to the point, BSA does address her question, "What is controversial about giving students the opportunity to question evolution?"

Is it fair or good science education to teach about an unsuccessful, scientifically useless explanation just because it pleases people with a particular religious belief? Is it unfair to ignore scientifically useless explanations, particularly if they have played no role in the development of modern scientific concepts? Science education is about teaching valid concepts and those that led to the development of new explanations.

There is no controversy, really. No one advocates that schools teach both sides of every topic. That would be ridiculous. Are we also to give equal time to the Geocentric Theory of the solar system? Her statement, "There is nothing religious about creationism, or even about intelligent design, in the new Ohio standards." is disingenuous. I haven't read the new Ohio standards, but I will accept her stipulation that those standards do not define creationism as a religious teaching. But does she want us to believe that creationism (along with the variant, Intelligent Design) is not inherently a religious issue? If it is not a religious issue, then why is it that so many (if not all) promoters of creationism are Christian fundamentalists? And why are they so adamant about the evolution/creationism issue, and not out there campaigning for equal time for other scientific controversies? After all, there are controversies in every branch of science. Some of them are even worth talking about. If creationism is not a religious issue, why do busloads of church congregations go to staged "debates" about creationism.

Back to Schlafly:

The new lesson encourages students to consider both supporting and "challenging" evidence for evolution. The challenges to the theory are understated and are backed up with facts.

For example, the lesson says that the fossil record supports evolution with its increasing complexity of living forms. But the lesson also observes that "transitional fossils are rare in the fossil record" and "a growing number of scientists now question that ... transitional fossils really are transitional forms." The lesson notes that some changes in species occur quickly in the fossil record relative to longer stretches that manifest no change.

What does the BSA essay have to say about this? Are the challenges to evolutionary theory backed up with facts? Is there a "growing number of scientists" who question the fossil record? What has the number grown to? From two to seven? Maybe there are now as many as twelve scientists who question that transitional fossils are in fact transitional forms. The BSA essay contains a response to her assertion that "the challenges to the theory are ... backed up with facts."

The hypothesized speciation events were actually recreated, an accomplishment that allows plant biologists to breed new varieties of emmer and bread wheats. Using this speciation mechanism, plant biologists hybridized wheat and rye, producing a new, vigorous, high protein cereal grain, Triticale.

[...] Creationism has not made a single contribution to agriculture, medicine, conservation, forestry, pathology, or any other applied area of biology. Creationism has yielded no classifications, no biogeographies, no underlying mechanisms, no unifying concepts with which to study organisms or life. In those few instances where predictions can be inferred from Biblical passages (e.g., groups of related organisms, migration of all animals from the resting place of the ark on Mt. Ararat to their present locations, genetic diversity derived from small founder populations, dispersal ability of organisms in direct proportion to their distance from eastern Turkey), creationism has been scientifically falsified.

One of the best ways of testing the validity of a theory is to see if it works when applied to a practical problem. This has been done in the case of evolutionary theory, but we still are waiting for the first practical application of creationism.

Near the end of her piece, Ms. Schlafly states:

Diehard evolutionists have enjoyed censorship of any criticism of their beliefs for 100 years, and they won't willingly give up their academic turf. Their censorship demands became so irrational that Rich Baker, the Ohio board's vice president, called them "a bunch of paranoid, egotistical scientists afraid of people finding out (they) don't know anything."

I happen to be in a position to say something about this, having completed a residency in psychiatry at the University of Michigan, and having spent time in classrooms, labs, and in the field with numerous proponents of evolution. (You can't hide paranoia while living in a tent in 100+ degree heat for a summer.) Mr. Baker is wrong. Evolutionists are not paranoid, as a rule. I think there were one on two undergrads who were paranoid, but they didn't get far in their academic careers. Is the evolutionist's behavior due to ego problems or turf battles, or is there a reasonable explanation for why they argue against creationism?

While creationism explains everything, it offers no understanding beyond, "that's the way it was created." No testable predictions can be derived from the creationist explanation.

Creationism is predicated upon miracles. Any observation can be explained by saying it is/was a miracle. Miracles are not testable, at least by mortals. Even paranoid, egotistical turf-deprived scientists do not try to test miracles. In science, validity is tested by replicability of observations. Miracles are one-time events. I suppose that if there were some way of producing miracles on demand, we could do some real science with them.

Is there any evidence that evolution proponents encourage censorship? If so we would expect to see scientists making systematic efforts to shut out opposing views. Thinking back to my high school days, I clearly recall many instances of scientists -- including biologists -- mentioning opposing views. In fact, I believe that Lamarckian evolution and spontaneous generation still are mentioned in classrooms. They are mentioned because they are historically significant. This is evidence that evolutionists are not categorically shutting out all opposing views. They do, justifiably, pass over views than have no merit.

Ms. Schlafly concludes by pointing out:

Ohio has become the cutting edge in the long-running evolution debate. Georgia, New Mexico, Minnesota, West Virginia and Kansas have all wrestled with science standards and curricula on evolution in recent years.

The Alabama Senate Education Committee last week approved the "Academic Freedom Act," which says that no teacher or professor in public schools or universities may be fired, denied tenure or otherwise discriminated against for presenting "alternative theories" to evolution. The bill would also prohibit any student from being penalized because he held "a particular position on biological or physical origins" so long as the student demonstrated "acceptable understanding of course materials," which include evolution.

Again, if this is not a religious issue, why is it that so much effort is going to this one topic? If the interest truly were secular, we should be seeing similar efforts toward giving equal time to minor theories in all areas. Did Shakespeare really write all those sonnets? Is obsessive-compulsive personality disorder really caused by anal fixation? Why aren't there any fundamentalists out there campaigning for equal time for the anal fixation theory?

Fibonacci Numbers and the Golden Section

While I work on the next bioethics article and another one about creationism, here is a post just to put something up today. I found a link to a great site that has a ton of information about Fibonacci Numbers and the Golden Section.

The Fibonacci numbers are 0, 1, 1, 2, 3, 5, 8, 13, ... (add the last two to get the next)

The golden section numbers are ±0·61803 39887... and ±1·61803 39887...

The golden string is 1 0 1 1 0 1 0 1 1 0 1 1 0 1 0 1 1 0 1 ...
a sequence of 0s and 1s which is closely related to the Fibonacci numbers and the golden section.

Here is the Home page for Ron Knott's Surrey University multimedia web site on the Fibonacci numbers, the Golden section and the Golden string. It even includes a Fibonacci Calculator !

Just in case you've got nothing better to do today.

Tuesday, March 23, 2004

Michigan Mock Trial 2004 championship

Here are the pictures from the high school mock trial competition held in Lansing, Michigan, on March 20, 2004.

	Here, Kevin sits with Mary Hennessey after the first two rounds. They soon will learn which teams advance to the semi-finals. They seem remarkably relaxed.
	This is the team of prosecuting attorneys. Since it is a murder case, I guess it makes sense to have three of them. This is from the first round. The young lady on the right is Zahreen Ghaznavi. I can't identify the person in the middle, but maybe someone will leave a comment. The young lady in the middle is Maggie Klein.
	After four trials, each about two hours long, one team is victorious. They started the day at 8:30AM and finished at 7:00PM Everyone is still smiling. The young lady in pink is really smiling, because she got away with murder. Si Quaeris Peninsulam Amoenam Peto Florida!!! (did I get that right?)

Suzanne Fields Ponders Bioethics
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The Softer Side of Leon Kass?

In today's (3/22/2004) edition of Townhall.com, a conservative newsletter, there is an essay by Suzanne Fields. She was fortunate enough to get a copy of the President's Council on Bioethics (PCBE) publication, Being Human: Readings from the President's Council on Bioethics. Unfortunately, this is no longer available to the general public:

Notice: If you are interested in receiving a copy of Being Human, we regret to inform you that we have run out of copies due to the unforeseen demand for this publication. Unfortunately, our copyright agreements prevent us from posting the book on our website or from printing further copies at this time. We are looking at different options and if you have already requested a copy, we will keep your name on a waiting list. We thank you for your understanding.

Being Human is a collection of writings by a wide array of authors, with a sampling of fiction, Classics, philosophical treatises, etc. Although the book itself is not available, the table of contents, several selections of text, and the Council's introductory comments to each section, can be found on the Bioethics.com site.

The Corpus Callosum today presents you with, not a review of Being Human, but a review of the review; this is because the actual book is not available. Others have written about Being Human, but I chose to not try to include the material from all the other reviews. That would take too long. Check out these links if you want to see for yourself what others have had to say about the topic: 1 2 3 4 5 6 7 8.

Ms. Fields starts by commenting about the book's cover, which is graced with a variety of visual arts:

Together, these illustrations tell you that this book wants to create a dialogue between biology and art, science and the humanities, medicine and poetry.

Ok, that sounds akin to the mission of this blog: "to develop connections between hard science and social science, using linear thinking and intuition; and to explore the relative merits of spontaneity vs. strategy." So it is natural for me to have an interest in Being Human. This interest was piqued by Ms. Fields' comment:

What's so extraordinary about this volume is that it's devoid of grandstanding, lobbying by "experts" and pompous recommendations of what to do and how to do it. It asks, with a certain humility, for the reader to think for himself about the implications of the scientific discoveries that can make our lives happier, healthier - and scarier.

Getting people to think for themselves is a good thing. I was a bit skeptical of this at first, since encouraging free thought is not a common practice in any political bureaucracy in general, and especially not among the current Administration. Having read some of the other works by the PCBE, I am faintly encouraged that there are some persons within the Bush camp who do think for themselves and want others to do the same. Despite my earlier criticism of the Council and some of their recent actions, I do think that much of what they have written is serious, thoughtful work. Not all of it is fully congruent with prevailing neoconservative thought. Ms. Fields points out:

The new book neither pontificates nor philosophizes. Instead, it presents an anthology of poetry, essays and fictional narratives for the whole family. Leon Kass, the chairman of the President's Council, rightly says it "can contribute to a richer understanding and deeper appreciation of our humanity, necessary for facing the challenges confronting us in a biotechnical age."

I happen to agree with this. Although I have read only some parts of the book, it appears that the book is a collection of works that are intended to provoke thought; to serve as a source of inspiration, not indoctrination. It is not entirely free of bias. For example, the book contains a passage from Drugstore Athlete, by Malcolm Gladwell (published in The New Yorker; also noted by Nick Schulz on Corante). Ms. Fields picks up on a passage from the end of the story:

Malcolm Gladwell, in "The Drugstore Athlete," is an ambivalent consideration of artificial enhancements, such as steroids, to increase an athlete's ability. We don't like the unfair advantage drugs give to athletes, but we have no problem cheating nature in other ways: "We have come to prefer a world where the distractable take Ritalin, the depressed take Prozac, and the unattractive get cosmetic surgery."

Although the works cited in Being Human are not intended to be pronouncements of policy, the inclusion of that passage could be taken to imply that depressed people taking Prozac are in some way comparable to unattractive persons getting cosmetic surgery; and, that both constitute "cheating nature." Neither implication is accurate. Indeed, I would argue that it is dangerous to trivialize such treatments. Ms. Fields' commentary at the end of her review is:

Leon Kass is eager to establish a national dialogue about issues both rarified and as down-to-earth as science fiction. We're wandering over terrain studded with hidden landmines. How do we balance regulation and responsibility, limitation and aspiration, our longing for the stars when our feet are made of clay? How do we resist allowing the light of information to shade into the darkness of manipulation?

I am left wondering about the purported intent of Being Human. If, as Ms. Fields' states, the intent is to "establish a national dialogue," I think the book may contribute to that end. The heretofore unspoken question is: could there be some other agenda? That is, could the intent be, not only to start a dialogue, but also to influence the outcome of that dialogue? After all, setting the starting point for a process can have a big influence on the end point, even if the process itself is free of bias. (This is seen in the founder effect, one of the principle mechanisms of evolution.)
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If my article had ended with the above paragraph, you would have been left with questions but no conclusion. Much of the output of the PCBE does exactly that. They cite a bunch of stuff, ask provocative questions, then wrap it up with no real conclusions or recommendations. That may be an effective way to generate dialogue; indeed, it has generated a great deal of chatter in the blogosphere. However, I find it unsatisfactory. The practice of asking questions without drawing a conclusion makes it difficult to argue against whatever you just read. It presents the Columboesque appearance of one merely asking questions, without appearing to lead to a specific conclusion, when in fact, there is a specific conclusion you are establishing.

Sunday, March 21, 2004

Activist Congressmen
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Flouting the Constitution

Have you just about had it up to here [gesture toward forehead] with those activist judges? Well, what about activist congressmen? A few days ago I wrote about Robert Anderholt (R-AL) drafting a bill (HR. 3799 and companion bill S.2082) that would allow the government to do anything it wants in the name of religion:

[...]The Supreme Court shall not have jurisdiction to review, by appeal, writ of certiorari, or otherwise, any matter to the extent that relief is sought against an element of Federal, State, or local government, or against an officer of Federal, State, or local government (whether or not acting in official personal capacity), by reason of that element's or officer's acknowledgment of God as the sovereign source of law, liberty, or government. [...]

Now, we hear that Ernest Istook (R-OK) inserted a provision into the Consolidated Appropriations Act (HR. 2673) that disallows federal funding to any transit agency that accepts, or allows to be displayed, certain advertisements:

SEC. 177. None of the funds in this Act shall be available to any Federal transit grantee after February 1, 2004, involved directly or indirectly, in any activity that promotes the legalization or medical use of any substance listed in schedule I of section 202 of the Controlled Substances Act (21 U.S.C. 812 et seq.).

One of the advertisements affect by the law

When I heard the report during a broadcast of On the Media (streaming audio), I was taken aback by the statement that the disallowed advertising would include anything that promoted the medical use of anything classifies as a controlled substance. SInce most controlled substances are legitimate pharmaceuticals, it sounded pretty strange to me.

Now, I have researched it a bit more. The law actually refers to chemicals that are classified under Schedule I, which is the FDA's category for things like crack cocaine, heroin, etc. which makes a little more sense. A little more. What this law does is allow the display of the government's advertisements that advocate for the War on Drugs, while restricting the display of advertisements that promote a contrary view.

The On the Media piece includes an interview with Mr. Istook. He makes a big deal about the fact that the public transport vehicles affected are "taxpayer funded." He seems to think that this gives them some kind of special status. Now, the First Amendment issues are fairly obvious:

Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the government for a redress of grievances.

But what about the fact that buses and subway trains are taxpayer funded, public property? It seems that, if anything, public property would be one of the best places for display of material expressing dissenting opinions. If they have a special status, they should be especially protected, not subject to even the slightest hint of censorship.

Pete Guither has posted an article with more information here on his site, Drug War Rant. There is a nice review of the issues on the site, Reason, written by Ernest Money. Mr. Money states:

Last fall Istook was offended by ads in Washington's Metro system in which Change the Climate said the government should "Legalize and Tax Marijuana." So he did what any intolerant, power-mad politician would do: He wrote legislation to ban the speech he did not like, not only from Metro buses, trains, and stations but from every mass transit system in the country that receives federal funds.

The Good News Blog has a post that reviews what the ACLU has to say about the legislation, citing a WaPo article on the matter. Loki at Infojunkies cites a similar article from the AP.

The NORML site has an article as well. MPP has posted a copy of a letter (PDF) that is rather amusing to read. It is a letter, written to Istook, that expresses the opinion:

Your amendment is an insult to the spirit of democracy and the belief in the freedom of ideas upon which this nation was built. You may be satisfied with this nation's marijuana laws -- and the fact that approximately 700,000 Americans are arrested each year for possessing a substance far less harmful than alcohol -- but that does not give you the right to deny Americans the opportunity to discuss and debate possible changes in the law.

What makes your sponsorship of this amendment even more outrageous is the fact that you accept campaign contributions from the alcohol industry. Like the leading anti-marijuana zealot in the U.S. House of Representatives, Rep. Mark Souder, your campaign committee has received a large sum of money from the National Beer Wholesalers Association PAC. (Interestingly, the NBWA contributed $5,000 to your campaign just a few months ago, in October 2003. Rep. Souder received $7,500 from NBWA during the 2001-2002 election cycle.) Perhaps you could explain -- in a public debate, perhaps -- why you accept money from the purveyors of a relatively more dangerous drug¹ while denying the First Amendment rights of people who simply want the public to reconsider the laws prohibiting a less harmful substance.

1For example, the most recent issue of the journal Addictive Behaviors contains a study demonstrating that
the use of alcohol is associated with significant increases in the likelihood of domestic violence against
women, while marijuana use is not associated with any increase. (In fact, the likelihood of physical
aggression appeared to decrease slightly with the use of marijuana.)

One could argue about the accuracy of their allegation that alcohol is more harmful that cannabis. After all, the harm from a substance of abuse varies widely from person to person and is greatly affected by the pattern of use. Regardless, their point emphasizes the fact that there are valid points of debate here. This underscores the need for an open forum for that debate.

I am less amused by the paradox of supporting alcohol while criminalizing cannabis, than I am by the paradox of conservative congresspersons criticizing activist judges, while there are congresspersons who clearly are equally activist. Federal elected officials swear to uphold the constitution, yet some go ahead and flout the constitution with apparent indifference.

A Plug for Human Stem Cell Research

New Toxicity Test Could Cut Animal Testing

To test whether chemicals are toxic to humans, researchers need to use liver cells that have been freshly harvested from mice or other mammals. A new collection of stable cell lines, described in BMC Biotechnology this week, could reduce the numbers of animals needed in such experiments.

The MMH-GH cell lines are derived from the liver cells of transgenic mice. These cells have been engineered to secrete human growth hormone when they are exposed to toxic compounds. The cells also continuously produce an activated version of the growth factor receptor, c-MET, which enables them to survive for longer than normal liver cells and to retain features of differentiated liver cells when they are grown in culture.

The researchers who created the cell lines come from Istituto Tecnologie Biomediche-National Research Council in Milan and Università La Sapienza in Rome. They write: "We believe that the MMH-GH cell lines provide a cheap, reproducible, rapid, reliable and ethically acceptable tool," for assessing the toxicity of chemicals.

To test their system the researchers added toxic arsenic and cadmium compounds to the cells and then looked for human growth hormone in the culture media. They found that even at low doses these compounds caused the cells to secrete the hormone -- and were therefore deemed to be toxic. These low concentrations of the chemicals would not have been picked up by current toxicity-testing methods, which brand a chemical as 'toxic' only if it kills liver cells.

[...]

The MMH-GH cell lines have a further advantage over current toxicity testing methods, according to the researchers. As they are derived from clonal cell populations assays using these cells should also be easier to standardise than current tests, which use heterogeneous primary cell cultures.

As there is considerable discomfort about the use of animals in research, researchers have tried to develop methods that reduce our reliance on animal experiments. Although lower organisms, such as yeast, can be used to carry out toxicological studies, assays using mammalian liver cells retain an important role. This is because mammalian cells will treat chemicals differently to cells from lower organisms. For example, a compound that seems benign in preliminary experiments could be broken down in mammalian cells to produce a toxic product.

Analysis: This could be used to lower the cost of new drug development. It also could have applications in environmental testing. Of course, if we could develop liver cells derived from (noncancerous) human cell lines it would be even better.

Improved Understanding of Dopamine Signaling
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Implications for Drug Development

A Mechanism for Amphetamine-Induced Dopamine Overload

DOI: 10.1371/journal.pbio.0020087
Published March 16, 2004

Copyright: © 2004 Public Library of Science. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

(All PLoS Biology research articles are accompanied by a synopsis written by a professional science writer for a general audience. It is our goal that the synopses will provide non-experts with insight to the significance of the published work. We hope you enjoy reading them.)

The notion of a neurally encoded "reward system" that reinforces pleasure-seeking behaviors first emerged fifty years ago. Psychologists James Olds and Peter Milner discovered this phenomenon when their "lack of aim" landed an electrode outside their target while studying the behavioral responses of rats given electrical stimulation to a particular brain region. It was known that stimulation of certain brain regions would induce an animal to avoid the behavior that produced the stimulus. But in the rat with the "misplaced" electrode, stimulation of this new region caused the rat to repeat the behavior that caused the stimulus. Stimulation of certain brain regions provides a very strong incentive to restimulate, creating a feedback loop that reinforces both the behavior and the neural response to it. When gentle shocks were delivered to the rat hypothalamus, for example, the animals would "self-stimulate" 2,000 times per hour by pushing a lever. The neurotransmitter dopamine, it was later discovered, plays an important role in the brain's reward system -- and in laying the biochemical foundation of drug addiction.

Essential for normal central nervous system function, dopamine signaling mediates physiological functions as diverse as movement and lactation. The dopamine transporter (DAT) is involved in terminating dopamine signaling by removing the dopamine chemical messenger molecules from nerve synapses and returning them into the releasing neurons (a process called reuptake). DAT can also bind amphetamine, cocaine, and other psychostimulants, which inhibit dopamine reuptake, and, in the case of amphetamine, also stimulate the release of dopamine through DAT. It's thought that abnormal concentrations of dopamine in synapses initiate a series of events that cause the behavioral effects of these drugs.

[...]

The researchers found that amphetamine-induced dopamine release was reduced by 80% in cells expressing a mutant dopamine transporter in which the first 22 amino acids of the N-terminal domain had been removed (del-22). Surprisingly, this truncated transporter displayed normal dopamine uptake. In a full-length DAT, mutation of the five N-terminal serine amino acids to alanine amino acids, which prevented phosphorylation, produced an effect similar to removing the 22 amino acids. In contrast, replacing these five serine residues with aspartate residues to mimic phosphorylation led to normal dopamine release as well as normal dopamine uptake.

These findings suggest that phosphorylation of one or more of these serine residues is necessary for amphetamine to flood the synapses with dopamine. While phosphorylation is a normal mechanism for regulating protein activity in a cell -- and DAT is "significantly phosphorylated" under normal conditions -- amphetamine could increase the level of DAT phosphorylation. Elucidating the mechanisms through which phosphorylation of DAT's N-terminus facilitates dopamine overload could lead to the development of drugs that block the "rewarding" effects of amphetamines and other addictive psychostimulants without interfering with normal dopamine clearance.

Analysis: The text above is a layperson-accessible report distilled from a article published in PLoS Biology, N-Terminal Phosphorylation of the Dopamine Transporter Is Required for Amphetamine-Induced Efflux. The technical writer points out that the new understanding of the dopamine transporter could lead to development of drugs to treat addiction to psychostimulants. That is true, but I think they missed two implications that potentially could be much greater. Schizophrenia and other psychoses have a complex pathophysiology, but excess dopamine signaling is an important part of most, if not all, psychoses. If this research could lead to development of a new class of antipsychotic medication, that would be a tremendous advance in psychopharmacology. The number of persons with psychostimulants addiction is small; the number of persons with schizophrenia is large. Looking at it the other way, if this could lead to new ways to increase dopamine output safely, it could lead to treatments for Parkinson's Disease and other causes of Parkinsonian symptoms.

Bioethics.com tidbit

For the last several days, I have been writing a critique of the President's Council on Bioethics' publication, Beyond Therapy: Biotechnology and the Pursuit of Happiness. It is turning out to be rather complicated, so it will be a while before I post it. In the meantime, I need to retract my previous criticism of their website for not having a working search function. I kept getting a "connection refused when attempting to contact 192.73.61.177:81" error.

The search function is working now.

VICTORY!!!

What is the Mock Trial Competition? This is an extracurricular activity conducted at high schools in most states, in which students conduct mock trials in front of judges. The judges, true to their nature, judge them. In Michigan, there are 43 teams. Ten teams advance from the Regional Tournament to the State Finals. This year, those 10 teams were: Andover HS, City HS (Grand Rapids), Community HS (Ann Arbor), East Kentwood HS, Forest Hills Northern HS, Howell HS, Ida HS, Kalamazoo Central HS, Lahser HS, and Midland HS.

Four teams make it to the Semifinals, and two teams get to the "Blue Ribbon Round." I uses quotes because I did not see any actual blue ribbons. Yes, my son Kevin was in the Blue Ribbon Round. And his team -- well, the team he is on -- won the big prize.

The toughest match was not the final round. In the semifinals, they went up against Lahser. Kevin played the part of a prosecuting attorney. He was marvelous. Afterward, the judges provide a critique. Kevin was mentioned by name, twice, for his meritorious performance. A few others from both teams were mentioned by name; I say this in a feeble effort to be "fair and balanced." Kevin was the only one mentioned twice.

Both Community and Lahser got scores over 100 (out of a possible 120). Typically, a winning score is around 80 or 90. So both teams did really well.

The kids from Lahser HS were: Omaima Bokhari, Jonathan Fleischmann, Chris Hanson, Juliet Happy, Jessica Hiett, Peter Krzywicki, Adam Masserang, Kyle Miletic, Alison Murray, and Meg Townsend. I would like to thank them for providing worthy competition.

Kevin's teammates were Marie Alexander, Helen Bates, Brandon Collins, Josh Florida, Zahreen Ghaznavi, Mary Hennessey, Alice Holbrook, Maggie Klein, and James Leaf. Their teacher coach is Cheryl Grace -- who did a great job. I would like to thank Ms. Grace for contributing to Kevin's intellectual development. Not that he needed it, but every bit is a good thing. Their attorney coaches were Griffith Dick and Robert West. They contributed a great deal.

In the Blue Ribbon round, Community High faced off against Forest Hills Northern. This also was a good round, although in my non-expert opinion, it was not as close as the semifinal round. The team from Forest Hills Northern consisted of Chris Chen, Norah Comstock, Megan Eardley, David Fraker, Nina Hart, Mitch Kosowski, Ben Levick, Noah Manger, Rasika Ranganathan, and Steve Vossler. Congratulations to all.

I don't have the pictures yet so I am posting their picture from last year. Of the two guys in the back, flanking the State Seal, Kevin is the one on the left.

2003 Michigan High School Mock Trial Tournament Blue-Ribbon Finalists from Community High School, Ann Arbor, along with blue-ribbon judges (at left) Nancy Diehl, treasurer for the State Bar of Michigan; Stu Sandler, representing Attorney General Mike Cox; and Justice Marilyn J. Kelly, Michigan Supreme Court.

When the winners were announced, I had to refrain from doing the Howard Dean Scream. (1.6Mb mp3 file)

The team will be going to Orlando, Florida May 6-9 for the Nationals, for the second year in a row.

Saturday, March 20, 2004

The Corpus Callosum Makes the Headlines
---
Well, Sort of

Psychopathic Brains Are Hardwired That Way
By rickyjames, Section News Posted on Fri Mar 12th, 2004 at 08:10:46 AM PST

From: SciScoop, also appears on ScienceDaily, adapted from a news release issued by University Of Southern California.

This article deals with the research of Adrian Raine, Ph.D., who is the Robert Grandford Wright Professor and Professor of Psychology at USC; he has devoted his career to the study of the biological basis of Antisocial Personality Disorder (APD.) For a quick overview of his work, you can go the the USC site and search on the string "Adrian Raine".

Adrian Raine, Ph.D. - Photo by Usha Sutliff Dr. Raine has focused his research on two parts of the brain: the hippocampus, a portion of the temporal lobe that regulates aggression and transfers information into memory; and the corpus callosum (CC), a bridge of nerve fibers that connects the cerebral hemispheres.

"Scientists have implicated different brain regions with respect to antisocial and aggressive behavior, and all are important and relevant," Raine said.

"But it goes beyond that to the wiring. Unless these parts of the brain are properly wired together, they'll never communicate effectively. They'll never result in appropriate behavior," he said.

Dr. Raine describes the key behavioral characteristics of persons who exhibit chronic sociopathic behavior. (See this link for an overview of the current conceptualization of Antisocial Personality Disorder.) He is quoted in the article as saying:

"They are glib. They use words well and can be charming. That lures people into their devious net," Raine said. "Psychopaths can be the life of the party for a few minutes or a few hours, and it can actually be a wonderful experience brushing shoulders with them. It's when you get to know them in the long term that you begin to see that they are not what they appear to be."

This is something I wrote about in the first two posts (1 2) on The Corpus Callosum. It is my opinion that the world would be a better place if all the non-narcisistic, non-antisocial people could recognize sociopathic behaviors more readily, so I often write about this topic. Naturally, when I encountered a story about sociopathy AND the corpus callosum, I decided to report on it and add some background information and miscellaneous commentary. The USC press release, and the articles that echo it, refer to two separate studies. One study focused on the hippocampus; the other focused on the corpus callosum.

The one pertaining to the corpus callosum was published originally in Arch Gen Psychiatry. 2003;60:1134-1142. What the authors did was to get a group of people, do personality tests on them, then match persons with APD with a control group without APD. They used MRI to get detailed measurements of the size and shape of the corpus callosum, then analyzed the data to see if there were any corellations. They also did some tests to see how much message traffic traversed the CC.

What they found is that the CC is longer (from front to back), thinner (from top to bottom), and has a greater cross-sectional area in persons with APD. They also found that there was a larger amount of information going back and forth between the two hemispheres of the brain, in persons with APD. They hypothesized that the greater area is due to either an unusual interruption in the normal pruning process, whereby nerve cells are destroyed in the developmental process; or that there is greater myelination. Since they could not do autopsies, they could not tell which explanation is correct. Of course it would be possible to generate other hypotheses, but the two mentioned here seem the most likely.

At first, the finding that there is more interhemispheric communication in persons with the disorder may seem counterintuitive. But in brain science, it is fairly common that you see a higher amount of brain activity in a certain area in a person with a disorder as compared to a person without a disorder. The significance of this is not known. It may be that the extra activity is an attempt to compensate for a defect, or that it is essentially wasted, nonproductive activity, or something like that.

In the case of sociopathy, it could be that there is extra activity in the corpus callosum because of all the scheming that a sociopath does, seemingly automatically. An example would be a person who lies just as easily as telling the truth. It may be that it takes more thinking to live your life like that. It will be interesting to see if anyone is able to figure out exactly what is going on with the extra communication between the hemispheres.

Friday, March 19, 2004

Updated Fish Safety Information

U.S. Issues Guidelines on Eating of Some Tuna

By JENNIFER 8. LEE

ASHINGTON, March 18 -- The Food and Drug Administration and the Environmental Protection Agency will recommend Friday that pregnant women, nursing mothers and young children eat no more than six ounces of albacore tuna or about one meal's worth each week, administration officials said.

Albacore tuna, often sold as canned white tuna, accounts for more than 5 percent of all seafood consumed in the United States, according to the F.D.A. Recent tests have shown that albacore tuna has higher levels of mercury than other kinds of tuna. Mercury is known to affect neurological development of fetuses and young children.

The new guidelines will say that young children and women who are pregnant, nursing or planning to become pregnant can eat up to 12 ounces per week of light tuna, which has less mercury and accounts for about 13 percent of the nation's seafood consumption.

The agencies will continue recommending that those groups limit their intake of shark, swordfish, king mackerel and tilefish, which can also have high levels of mercury.

Fish that are low in mercury and safe to eat two or three times a week are shrimp, salmon, pollock and catfish, the advisory says.

Mental health advocates often advise people to increase their intake of fish, based upon the belief that certain essential fatty acids can improve symptoms of mood disorders. See this Medscape article for background. Essential fatty acids are nutrients that your body needs, but which it cannot produce by itself. The omega-3 fatty acids, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), are thought to be the most important. Mercury, though, is extremely toxic to the brain. See the Mercury Policy Project for more information on this.

Those who wish to obtain the benefits of fish oil, but avoid the mercury risk, might be reassured by the findings of a Consumer's Union report. The report indicates that they tested 16 brands of fish oil capsules and found that none contained significant amounts of mercury, PCBs, or dioxin.

Life Is Too Serious

I signed up for the Blogsnob link exchange thing, which basically puts a random link to someone else's blog on your own page. This picture is from one of those links. There is too much bad news in the world right now, and it is too dreary reading all the blogs that I usually read. So there.

Thursday, March 18, 2004

Multidrug-resistant TB
---
Lessons About Medical Reasoning
---
The World is Full of Surprises

On March 16, 2004, the World Health Organization released a report on multidrug-resistant tuberculosis. This is a serious problem, especially in the former Soviet states of eastern Europe. This is an example of a trend in world health: more and more often, we are seeing infections caused by bacteria that are able to resist treatment with antibiotics. A lot has been written about the topic, so I will not discuss the more fundamental aspects of the problem. See this article for a good background review of antibiotic resistance, and this site for basic information about TB. Derek Lowe on Corante has a detailed explanation. Blogger comments are here: 1 2 3

I often hear people say that infectious disease is one of the more straightforward kinds of illness to understand and to treat. Well, simplicity is relative. Compared to something like rheumatoid arthritis, most infectious disease are simple. But this apparent simplicity is deceptive. Take the example of tuberculosis. TB is caused by a kind of bacterium, Mycobacterium tuberculosis. People are not supposed to have these bacteria growing in them. When they do, they are sick. The sickness is treated by giving a chemical that kills the bacteria. Seems simple. It turns out, though, that the battle between us and TB has been going on for some time. Both adversaries have developed sophisticated means to try to outwit the other. The whole topic is incredibly complex, but to illustrate, I cite the following article:

Researchers Find How Tuberculosis Bacterium Evades Detection By Immune System
Sciencedaily.com
7/16/01

A new study published in the July 15 issue of the "Journal of Immunology" may unlock a door in the search for a vaccine. The study from Case Western Reserve University's School of Medicine and University Hospitals of Cleveland details how the tuberculosis bacterium evades detection by the body's immune system.

[...] When an infection invades the body, the immune system is called upon to control and stop the infection. Important soldiers in the war against infection are scavenger cells called macrophages which chew up invading bacteria and deliver pieces of them to white blood cells named CD4 T cells.

Macrophages have a specialized set of molecules, called MHC-II (which stands for class II major histocompatibility complex). This set of molecules is used to present the pieces of invading bacteria to CD4 cells. These pieces, called antigens, are the way CD4 cells can recognize and eliminate invading bacteria.

The CWRU/UHC researchers have discovered that the TB bacterium stops the immune system from using this important piece of equipment from its arsenal. The bacterium inhibits the specialized MHC-II molecules by taking up residence in the macrophages and making a large protein in abundant quantities which interferes with MHC-II production.

Furthermore, the bacterium does this while engaging a macrophage receptor normally used for protection against a large number of infectious diseases. By employing that receptor and inhibiting MHC-II molecules, the bacterium evades detection.

Even before the introduction of antibiotics, TB evolved a mechanism to evade detection by the human immune system. As soon as antibiotics were introduced, TB began evolving in ways that cause the antibiotics to become less effective. Naturally, this is an alarming development, one that poses a problem begging for a solution.

To attempt to solve this problem, the first temptation is the Tool Time Method: "more power." That is, develop a second antibiotic that is stronger that the first one. Generally, this is done by generating a zillion new molecular entities and testing them, one by one, to see how effectively they kill the bacteria. The problem with this approach is that it, too, will fail eventually. The bacteria can evolve faster than we can develop new drugs, at least using the trial-and-error approach. Thus, the Tool Time approach will, at best, buy us a little more time:

Drug resistant tuberculosis levels ten times higher in Eastern Europe and Central Asia
WHO Global Report

16 MARCH 2004 | GENEVA -- Tuberculosis patients in parts of Eastern Europe and Central Asia are 10 times more likely to have multidrug-resistant TB (MDR-TB) than in the rest of the world, according to a World Health Organization (WHO) report into the deadly infectious disease. China, Ecuador, Israel and South Africa are also identified as key areas.

[...] MDR-TB is TB that is resistant to the two medicines most commonly used to treat it, Isoniazid and Rifampicin. Without the correct drugs MDR-TB is untreatable and in most cases fatal. Though curing 'normal' TB is cheap and effective - a six month course of medicines costs US$ 10 - treating drug resistant TB is a hundred times more expensive. Even then a cure is not guaranteed. With no effective vaccine, everyone is vulnerable to infection simply by breathing in a droplet carrying a virulent drug resistant strain.

[...] WHO's leading infectious disease experts estimate there are 300 000 new cases per year of MDR-TB worldwide. There is also new evidence proving drug resistant strains are becoming more resistant, and unresponsive to current treatments. 79% of MDR-TB cases are now "super strains", resistant to at least three of the four main drugs used to cure TB.

The second strategy is to figure out how the bacteria are overcoming our first strategy. That involves studying, on a molecular level, how the bacteria become resistant to antibiotics. This takes a bit of effort, but it is possible to do it because the bacteria are simple structurally, compared to humans:

Multidrug-Resistant Mycobacterium tuberculosis: Molecular Perspectives
Emerging Infectious diseases, Vol 4, No. 2 April-June 1998

Ashok Rattan, Awdhesh Kalia, and Nishat Ahmad
All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Multidrug-resistant strains of Mycobacterium tuberculosis seriously threaten tuberculosis (TB) control and prevention efforts. Molecular studies of the mechanism of action of antitubercular drugs have elucidated the genetic basis of drug resistance in M. tuberculosis. Drug resistance in M. tuberculosis is attributed primarily to the accumulation of mutations in the drug target genes; these mutations lead either to an altered target (e.g., RNA polymerase and catalase-peroxidase in rifampicin and isoniazid resistance, respectively) or to a change in titration of the drug (e.g., InhA in isoniazid resistance). Development of specific mechanism–based inhibitors and techniques to rapidly detect multidrug resistance will require further studies addressing the drug and drug-target interaction.

Understanding the molecular basis of drug resistance can help us redesign old drugs, develop new drugs, and figure out how to combine two or more drugs for a greater effect. By increasing the rate of development of new strategies, it might be possible for us to keep pace with the evolution of the bacteria. This is an example of the problem-solving strategy of first understanding why the problem exists, before trying to solve the problem.

Ok, so much for linear thinking. Sometimes, luck turns out to be what does the trick.

Paroxetine (Paxil) is a chemical, called a selective serotonin reuptake inhibitor, that is used as an antidepressant. It slows down the action of a protein on certain nerve cells. The protein it acts on is the serotonin transporter. Wouldn't it be really strange if a drug that is used to treat a mental illness turned out to be useful for treating an infectious disease?

Phenylpiperidine selective serotonin reuptake inhibitors interfere with multidrug efflux pump activity in Staphylococcus aureus.
Int J Antimicrob Agents. 2003 Sep;22(3):254-61.

Kaatz GW, Moudgal VV, Seo SM, Hansen JB, Kristiansen JE.

Division of Infectious Diseases, The John D. Dingell Department of Veterans Affairs Medical Center and the Department of Internal Medicine, Wayne State University School of Medicine, B4333, 4646 John R, Detroit, MI 48201, USA. gkaatz@juno.com

Structural variants of phenylpiperidine selective serotonin reuptake inhibitors (P-SSRIs) inhibited the function of two unique Staphylococcus aureus multidrug efflux pumps. The most active compound was the paroxetine isomer NNC 20-7052, which had an IC(50) for ethidium, acriflavine, and pyronin Y efflux of 9, 53, and 18% of its MIC, respectively, against the NorA pump. The unbalanced effect of NNC 20-7052 on the efflux of different substrates suggests the possibility that P-SSRIs function by a physical interaction with NorA. Under the conditions employed pump inhibition partially extended to the resistance-nodulation division (RND) pump AcrAB-TolC, but not to the Pseudomonas aeruginosa RND pumps MexAB-OprM or MexCD-OprJ.

What does this mean? Just as human nerve cells have proteins that move serotonin across the cell membrane, bacteria have proteins that move antibiotics across the cell membrane. In the case of bacteria, the pump only goes one way: it removes antibiotics from the inside of the cell, rendering them useless. These proteins are called efflux pumps. And it turns out that the efflux pumps can be affected by the same kinds of chemicals that affect serotonin transporters.

High-resolution structures of a multidrug efflux transporter responsible for bacterial resistance. | By Andrea Rinaldi

Bacterial resistance to multiple antibiotics and other drugs is a major, increasingly common problem throughout the world. Resistance is often associated with the overproduction of bacterial inner membrane proteins that are capable of extruding a variety of structurally unrelated drugs, antibiotics, and toxic compounds. In the May 9 Science, Edward Yu and colleagues at the University of California, Berkeley, disclose the structural basis of the activity of AcrAB, a constitutively expressed, major multidrug efflux system of Escherichia coli energized by proton motive force (Science, 300:976-980, May 9, 2003).

Now, it turns out that the mutations that cause antibiotic resistance in TB are not mutations that alter the structure of efflux pumps. Using a linear problem-solving approach, the tendency would be to focus on the structures that mutate in order to produce drug resistance. Now, at this point, there is no evidence that paroxetine actually has any clinical utility in the treatment of TB. Do not rush out and get Paxil if you have TB. However, the serendipitous finding that paroxetine can slow down the action of the efflux pumps could lead to a new class of drugs that, by themselves, do not kill bacteria; but which, in combination with traditional antibiotics, could render them more effective.

In the title, I said that the world is full of surprises. It turns out that the very first drug known to have antidepressant properties was iproniazid. Iproniazid happens to be an old antibiotic that was used to treat... tuberculosis!

Wednesday, March 17, 2004

More Problems with Counterfeit Medications

Pharmacy Fakes

Sick Patients Get Bogus Drugs Instead of the Real Thing

By Lisa Stark and Philip Stewart

March 16 — The prescription drug industry is a $190 billion-a-year business. With that much money to be made, and with the price of drugs in the United States skyrocketing, an increasing number of criminals are turning to a lucrative trade — counterfeit medications.

"The counterfeiters are getting more sophisticated," said Dr. Mark McClellan, commissioner of the Food and Drug Administration. "We're seeing increasingly well-organized criminal operations coming into the drug distribution system and trying to make a fast buck at the expense of the public health."

The FDA currently has 22 counterfeit drug investigations under way, according to McClellan. That has increased fourfold from the late 1990s, when the agency averaged only five such investigations a year. It is scheduled to address drug wholesalers, manufacturers and other industry officials Wednesday in an effort to raise awareness of counterfeit drugs.

[...] To prevent the growing problem, the FDA wants drug manufacturers to put a tracking system in place voluntarily by 2007. The makers of tracking devices have been testing tiny radio frequency computer chips that would be attached to drug labels or the prescription packaging.

"FDA will not rest until we have strong protections in each link of the drug supply chain, and we intend to work with all of those involved in getting medicines to Americans legally and safely to make sure that Americans are protected," McClellan said.

Analysis: This is a really nasty problem. I urge everyone to be vigilant about every aspect of getting prescriptions filled, checking the labels and the contents of what they get, and reporting any suspected problem to their pharmacy immediately. The mandatory tracking system is going to be expensive, and it will difficult if not impossible to use for drugs that people get from foreign countries (other than Canada). Until the tracking system is in place, I think it would be best for us to still use local pharmacies, instead of mail-order pharmacies, whenever possible.

With a local pharmacy, you can take the drug back and have the pharmacist look at it, without too much trouble. With mail order, it could take days to get the medication back to the pharmacy and have someone look at it or test it. Most people won't go through the hassle unless they is something way out of line.

Having the pharmacist look at the medication will not always resolve questions about the drug's authenticity, but it could help catch some of the problems.

We need a special prison for these kinds of criminals. Medication counterfeiters, the people who collected donations after 9/11, and pocketed the money; people who impersonate police officers; and high-profile corporate crooks like Ken Lay, all deserve special treatment.

Tuesday, March 16, 2004

More on Elizabeth Blackburn and the Bioethics Council
---
Early Release Article from NEJM

I am very much aware of the fact that much has been written about the Bioethics Council and about Dr. Blackburn's dismissal from the Council. In a quick survey of a Bloglines search, I did not see any commentary on the latest development. The news comes from a source that is not widely available, so I will report on it here to the general blogience.

The latest development is the early release of an editorial in the New England Journal of Medicine. For those unfamiliar with the Journal, it is the oldest medical journal in the USA. NEJM is in fact one of the most prestigious medical journals in the world. The Journal occasionally issues what the call "early release articles." These are papers that are felt to have a high degree of significance and that deserve immediate publication. For example, some of the first papers on the SARS virus were released in this manner.
Sweetwaters Cafe in Saline, Michigan

Articles published in NEJM are freely available, but only after they are six months old. To read the latest stuff, you need to have a paid subscription. Because of the importance of early release articles, though, they are freely available from the moment of publication. It is possible to sign up for e-mail notice of these releases at http://www.nejm.org/alerts.

This morning, I saw such an alert in my e-mail at work. I had not even finished my first cup of Sweetwaters coffee when I read Dr. Blackburn's Perspective article, Bioethics and the Political Distortion of Biomedical Science. Not to make light of it, but you know it must be important if I read it before finishing my coffee.

The article to which I am referring was written after the one that was published in PLoS Biology. I mention that because, to get the complete picture, it is necessary to read both of them. Additional perspective can be gained by reading the WaPo editorial by the head of the Council, Leon Kass.

What is new?

Dr. Blackburn provides some background on her selection to the Council, and her personal decision to join. She also talks about the experience of being dismissed:

Unfortunately, my initial misgiving proved to be
prescient. In a telephone call from the White House
one Friday afternoon last month, I was told that my
services were no longer needed. The only explanation
I was offered was that “the White House has decided
to make some changes in the bioethics council.”
Persons who are versed in such matters have
since suggested that the prearranged timing of the
call was not a coincidence: this administration commonly
takes controversial action on Friday afternoons,
when the news is expected to fall into a
weekend void.

People have argued about the significance of the dismissal of Dr. Blackburn. Skeptics have impugned her honesty; one attempted to invalidate her subsequent comments as the fury of a scorned academic (on The Evangelical Outpost). This, of course, is completely unwarranted and mean-spirited. Kevin T. Keith wrote an incredibly detailed refutation of Evangelical's criticism -- see his comments. Tom Van de Ven had a more restrained criticism on his blog, undercaffeinated.

Anyone familiar with academic life knows that Dr. Blackburn was making a significant personal sacrifice in joining the Council. Now that she is free of the political nonsense, and free to pursue her chosen profession, it is safe to say that she is much happier now than she was when she was on the Council. She would not have joined the Council if her motives were purely self-serving. As a recipient of the California Scientist of the Year award, she is likely to be a candidate for the Nobel Prize. (Eleven of the 51 CSOTY winners later were awarded Nobels.) Taking time away from her research (to participate on the Council) could only detract from her opportunity to enhance her reputation in the scientific community.

Since I am not a specialist in stem-cell research,[...]
in preparation for the meetings and reports of the
council. I therefore read and assessed the published
science, attended sessions on current stem-cell
research at national and international scientific
conferences, and consulted with stem-cell biologists
throughout the country.

Obviously, this activity was not related directly to her main line of research, so she spent all that time and effort in order to contribute to the public debate on bioethics. It did not advance her career at all for her to do this. In my view, this altruism enhances her credibility and casts doubt upon any attempt to characterize her as a "scorned academic." If her commentary is the mere grousing of a disgruntled outcast, there should be other references to her complaining about various things. Although there are many articles about her on the Internet, I did not find any mention of her raising objections to anything other than the activities of the Council. Therefore, there is no basis for characterizing her as a complainer.

Dr. Blackburn describes her main concern about the Council:

I was assured repeatedly by the chairman
that the science would be represented clearly in
our reports.

I was therefore concerned when I read the sections
concerning research on embryonic stem cells
in the drafts of the report and the final Report on
Monitoring Stem Cell Research. Work with animal
models has been indicating the potential benefits of
research involving embryonic stem cells for more
than two decades. More recently, research breakthroughs
in the generation and differentiation of
human embryonic stem cells and increased understanding
of these processes have suggested that this
avenue of research will eventually lead to beneficial
uses in health care. Work with animal models increasingly
suggests that such research may result in
therapies for diabetes, Parkinson's disease, and spinal
injuries, among other conditions. Yet the best
possible scientific information was not incorporated
and communicated clearly in the council's report,
suggesting that the presentation was biased.

Her concern is practical as well as academic:

I was recently contacted by a world
leader in research involving neural stem cells from
adults; he was considering withdrawing his agreement
to provide his expert opinion to the council,
for fear that the potential of research involving adult
stem cells would be overstated as a justification for
a continued ban on federal funding for promising
research on embryonic stem cells.

When prominent scientists must fear that descriptions
of their research will be misrepresented
and misused by their government to advance political
ends, something is deeply wrong.

Her conclusion is alarming:

The healthy skepticism of scientists
has turned to cynicism. There is a growing sense
that scientific research — which, after all, is defined
by the quest for truth — is being manipulated
for political ends. There is evidence that such manipulation
is being achieved through the stacking
of the membership of advisory bodies and through
the delay and misrepresentation of their reports.
As a naturalized citizen of the United States, I have
an immigrant's love for my country. But our country
must not fail us. Scientific advice should and must
be protected from the influence of politics. Will the
President's Council on Bioethics be up to that challenge?

A search of blogs, using Bloglines, indicates that the vast majority of bloggers who have commented on the subject (1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17) are troubled by the dismissal of Dr. Blackburn and Dr. May from the Bioethics Council. Likewise, major news outlets have reported that several scientific organizations have expressed similar concerns (1 2 3 4). Michael Gazzaniga, one of the remaining Council members, said that he was upset by the dismissal of Dr. Blackburn. Of course, the fact that NEJM disseminated Blackburn's commentary as an early release article indicates that the editors of the Journal agree with her concerns.

I was not able to find any reference to anyone actually supporting the changes in the composition of the Council. Even Evangelical's post does not actually support the changes. He does say, though:

Eventually the Council will tire of Blackburn's lies and will start fighting back...

That was posted on March 6th, and we still have not heard anyone "fighting back." Leon Kass did write his editorial in the WaPo, but that served to defend Bush's decision to change the Council membership. It did not contain any refutation of Dr. Blackburn's arguments.

It seems likely that George W. Bush does not want this issue to get any more press than it already has. That being the case, it is not at all likely that there will be any fighting back.

Monday, March 15, 2004

More Sleep Research

Psychiatry Clin Neurosci. 2004 Apr;58(2):138-144.

Links

Clonidine effects on all-night human sleep: Opposite action of low- and medium-dose clonidine on human NREM-REM sleep proportion.

Miyazaki S, Uchida S, Mukai J, Nishihara K.

Department of Neuropsychiatry, Tokyo Medical and Dental University and Department of Sleep Disorders Research, Tokyo Institute of Psychiatry, Tokyo, Japan.

Norepinephrine (NE) is considered to play a permissive role in the occurrence of rapid eye movement (REM) sleep. Clonidine is an NE alpha-2-receptor agonist, which has been considered to act mainly on the autoreceptors of presynaptic noradrenergic neurons to reduce their release of NE. However, previous studies of clonidine effects on REM sleep have produced controversial results and the effects of clonidine remain uncertain. To clarify the pharmacological effects of clonidine on human sleep, the sleep electroencephalograms (EEG) recorded from 15 young normal subjects after a single administration of either a low (25 micro g) or medium (150 micro g) dose of clonidine were examined, and fast Fourier transformation (FFT) spectral analyses of the C3-A2 EEG were performed. Low-dose clonidine significantly increased the amount of REM sleep and decreased the amount of non-REM (NREM) sleep during the second one-third of the drug nights compared to the corresponding hours of baseline night recordings. In contrast, medium-dose clonidine significantly decreased REM and increased NREM on drug nights compared to baseline nights in the entire night. The opposite actions of low and medium doses of clonidine on NREM-REM proportion may indicate that low-dose clonidine mainly affects the alpha-2-receptors on locus coeruleus-NE neurons presynaptically, reducing the release of NE, whereas medium-dose clonidine acts more post-synaptically.

PMID: 15009817 [PubMed - as supplied by publisher]

Analysis: This is an interesting study because it shows how important it is to avoid thinking in strict mechanistic terms when prescribing medication. All too often, we think of the mechanism of action of a drug as something that is always the same. Experience shows that medications affect different people differently. This study shows that different doses of the same medication can affect the same person in different ways, depending on the dose.

Sometimes patients come back to their doctor after having gotten a prescription, and report an unexpected outcome. Sometimes the doctor says, “that can’t happen.” This leads to all kinds of misunderstanding and hard feelings. This study shows one mechanism for possible unexpected results.

It is important for doctors and patients to understand that, in the case of an unexpected outcome, you start out the analysis by recognizing what happened. After making the pertinent observations, you draw a hypothesis, then test the hypothesis if clinically appropriate. To start out be saying “that can’t happen” is an unproductive strategy: you don’t start with a conclusion, you start with observation.

Sunday, March 14, 2004

Huh?

While I was busy reformatting my template and doing hospital rounds and reading about Bioethics, this slipped by me. Legislation has been introduced to allow the government to do anything it wants in the name of religion. It applies to all government officials, and covers their behavior whether or not they are acting in an official capacity. Excuse me if you all have seen this already, but it is so shocking I had to write about it.

	News from Congressman Robert Aderholt Fourth District, Alabama FEBRUARY 17, 2004

Congressman Aderholt Introduces Constitution Restoration Act in House Legislation Will Restore The Fundamental Precepts Upon Which The Constitution And Government Are Based

WASHINGTON, DC - Congressman Robert Aderholt (R-Haleyville) announced today in Alabama that he has introduced "The Constitution Restoration Act" (H.R. 3799), a bill requiring the federal courts to operate within the jurisdiction given to them by the United States Constitution as it pertains to the public acknowledgment of God as the sovereign source of law, liberty, and government. "Federal courts prohibiting the acknowledgment of God is a denial of the very source of life, liberty, and pursuit of happiness which our founding fathers specifically recognized in the Declaration of Independence," said Congressman Aderholt. "Our founding fathers acknowledged this as an unalienable right given by God. Prohibiting public officials from recognizing God violates the Constitution's Tenth and First Amendments." "Today, you'll find the recognition of God by state and federal authorities in oaths, mottos, documents, prayers, and monuments; and it is the duty of the Congress, under Article III, to regulate the appellate jurisdiction of the U.S. Supreme Court and other federal courts. This is a check on the Judicial Branch to prevent it from exceeding its jurisdiction. The Constitution Restoration Act would preserve and restore the acknowledgment of God to our law and government," added Congressman Aderholt. "Therefore, whether it is a public display of the Ten Commandments, the Pledge of Allegiance in the classroom, or a nativity scene at Christmas, all would be protected since it is in essence the acknowledgment of God. H.R. 3799 has been referred to the Committee on the Judiciary. Senator Richard Shelby (R- Ala.) Has introduced identical legislation in the United States Senate. -End-

The Moscow Times has some interesting commentary on this. (link via Blog Amy)
Also see Moteworthy, Stephen Laniel, Political Devotions, Gullibility isn't in the dictionary, Phyllis Schlafly, Bound in a Nutshell, Rense.com, Daily Pundit, obscurantist, X-tra Rant, Strike the Root, Eschaton, and Balkinization
See the House version of the bill in this PDF (from thomas.loc.gov)
See the Senate version in this PDF

the Senate version:

108th CONGRESS 2d Session

S. 2082

To limit the jurisdiction of Federal courts in certain cases and promote federalism.

IN THE SENATE OF THE UNITED STATES

February 12, 2004

Mr. SHELBY (for himself, Mr. MILLER, Mr. BROWNBACK, Mr. GRAHAM of South Carolina, Mr. INHOFE, and Mr. ALLARD) introduced the following bill; which was read twice and referred to the Committee on the Judiciary

A BILL

To limit the jurisdiction of Federal courts in certain cases and promote federalism.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the `Constitution Restoration Act of 2004'.

TITLE I--JURISDICTION

SEC. 101. APPELLATE JURISDICTION.

(a) IN GENERAL-

(1) AMENDMENT TO TITLE 28- Chapter 81 of title 28, United States Code, is amended by adding at the end the following:

`Sec. 1260. Matters not reviewable

`Notwithstanding any other provision of this chapter, the Supreme Court shall not have jurisdiction to review, by appeal, writ of certiorari, or otherwise, any matter to the extent that relief is sought against an element of Federal, State, or local government, or against an officer of Federal, State, or local government (whether or not acting in official personal capacity), by reason of that element's or officer's acknowledgement of God as the sovereign source of law, liberty, or government.'.

(2) TABLE OF SECTIONS- The table of sections at the beginning of chapter 81 of title 28, United States Code, is amended by adding at the end the following:

`1260. Matters not reviewable.'.

(b) APPLICABILITY- Section 1260 of title 28, United States Code, as added by subsection (a), shall not apply to an action pending on the date of enactment of this Act, except to the extent that a party or claim is sought to be included in that action after the date of enactment of this Act.

SEC. 102. LIMITATIONS ON JURISDICTION.

(a) IN GENERAL-

(1) AMENDMENT TO TITLE 28- Chapter 85 of title 28, United States Code, is amended by adding at the end of the following:

`Sec. 1370. Matters that the Supreme Court lacks jurisdiction to review

`Notwithstanding any other provision of law, the district court shall not have jurisdiction of a matter if the Supreme Court does not have jurisdiction to review that matter by reason of section 1260 of this title.'.

(2) TABLE OF SECTIONS- The table of sections at the beginning of chapter 85 of title 28, United States Code, is amended by adding at the end the following:

`1370. Matters that the Supreme Court lacks jurisdiction to review.'.

(b) APPLICABILITY- Section 1370 of title 28, United States Code, as added by subsection (a), shall not apply to an action pending on the date of enactment of this Act, except to the extent that a party or claim is sought to be included in that action after the date of enactment of this Act.

TITLE II--INTERPRETATION

SEC. 201. INTERPRETATION OF THE CONSTITUTION.

In interpreting and applying the Constitution of the United States, a court of the United States may not rely upon any constitution, law, administrative rule, Executive order, directive, policy, judicial decision, or any other action of any foreign state or international organization or agency, other than English constitutional and common law.

TITLE III--ENFORCEMENT

SEC. 301. EXTRAJURISDICTIONAL CASES NOT BINDING ON STATES.

Any decision of a Federal court which has been made prior to or after the effective date of this Act, to the extent that the decision relates to an issue removed from Federal jurisdiction under section 1260 or 1370 of title 28, United States Code, as added by this Act, is not binding precedent on any State court.

SEC. 302. IMPEACHMENT, CONVICTION, AND REMOVAL OF JUDGES FOR CERTAIN EXTRAJURISDICTIONAL ACTIVITIES.

To the extent that a justice of the Supreme Court of the United States or any judge of any Federal court engages in any activity that exceeds the jurisdiction of the court of that justice or judge, as the case may be, by reason of section 1260 or 1370 of title 28, United States Code, as added by this Act, engaging in that activity shall be deemed to constitute the commission of--

(1) an offense for which the judge may be removed upon impeachment and conviction; and

(2) a breach of the standard of good behavior required by article III, section 1 of the Constitution.

END

This bill, if passes, would say that any "element of Federal, State, or local government, or against an officer of Federal, State, or local government (whether or not acting in official personal capacity)" could do whatever to you, and as long as he/she was "acting by reason of that element's or officer's acknowledgment of God as the sovereign source of law, liberty, or government" The Supreme Court could not do anything about it.

Saturday, March 13, 2004

The Ethics of Bioethics
---
Or the Lack Thereof

Leon Kass delivers lecture at Harvard 3-12-2004

Amy Greenwood has a nice blog, positive and dense. It's nicely designed, with well-written articles. The only criticism is that she doesn't post very often. On 3/11/2004 she posted some comments about a lecture she had attended. The lecture had been given by Leon Kass. Dr. Kass is the head of the President's Council on Bioethics. An excerpt follows:

In short, Kass' position is that some of the controversial biomedical advances being developed today will degrade our humanity and trivialize our lives. Even if we approach them with the best intentions, we will be less human if we embrace them.

In particular, he made examples of stem cell biology, therapeutic cloning, genetic enhancement, psychotropic drugs, steroids, and longevity research. For each technology he mentioned a few of the possible real dangers, and then claimed that worse than these, we would lose most by the fact that our thinking about our lives and identities would change.

It is precisely here where I dig in my heels. I am willing to admit that many good technologies have a bad side, perhaps even that every advance has a cost. If that was his message, I would agree with him. But it's not. Kass proposes that the consequence of getting what we desire: good health, longer lives, decreased suffering, will cause us to cross a line into triviality. He specifically says that our lives will be less rich, less meaningful, less heroic. We will be less human.

Wow. That's some thesis.

Dr. Greenwood's article caught my attention, because it addresses a topic that I considered in a term paper I wrote in 1978. At the time, I was taking a course in the ethics of science. The assignment was to write about an ethical issue pertaining to science, but that had not been covered in class. I chose to write about the potential impact of neuroscience on our perception of ourselves as humans. The paper is long gone, but I remember the outline. I began with a review of the impact of three important scientific developments: the Copernican notion of a heliocentric solar system, the Darwinian view of evolution, and the Freudian view of human psychology. I argued that all three developments had successively dehumanized humanity. First we were dethroned from the center of the Universe. Then our bodies were equated with those of other primates. The final blow came when the greatest products of the human mind: our art, literature, etc., were revealed to be the product of mundane impulses of sex and violence. First our planet, then our bodies, then our minds; all were revealed to be nothing more significant than any other pile of molecules.

Modern neuroscience, I argued, would extend the dehumanizing impact of science. Not only would our thoughts, but our emotions, would be understood as mere chemical reactions. Reactions that could be replicated in a test tube would be no more and no less meaningful that love, hate, striving, or desperation.

In 1984, (irony noted), I spent the summer in the lab run by Charles B. Smith, MD, Ph.D.. We would grind up rat brains and run assays on the alpha-2 receptors in the locus coeruleus. We also drew blood from patients with panic disorder, and compared the binding characteristics of platelet alpha-2 receptors before and after treatment. I gained a better understanding of neuroscience, and in so doing, gave up my belief that neuroscience is inherently dehumanizing. Quite to the contrary, neuroscience helped me understand more clearly the need for humanistic values in medical practice.

Dr. Kass' lecture seems to have been noticed by few. The Harvard Crimson staff took a picture of him and published it, but did not publish an article on the lecture. Likewise, nothing appeared in the Boston Globe. The Crimson does have an article written by a student before the lecture, but nothing about the lecture itself.

Dr. Greenwood reported that Dr. Kass commented on psychotropic drugs and that he claimed " we would lose most by the fact that our thinking about our lives and identities would change." [Dr. Greenwood's words, presumably not a direct quote from Dr. Kass.]

I wanted to see more of what Dr. Kass has to say on the subject of psychotropic drugs. So, I looked around on the Internet. The first thing I noticed is that the bioethics.gov site has no search function. This seems odd. It is as anomalous as finding one of Saddam Hussein's palaces with no toilet. Even The Corpus Callosum has a search function.

Ok, so the lack of a search function is a minor gripe. You still can find things; you just have to take more time doing so. In so doing, I found that Kass has published a book, Beyond Therapy: Biotechnology and the Pursuit of Happiness (ISBN: 0060734906) that can be purchased at the American Enterprise Institute website. It is listed as comprising 352 pages. This is curious, because there is a 4.6Mb PDF file with the same title, containing a 347-page document, available for free download from the bioethics.gov website. Frankly, it seems inappropriate to me that someone would be making money by selling a government publication that is available elsewhere for free. The publication was produced by Kass in his capacity as a government employee, then he turns around and sells it for profit. The government website says that they will mail you a copy of the report if you send them an e-mail. Even if you do not have a computer with which to view a PDF, you still don't have to pay for the book.

Anyway, rant tangents aside, I did want to see what Kass has to say about psychotropic medication. Bioethics.gov does have a paper entitled Human Flourishing, Performance Enhancement, and Ritalin. It is not clear who wrote the paper. It was used as a background paper for their Thursday, December 12, 2002 meeting. The session during which Ritalin was discussed was chaired by Dr. Diller, who is described as follows:

Dr. Diller has occupied the sober middle, a good place for someone talking about a controlled substance. The man in the sober middle has this to say about the mechanism of action of methylphenidate:

PET scan images, taken at the level ofthe striatum (left) and the cerebellum (right) of a radiotracerspecific to dopamine D2 receptors, show reduced binding of thetracer in the striatum after administration of 60 mg of oralmethylphenidate (bottom) compared with placebo (top).[...]

Notice two things: 1) The mechanism of action of methylphenidate involves blockade of the dopamine reuptake transporters, not the dopamine receptors, and 2) The increased dopamine shows up in the striatum, not the prefrontal cortex. (The dopamine displaces the radioactive tracer from the receptors, so the treated patients show less radioactivity where there is more dopamine released.)

Dr. Diller may be sober, he may not be a zealot or a radical, but in his work helping to refine science policy for the President of the United States, he made two factual errors in one sentence.

OK, so their science is wrong. That does not say anything about the policy they advocate. Perhaps, despite getting the facts wrong, they somehow come up with the correct policy. What does Dr. Diller say about policy?

[...]I want to get into the issue here of ethics and values. Okay. First of all, the issue of ADHD as a neurobiological diagnosis, and what that means is that either when a child or an adult has this, and what it means politically very often is that it could be used in the service of saying-- "Well, we can't really do anything about this kid environmentally. He is really pretty much determined to have this problem. The only thing is to contain him and to give him drugs." It also again raises issues on a moral level that if indeed they are so determined this way, then in fact if they make wrong choices, they can't be held morally culpable.

I actually like what Russell Barkley says about this. He is the intellectual guru you might say of ADHD, and he says that ADHD might be considered an explanation, but not an excuse for behavior.

Here we see maladaptive behavior as disease, versus accountability and responsibility. This is a big issue in the schools, particularly over discipline. And that the disability movement has held schools accountable in the sense that unless they make adaptations to their children's diagnosis, the child can't be held responsible for acting out behavior. This whole issue really pits the rights of the individual versus the rights of the community in probably some of the most provocative ways.[...]

Dr. Diller does put his finger on one of the important policy questions: If a person has a diagnosable illness, does that diagnosis provide an excuse for aberrant behaviors related to the diagnosis? This, of course, is not a medical question. Dr. Diller makes a good point in this regard:

[...] the ADHD defense has been raised repeatedly in criminal law. It has never gotten a criminal off because those are based more on the McNaghten Rule of knowing right from wrong, but it has mitigated sentences, and I would suspect that you will see wealthy clients using that defense more than poorer clients in criminal cases. [see Wikipedia articles on McNaghten Rule and Insanity Defense for explanation]

This underscores a very important point about mental illness diagnoses. The diagnosis is a description of the illness; it has no other meaning. It explicitly leaves aside the questions about whether the patient is a good person or a bad person, or whether their behavior is right or wrong. Dr. Diller makes an error in this regard, in the question-and-answer segment of the Council meeting:

DR. DILLER: You know, we had lunch, and we agreed a lot about problems with the DSM, but being entirely realistic, the DSM is not only an ideological document, but it is a legal and financial document.[...]

Where in the world does he get this??? He is referring to the Diagnostic and Statistical Manual, which is one of the books used to define the diagnostic categories of mental illness. I agree that the book often is pressed into service in legal and financial contexts, but I maintain that these uses are questionable at best. The DSM was prepared and validated for clinical and research use. As far as I know, none of the authors has advocated that it be used for any other purpose. If the legal profession wants a diagnostic and statistical manual to use in court, let them write and validate their own book. Same for insurance companies.

Dr. Diller continues in his erroneous line of reasoning ...

[...]And it is particularly in its accessing services and money that the DSM is powerful, and the DSM for nature will not change until we are able to offer services and/or rights to people in another way.

Again, the drive towards disability, and the drive towards pathologization comes, and people are in genuine need much of the time, and they are looking for help and the way that they can access that help either in terms of services or money is by obtaining a diagnosis.

This economic push, and then there is a service industry built around that, in terms of the physicians and the mental health industry. Until that changes, and again I think that more and more people are asking about that, but there is a very entrenched bureaucracy here that sees it working well.

Immediately after Dr. Diller concluded that above, another participant, Dr. McHugh, stated:

DR. McHUGH: A bureaucracy built by the psychiatric choice of a DSM-based approach, and the linkage that they could have with powerful drug companies.

It took only a few years to build that bureaucracy, and a coherent attack on it could I think bring it down, especially if you could show -- and we can show -- that an approach to patients -- that it takes a little more time, but it is bottom up rather than top down -- will not only do better for the patients, but do better for research. Ultimately right now our research on depression is incoherent.

Is he trying to be insulting? And exactly whom is he proposing that we attack? Is this an example of our government's new policy of preemptive attack? Is there some sinister cabal conducting weapons of mass diagnosis-related program activities? And what is his agenda when he says that our research on depression is incoherent? He was not attending a conference on depression.

If you look at the history of psychiatry, you see that the trend has been for doctors to spend less time with patients. Dr. McHugh is correct, that we should spend more time; and we should construct a diagnosis from the bottom up, meaning that you start with a comprehensive review of the history, conduct a survey of the biological, psychological, and social factors related to the presenting complaint, establish a list of possible diagnoses, then generate and test various diagnostic hypotheses, all before initiating treatment. If the Bioethics Council wants to recommend that someone come up with the funding for that, I'm all for it.

Do they ever get to the point of making such a policy recommendation? No. Near the end of the conference, Dr. Diller states:

I think -- and I don't know how long it is going to take, but this disability-driven diagnostic driven system, everyone on the outside is pretty much agreeing that it is crazy, but no one seems to be able to stop it.

I would like if we can reach some impressionable Congressional or Executive minds with that kind of solution, and begin to work on it, because DSM-V is coming, and it is not going to be very different.

It's can we subvert -- you know, the DSM-V may have some value, but there is some real pernicious aspects to the DSM-V, which is mostly driven by service and dollar values.

If we can alter the need for that kind of diagnosis, then let them have their DSM-V for research purposes. It may be a useful document on some level for those purposes, but not for clinical decision making.

The DSM is not a "disability-driven diagnostic system." It is true that each diagnosis has a severity criterion, such that a patient cannot be given the diagnosis unless the problem leads to substantial distress or impairment. The purpose of the severity criterion is to prevent people from getting a diagnosis for a trivial problem. But the point of the diagnostic system is to define the characteristics of the illness, not to make a determination about disability. And what is this business about subverting? I agree we can "let them have their DSM-V for research purposes". But to discount it as a tool for clinical decision making is just plain dumb. DSM has flaws -- everyone who uses it knows that and does not need to be reminded of the fact -- but right now there is nothing better. Yes, DSM-V is coming. That is the point. We know the diagnostic system is flawed. That is why it is being updated continuously. We even know what some of the flaws are. They are documented in the book, A Research Agenda for DSM-V. (2Mb PDF download). Do they end up making recommendations for a research effort to find an alternative diagnostic system? No. They just sit around and criticize the existing system. They talk about "subverting" it, but doesn't actually do anything about it.

I never did find out more about what Dr. Kass himself has to say about psychotropic drugs. I can tell you that, based upon what Dr. Greenwood reported, his notions are similar to those that I had as a college junior. However, my opinions have evolved since then. It appears that his have not.

The Bioethics Council members make profit from private sales of their public work, incorrectly cite scientific research, criticize well-meaning physicians without offering anything better, and wind up their conference with no useful recommendations. All at public expense. This is ethical?

Thursday, March 11, 2004

Arrgh! Yet Another Internet Quiz

What Irrational Number Are You?

You are φ

Of all the irrational numbers, you are considered to be the most beautiful. Those who know you well have called you by many names, all golden. However, most people don't know you by name and probably won't even recognize you by sight, but they do like to see you. Despite your pretty face, you are by no means shallow. You are involved it many things: finance, biology, architecture, art, music, and much more.

In some ways you and e are a nearly perfect match. The power and intensity of e excites you.

Your lucky number is approximately 1.61803399

Shiny Lemur

Straif's Blog

(link found via Letters of Marque)

It turns out phi (φ) is a pretty special number in nature and the universe. It pops up all over the place. I’m not much of a math person, but phi has some interesting math properties — phi² = phi + 1. And phi shows up in human bodies, seashells, and sunflowers, making it known as “the golden ratio.” In art it’s used to make the “golden rectangle,” where the ratio between the long side of a rectangle and the short side is phi—the most visually appealing ratio to the human eye (the same ratio as that of a credit card). It’s also related to the Fibonacci sequence (1, 1, 2, 3, 5, 8, 13, 21). And according to goldennumber.net, it’s found in music (both composition and Stradivarius’s violins), population growth, DNA, and the Pyramids. The human body ratios are the most fascinating to me by far: phi is found in ratios of length from head to navel and navel to toe, finger bone lengths, arm to forearm lengths—the list goes on and on.

(The above is from Gross Anatomy)

Just like the What Personality Disorder Are You quiz, this one is pretty far off the mark. I am not beautiful, my navel is too close to the ground, and I am not at all involved in music.

Annoy Your Liberal Neighbors
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Ann Coulter and the Serotonin Transporter
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A Study Shows How and Why People Respond to Faces

Pre-order for November!
Ann Coulter Talking Action Figure
Amuse your conservative friends and annoy your liberal neighbors with the brand new Ann Coulter Talking Action Figure. This incredibly lifelike action figure looks just like the beautiful Ann Coulter, and best of all . . . it sounds like Ann, too! This highly collectible doll comes in a display box with information highlighting Ann's unique contributions to America's political discourse. If you can't get enough Ann Coulter, you'll want to order the Ann Coulter Talking Action Figure today!

There really is a gap in understanding between conservatives and liberals, if conservatives think that liberals will be annoyed by this doll action figure. I would bet that as many of these are purchased by liberals as by conservatives.

Now, being of a psychologically-minded sort, I noticed that I first typed the word "doll" when the company that markets this thing refers to it as an "action figure." This brought to mind an early memory:

1964
G.I. JOE Action Figure makes his debut as an 11-1/2 inch "doll" for boys with 21 moving parts. He is named G.I. JOE after the movie "The Story Of G.I. JOE." G.I. JOE becomes the first boy's "Action Figure" in the world.

I would have been six years old. Like most kids at the time, I was unaware of the Viet Nam war, I knew that most of my older male relatives had been in World War II, and the military was being presented in a favorable light in the media. I actually owned a GI Joe. This seemed perfectly natural. My sisters had dolls, and now there was a doll for boys. Made sense. People were starting to talk about gender equality, and equality, by definition, goes both ways. Why not have dolls for boys? What I remember from that time was: I

3-D MRI rendering of a brain with fMRI activation of the amygdala highlighted in red.

thought it was odd, that they did not call it a doll. Then I realized that it was a marketing gimmick. Girls play with dolls; boys play with action figures. At the tender age of six, I suddenly realized that the world is full of people who use words to manipulate others.

$Gottfried Wilhelm von Leibniz, 1646-1716$ Being psychologically minded, I now pause to reflect on the fact that I started out writing about Ann Coulter, then ended up writing about people who use words to manipulate others. According to the theory of psychological determinism, that would suggest that I have an emotional association between those two concepts: Ann Coulter ---> using words to manipulate. The term, psychological determinism, usually is attributed to Sigmund Freud. In Freudian theory, the idea is that one state of mind (a set of thoughts, feelings, perceptions, and behaviors existing simultaneously at one point in time) leads directly to the next state of mind, and that there are understandable rules that govern how one state of mind leads to the next. The concept actually originated before Freud. The phrase was used by Gottfried Leibniz, a philosopher who pondered the ancient question of Free Will vs. Determinism.

Sigmund Freud, 1856-1939

Before dismissing this as mere psychobabble, remember two things. First, I always have a point to make at the end of the essay; Second, Freud himself stated that he thought all of his observations eventually would be found to have a neurological basis. He was a neurologist at the start of his career. He knew that he was constructing an abstract model of psychology, and that the state of medical technology at the time was not sufficiently sophisticated to enable determination of the biological correlates of his observations.

In the 21st century, we have the technology. Functional MRI is being used routinely to perform investigations of the sort that would have interested Freud. In fact, there was a study done on the neurobiology of the emotional response to the viewing of faces. The original report appeared in the 19 July 2002 issue of Science (Ahmad Hariri and Daniel Weinberger, Science 297: 400-403 -- subscription required). If you do not have subscriber access to Science, you can view the semi-technical rendition at the NIMH website.

What is really interesting about the Hariri article is that they not only show that the amygdala is involved in processing the emotional response to faces, but they show that the intensity of this response is influenced by genetics. The gene involved is the one that codes for a protein that occurs in certain nerves cells. The protein, called the serotonin transporter, is involved in the regulation of the amount of a chemical messenger -- serotonin -- that is present between adjacent nerve cells. The serotonin is what sends the message from one cell to another. Thus, the amount of serotonin determines the strength of the message. There are two versions of this gene in humans. One version makes a lot of the protein. The other version makes less. Each person has two copies of the gene. Thus, some people have two copies of the gene for more protein, others have two copies for the one that makes less, and some people have one copy of each.

The study showed that people who make less of the serotonin transporter have greater activation of the amygdala that those make more, when they view a fearsome face. This effect is seen only on the right-hand side of the brain, which is where facial recognition takes place. The amygdala is known to regulate the process of emotional association. That is, when a person sees something, and the view of the thing generates an emotional response, the amygdala regulates the strength of the response. This demonstrates one of the biological substrates of psychological determinism.

Viewing Ann Coulter's face, my right amygdala lights up like a Christmas tree.

"I'm A Uniter, Not a Divider"
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Bush Said it, Clinton Did It
---
Our Greatest Weapon Against Terrorism

[left brain stuff:] One of George W. Bush's most famous quotes for his 2000 campaign was : "I'm a uniter, not a divider." This has generated a lot of commentary. This post by Melanie at Daily Kos, entitled, "I'm a uniter, not a divider," generated 249 comments. It is interesting that Melanie wrote about the quote in a religious context, referring to the practices of some previous Presidents of extending welcome to members of minority religions.

An article in Salon, referring to the quote, provides the following example of Bush's inclusiveness:

"I'm a uniter, not a divider"

Bush
George W. Bush talks with David Horowitz about going from patrician to populist -- and from party boy to presidential front-runner.

- - - - - - - - - - - -
By David Horowitz

May 6, 1999 | I like George Bush. He has a strong set of core convictions, including a significant religious faith, but he is also genuinely tolerant, open and warm-hearted toward people with whom he disagrees.

He has made, for example, the strongest statements of any Republican candidate about including homosexuals in the American family, and treating them with Christian charity and civic respect. "I was taught," he said in response to Trent Lott's infamous remarks, "that we should look after the beam in our own eye before searching for the mote in someone else's." [...]

The bold emphasis is mine. It seems to be a strange warping of reality to think that, before the election, Bush was touting his openness to homosexuals. Over the subsequent years, many persons have been critical of Bush's statement about being a uniter. Many bloggers have provided counterexamples, or just plain disbelief (1 2 3 4 5 6 7). Others have emphasized the importance of Bush trying to stay true to his self-portrayal as a uniter (1 2 3 ).

One of the rules in my household is that, if you are going to criticize something, you have to be able to offer something better. (You don't like to go to Applebee's, ok, where should we go instead? you don't like the way I load the dishwasher, show me a better way.) Can anyone offer something better, an example of really being a uniter, not a divider? How about ex-President Clinton? (Link found va Matthew Yglesias, who calls this a "must read.")

U.S.-ISLAMIC WORLD FORUM CLOSING ADDRESS (PDF)
by WILLIAM J. CLINTON 42nd President of the United States
January 12, 2004 Doha, Qatar

[...]The defining feature of the modern world is not terror, nor is it trade nor technology, although terror, trade, and technology are manifestations of the defining feature of the modern world, which is its interdependence--a word I far prefer to "globalization," the more common word, because for most people globalization has a largely economic meaning. "Interdependence" is a broader word. It simply means we cannot escape each other. And our relationships go far beyond economics. The main point I would like to make about the interdependent world that applies to the relationships between the United States and the Islamic world is that the interdependence we enjoy has been of great benefit to some of us, but it is unequal, unstable, and unsustainable.[...]

Now, the United States has enjoyed good relationships with Qatar under Republican and Democratic administrations. In good and bad times, you have been our friend, and I am grateful. Our relationships with the rest of the Islamic world, both in the Middle East and elsewhere, are not all that good. Sometimes they're good and sometimes they're not so good. Why? Well, there are differences. There are deep historical wounds. There are honest and perplexing misunderstandings. That's why this meeting's a good thing. Serious good people of good will can get a long way just by having honest conversations. So I have been asked to come here to participate in that conversation, and I would offer four observations: We need to do more to understand how the two major players here understand each other. We need, secondly, to improve our capacity for self-criticism. Third, we need to identify our common interests. And, fourth, we need to build the habits of mind and heart necessary to end the habit of demonizing those who are different from us. Striving to understand how each other views the world requires at least knowing that our attitudes toward one another are born of history, faith, circumstance, national interest, and collective psychology as well. Too many Americans know too little about the Islamic world, and much of what they know they learned after September the 11th through the narrow lens of terror. It is important but not sufficient, because what people do out of anger, pain, and fear both darkens and distorts reality. If people in the United States better understood the glorious paths that Islam took in its early centuries, they might better understand the frustrations of many people in the Muslim world today as well as their dreams for a better future.[...]

{right brain stuff:] Mr. Yglesias chose to not comment on Clinton's address, but as of this writing, nine others have posted comments. I would like to add some commentary of my own. Clinton is right that global interdependence is the the defining feature of the modern world. What was one consequence of the 9/11 attacks? Demand for oil fell, oil prices went into the basement, and many Islamic countries lost considerable revenue. What was one consequence of the invasion of Afghanistan? Increased opium production, and increased supply of heroin in the USA. These are examples of the great significance of global interdependence: you cannot attack your enemies without harming your own cause.

It may well be true that the greatest weapon we have against terrorism is for us to be uniters, not dividers.

Tuesday, March 09, 2004

Profit Motive for Abortion???
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Phyllis Schlafly on the Abortion Industry

A few days ago I stumbled across -- well, no, actually I found it via a Google search -- a website called townhall.com. It is a site with lots of columns written by persons with conservative political tendencies. The column I read first was called Deficits Don't Matter, by Johan Goldberg. Although I don't agree with everything he says, or even his main point, it was a reasonably good and informative piece. So, I signed up for their e-mail TOC. As a result, I read a column by William F. Buckley, The Impossible Reform; and one by George Will called You're Not In Control. Again, well-written works, and not awfully ideologically slanted. I read a few others, less noteworthy, but not overtly offensive, either.

Then -- it had to happen -- I stumbled across a column by Phyllis Shlafly. It is called Ashcroft Stands Up to the Abortion Industry. This article is noteworthy, yes, but only for its offensiveness.

Ashcroft stands up to abortion industry
Phyllis Shlafly March 8, 2004

Abortion has been legal in the United States for more than 30 years, yet little is publicly known about the practices of this billion-dollar industry. American taxpayers foot many of the costs but are left in the dark about what they fund.

That may soon change, thanks to the courageous defense by U.S. Attorney General John Ashcroft of the Partial-Birth Abortion Act. The Justice Department is battling three lawsuits that seek to overturn this statute, which President Bush signed into law on Nov. 5, 2003. [...]

The Justice Department has issued subpoenas for records about abortions performed by plaintiffs and their witnesses. When they ultimately take the witness stand to argue "medical necessity" for their abortions, U.S. attorneys can cross-examine them based on their own records.

No patient names will be revealed, as the government has already agreed to delete personal identifiers from the records. The issue is the conduct by the doctor, not the patient.

Requiring disclosure of material central to a lawsuit is Litigation 101, basic to the Anglo-American legal system. For hundreds of years, trials have relied on this adversarial system to sift fact from fiction.

Most people accept these rules of fairness. But abortionists are accustomed to withholding information about abortion, such as its correlation with breast cancer.

[...]The former Republican counsel to the U.S. Senate Judiciary Committee, Manuel Miranda, recently observed that clinics derive an average of $1,000 for each abortion performed.

In its 2002-2003 annual report, Planned Parenthood reported a hefty operating gain of $36.6 million. At a time when companies are struggling to remain profitable, Planned Parenthood reported a 200 percent increase over the previous year's $12.2 million gain.

In a riveting interview, Miranda explained that the political fight over abortion is about "profits," not just "rights."

I could write objections all day long, just to this excerpt; if I commented on the entire article, it would take a couple of days. I will confine this to a just a couple of remarks. First, the issue of breast cancer being linked to abortion is not an example of abortionists withholding information. On the contrary, it is an example of some politicians suppressing scientific information. The most comprehensive information, which includes an analysis of 1.5 million women, including 370,715 induced abortions and 10,246 cases of breast cancer, indicates no increased risk. See the original article at the NEJM website. This site also includes links to more recent articles that have referenced the original one, so it is easy to see all of the more recent work on the subject. For Ms. Schlafly to repeat the implication that abortion is linked to breast cancer is either an indication that she has not done her homework, or that she has knowingly repeated a lie. Anyone who wants to can go to Entrez (the new metasearch engine at NCBI) and do a complete search of the medical literature on the subject.

Second, the notion that there is an "abortion industry" with a "profit motive" is both ludicrous and ironically vexing. Any Ob/Gyn could easily make twice the money she or he makes working at planned parenthood, just by working in a hospital or a private practice. Yes, doctors do make money doing abortions. But they would make far more doing something else. Furthermore, it is ironic that a column posted on a conservative website would decry an activity for being profitable. Since when is making a profit contrary to conservative values?

Third, there is no justification for accessing medical records of persons who are not parties to the lawsuit. Although it is a nice gesture to remove "personal identifiers" from the records, the fact is that even this does not guarantee the anonymity of the patient. Seemingly anonymous information, such as the time and date that a prescription was called to a pharmacy, could be used to identify a patient. Yes, it would take detective work to do this, but I think Ashcroft has at least a few detectives under his command. Remember, this is going to be a very public proceeding. It is likely that any document used in the trial will become a public document. Her point that requiring disclosure of information is "Litigation 101" is overly simplistic. For the government to demand release of privileged information from a person who is not party to the suit is something that demands judicial oversight, with the burden of proof of relevance falling heavily on the side of the person demanding the information.

One last comment. She cites information presented by Manual Miranda. He is hardly a credible source of information, having just resigned (1 2 3 4) in the face of a Senate scandal.

OK, really, one last comment: Phyllis Schlafly, the one who complains about a "profit motive" has this below her column:

Just released! Phyllis Schlafly's latest!
Feminist Fantasies
No assault has been more ferocious than feminism's 40-year war against women, and no battlefield leader has been more courageous than Schlafly. In a new book of dispatches from the front, feminism's most potent foe exposes the delusions and hypocrisy behind a movement that has cheated millions of women out of their happiness, health, and security. <read book review>

That's right, after complaining about a "profit motive," there is an advertisement for her book. Tell me, is she is donating the profit to charity?

Other bloggers comment on the National Abortion Federation v. Ashcroft case (1 2).

Problem SOLVED!!!
---
The Problem of Activist Judges

We hear a lot of talk about activist judges these days. In the Washington Times, columnist Thomas Sowell writes:

The time is long overdue to start impeaching judges who think their job is to veto laws they don't like or condone lawlessness that they agree with. The time is also long overdue to re-examine lifetime appointments of judges, which allows them to act like little tin gods, at the expense of our freedom and the country's elected government.
An independent judiciary does not mean judges independent of the Constitution from which they derive their power or independent of the laws that they are sworn to uphold. [bold emphasis mine]
(link via I Love Jet Noise)

In a similar vein, timster at blackcore writes:

Won't be long before all states start marrying gay people.

Won't be long before activist judges hellbent on destroying the very foundations of society will rule that gay people must be allowed to marry and multiply in numbers all over our formerly pure, unspoiled nation corrupting our innocent children.

Under the black shadow of married homosexuals violating the laws of Leviticus, the sanctity of marriage is whithering away, before we know it, our streets will be overrun with pedophiles, people practicing beastality, and other unspeakable horrors.

Children will soon be born bearing the mark of the Beast on their foreheads, raised in sin and go on to become axe murders and other similiar cancers of society, because two men or two women cannot be an wholesome and morally upstanding family. [bold emphasis mine]

On the nicely-named blog, Coffeehouse at End-of-Days, Russ Lipton writes:

This [Federal Marriage] Amendment is nothing more than a preliminary stake in the ground at the moment but that is something different than a mere response by Bush to his conservative base. The proposed Amendment, as Bush himself has hinted, is a warning to activist judges to walk carefully. That alone makes the initiative timely - not premature.

Mr. Lipton was writing in response to Pejman Yousefzadeh's article on Tech Central Station.

Judging from the commentary, I would have to say that there is a problem with activist judges. Perhaps an epidemic. Perhaps Bush should appoint a Council at the Center for Disease Control to investigate this issue.

The problem, it seems, is that some judges want to exercise something called "judgment." We all know that judges must not do that. They must interpret the law strictly. Here at The Corpus Callosum, it is traditional to try to take two tangentially related concepts and link them is a creative way. It turns out that this approach can be used to solve, once and for all, the problem of activist judges.

Concept #1: Robocop. Acting according to a pre-set program of Prime Directives, Robocop runs all over creation, enforcing the rule of law. Even if it is his own creator who is violating The Law, Robocop has no mercy.

Concept #2: Valerie the Roboreceptionist. (thanks to Invisible Adjunct and quantumBlog for links) Valerie is practically human. She has social awareness, her own personality, and even her own blog! But despite her charm, she still follows all of the rules, all of the time.

Solution: Since independent judgment is not necessary for a judge to function, and may even result in human children being born with the mark of the Beast on their foreheads, why not simply replace all the judges with robots? Sure, the unemployment stats would take a blip upward, but the size of government would be reduced. And we would not have to worry about judges acting like little tin gods. We would have little tin robots acting like little tin gods.

Monday, March 08, 2004

New Template

It was called to my attention that my template no longer resulted in correct formatting of this blog, when viewed with Internet Explorer. I always use Netscape, so I had not known. That is why there is a whole new look here at The Corpus Callosum; I picked a new templete, and I am slowly putting back all of the customizations. I have not yet reintroduced all of the elements. This time, I add things one at a time, republish, then view the blog using Explorer, Netscape, Opera, and Mozilla Firebird. Then I make one more change. So far it seems to be OK with all of them. But it is a slow process to do it this way.

Sunday, March 07, 2004

Arrgh!!! Yet another Internet Quiz

Background: The standard diagnostic system used in the USA is the Diagnostic and Statistical Manual, Fourth Edition, Text Revision. It describes ten personality disorders, placed into three clusters. The personality disorders were included in DSM to satisfy those who still believed in the biological/psychological dichotomy of mental illness. That paradigm has been obsolete for at least a decade, but the tradition persists.

Study:

schizoid

Which Personality Disorder Do You Have?
brought to you by Quizilla

Analysis: This quiz asks six questions, so it can't be very accurate. There are some questionnaires that ask more questions, such as the Millon Clinical Multiaxial Inventory, that actually can produce meaningful results. The MCMI-III has just 175 questions. The problem with it is that just one or two idiosyncratic responses can lead to strange results. No one has come up with a written test that can replace a face-to-face interview.

With the personality disorders, the onset, and course over time, of the difficulties are critical diagnostic features. This is something that is very difficult to assess in a multiple-choice test. Another critical aspect of personality disorders is that the person has minimal capacity to adapt, to try different strategies in life, if the current strategy obviously is not working. Again, this is very difficult to assess without a direct interview.

This Quizilla quiz is pretty far off the mark, in my case. It put me in cluster A of the personality disorders, whereas I actually am more of a cluster C kind of guy. Nobody is afraid of me, and besides that, schizoid people do not tend to be scary. The picture doesn't look like me, either.

The Quizilla quiz has no questions designed to assess onset, course, and inflexibility of the personality traits, so it is more of a measure of one's current state of mind rather than a test of actual personality.

Note that the author did include a disclaimer, that it is meant for fun only. That seems kind of obvious, but I guess you never know.

I Thought I was Clever...

...when I found the discrepancy between what George W. Bush said about supporting Veterans, and what he actually did. Via Hartsongs, I found a link that actually outdoes me by a factor of 17. This is on the House.gov website. It documents 17 instances of Bush meeting with folks, telling them he was going to do one thing, then going back to Washinton D.C. and doing the exact opposite. This is not a waffle; it is more like a whiffle ball: solid on one side; full of holes on the other. And it doesn't go very far.

News from NIMH
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High Value of Low-Cost Interventions

Background: often, news reports about mental illness focus on high-tech reports (fMRI, psychopharmacology). This sort of thing captures the public's interest, and serves a purpose by reminding us of the role of research technology in improving quality of life and functional capacity for persons afflicted by mental illness. The human brain is the most complex organ in the body; indeed; it is the most complex entity that we know of in the universe. So it is understandable that the most modern technology would be needed to make advances in the field.

Despite the value of the more glamorous studies, it is important to remember that effective treatment methodologies do not have to be expensive. The study cited here is a good example of this. Major Depressive Disorder is a serious problem. Studies indicate that MDD has a economic impact each year in the USA of more than $40 billion. (1 2 3) Most of this cost comes from lost productivity. Modern treatment yields response rates of about 70% in routine clinical practice. Although treatment response does not always restore a person's occupational function to premorbid levels, it can have a significant impact. Consider the fact when a person becomes unable to work, there are two sources of economic impact. First, the person is not working, so that productivity is lost. Second, providing support to the person generates costs that would not exist if the person were well. Thus, effective treatment of each individual patient can have a significant positive effect on the economy but simultaneously increasing productivity and reducing entitlement costs.

Study Summary:

"Care Managers" Help Depressed Elderly Reduce Suicidal Thoughts

03/02/2004

"Care Managers" Help Depressed Elderly Reduce Suicidal Thoughts

An intervention that includes staffing doctors' offices with depression care managers helps depressed elderly patients reduce suicidal thoughts, a study funded by NIH's National Institute of Mental Health (NIMH) has found. Martha Bruce, Ph.D., Cornell University, Charles Reynolds, III, M.D., University of Pittsburgh, and colleagues report on the outcome of the intervention in three major Eastern U.S. metropolitan areas in the March 3, 2004 Journal of the American Medical Association.

Older Americans comprise 13 percent of the population but account for 18 percent of all suicides. The major risk factor for suicide in late life is major depression.

"Since most older Americans who kill themselves have seen their doctor within a month of the event, effectively treating depression in primary care is a preventive intervention that can save lives," noted NIMH Director Thomas Insel, M.D.

Reynolds and colleagues set out to demonstrate that by educating physicians and improving treatment up to guideline standards, a social worker, nurse or masters-level psychologist can significantly improve clinical outcomes. The "depression care managers" were assigned to 10 randomly selected primary care practices in greater Philadelphia, Pittsburgh and New York City. Each practice was paired with a similar practice, which served as a control by providing its "usual care" in the study, called PROSPECT (Prevention of Suicide in Primary care Elderly: Collaborative Trial).

In initial screenings over two years, about 12 percent of the primary care patients tested positive for depression. From these, 598, mostly females and two-thirds with major depression, were recruited into the study.

The care managers applied structured treatment guidelines: First, they offered patients the serotonin selective reuptake inhibitor (SSRI) or another antidepressant if clinically warranted. If a patient didn't want medication treatment, the doctor could recommend Interpersonal Psychotherapy (IPT) from the care manager, who was supervised weekly by a psychiatrist investigator. Occasionally, patients received combination treatment. The care managers actively followed up the patients, monitoring their symptoms, drug side effects and treatment adherence.

Suicidal thinking resolved more quickly in patients who received the intervention. Also, intervention patients had a more favorable course of depression, as measured by severity of symptoms, rate of treatment response and remissions. For example, at eight months, about 70 percent of intervention patients initially plagued by suicidal thoughts were free of them, compared to about 44 percent of "usual care" patients. Although the intervention didn't lift depression symptoms in patients with minor depression any more than usual care, it did significantly decrease suicidal thoughts in those who had them. Suicide itself occurs too infrequently in primary care for the study to have measured any impact on actual suicide rates, note the researchers.

"Without such structured, formal screening and diagnostic procedures, patients are less likely to volunteer information, accept a diagnosis of depression or initiate treatment," explained Reynolds. "Our finding in an elderly population adds to evidence from other studies that structured interventions can improve the quality of depression care in primary care."

The results of PROSPECT indicate that quality treatment of depression in primary care can be a prevention strategy to reduce the risk for suicide in late life.

Other researchers participating in the PROSPECT study are: Herbert Schulberg, Ph.D., Gail McAvay, Ph.D., George Alexopoulos, M.D., Cornell University; Thomas Have, Ph.D., Ira Katz, M.D., Ph.D., Gregory Brown, Ph.D., University of Pennsylvania; Benoit Mulsant, M.D., University of Pittsburgh; Jane Pearson, Ph.D., NIMH.

Analysis: This study described above shows that the use of a care manager can result in significant improvement in outcome, even though they were studying a population of persons who are elderly and who thus present more complex and difficult-to-treat problems. It often is harder to demonstrate a treatment effect when the study population is inherently treatment resistant. Thus, the demonstration that a low-tech, low-cost intervention can be helpful is impressive. Considering that the population they studied is a population in which treatment is generally paid for by Medicare, and the fact that Medicare costs are a significant political issue, this finding is pertinent for those with an interest in cost containment in government. When politicians embark on budget-cutting escapades, it is common for them to target programs when they do not understand the value of the program. Care management is one such target. Recently, we have seen huge reductions in the staffing of care managers in public mental health clinics. This is the kind of thing that can produce a temporary improvement in one program's balance sheet, but it is likely to generate greater costs elsewhere. For additional information of the cost savings that can result from appropriate mental health care, see the NIMH publication at this web page.

Bioethics Council Update
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Leon Kass' Rejoinder
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Council Membership Changes Still Are Questionable

Previously, I commented (see archive) on the recent widespread criticism of the changes in the membership of the President's Council on Bioethics. Since then, more information has become available, and more discussion has taken place. Since this is an important matter, I have pulled together the most pertinent new information that I could find. There are two reasons that this is important. First, Bioethics is an important consideration in many of the most active areas of research in modern times. (See the IRB Forum including their open letter to Bush regarding the Council changes, Bioethics News, and Bioethics.com for background.) Second, the change in the membership of the Council is another instance of a systematic pattern of behavior by the Bush administration that casts an ideological veil over the government's use of scientific information.

Instapundit has a link to Virginia Postrel's commentary on Leon Kass' editorial in the WaPo. She links to a thoughtful piece in The Reason, by Ronald Bailey , who took the time to do some research on the backgrounds of the new Council members. He points out what appear to be valid reasons to question the motivations behind the changes in the Council membership. Additional commentary is posted on The Carpetbagger Report. Dr. Kass' editorial does not lay to rest the concern that has been raised about playing politics with science, which is what he set out to do. My reasons for saying this follow the excerpts from his editorial.

For the record, I commend Dr. Kass for responding to public criticism. The fact that he chose to respond in a forum such as WaPo indicates that he is taking the matter seriously.

Leon R. Kass, M.D., Ph.D., is the Addie Clark Harding Professor in the Committee on Social Thought and the College at the University of Chicago (on leave of absence) and Hertog Fellow in Social Thought at the American Enterprise Institute.

We Don't Play Politics With Science

By Leon Kass
Wednesday, March 3, 2004; Page A27
[Wahingtonpost.com]

Even before the President's Council on Bioethics had its first meeting in January 2002, charges were flying that the council was stacked with political and religious conservatives, appointed to rubber-stamp the president's moral and political views. One newspaper story on the day of our first meeting even went so far as to compare us to the Taliban. [...]

Today those charges are swirling again, in response to three new appointments the president has made to the council, as we begin our second term. The charges were malicious and false then, as they are now.[...]

This council is easily the most intellectually and ethically diverse of the bioethics commissions to date. We have worked with mutual respect while not papering over our differences. No one who has attended any of our meetings or read the transcripts can believe that we do anything but serious and careful work, without regard to ideology, partisan politics or religious beliefs. Many of the remaining members are on record as disagreeing with the president on stem cell research policy. The council was and remains diverse by design.[...]

Their personal views on the matters to come before the council in the coming term are completely unknown, but I am confident that they will come to them only as a result of genuine reflection and a full consideration of all the scientific and other evidence.

Our new members are all people of distinction, ethical seriousness and intellectual independence, with the sorts of competences we need for the new and different work ahead.

Unfortunately, these membership changes were met with unfounded and false charges of political "stacking" of the council. Such charges are as bogus today as they were when the council was formed. We shall continue to honor the diversities of our views, confident that the reports we write will contribute to public understanding and earn the respect of fair-minded readers.

I wish Dr. Kass provided a reference to the newspaper story that compared the Council to the Taliban. That does seem to be an unfair comparison; I wanted to see it in context, so I ran a Netscape search on "Leon Kass" Taliban. I did not find any newspaper articles; but, serendipitously, I did find an article in The Crisis (a Catholic magazine) entitled The Puzzle of Leon Kass By Dana Wilkie, dated June 1, 2002. Ms. Wilkie wrote the article after attending the Council's second meeting.

The Crisis can hardly be considered to be a liberal news outlet, and the article is not an ideological condemnation of Dr. Kass. Even so, Ms. Wilkie provides some information on his background that I find to be alarming:

Clearly, Kass’s writings and speeches establish him as a conservative in the classic sense. The man in the chairman's seat that February afternoon is as much noted for his writings on the Bible, Aristotle, and social mores as he is for his thoughts on the ethical questions that accompany advances in medical technology. Some even say Kass’s views cast him on the fringe of medical, scientific, and social consensus: He has questioned the use of cadavers for medical research and teaching, drugs designed to alter brain chemistry, and medicine’s efforts to prolong life. Kass has spoken against affirmative action and complained that women in their 20s are putting off having children as they build careers. He has written that the concept of safe, promiscuous sex is delusional, because even if contraception can prevent venereal disease and unwanted pregnancies, promiscuity remains dangerous spiritually and culturally: "Sexuality itself means mortality—equally for both man and woman," Kass has written. "Whether we know it or not, when we are sexually [promiscuous], we are voting with our genitalia for our own demise. ‘Safe sex’ is the self-delusion of shallow souls." He has also criticized society’s turn toward feminism, gay rights, divorce, single parenthood, sex outside marriage, and children born outside marriage.

(Again, I wish there were references. I would like to see the context of the statement, "Sexuality itself means mortality—equally for both man and woman." Obviously, both men and women are equally mortal, so what was his point? It is true that sexuality leads to birth, which leads to death; again, what is his point?)

Ronald Bailey's article in The Reason addresses some points made by Dr. Kass. Mr. Bailey takes issue with Dr. Kass' statement that the new Council members' "personal views on the matters to come before the council in the coming term are completely unknown." He points out that the new members have published articles on the issues. He cites some of what they have published. Some of these citations indicate strong ideological positions that are congruent with those of the Bush administration. He also points out that Kass attended a conference in which one of the new members spoke about human cloning. These revelations cast doubt on the veracity of Kass' statement that the personal views are completely unknown.

The article on The Carpetbagger site points out that Dr. Kass's editorial is mostly a recitation of the virtues of the new members. This does nothing to refute the contention that the changes in the council membership were politically motivated:

Of course, no one has questioned the scholarship of the new members, rather, many scientists and public officials have charged the White House with playing politics with the entire commission. Kass seems to be intentionally missing the point.

To expand on this, I don't think anyone questions the qualifications of the new members. Each individual does have something to contribute. The problem has to do with the overall composition of the Council. Dr. Kass claims that the composition "is the most intellectually and ethically diverse of the bioethics commissions to date." This is questionable, but even if true, it is not reassuring. Even if the current composition is the most diverse to date, is the diversity suitable to the public duty of the Council? Or is it more suitable to the private purpose of our President? I suppose the answer is implicit in the name of the organization: The President's Council on Bioethics. Clearly, it is the President's council, not the American People's council. Yet it is the American People who are paying them.

Saturday, March 06, 2004

Who's Zooming Who(m)
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Veteran's Benefits May Get Amputated
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WISINAWYG

WISINAWYG: What I say is not always what you get:

Remarks by the President to the Veterans of Foreign Wars

Annual Convention
Midwest Express Center
Milwaukee, Wisconsin

For Immediate Release
Office of the Press Secretary
August 20, 2001

11:20 A.M. CDT

      My administration understands America's obligations not only go to those who wear the uniform today, but to those who wore the uniform in the past: to our veterans. And at times, those obligations have not been met. (Applause.) Veterans in need of care have been kept waiting, and thousands of veterans' claims have been delayed, or in some cases lost in the bureaucracy.

     Many veterans have observed that the government seemed to work a lot more efficiently when it wanted something from them. When the Draft Board got your file, it worked efficiently. (Laughter.) But now, when you need health care, forms get lost and answers come late. That is no way to treat America's veterans, and that is going to change. (Applause.)

     Secretary Principi is conducting a top-to-bottom review of the claims processing. Currently, there are about 600,000 pending applications, of which 53,000 have been pending over a year. Many of those belong to veterans over 70 years of age. That's not right. I have given Secretary Principi the clearest of clear mandates. He must bring those claims to a speedy and fair resolution. We must move as quickly as possible on the backlog, and we will. (Applause.) We will improve cooperation between the VA and the Department of Defense in providing care to those who served.

Veterans Groups Critical of Bush's VA Budget
Dismay Over Higher Fees and Staff Cuts Could Be Boon for Democratic Nominee

By Edward Walsh
Special to The Washington Post
Wednesday, March 3, 2004; Page A25

After three years of mostly good relations with President Bush, Edward S. Banas Sr., commander in chief of the Veterans of Foreign Wars, called the president's proposed budget for veterans' health care "a disgrace and a sham." (Joe Mitchell -- AP)

After three years of mostly good relations with President Bush, Edward S. Banas Sr., commander in chief of the Veterans of Foreign Wars, called the president's proposed budget for veterans' health care "a disgrace and a sham." (Joe Mitchell -- AP)

Military veterans have already played a prominent role in the 2004 presidential campaign, helping to propel one of their own -- Sen. John F. Kerry of Massachusetts -- close to the Democratic nomination. If he is the nominee, Kerry is counting on strong support from his fellow veterans in the general election battle against President Bush.

And Kerry may be getting an unintended boost from the Bush administration's proposed budget for the Department of Veterans Affairs in the next fiscal year.

After three years of mostly cordial relations with the administration, leaders of veterans' organizations and a union that represents VA workers are voicing strong criticism of Bush's fiscal 2005 budget plan. They assert that the budget would only worsen the backlog in processing disability claims, reduce the number of VA nursing home beds just as the number of veterans who need long-term care is swelling and force some veterans to pay a fee simply to gain access to the VA health care system.

In a statement issued shortly after the budget was released, Edward S. Banas Sr., commander in chief of the Veterans of Foreign Wars, called the VA's health care spending proposal "a disgrace and a sham." [...]

According to John Gage, president of the American Federation of Government Employees, the VA is calling for a reduction of 540 full-time jobs in the Veterans Benefits Administration, which handles disability, pension and other claims by veterans.[...]

VFW Supports Recommendation to Increase VA Budget

Washington, D.C., March 1, 2004--"The House Committee on Veterans Affairs' recommendation to add $2.5 billion to the Bush Administration's fiscal year 2005 budget request for the Department of Veterans Affairs (VA) medical care programs represents a solid commitment to this nation's veterans" said the leader of the Veterans of Foreign Wars of the U.S.[...]

"With the Centers for Medicare and Medicaid projecting a 7.8 percent increase in health care spending and VA officials testifying that the veterans' health care system requires 13-14 percent annually to meet the needs of sick and disabled veterans anything less than the House Veterans Affairs' Committee's recommendations would amount to a denial of care. It would also fail to fully acknowledge our duty to those service men and women returning from Afghanistan and Iraq.

Issue Date: June 30, 2003

Nothing but lip service

In recent months, President Bush and the Republican-controlled Congress have missed no opportunity to heap richly deserved praise on the military. But talk is cheap — and getting cheaper by the day, judging from the nickel-and-dime treatment the troops are getting lately.

For example, the White House griped that various pay-and-benefits incentives added to the 2004 defense budget by Congress are wasteful and unnecessary — including a modest proposal to double the $6,000 gratuity paid to families of troops who die on active duty. This comes at a time when Americans continue to die in Iraq at a rate of about one a day.

Similarly, the administration announced that on Oct. 1 it wants to roll back recent modest increases in monthly imminent-danger pay (from $225 to $150) and family-separation allowance (from $250 to $100) for troops getting shot at in combat zones.

Then there’s military tax relief — or the lack thereof. As Bush and Republican leaders in Congress preach the mantra of tax cuts, they can’t seem to find time to make progress on minor tax provisions that would be a boon to military homeowners, reservists who travel long distances for training and parents deployed to combat zones, among others.

Incredibly, one of those tax provisions — easing residency rules for service members to qualify for capital-gains exemptions when selling a home — has been a homeless orphan in the corridors of power for more than five years now.

The chintz even extends to basic pay. While Bush’s proposed 2004 defense budget would continue higher targeted raises for some ranks, he also proposed capping raises for E-1s, E-2s and O-1s at 2 percent, well below the average raise of 4.1 percent.

I don't think I need to comment on this. WISINAWYG.

Judge Not and Ye Shall Not be Judged

Earlier today, I ran across a post at Lotus - Surviving a Dark Time that almost spurred another rant. He posted an excerpt from NYT:

Scumbag Medal

...with dripping garbage clusters.

Washington (AP) - A Senate measure to extend federal unemployment benefits failed by two votes Thursday despite the election year support of 12 Republicans from states hit hard by layoffs. ...

The measure would have extended the emergency benefits program for six months, providing 13 weeks of extra unemployment benefits to people who exhaust their state benefits - usually after 26 weeks. ...

"I think we have to determine when's enough," said Sen. Don Nickles, R-Okla. "And I happen to think that we've crossed that line."

Nickles said jobless workers have more incentive to find a job when the extra unemployment benefits stop. "The more you pay people not to work, the less inclined they are to work," he said.

Yes, all those people just lazing in luxury in the comfort of unemployment, falling behind on their rent/mortgage, electricity being shut off, phone service being ended, but what do they care? They have unemployment benefits! Ah, happiness![...] #

I also encountered a post on The Extended Phenotype, about something different, but with the same theme. This time, instead of Sen. Nickles being quoted disparaging the unfortunate, it was Pres. Bush:

At Harvard Business School, thirty years ago, George Bush was a student of mine. I still vividly remember him. In my class, he declared that "people are poor because they are lazy." He was opposed to labor unions, social security, environmental protection, Medicare, and public schools. To him, the antitrust watch dog, the Federal Trade Commission, and the Securities Exchange Commission were unnecessary hindrances to "free market competition." To him, Franklin Roosevelt's New Deal was "socialism."

[Note: Phenotype got the link from Atrios, who got it from Jerome Doolittle, who found it in Yoshi Tsurumi's article on GLOCOM Platform; Gelatinous Cube also makes reference to this]

The attitude expressed by Bush and Nickles it common, and it is very much like the stigmatization that people with mental illness experience. In the case of poverty, like that of mental illness, there are perfectly understandable causes that have nothing to do with laziness.

There is ample evidence for the genetic and neurochemical basis for mental illness. Furthermore, there is ample evidence that interventions such as medication, ECT, bright-light therapy, etc., can cause remission of mental illness. If the problem were due to a moral failure, these treatment would not work.

If poverty is due to a moral failure, how does one explain the observation that poor people are getting poorer, and rich people are getting richer? (See this article on the widening income gap) If you are poor, it is harder to get ahead, and it is harder to shelter yourself from events that get you further behind. For example, if a person needs a car to keep their job, and the car breaks down, it is no problem if you are rich. But if you are lower-middle class, that single misfortune could be the start of a downward, unrecoverable spiral. This has nothing to so with one's moral virtue.

Likewise, how would one explain the Great Depression? Did millions of people simultaneously loose their work ethic? No, millions of people simultaneously lost their jobs.

Am I saying that Bush and Nickles are bad people? I can't say; I don't really know them. So, I am not judging them; I am judging what they said. My judgment is that what they said is not supportable by the evidence.

Atlantic Monthly Articles of Interest
---
Shock and Disbelief
---
Radical Tax Reform

Rodger Payne left a comment on my rant about taxes. Naturally, I went to his blog and found that he has a lot to say about Human Security. This is a term I had not heard before, but I like it, because it seems to encapsulate the topic of some of my recent posts about public health and the relationship between arms control and public health. In his comment, he left a URL to an Atlantic Monthly article by Maya MacGuineas about tax reform. The title is Radical Tax Reform. I read that next. It reminded me of an article I had read there earlier, about electroconvulsive therapy (ECT). The title is Shock and Disbelief, by Daniel Smith. It was republished later in The Best Science and Nature Writing, 2002.

Tax reform and electroconvulsive therapy have little in common, at first glance. But there are some commonalties, and it is up to the Corpus Callosum to make the connection.

Neither is a pleasant topic. Both are things we wish were not necessary. Neither is something we want to undergo. Undergoing either one can feel unpleasantly like some kind of passive submission to a higher authority. Both elicit strong emotional reactions and provoke heated -- sometimes uniformed -- discussion. Both seem destructive, but both actually can enhance growth, if applied wisely. (1 2 3 on ECT and neurogenesis; 1 by Mike Moffatt, on tax increases)

There are some crucial differences. ECT already has been reformed in a major way, and is undergoing a slow process of further improvement, guided by objective, scientific study. Taxes are undergoing a slow change, but no improvement is in sight. The change is not guided by scientific study. This is not because economists are unscientific; it's because politicians are unscientific.
The Best American Science and Nature Writing 2002

The Best American Science and Nature Writing 2002

Both articles are well-written, and present an even-handed treatment of their respective difficult topics. The author of Shock and Disbelief, Daniel Smith, carefully lays out the history of ECT, and alongside, the history of public perceptions of ECT. He glosses over much of the science. This is not a criticism, as the science is rather esoteric. The article on taxes is interesting because it does not address the usual topic of higher versus lower taxes. Thinking only in terms of higher or lower taxes is such a gross oversimplification that it is useless. Worse that useless; in fact, it is misleading. Ms. MacGuineas instead addresses tax structure. Specifically, she advocates for a tax system that encourages saving more and spending less. This could be accomplished by allowing a complete tax deduction for contributions to savings accounts such as IRA's:

Imagine a "progressive consumption tax" levied not on individual purchases but on total spending, as measured by the difference between what you earn and what you save. It might work like this: no tax at all on the first $25,000 you spent, a 10 percent tax on spending from $25,000 to $100,000, Maya MacGuineas

and a 15 percent tax on all spending above $100,000. In effect, basic necessities would not be taxed, and luxuries would be taxed at higher rates. This plan would be simple to execute. Each year taxpayers would calculate their total income from wages, investment income, and other sources, just as they do now. But then they would take a second step, subtracting the value of all their savings that year—such as savings accrued in a bank account, through a 401(k) plan, or through an investment fund (all of which are easily tracked, meaning that it would be hard for cheats to escape detection)—from their total income. The resulting figure would be the base amount to which the consumption tax would apply, at progressive rates. The less you spent, the lower your tax rate would be. Low-income earners would for the most part be taxed less onerously, since they spend less; and middle- and high-income earners would have an incentive to save their money, preparing for retirement and bolstering the country's long-term economic prospects. A national progressive consumption tax would go a long way toward recouping revenues lost from the elimination of the payroll tax, and it would make the system fairer, too.

Let me get back to a statement I made earlier in this article, a statement that was intended to be provocative. I stated that higher taxes can increase economic growth. Note that I included only one reference to support this contention. Honestly, it was the only reference I could find. This is probably because, in general, higher taxes do not increase economic growth. Just like, in general, delivering a large electrical shock to the brain does not increase neurogenesis. As Mike Moffatt points out in his article on taxes, the key to using higher taxes to increase growth is to tax at the right rate, tax the right things, and spend the money for the right reasons. The key to success with ECT is in using the right dose, for the right people, and for the right diagnosis.

Postscript: as I was finishing this up, I came across a reference on RETURN of the RELUCTANT to a $20 million lawsuit being filed against Daniel Smith and the Houghton Mifflin Company (publisher of The Best American Science and Nature Writing 2002).

January 29, 2004

Can Houghton Mifflin Handle the Truth?

Some distressing news from Publisher's Lunch. The ironically named Committee for Truth in Psychiatry has sued Houghton Mifflin and writer Daniel Smith for $20 million in punitive damages. The suit comes about because Smith's investigative piece on electroshock treatment appeared in The Best Science and Nature Writing, 2002.

Even if this suit is settled or dismissed, there's still the larger issue of whether hard-hitting exposes will appear in Houghton Mifflin's compilations. Will Houghton Mifflin backpedal on future selected essays? Even if the author were to prove all of the facts were on his side, my fear here is that tomorrow's compilations will be fluff that maintains the status quo.

Posted by DrMabuse at January 29, 2004 09:29 AM | TrackBack

DrMabuse refers to the Committee for Truth in Psychiatry as "ironically named." This reminds me of the State Peace and Development Council, the name for the brutal junta that took over Myanmar (Burma). See this World Press Review article for a good review of recent Myanmar history. Disclaimer -- don't sue me -- the CFTP is not a brutal dictatorship, but their name is ironic.

Friday, March 05, 2004

Human Health in the Spotlight
--
Arms Control as a Public Health Issue, Part III

This is a continuation of the series from the past two days. The first article in the series was a general discussion of disarmament/arms control as public health issue; specifically, a public health issue that should be considered by voters in the USA in the November 2004 election. Health care is recognized as a big issue for the candidates, as is national security. Arms control is an issue as well, but it does not appear to be shaping up as one of the major contested issues. These issues are not entirely separate. If national security is threatened, it could be bad for our health. If arms control is not pursued avidly, it could be bad for our health. I suppose one could close the circle by saying that if health care is not addressed appropriately, it could be bad for our national security.

One kind of political sophistry involves blurring of issues. For example, one could blend the issue of arms control and national security, effectively discounting the importance of arms control. Today, I emphasize that these issues are related, but should be examined and discussed with clarity. In practice, that means talked about them as issues that are distinct but related.

My original intent was to focus on George W. Bush's arms control policies yesterday, then contrast those with the policies voiced by Edwards and Kerry. After Edwards withdrew, I wrote that I would not review what he had said about arms control. Accordingly, today I will review what appears in the media, in NGO websites, and in blogs about Kerry's advocacy of arms control policies.

News Media:

February 26, 2004

THE RACE TO THE WHITE HOUSE
Sizing Up the Democratic Contenders' Strengths: Kerry
By Maria L. La Ganga and Janet Hook, Times Staff Writers
JOHN KERRY: He claims bold leadership in the Senate on several major issues. The record bears him out on some but not quite on others.

[...]"I've been a leader … on arms control issues, the MX missile, the antisatellite weaponry and the 'Star Wars' program." — Jan. 30, Wilmington, Del.

Kerry offered many amendments to curb funding for the missile defense initiative proposed by Reagan that was known as Star Wars, and for antisatellite weapons programs. But most of those issues have faded from prominence, as Democrats have backed away from confronting Republicans on the need for such missile defense systems.

"Democrats have largely ducked," said John Isaacs, head of the Council for a Livable World, an arms control group. "That includes all of them that have been active in the past. Kerry was active."

Democrats had planned to confront Bush on his plans to develop a missile defense program akin to Star Wars after he campaigned on the issue in 2000. But they decided not to oppose the program after the Sept. 11 terrorist attacks. Research is proceeding and the Pentagon hopes the system will start operating in Alaska in September.[...]

It is tricky to interpret this. This would appear to be an instance in which his claim of "bold leadership" is borne out by his actions: Kerry was active.
Why the authors include the statements "Democrats have largely ducked," and "they decided not to oppose the program after the Sept. 11 terrorist attacks," is not clear; they do not appear germane to the ostensible purpose of the article: Sizing Up the Democratic Contenders' Strengths: Kerry. These statements appear to serve the purpose of introducing journalistic bias. They are negative statements, and as such, they lend an general negative cast to the article without actually saying anything negative about Kerry specifically. I encourage readers to look at the factual content of the article: Kerry said that he was a leader on arms control issues. The record indicates that he made efforts to curb military spending. That is what is pertinent. Whether the Democrats in general have backed way from confronting Republicans is a different matter.

THURSDAY
February 12, 2004
Bush wants new nuke rules
By Dana Milbank
The Washington Post [as echoed in Salt Lake Tribune]
WASHINGTON -- President Bush called Wednesday for a tightening of international rules governing the spread of nuclear technology, a proposal that, if adopted, would be the most significant change to nonproliferation efforts in more than three decades.
In a speech at the National Defense University, Bush proposed revoking the long-standing bargain in the 1970 Non-Proliferation Treaty that allows countries to develop peaceful atomic energy in return for a verifiable pledge not to build nuclear weapons. Calling that agreement a "loophole" exploited by North Korea and Iran, Bush instead proposed that nuclear fuel be provided only to countries that renounce nuclear enrichment and reprocessing.

[...]"Nothing the president proposed today will be successful unless the administration reverses course and undertakes serious and sustained cooperation in law enforcement, intelligence gathering and diplomacy to halt nuclear proliferation," said Sen. John Kerry of Massachusetts, the leading Democratic candidate for president.

This article doesn't say much about Kerry, except that he alleges that Bush's efforts toward arms control have been weak. From the way the article was written, we cannot tell if Kerry had more to say on the subject. I would have liked to see a more specific statement by Kerry, pointing out that it will be hard for the USA to obtain "sustained cooperation" unless we drop the unilateralist posture that has been so pervasive lately.

Kerry, Too, Needs to Clear the Air

By Scott Ritter
Scott Ritter, former UN chief inspector in Iraq, 1991-1998, is the author of "Frontier Justice: Weapons of Mass Destruction and the Bushwhacking of America."

February 9, 2004

On April 23, 1971, a 27-year-old Navy veteran named John Kerry sat before the Senate Foreign Affairs Committee and chided members on their leadership failures regarding the war in Vietnam.[...]

Sen. Kerry was given the opportunity to make good on his promises that he had learned the lessons of Vietnam. During a visit to Washington in April 2000, when I lobbied senators and representatives for a full review of American policy regarding Iraq, I spoke with John Kerry about what I held to be the hyped-up intelligence regarding the threat posed by Iraq's WMD. "Put it in writing," Kerry told me, "and send it to me so I can review what you're saying in detail."

I [Scott Ritter] did just that, penning a comprehensive article for Arms Control Today, the journal of the Arms Control Association, on the "Case for the Qualitative Disarmament of Iraq." This article, published in June 2000, provided a detailed breakdown of Iraq's WMD capability and made a comprehensive case that Iraq did not pose an imminent threat. I asked the Arms Control Association to send several copies to Sen. Kerry's office but, just to make sure, I sent him one myself. I never heard back from the senator.

[...] Sen. Kerry followed up this performance in October 2002 by voting for the war in Iraq. Today he justifies that vote by noting that he only approved the "threat of war," and that the blame for Iraq rests with President George W. Bush, who failed to assemble adequate international support for the war. But this explanation rings hollow in the face of David Kay's findings that there are no WMD in Iraq. With the stated casus belli shown to be false, John Kerry needs to better explain his role not only in propelling our nation into a war that is rapidly devolving into a quagmire, but more importantly, his perpetuation of the falsehoods that got us there to begin with.

President Bush should rightly be held accountable for what increasingly appears to be deliberately misleading statements made by him and members of his administration regarding the threat posed by Iraq's WMD. If such deception took place, then Bush no longer deserves the trust and confidence of the American people.

But John Kerry seems to share in this culpability, and if he wants to be the next president of the United States, he must first convince the American people that his actions somehow differ from those of the man he seeks to replace.

Here, Scott Ritter points out that Kerry had access to Ritter's Arms Control Today paper that claimed Iraq had no WMD's, and that, despite having access to the information, he voted (two years later) by voting for the war in Iraq. Ritter's point is that, had the Arms Control Today article been given sufficient weight, Kerry should not have voted for the Iraq War.

Democratic candidate and Middle East policy by John Munro24-02-2004

[...]Of perhaps greater significance is the person John Kerry tapped for advice on the Middle East, Rand Beers, a counter-terrorism expert who made news recently by leaving public service under President Bush to assist Kerry’s campaign. A former US marine, Beers is a forceful supporter of America’s war against illegal drugs. In fact, he was the public face of Washington’s much criticized aerial crop fumigation campaign in Colombia, which certainly helped eradicate the cultivation of illicit drugs but also reportedly induced cancer among the local population and forced the already impoverished peasants to the brink of starvation. But Beers was unrepentant, saying that “an illegal activity is an illegal activity. And one doesn’t get a special pass for being poor.” Beers is also on record for making the bizarre statement that Colombia’s FARC guerrillas had been trained in Afghanistan. With regard to Israel and Palestine, he seems to share the Sharon government’s view that one should tackle “terrorism” first then talk about peace later. He was against US intervention in Iraq, however, but only because he felt it “clouded” the international fight against terrorism.[...]

The quote above comes from the Middle East gateway, Al Bawaba, which appears to be a portal site, something like Yahoo, but more modest. The author, John Munro, is described: John Munro has been an educator and freelance journalist living in the Middle East for more than thirty years. He is currently visiting lecturer in media and human rights at the University of Malta. The article does not address directly Kerry's arms-control policy, but it does provide some information on the issue, by reporting on one of his advisors. It presents Rand Beers in an unfavorable light.

Symposium

Do Democrats have a better game plan for protecting U.S. national security?

Post March 4, 2004

By Lawrence Korb

YES: The Democrats advocate a strategy that is based on reality instead of ideology.

[...]It is not surprising that Kerry labeled this [Bush's] foreign policy as the most inept, reckless, arrogant and ideological in U.S. history. But when leading Republicans such as Sen. Chuck Hagel of Nebraska and former national-security advisers such as Brent Scowcroft and Henry Kissinger express similar sentiments, Americans should be worried and seek a different policy. Hagel has argued that our interests are best served through alliances and consensus. Scowcroft has warned that we cannot win the war on terrorism without enthusiastic international cooperation, and Kissinger has noted that it is not in our national interest to establish pre-emption as a universal principle. Democrats do advocate a different national-security strategy - one based on reality, not ideology and false illusions. This strategy agrees that terrorists with a global reach (as opposed to all terrorists), rogue states, and nuclear, chemical and biological weapons and materials are the most serious threats to U.S. security and the American way of life. But it also acknowledges that we cannot deal with these threats effectively in all places and at all times through the unilateral use of U.S. military force. The Democratic strategy is based on five principles.

First, focus on the primary threat to the security of the United States. The threat today is terrorists with a global reach, such as al-Qaeda and its affiliates. While the United States must combat global terrorism that threatens U.S. interests, the security of the United States is not threatened equally by all terrorists or tyrants. Therefore, the United States must give priority to minimizing the threat from al-Qaeda and prevent its members from obtaining nuclear, chemical or biological weapons, materials and technologies.

Second, ensure that our armed forces and first responders are strong enough to carry out their missions. Rather than wasting money on such Cold War-era weapons as the F-22, V-22 and Virginia-class submarines, or spending more than $10 billion to deploy an untested national missile-defense system and developing a new nuclear weapon, the United States must focus on the people who fight our battles at home and abroad. We need an active-duty and reserve army that has two more divisions and is equipped to carry out multiple tasks in many theaters across the globe. We also need police, fire and medical personnel properly equipped and trained for their duties at home.

Third, use and adequately fund every weapon in our arsenal - diplomatic, economic, technological and military. Force as the centerpiece of a national-security strategy will not by itself be able to address all transnational threats. The United States must emphasize diplomatic and economic cooperation - from strengthening treaty regimes to increasing development assistance. We need to remain the strongest military power on Earth, but we also should lead and adequately fund collective efforts to gather intelligence on threats that extend beyond orders; prevent the spread of WMD; and confront health, humanitarian, environmental and other catastrophes that can lead to failed states.

Fourth, work with allies and international institutions to best advance our national interests. This does not mean giving other nations a veto over America's actions in pursuit of its security, nor does it navely hold that the national interests of others always can be set aside to achieve consensus in favor of U.S. interests and values. But alliances provide a vital framework to achieve a shared perception of common threads and a shared responsibility for the cost of action. They enhance rather than detract from our ability to succeed in today's complex threat environment.

Fifth, employ U.S. power and technology to strengthen those norms and institutions designed to prevent the proliferation of nuclear, chemical and biological weapons, including the Nuclear Non-Proliferation Treaty, the biological- and chemical-weapons convention, the Comprehensive Test Ban Treaty, and the International Atomic Energy Agency. These are conventions we should rely on to verify that countries such as Iran and Libya are meeting their treaty obligations. At the same time, existing cooperative security agreements, such as NATO, should be further adapted to deal with the new threat environment.

This cooperative and multilateral Democratic approach will make this nation more secure than the arrogant, narrow unilateralism of the Bush administration, which is not in keeping with the traditions of this country or the Republican Party.

Lawrence Korb is a senior fellow at the Center for American Progress and a senior adviser to the Center for Defense Information, both in Washington,and served as assistant secretary of defense in the Reagan administration.Contact Korb at lkorb@AmericanProgress.org.

The above article was taken from Insight, a conservative publication. It purports to report on Kerry's arms control stance, although from the way it is written, I have the impression that it present's the author's opinions as much as Kerry's.

Also in Insight is a companion article that argues for sticking with Bush's policies. It does not say much about Kerry in particular; rather, is speaks of "Democrats like Kerry," lumping all Democrats together as though they all have the same arms control policies. The companion article can be found here, but is not included here because it is so vague about Kerry.

NGO's

The Zionist Organization of America
Jacob & Libby Goodman ZOA House Phone: 212-481-1500
4 East 34th St. New York, NY 10016 Fax: 212-481-1515
e-mail: email@zoa.org Web Site: www.zoa.org

March 2, 2004 Contact: (212-481-1500)

All Four of Kerry's Possible Candidates for U.S. Envoy To Arab-Israeli Talks Are Biased Toward Arabs

NEW YORK- All four of the reported candidates for a future position of U.S. envoy to Arab-Israeli negotiations have records of pro-Arab bias, the Zionist Organization of America (ZOA) has warned.

The New York Times reported on March 1, 2004, that U.S. Senator John Kerry has mentioned former National Security Adviser Sandy Berger and former Mideast envoy Dennis Ross as possible choices for the post. Previously Senator Kerry also named former President Jimmy Carter and former Secretary of State James Baker as additional candidates.[...]

The ZOA article is critical of Kerry because of the list of choices he has presented, regarding possible choices for Envoy to the Mideast. The rest of the article states that Kerry could be dangerous as President, at least to Israel, because his choices seem to be pro-Arab.

January/February 2004
A veteran—and outspoken opponent—of the Vietnam War, John Kerry has made foreign policy both a high priority during his 18-year Senate career and a centerpiece of his campaign for the Democratic nomination. He has been a member of the Foreign Relations Committee since entering the Senate in 1985 and points to the normalization of U.S. relations with Vietnam as one of the high points of his congressional service.
[...] The senator fought for ratification of the Comprehensive Test Ban Treaty, stating that failure to do so “will seriously undercut our ability to continue our critical leadership role in the global nuclear nonproliferation regime.”
[...] As president, Kerry says he would move quickly to shore up U.S. alliances abroad and develop a multifaceted approach that leverages international cooperation against the proliferation of weapons of mass destruction (WMD). According to the candidate: “It is time…for the most determined, all-out effort ever initiated to secure the world’s nuclear materials and [WMD].” Kerry would appoint a presidential coordinator to direct a “top-line effort” to secure nuclear weapons and materials worldwide and claims that, within four years, his administration will have “entirely” removed chemical, biological, and nuclear materials from the world’s most vulnerable sites.
[...] Kerry vows that his administration would be “committed to revitalizing the arms control process” and said efforts to research a new generation of nuclear weapons “could set off a dangerous new nuclear arms race.”
[...] Like the other Democratic candidates, Kerry supports negotiations with North Korea that would include providing Pyongyang with strong incentives to end its nuclear weapons program verifiably. He advocates direct negotiations addressing a broad range of issues, including conventional force deployments; North Korea’s alleged drug running and human rights record and dire humanitarian conditions; and Pyongyang’s security concerns.

This is from the ACA review of the arms control policies espoused by the various candidates. I have selected the high points, but interested readers should consider reading the entire article, since it appear to be one of the more comprehensive treatments available.

Where do the Candidates Stand on Foreign Policy?

John Kerry
US Senator from Massachusetts
www.johnkerry.com

1. Do you oppose the development and funding of new nuclear weapons? Yes
2. Do you support programs designed to reduce and secure the world’s existing nuclear stockpiles? Yes
3. Do you support the resumption of explosive nuclear weapons testing? No
4. Do you support the development of national missile defense? Yes
5. Would you work to prohibit US arms sales and military training to governments that the State Department deems human rights abusers? Yes
6. Do you support government restrictions on civil liberties (such as those imposed by the USA Patriot Act) in the name of national security? UNCLEAR
7. Do you intend to uphold the rights of those who dissent, such as the right of Americans to hold peaceful