It's time to wind up my little tour of biology with an odd little subplot. You can find plenty of arguments over the definition of life, what it is exactly that makes us call something alive. This is all very interesting as we think about what we might encounter out there, beyond the earth; and it was at one time all very interesting back when we didn't understand very much about life here on our little rock. But nowadays, the answer to what constitutes life on earth is simple and unequivocal: life is cells.

A cell is a comparment enclosed by a phospholipid bilayer containing a chemical system in a salty solution that includes polypeptides -- long chains of chemical units called amino acids -- shorter peptide chains, and polymers of varying length called RNA and DNA, among other important kinds of chemicals. Some cells, such as your own, also have smaller membrane-enclosed comparments within the larger compartment, in which specific processes take place, but that's optional. Y'all ought to know by now about the system in which information stored in DNA is read out onto RNA and translated into polypeptides. If you don't, look it up. Cells use a chemical process to extract energy from sugar to fuel all that chemistry. They get the sugar in various ways, and they can burn it with or without oxygen, but those are just details.

A couple of recent reports in the popular press on academic exercises offer considerable food for thought. First, I'll offer my own well-fed cogitations on this effort by a task force of physicians in various powerful positions to decide who gets triaged to the scrap heap in the event of an influenza pandemic or a comparable mass casualty event. Unfortunately, the issue of Chest in which this report appears hasn't made it onto my library's on-line subscription service yet, so I can only go by the news report. Hence I don't know the full composition of the task force. It includes representation from the military and the Department for the Impregnable Defense of the Glorious FatherlandHomeland Security, among other federal agencies, as well as medical societies and prominent academic physicians. I'm sure many will see this as vaguely sinister but I'll give them the benefit of the doubt as to motive.

My thanks to the commenters on my post about my father -- and thank you particularly for sharing some of your own stories. I try to let my personal life intrude minimally here, but as a disciple of the late Irving Kenneth Zola I take very much to heart his insistence that sociology can only be called objective when we disclose ourselves. It may seem paradoxical but only if you haven't thought about it very hard. Obviously, I have a personal stake in the issues I write about here. You should only conisder me credible to the extent I reveal it.

Like you, I really don't have a clue what exactly TF Hillary Clinton thinks she's been doing for the past couple of months, or why she's been doing whatever it is, but in any event, no matter what she says tonight, starting right now Barack Obama and the Democratic Party -- with the possible exception of Hillary and 182 fervent supporters who will continue to hold out in caves on some remote Pacific islands -- will start to run against John McCain for the office of prezneh unigh stay, as Sen. McCain pronounces it. That means that if we are very lucky, we just might hvae some conversations about public policy.

So here's my list of public health priorities. It's difficult to put them in order, and I might change my mind five minutes from now, but as of 1:42 pm eastern time they are:

Understanding evolution is fundamental to the field of public health -- which, as I've said before, is everything. If we teach our children falsehoods, it obviously undermines their prospects to survive and succeed in the world. We aren't just battling for truth, we're battling for survival. Here are just a couple of reasons why the truth really matters.

First and most obviously, we are in a race with the evolution of pathogens, and it's a race we are losing. Heritability works differently in viruses and prokaryotes than it does in the multicellular eukaryotes, but the basic principles of Darwinian evolution apply all the same. HIV evolves to escape antiretroviral drugs and influenza viruses to overcome oseltamivir, bacteria evolve to render our antibiotics useless, and the malaria parasite (a metazoan) evolves to overcome our antimalarial agents. The day may come, and pretty soon, when the revolution in human health and longevity that occurred in the 20th Century is reversed, when we fall helplessly before common infections we thought we had conquered. It won't be any intelligent designer doing that, and praying won't do any good at all.

Understanding evolution is also essential to understanding ourselves. We're astonishingly complex and capable entities, but in many respects, our design is not very intelligent.

So okay, I could wallow around in wishy-washy sophomoric philosophy for a few more days, but let's put the key issue on the table. What do we mean by good health? Sure, that's technically just a semantic question, but it's actually substantive because the word "health" tends to stand in for whatever the ultimate goal is supposed to be of the blob that ate the economy -- or at least one of the blobs, the Department of Imperial Hegemony Defense being the other.

I'm not going to give much in the way of references or concrete history in this post -- it's basically for conceptual background. But, just pulling it out of an orifice, the story goes something like this.

Until around about the 1960s -- by which I really mean the early 1970s, since the 60s lasted from about 1965 through 1974 -- there was very little questioning of the medical enterprise from within -- or from without, for that matter. Or at least there hadn't been for a long time, since the critical ferment surrounding the Flexner Report in 1910. Back then, the criticism was essentially that medicine was largely unscientific, but in the 1960s, the problem turned out to be just the converse -- that medicine had become too narrowly biological, in the process becoming patriarchal, inhumane, and even contrary to the interests of patients.

Our good friend Jean, in response to my asking for contributions to President Obama's "to do" list, proposes honest, effective, and comprehensive health education. I think that's an excellent addition. Although I'm afraid it may be too hot to handle for the campaign, it's something we're going to need to address after the dust settles in January.

If we're going to have honest and effective health education, it has to start with honest and effective biology education. And here, we have a problem. Michael Berkman and colleagues in the May PLoS Biology lay the bad news on us. Sixteen percent of U.S. high school biology teachers admit to believing that "God created human beings in their present form at one time within the last 10,000 years," and 47%, while agreeing that humans developed over millions of years, believe that God guided the process, and one in eight say they teach creationism in a positive light.

They got some pretty little women there and .. .

Oh, never mind. Anyway, my jet setting lifestyle continues as I will be in Jersey City Sunday through Wednesday for the Third International Conference on Antiretroviral Adherence. Sounds a little narrow, I know, but the subject actually is quite revealing as a test case for physician-patient relationships and communication and disease management and stuff in general.

Conference presentations aren't as strictly and paranoically embargoed as journal articles, so I will tell you that in general terms, my colleagues and I have found that if you give doctors a report about their patients' medication taking behavior, they will indeed talk about it more during the visit -- twice as much, on average, in fact. However, that does not result in the patients being more adherent to their medication regimens.

In fact, it has the opposite effect.

The CDC has asked a colleague of mine to participate in a consultative group on HIV prevention for Latinos, and she asked me to contribute my thoughts on the four big questions they are asking. My pleasure, I do happen to have some opinions.

Based on your knowledge of HIV/AIDS among Hispanics in the United States;

1. Identify at least two community and two societal-level factors that place Hispanics/Latinos at disproportionate risk for acquiring HIV. How should CDC
address these factors?

Much of the disproportionate risk for HIV among Latinos in the northeast is related to injection drug use. While primary prevention is certainly what we would most want to achieve, unfortunately the evidence base for primary prevention is limited. (See below.) We do know that treatment can be effective, and furthermore, as IDU must be transmitted from users to non-users, treatment of current users does constitute a form of primary prevention as well. (Think of it as analagous to infectious disease control. Current users are infectious; get them into recovery, and you stop transmission.)

And no free pass for President Obama either. As you know if you've been reading -- because I mentioned it a few days ago -- Obama's health care proposals include requiring insurers to cover preventive services, which he claims will reduce health care costs. Hillary Clinton makes some vaguer claims along the same lines, to the effect that universal coverage will end up saving money because people will get timely preventive care.

Joshua Cohen and colleagues in NEJM consider this proposition. (And you'll be pleased to know that this is one of those articles of broad public interest that the editors have made available to the rabble, so go ahead and read it.)

Alas, as a general proposition it isn't so. Screening and prevention may be worthwhile, but that isn't the same as saving money. Very few procedures actually produce a net cost saving. Cohen et al don't point it out, because it isn't really the focus of their analysis, but the really bad news is that extending people's lives actually costs money. If somebody drops dead of a heart attack, you only have to pay for the funeral. But if they live for 20 years taking beta blockers and ACE inhibitors and statins and getting angioplasties etc., you've prevented a heart attack, but spent a helluva lot of money.

No time today to continue my project of Thinking Deep Thoughts, it will return tomorrow. I spent most of the day at a symposium on access to cancer clinical trials for minorities, where I facilitated a workshop. An interesting subject though a bit more complex, in my view, than many of the other participants see it. African Americans, Latinos, Native Americans are all grossly underrepresented in clinical trials of cancer treatments. That should not be.

This morning we heard from Dr. Kelly Kelleher about how it's a great idea for primary care doctors to screen for alcohol and other drug abuse problems. There are, however, some difficulties.

Every disease advocacy organization in the world wants primary care doctors to be screening -- for asthma, diabetes risk, cancer, depression, domestic violence, you name it. In fact there are something like 700 questions that primary care docs are supposed to be asking their patients. However, they generally see 4 or 5 patients an hour. Since the patients are presumably there for some reason other than to be asked the first 30 or so of 700 questions, it's unlikely we're going to get very far with that.

I was as confused as hell today when I first read this in the New York Times, then I checked out this week's NEJM and read this (abstract only for you uncredentialed scum).

Item One:

For decades, researchers believed that if people with diabetes lowered their blood sugar to normal levels, they would no longer be at high risk of dying from heart disease. But a major federal study of more than 10,000 middle-aged and older people with Type 2 diabetes has found that lowering blood sugar actually increased their risk of death, researchers reported Wednesday. . . .

Among the study participants who were randomly assigned to get their blood sugar levels to nearly normal, there were 54 more deaths than in the group whose levels were less rigidly controlled. The patients were in the study for an average of four years when investigators called a halt to the intensive blood sugar lowering and put all of them on the less intense regimen.

Item Two:

Readers are begging for more about the Massachusetts health care reform legislation. Okay, not begging, but they have expressed mild interest. You can get a one page overview here, and the authority responsible for administering the law, called (weirdly) The Connector, provides links to the actual legislation and associated regulations here.

Unfortunately, in my view, this legislation has become the model for the leading Democratic national proposals. To answer Kathy A.'s question, the law provides sliding scale subsidies for low and moderate income people to purchase insurance. To answer Roger's question, it provides for fairly stiff fines for individuals who don't get insurance, although less than the cost of actually buying it.

I claim no psychic powers. I've been telling y'all for years now that antidepressants basically don't work. The drug companies have been promoting the fiction that depression is a specific disease of the brain caused by a "chemical imbalance," specifically a deficiency of the neurotransimtter serotonin, which their potions -- Prozac, Zoloft, etc. -- purportedly cure. It's all nothing but a big pile of crap.

Irving Kirsch and colleagues, in PLOS Medicine, tell us what shakes out when you look at all the RCTs that have been done on these "medications," including the ones the drug companies made sure not to publish. Naturally, the ones they didn't publish are the ones that show their products in the worst light.

Got a tip from reader Kathy about a little business as usual at a health insurer in Cal that ducked $35.5 million in expenses by dumping sick people. Yeah, that's what the God-given Free Market does folks. The scandal, as far as the LA times is concerned, is that their head hit-woman was given the assignment of wacking 15 sick people a month, and paid a bonus for exceeding the goal. That's not a scandal, that's how insurance companies work. The scandal is that she only got 20 grand for screwing over 301 people and saving the company $6 million bucks. Come on, Health Net, have a heart.

But they do try to predict health care costs ten years out. You may have seen a news brief about the new prediction that health care spending will be 19.5% of GDP by 2017. Health Affairs has made this open access, so go for it if you are turned on by wonkery.

Now, there are a lot of assumptions that go into any such prediction, and it's pretty obvious that unless the McCain campaign succeeds in its increasingly transparent plan to make voters believe that Barack Obama is a secret muslim extremist who has been planted by al Qaeda to turn the country over to Islamofascist infiltrators and give Tomahawk cruise missiles to Hamas,* some of those assumptions will be overturned somehow some way, and they probably won't all work out anyway. But, for what it's worth, the broad outlines of what these perpetrators of deep wonkery expect assuming that nothing major changes are as follows.

Suppose you knew you had a terminal illness, and the doctor told you there was a drug that cost almost $100,000 a year, that had not been shown to help people with your condition live any longer; had potentially serious side effects; and might even kill you itself. However, it did seem to slow the progression of signs of your disease such as the appearance of x-rays. Would you take it? As a taxpayer or a payer of insurance premiums, would you want the government or your insurance company to use your money to pay for it?

The FDA says yes, and yes. Avastin, a so-called angiogenesis inhibitor, was just approved for use in metastatic breast cancer, even though all of the above applies, and the relevant advisory council had voted against approval. Avastin has been shown to slow the growth of tumors, but not to confer any significant survival advantage. Again, the FDA has approved a drug on the basis of a so-called "surrogate" end point, some element of a disease process or a presumed risk factor that it affects, without any evidence that the drug actually benefits patients in any subjectively meaningful way.

As I was intending to get back to the mind/body thing, along comes a fortuitous hook: Pfizer, the same people who give you the whorish Dr. Jarvik hawking an expensive statin that is no better than its far cheaper generic competitors (even though he has no relevant expertise and has never practiced medicine), is now marketing a new drug for fibromyalgia.

To us medical sociologists, fibromyalgia is an endless source of fascination. Like the psychiatric "diseases," it is diagnosed based on a checklist of self-reported, qualitative and subjective symptoms. There is no known etiology and there are no physical findings whatsoever. So there is raging controversy over whether there is any such "disease" as fibromyalgia.

The Randomized Controlled Trial (RCT) is the so-called gold standard for determining what is and is not evidenced based therapy. When we talk about the clinical trials submitted to the FDA in new drug applications, that's what we're talking about. When people call for Evidence Based Medicine, they mostly want doctors to use interventions that have been "proven" through RCTs.

So it was refreshing to day to hear Malcolm Gordon, who is an official of the Center for Mental Health Services, tell us about many of the reasons why RCTs don't necessarily tell us what does and does not work when it comes to mental health services. For example, they are very expensive to do, so they seldom go on long enough or have large enough sample sizes to support adequate subgroup analysis. An intervention that works for some people might not work for others, but we just don't get the information we need from RCTs to understand that. Attrition is a big problem in trials, particularly of mental health treatments, and it can seriously mess up the statistics. A truly major problem is that interventions are developed, implemented and tested in highly specialized settings and circumstances that just don't correspond to anything that is likely to happen in the real world of the mental health system.

and one way to beat it. Before I do my usual weekend disappearing act, I do want to encourage all you common rabble out there to read at least one medical journal, and the really great news, as I have pointed out before, is that you can do it for free.

Public Library of Science Medicine is linked on my sidebar. If you go to the home page this month you'll see a lot of boring looking technical stuff that you might not feel like reading, but do click on through to the current issue and see what's in the table of contents.

While Freud got psychiatrists out of the lunatic asylum and into cushy offices, nevertheless his work only increased the influence of dualism in psychiatric practice and the relationship between psychiatry and the rest of medicine. While the theory of "functional disorders" did forge a link between mind and body, the etiology of the disorders lay in psychodynamic processes, the still ethereal stuff of mind. A psychiatric diagnosis depends on ruling out "organic illness," and vice versa.

In the 1930s, psychiatrists tried to further advance their prestige within the medical profession by creating the field of psychosomatic medicine. In the functional disorders, patients experience physical symptoms but no organic referent for those symptoms can be found. Psychosomatic illnesses, in contrast, are "real" in that organic symptoms are observable.

As I have said before, I'm not going to be all over the health care proposals of the presidential candidates because whatever they are saying now is not miraculously going to become reality after January 20. It's all going to get processed through the Congressional/K Street/Moronic Corporate Media meat grinder anyway, and who knows what vile offal might emerge?

But, the debate last night has no doubt raised questions in people's minds regarding what that was all about with the mandates and the amputations and what not. Let me say, first of all, that the debate as a whole was extremely heartening. It was largely substantive, we've got two capable candidates who both demonstrated a willingness to submerge their competing personal ambitions for the good of the nation, and it would be absolutely shocking if one of them doesn't become president. Whoever it is will spend the next few years shoveling out a shitpile that makes the Augean stables seem like your cat took a dump on the rug, but maybe they'll get something done on health care.

So, you can go to the respective web sites and read it all for yourselves, but here's my executive summary.

It has often been said that the family is the most violent institution in society. That probably is not true -- the prison system probably wins that competition -- but there is no doubt that the most likely assailant of a woman or child is a family member. Statistics on this point are not very reliable -- family violence happens in private, usually in secret, and usually does not come to the attention of the authorities. Advocacy groups have been known to exaggerate, but This fact sheet seems to offer a level-headed overview.

One can frame this problem in terms of gender role norms. Women are certainly capable of assaulting their spouses and children, but men are more likely to do so. (I'm steering clear of quantification here because it's not reliable.) We now understand that the phenomenon commonly called battering is not really about anger; it's a pattern of coercive control. Batterers are extremely possessive, jealous, and need to monopolize power in their intimate relationships. It's no surprise that they typically victimize children in their households as well as their spouses or partners.

Barbara Burke in the new JAMA reviews Bipolar Children: Cutting Edge Controversy, Insights, and Research, Edited by Sharna Olfman. Unfortunately, it's subscription only, but I'll give you a fair-use quote:

IN EUROPE AND ACROSS THE GLOBE, MANIC DEPRESSION IS rarely diagnosed in the pediatric population. In the United States, on the other hand, the American Academy of Child and Adolescent Psychiatry (AACAP) suggests that it may exist in up to 13% of children.1 Prescriptions of sedating drugs (anticonvulsants, -agonists, and atypical antipsychotics) have increased up to 3-fold in the last decade.2 Both of these anomalous trends, poorly substantiated by quality research, have occurred during a time of dramatic economic change in the health care industry. Meanwhile, US children appear to be getting less mentally healthy, not more, with diagnoses of “mood disorders” and “pediatric bipolar” (PBD) topping the list. This is clearly crazy, but where does the madness lie? In the children, the prescribers, or society as a whole?

Monday morning I continue my jet setting lifestyle by flying off to DC for the Joint Meeting on Adolescent Treatment Effectiveness. That refers to substance abuse treatment.

Now, like a lot of you, the way I remember my adolescence the biggest drug problem we had was insufficient supply. However, the problem we have today is entirely different. There is a major epidemic of adolescent opioid addiction in the U.S. right now, including 16 and 18 year old kids who inject heroin. When I was a youth the idea of going anywhere near heroin was absolutely appalling. I never knew anyone who would even consider it. Ditto with meth. Yes, people got into that stuff but usually not so young, and it was largely limited to poor communities. Scholars of addiction could honestly say that the problem was not drugs, but lack of life prospects, or psychological damage. People with jobs to go to and education to pursue could get high on weekends but they would show up on Monday because they had a reason to, and they did not become addicted.

Continuing with the question "What is health?", let's consider the mind-body problem.

The ancients viewed the mind and body as a single entity. Hippocrates could write with equal authority about diseases we would today differentiate as physical or mental. "Hysteria," for example, was caused by movement of hte uterus, and depression by imbalance of the humors.

Modern positivist philosophy, often traced back to Descartes, has famously split mind and body. From Descartes' time until very recently, if at all, the inner workings of the mind have not been readily susceptible to empirical investigation by the standards of positivist science. (Maybe functional Magnetic Resonance Imaging is changing that -- we'll see.)