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.

In my last post, I asked people to think through the implications of accepting the idea that fibromyalgia (for example -- the analysis extends much further) is, yes, a real phenomenon and a physical phenomenon, and also is located in the brain, not the body parts that hurt. C. Corax notes, correctly, that making the diagnosis psychiatric or psychological both stigmatizes sufferers, and may limit their insurance benefits for the condition. But why is this?

Now I get to the stuff I'm supposedly an expert at, and I find it difficult to do a post. The reason is that I'm accustomed to writing about these issues with footnotes and exact numbers and scholarly reserve and all that, and I don't have time for it in a blog post and it would be boring anyway. So I'm just going to lay out some qualitative ideas and if you want the bibliography, send me an e-mail.

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.

With the Scripps National Spelling Bee underway I find it fitting to do a post on this.

First off I want to clarify this, I love watching the spelling bee, it is very interesting and I am always amazed at how smart these kids are.
But really now, I mean this is really pathetic. We have these kids studying and learning to spell these insane words all day.

Many of these kids spend all day couped up inside their homes studying to be the best and the smartest, I mean come on now. We even have spell check now (and boy I am glad we do)! So why can't they use it?

Well we obviously need to have some sense of how to spell words, but if I can make it by then these kids can too. There is no need for these kids to spend their whole lives studying these words the majority of America can't even pronounce.

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.

This morning we heard from representatives of the Children's Defense Fund, who discussed the Fund's report and campaign called Cradle to Prison Pipeline. Using what a take to be the method called Life Table Analysis (although they didn't actually say so), CDF has figured out that a Black boy born today has a 1 out of 3 chance of going to prison during his lifetime, and a Hispanic boy a 1 out of 6 chance, compared to 1 out of 17 for a white boy. Ratios for girls are similarly disproportionate, although the absolute chances are lower.

The CDF points out that 1 out of 6 children in the U.S. are living in poverty, and that the numbers living in poverty, and the poverty rate has increased during the reign of the current Christian moral values administration -- most dramatically among the very poor. Poverty is of course associated with all sorts of problems for children -- failure in school being the most pervasive. The CDF goes on to talk about all the other ills that afflict poor children, and disproportionately afflict poor and minority children, but I want to get to the bottom line.

No, I'm not talking about Paul Pierce, Kevin Garnett and Ray Allen. These are three great mysteries that trouble the Enlightenment project -- the quest to understand the universe from the human perspective. These enduring mysteries are among the reasons so many people still cling to irrational beliefs and mysticism. In ascending order of philosophical profundity (in my personal ranking) they are:

The origin of life: This does not in fact present a philosophical challenge to scientific inquiry. It's just a puzzle. We can certainly solve it, in principle, using hard core positivist logic and standard tools of scientific inquiry. The bad news, potentially, is that it happened an awfully long time ago and we just might not ever get a definitive answer. There is a philosophical nugget in there, specifically that there are probably limits to knowledge, there just might be questions that seem very important to us that will always be questions. That may be annoying, or disappointing, but it's not a fundamental challenge to humanism.

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.)

Item One: It is my duty to comment on the study published last week in NEJM that came up with a new estimate of civilian deaths in Iraq following the 2003 invasion. The consensus spin on this was "See, those peaceniks got all hysterical over the earlier estimate of 600,000, it was only 150,000." So I guess the war was a good idea after all. Actually neither study is conclusive. The new one was based on a larger sample, which all things being equal is better, but it was conducted later, which is worse. The basic problem is that households in which people have died are less likely to be around to be sampled, and the problem gets worse as time goes on. This happens for a few reasons -- some households get wiped out entirely, and then there is no-one left to sample. Households that have lost the breadwinner are likely to dissolve, to move in with relatives, to leave the country entirely -- as 2 million Iraqis have done.

As the comments on the Sunday post demonstrate, there are a whole mess of issues tangled up in this human enhancement problem. People come at it from various directions, although we mostly wind up in the same knot.

So, my first proposal is that it's counterproductive to treat this as a single, general problem. The most prevalent attempt to generalize is a conservative take -- one that we hear not only from religious thinkers but also from a certain strain of environmentalists who have what I would call a quasi-religious or mystical view of nature. This is the claim that there is some entity called "human nature" which has a kind of sacrality. If we set out to make a new kind of human being, or a post-human, we will either be offending God, or destroying ourselves, however you want to look at it.

I haven't ranted very much lately about the democratization of science, and mea culpa. So the theme for today is that we can't have a more democratic scientific institution if most people lack the basic knowledge they need to participate.

This is the story of my professional life, actually. My day job is with a community based public health agency, and my academic half is concerned with people's control -- or usually lack thereof -- over their own health and health care. (As I often say, I am a community-academic partnership.) My work concerns all sorts of issues -- mental health, addiction, environmental justice, diabetes, heart disease, you name it -- but HIV is a particularly big piece of it, in part because it has paradigmatic qualities that make it particularly instructive for many of the principal concerns of medical sociology.

John Kenneth Galbraith's popular economic history of the first part of the 20th Century is called The Age of Uncertainty. My history of the present era -- once I get done with the other three books I keep meaning to write -- will be called The Age of Denial.

The presidential campaign we are now enduring is utterly surreal. Barack Obama, rightly, has gotten a major wacking for talking about a Social Security crisis, when there actually isn't one. But helloooooooooo Barack, Hillary, John, Chris, all you characters -- there really are crises out there, major problems that we need to acknowledge and get to work on. I don't expect the Republican candidates to be connected in any way to reality, but somebody has to be.

It turns out that Heath Ledger's death is what we in the biz call an iatrogenic event, i.e. "caused by healing." [sic] He had taken a lethal combination of oxycodone, hydrocodone, diazepam, temazepam, alprazolam, and doxylamine. Now, I have no reason to believe his death was not an accident, but if you wanted to kill yourself, that would be a good way to go.

He had prescriptions for two opioids, three benzos -- two of which are marketed as tranquilizers, and one as a sleeping pill, but they're similar -- and an antihistamine that makes you drowsy as what used to be a side effect, but is now the reason it is prescribed. He had apparently complained of difficulty sleeping, but I don't know why he had the scrips for the junk and the tranks. What I do know is that you sure as hell aren't supposed to take them all at the same time, for reasons which should now be obvious.

Forget the right-brain/left-brain thing for a second. Things aren't so black and white, yin and yang, Ben & Jerry: People's brains are wired differently, and this wiring - or configuration is the result not only of an individual's genetic disposition, but also the way in which they choose to approach problems, develop solutions, and then learn from the experience.

Stars: ****1/2

This book was read for the Jewish Literature Challenge and the Christmas Theme Challenge because I couldn't get a hold of the books I originally chose.

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.

From the Sacramento Bee:In 24 years as president and chief executive officer of Sacramento's Safe Credit Union, Henry Wirz said he's never seen such "widespread credit problems in the Sacramento region."
...
Q: You've been here since 1984 and seen all the cycles, up and down, good and bad. And this is the worst credit problem you've ever seen in Sacramento?

A: The reason I say that is this is touching not just the people who have traditionally always been a problem, which is people who have lower credit scores. In every crisis, when we first have a downturn, it's the people at the bottom of the economic pyramid who seem to experience the worst outcomes. I think what surprised us was in this downturn we're seeing people who had, at the outset, relatively good credit having negative outcomes.
...

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.

I've tried in recent posts to make the argument that the idea that the mind and body are separate -- that the self is somehow apart from its physical embodiment -- is mistaken. That's important for the philosophy of public health in many ways, which I intend to try to unpack as I go along. Once we unify the psychological and the biological - which I think for most people's sense of self would represent a movement from what seems the innermost core to a larger sphere -- the next step is the social, and that's where I want to go, to think of human health in a terms of a comprehensive bio-psycho-social model.

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?

That will be my topic today. Ok, I'm sure I've spouted off my radical leftist, environmental views before. Yes, I was on the forefront of environmentalism with my much beloved Hyundai Accent that I bought in 1996 and drove till I totalled her 3 years ago. Ok, so maybe that had more to do with the fact that the car cost $10K and I only made $17K, but still... I've actually always liked little cars. They're zippy and easy to paralel park (unless they don't have power steering, like my hyundai), and they're just gosh darn cute. So I've always been one of those anti-SUV people. I think they're pointless and for fat, lazy people who can't fit their fat asses into a normal size car. Plus the whole status thing... and the whole intimidation thing. Basically they represent everything I don't like about people.

And yet, there are those SUV lovers, (yes I"m talking to you people in TEXAS) who still refuse to let go of their gas guzzlers. I mean, if it was a sentimental thing...like if you had a 66 Corvair Monza that guzzled gas but looked really cool and said something about your personality..fine. But an SUV? Here are the irrational "reasons" people need SUVs:

--I have kids. Big deal! Kids are smaller than adults. They should take up LESS room.
--My kids play sports. Uh huh..I'm sure that soccer ball can't fit in the trunk of an Accord.

Remember Pumpkin?

Unfortunately our emotionally scarred cat has been causing some troubles at home. Troubles in the shape and smell of poop.

Not using the litter box is apparently a common problem for cat owners, so for the first couple of weeks we just figured it was a matter of figuring out the combination of factors that would make the cat comfortable.

For the first few days Pumpkin used the box consistently, but then one day for reasons unknown she dropped the kids off on the kitchen floor instead of at the beach. Despite a thorough scrubbing of the area (using ammonia free products), she would just pick a different spot near the box to do her business.

I realize they aren't mutually exclusive, but I'm leaning toward more of the latter than the former. The point is, I don't know for sure whether he believes in the alternate universe represented in his public pronouncements -- most recently his triumphalist crowing on the fifth anniversary of his world historic crime of invading Iraq -- or whether he knows it's all fantasy and he just figures that when George W. Bush lies, it's not a sin, because he's God's anointed.

That is the lede to a rambling post today, and the reason you're getting this, and didn't get one yesterday, is because of traveler's burnout. Honestly, I don't know how the candidates do it, constantly changing time zones, eating too much or too little and usually badly, sleeping erratically, but having to keep working and stay alert through it all -- it's just too much for a hairless ape from the African savannah to endure.

My email to a Popular Scrapbooking Magazine:

Hello

I'm very, very frustrated with your online subscription service. I moved six months ago and changed my shipping address at that time. For the past six months I've been receiving Scrapbooking Etc at my current address, no problem. This past month I didn't receive my magazine so I checked your online subscription service using my account #. Turns out it expired (this surprised me) but the address on the page was my old address.

Yes, tonight I discovered the wonders of non-alcoholic beer! Perhaps at one time in my life I scoffed at such things and wondered what the f-ing point was, but that's what getting older and wiser is all about I suppose. We went to a local Mexican restaurant/Irish bar (I know!) and I got tacos and an O'douls, and I have to say - it was lovely. aaah.... it was like having an old friend back. The comfort of a green glass bottle and a glass of amber beauty with a nice head on it. yum! Tasted just like bud or miller light, and with a 0.5% alcohol, I could pretend that I was getting a weeeeeeee bit of a buzz. Good stuff. Of course beer was never my drink of choice, so I've been thinking about looking for some non-alcoholic wine. I guess they would call that grape juice (unrefridgerated). : )

So what does that say about me... I need the illusion of having a drink in front of me more than the drink itself, which is true. At home, when I really feel like I need a drink, I just put ice cubes in my martini glass (the sound of home...clink clink clink in a cocktail glasss) and put some crangrape in their and just pretend there's vodka in it. I mean, I like getting drunk too, but more than anything, it's just a comfort to have something that I think will make me feel better. And it seems to work pretty well.

Via The Prescription Project, this link to a U.S. News and World Report article on the upcoming DSM-V: Who's Behind the Bible of Mental Illness. A taste:

By Kent Garber

In what is arguably the most important mental-health development since the early 1990s, the American Psychiatric Association will spend the next five years producing a new edition of the psychiatrist's "bible," the official guidebook for diagnosing mental problems. The Diagnostic and Statistical Manual of Mental Disorders, as it is known, is hugely influential because it determines what is and is not a mental disorder. In turn, it is responsible for much of the sales growth in prescription drugs.

Gary Taubes wrote Good Calories, Bad Calories. Dr. Weil liked it.

CNN's Larry King Live presented an interview with Gary Taubes last Friday. Jimmy Moore posted Dr. Weil's portion of the interview on YouTube:

For this segment (about 7 minutes):
Guest Host: Joy Behar, co-host of the talk show "The View."
Guest: Gary Taubes
Guest: Mehmet Oz, MD
Guest: Andrew Weil, MD