Monday, April 30, 2007
the Rx for American health care http://www.washingtonmonthly.com/features/2007/0705.longman.html
After making an exhaustive case for the argument that the problem with American healthcare is not a lack of money, but a system whereby doctors are incentivised to overtreat patients rather than manage their long term health care, Philip Longman of the Washington Monthly reveals a solution that lies right under our noses. A solution that no one on the Democratic Presidential stump seems to be talking about.
The bottom line is that if any Democratic candidate is serious about health care as an issue - yes, even Obama or Edwards, our putative "transformational" and "progressive" champions - then why aren't they talking about the VA? Why haven't they invoked it?
Maybe it is up to us, the netroots, to educate our erstwhile champions about this.
As far as I am concerned, Hillary's proposal (re-elect me in 2012 and I'll have healthcare solutions by the end of my second term) is a nonstarter. Obama and Edwards have complicated plans on the table that try to address speccific shortcomings that they perceive to be important. Fair enough. But in the case of health care, true transformational change is what is needed to really change the fundamental financial dynamic of the business of medicine. I don't think that either Edwards or Obama have really made the case that their untested ands complex proposals really fix the basic problem, which is as Longman points out,
HillaryCare, HillaryCareLite or HillaryCareNuevo just aren't going to address this fundamental problem. The first candidate to step to the plate and say, "let's start over - and extend the VA system to all Americans, effective immediately." will send a shock wave through the system. Coupled with a trebling of the VA budget, to be used to simply epxand facilities across the country to handle increased capacity so that any American can walk in the door, we might well see the problem of healthcare in America and the plague of murder by spreadsheet vanish in a generation.
THAT's transformational, progressive reform of American medicine. Obama, Edwards, are you listening?
The cure to America’s health care crisis is a system that’s already up and running right here in the United States, with facilities in every state, plus the District of Columbia and Puerto Rico. It is, in fact, the largest integrated health care system in the United States, and it points the way to the future.
Most of its doctors have faculty appointments with academic hospitals—over the years, two have won the Nobel Prize for medicine. The system’s innovations have included the development of the first artificial kidney, the cardiac pacemaker, the first successful liver transplant, and the nicotine patch, plus many advanced prosthetic devices, including hydraulic knees and robotic arms.
More impressively, health care quality experts also hail it for its exceptional safety record, its use of evidence-based medicine, its health-promotion and wellness programs, and its unparalleled adoption of electronic medical records and other information technologies. Finally, and most astoundingly, it’s the only health care provider in the United States whose cost per patient has been holding steady in recent years, even as its quality performance is making it the benchmark of the entire health care sector.
Though comparatively few Americans, especially among coastal elites, have any contact with this system these days, and even fewer qualify for its services, its example shows that it is possible to make vast improvements in the quality, safety, and effectiveness of the health care all Americans receive, and to do so for a fraction of what an unreformed health care system would cost.
I’m talking about the Veterans Administration, which over the course of the last decade or so has undergone a remarkable transformation. Even with its problems, the VA’s model of care turns out, in study after study, to be the best the American health care system has to offer. As Harvard’s John F. Kennedy School of Government gushed, in awarding the VA a top prize in 2006 for innovation in government: “While the costs of health care continue to soar for most Americans, the VA is reducing costs, reducing errors, and becoming the model for what modern health care management and delivery should look like.”
This is another inconvenient fact absent from the health care debate. What can you say about it? The VA is an example of the government running a health care system, not just writing checks to cover other people’s medical bills, which is all that Medicare does. The VA also has a near-lifetime relationship with its patients and therefore has an incentive to invest in prevention, disease management, and protocols of care that demonstrably work—incentives that are weak or absent throughout the rest of America’s fragmented health care system. Medicare for everyone, or some similar scheme for universal coverage, just doesn’t address the root cause of America’s health care crisis, which is poor-quality, uncoordinated care. The VA model of health care does.
[..]
Upon hearing some anecdote about the VA, we should always ask, “Compared to what?” As a system, the VA outperforms the rest of the health care sector by every conceivable metric, including wait times and, of course, protection from catastrophic medical bills. And it is more cost-effective: for every patient who switched from Medicare to the VA, the taxpayers would save about one-half to two-thirds in medical costs, while the patients themselves would receive demonstrably higher-quality care. Step one on the road to true health reform should be to allow all veterans on Medicare to use their entitlement for VA care, and then gradually expand access to the VA model of care for all Americans.
Adopting the VA model, with its salaried doctors and its extensive use of electronic information technology and evidence-based medicine, would cure the American health care crisis. Throwing more money into the current, fragmented, profit-driven system without changing the actual practice of American medicine might ease the problems of the uninsured temporarily, but would also give us more inappropriate, sometimes dangerous, and ever-more-expensive care.
The bottom line is that if any Democratic candidate is serious about health care as an issue - yes, even Obama or Edwards, our putative "transformational" and "progressive" champions - then why aren't they talking about the VA? Why haven't they invoked it?
Maybe it is up to us, the netroots, to educate our erstwhile champions about this.
As far as I am concerned, Hillary's proposal (re-elect me in 2012 and I'll have healthcare solutions by the end of my second term) is a nonstarter. Obama and Edwards have complicated plans on the table that try to address speccific shortcomings that they perceive to be important. Fair enough. But in the case of health care, true transformational change is what is needed to really change the fundamental financial dynamic of the business of medicine. I don't think that either Edwards or Obama have really made the case that their untested ands complex proposals really fix the basic problem, which is as Longman points out,
Remember first what American doctors and hospitals get paid to do. Outside the Veterans Administration and a few staff‑model HMOs, they don’t get paid to keep and make patients well. They get paid to provide treatments—and that’s a big difference. It means that most American doctors and hospitals have no economic interest in your long-term well-being, while they also have an enormous economic incentive to perform operations and procedures for which Medicare and private insurance pay well. The result is a systematic bias toward the overtreatment of patients—and particularly of those who are well insured—and a simultaneous neglect of prevention and well-being.
HillaryCare, HillaryCareLite or HillaryCareNuevo just aren't going to address this fundamental problem. The first candidate to step to the plate and say, "let's start over - and extend the VA system to all Americans, effective immediately." will send a shock wave through the system. Coupled with a trebling of the VA budget, to be used to simply epxand facilities across the country to handle increased capacity so that any American can walk in the door, we might well see the problem of healthcare in America and the plague of murder by spreadsheet vanish in a generation.
THAT's transformational, progressive reform of American medicine. Obama, Edwards, are you listening?
Labels: Edwards, healthcare, Obama
Friday, April 27, 2007
An intriguing hypothesis argued poorly http://scienceblogs.com/insolence/2007/04/peter_duesberg_chromosomal_chaos_and_can.php#comment-414320
Below the fold, I am reprinting a post I made at Dean's World which basically is a rehash of Orac's critique/endorsement of Peter Duesberg's ideas about aneuploidy in cancer.
Cancer surgeon and researcher Orac reviews Duesberg's SciAm piece about cancer aneuploidy over at Scienceblogs, and has a lot of insightful comments. Overall, he credits Duesberg with promoting an interesting hypothesis, though he rightly shoots down the ridiculous notion that Duesberg work on AIDS is in any way relevant - positively or negatively - to his cancer theory:
Orac then goes on to consider the aneuploidy hypothesis on its own merits, completely independently of his opinion about the HIV issue.
He starts out with some history about the aneuploidy hypothesis, which he notes has been around for about 50 years:
In a nutshell - aneuploidy is an old idea, and Duesberg isto be credited with reviving it, but the renewed interest in it is not solely due to Duesberg's advocacy.
In fact, it seems that the issue of gene mutation vs aneuploidy in cancer is really a chicken and egg problem, like the nature vs nurture debate on child rearing. Duesberg takes oe extreme, but the mainstream science on cancer aneuploidy is hardly at the other extreme, if anything it's largely in the middle.
And Duesberg very much occupies the extreme end of that spectrum -
Orac points to this concise summary by grrlscientist of Duesberg's arguments in support of this perspective. In a nutshell, these arguments are:
Orac takes each of these in turn. With respect to argument 1 about risk and age, Orac notes,
And provides much more detail (I am only giving an overview, not a summary).
For argument 2, Orac asks,
For Argument 3, Orac notes that Duesberg's foundational assumption is again simply wrong:
And provides an example using asbestos (used by Duesberg too) to illustrate why.
Orac finally touches more briefly on the remaining arguments, saying that they "range from the 'so what?' to the more intriguing" and again provides details with specific counterexamples. However, he then retreats from his critical stance:
In a nutshell, Orac's beef (and keep in mind he is both a cancer surgeon as well as a researcher in the field, so his qualifications for comment are equal and greater than Duesberg's in this regard) is that Duesberg is onto something, but is overselling it as "The One True Cause of Cancer" and portraying himself as the Prophet of Aneuploidy when in fact its an old idea whose time has come:
Orac closes by quoting Walter Giaretti, of the National Cancer Research Institute in Genoa, Italy:
and notes that Giaretti's question, "Don't we have now enough experimental evidence that cancer originates and progresses with the contribution of both gene mutations and aneuploidy?" may ultimately have the answer, "Yes." - but Duesberg is dogmatically wedded to the answer being "No."
If one's goal is a genuine solution to cancer, there is no dog in the fight between aneuploidy and genetic mutation' the issue is really how much of a dependent role each of these and other mechanisms play, so that the global understanding of the system can be improved. Only that way lies the hope of a true cure.
Cancer surgeon and researcher Orac reviews Duesberg's SciAm piece about cancer aneuploidy over at Scienceblogs, and has a lot of insightful comments. Overall, he credits Duesberg with promoting an interesting hypothesis, though he rightly shoots down the ridiculous notion that Duesberg work on AIDS is in any way relevant - positively or negatively - to his cancer theory:
[Duesberg's supporters] think nothing conflating the scientific validity of Duesberg's ideas concerning cancer, which might indeed be partially or mostly correct, with his discredited hypothesis that HIV does not cause AIDS, implying that because he might be correct about cancer implies that he is correct about AIDS. It doesn't. Sorry, but the two issues are at best peripherally and weakly related and at most not related at all.
Orac then goes on to consider the aneuploidy hypothesis on its own merits, completely independently of his opinion about the HIV issue.
He starts out with some history about the aneuploidy hypothesis, which he notes has been around for about 50 years:
First, the concept that chromosomal abnormalities cause cancer dates back at least to 1914, when the German zoologist Theodor Boveri, based on studies of sea urchin development, first suggested it. Indeed, this featured prominently as a milestone in cancer research in a display in at the recent 100th anniversary meeting of the American Association for Cancer Research. Thus, the basis of Duesberg's idea is quite old. Indeed, the concept that chromosomal derangements caused cancer predominated for 40-50 years, until the solution to the structure of DNA, the elucidation of the genetic code, and study of genetics led to an emphasis on genetic causes of cancer. Combined with the observation that tumor cells are genetically unstable, leading to many mutations, the genetic hypothesis led to the discovery of oncogenes and tumor suppressors. Now, potential chromosomal causes are again being looked at, and for whatever part Duesberg's advocacy had in spurring this he is to be acknowledged, even if his boosters do have an annoying tendency to make it sound as though scientists would have zero interest in studying chromosomal causes of cancer were it not for Duesberg, which, given the attention shown to this topic at recent meetings that I've attended, is ridiculous.
In a nutshell - aneuploidy is an old idea, and Duesberg isto be credited with reviving it, but the renewed interest in it is not solely due to Duesberg's advocacy.
In fact, it seems that the issue of gene mutation vs aneuploidy in cancer is really a chicken and egg problem, like the nature vs nurture debate on child rearing. Duesberg takes oe extreme, but the mainstream science on cancer aneuploidy is hardly at the other extreme, if anything it's largely in the middle.
On the one extreme, there is the argument that aneuploidy is the primary cause of cancer, causing the accumulation of genetic mutations through breaks in chromosomes. On the other extreme is the argument that aneuploidy is a consequence, not a cause, of cancer. Duesberg, as you may guess, takes the extreme version of the former view. These days, most other scientists studying this question tend to consider both important to varying degrees in the development of cancer, the present pressing scientific question being: Which causes which and how? It's very much a chicken-or-the-egg problem. Does mutation lead to aneuploidy or aneuploidy lead to large numbers of genetic derangements that lead to cancer? Or are both aneuploidy and mutation responsible in differing proportions depending on the cancer?
And Duesberg very much occupies the extreme end of that spectrum -
In essence, he argues that aneuploidy comes first and is the prime inciting event that starts the cascade of genetic changes that lead to malignancy. DNA is damaged, either through mutagens or other causes, and then, through what becomes a self-catalyzing process, aneuploidy leads to progressive chromosomal alterations that lead to increasingly widespread genetic alterations in a process that feeds on itself, leading to chromosomal instability and cancer. Indeed, Duesberg postulates that carcinogens work as "aneuploidogens" rather than as mutagens.
Orac points to this concise summary by grrlscientist of Duesberg's arguments in support of this perspective. In a nutshell, these arguments are:
- Cancer risk increases with age. Lamentably common, cancer afflicts about one in three people at some point in their lives, but mostly after the age of 50, which is when chances for malignancy soar. Thus, cancer is, by and large, a disease of old age. The gene mutation theory of cancer's origins, however, predicts that the disease should be quite common in newborns.
- Carcinogens take a very long time to cause cancer. Numerous chemicals and forms of radiation have been shown to be carcinogenic in animals or established as the source of occupational or accidental cancers in humans. But even the strongest carcinogens at the highest survivable doses never cause cancer right away. Instead the disease emerges only after delays lasting years or even decades. In contrast, when substances known to cause gene mutations are administered to bacteria, the cells begin displaying new phenotypes within hours; in larger organisms such as flies, the effect is seen within days.
- Carcinogens, whether or not they cause gene mutations, induce aneuploidy. Scientists have looked for the immediate genetic effects of carcinogens on cells, expecting to see mutations in many crucial genes, but instead have found that some of the most potent carcinogens known induce no mutations at all. Examples include asbestos, tar, aromatic hydrocarbons, nickel, arsenic, lead, plastic and metallic prosthetic implants, certain dyes, urethane and dioxin. Moreover, the dose of carcinogen needed to initiate the process that forms malignant tumors years later was found to be less than one-thousandth the dose required to mutate any specific gene. I
- Patterns of aneuploidy are seen in different tumors
- Gratuitous traits do not contribute to cancer's survival
- Cancer cells change much faster than genes
Orac takes each of these in turn. With respect to argument 1 about risk and age, Orac notes,
This argument is a strawman and neglects other factors, to boot. For one thing, contrary to what Duesberg states, the "gene mutation theory of cancer" does not necessarily predict that cancer should be quite common in newborns.
And provides much more detail (I am only giving an overview, not a summary).
For argument 2, Orac asks,
Does anyone see the flaw in an argument comparing humans to bacteria or flies in this manner? Let's look at flies, because they are eukaryotes. The average lifespan of, for example, Drosophila is much shorter than a human's, on the order of 30 days or so. Carcinogens generally require cellular replication before cancer can develop. So, let's see, a latency period for cancer after exposure to carcinogens of few days in the life of a fruit fly like Drosophila is not unlike a latency period of a couple of decades in a human, if you compare it to the organism's overall life span. Bacteria reproduce amazingly rapidly; so it is not surprising that they respond to chemicals even faster. As for strong carcinogens not causing cancer right away, nothing in the genetic mutation theory of cancer demands that they must, particularly given that strong doses may result in more deleterious mutations and that the ability of a normal cell to repair its own DNA is quite prodigious.
For Argument 3, Orac notes that Duesberg's foundational assumption is again simply wrong:
Sure, carcinogens induce aneuploidy, but just because some carcinogens do not directly damage DNA does not necessarily mean that the induction of aneuploidy must be the mechanism by which they cause cancer. It might be, but it doesn't necessarily have to be.
And provides an example using asbestos (used by Duesberg too) to illustrate why.
Orac finally touches more briefly on the remaining arguments, saying that they "range from the 'so what?' to the more intriguing" and again provides details with specific counterexamples. However, he then retreats from his critical stance:
Lest one think that I'm hostile to Duesberg's hypothesis, let me disabuse you of the notion right now. Although I think Duesberg's an utter crank and pseudoscientist when it comes to his HIV/AIDS denialism, I find some of his work in cancer intriguing, and I disagree with Mark and Larry that it was such a horrible thing to feature him in an article in Scientific American, especially given the disclaimer. It is clear to me that epigenetics (cellular factors other than genes that regulate gene activity) and chromosome structure are very important in carcinogenesis, more so than had been appreciated before.
In a nutshell, Orac's beef (and keep in mind he is both a cancer surgeon as well as a researcher in the field, so his qualifications for comment are equal and greater than Duesberg's in this regard) is that Duesberg is onto something, but is overselling it as "The One True Cause of Cancer" and portraying himself as the Prophet of Aneuploidy when in fact its an old idea whose time has come:
What really irks me about Duesberg with respect to his ideas about cancer is that he may be on to something, but he can't seem to stop himself from the same black-and-white, either-or thinking that apparently led him down the road of HIV crankery, nor can he seem to resist massively overselling his hypothesis as the be-all and end-all hypothesis to explain cancer initiation and progression. As I said at the beginning of my post, whenever someone postulates theirs as The One True Cause of Cancer, my skeptical antennae start twitching, and Duesberg's aneuploidy hypothesis is no exception. Cancer is a complex and resourceful foe, not to mention that it's hundreds of different diseases, not a single disease. Duesberg neglects a variety of other new hypotheses for causes of carcinogenesis that hold equal or greater promise than the chromosomal chaos hypothesis. Among these are cancer stem cells, tumor angiogenesis, and the aforementioned metabolic hypothesis of cancer (a.k.a. the Warburg effect). He even neglects what I consider to be a far more fascinating and sophisticated version of the chromosomal hypothesis, specifically Tom Misteli's concept that derangements in the higher order three dimensional structure of chromosome territories can lead to cancer by alterations in gene expression.
Orac closes by quoting Walter Giaretti, of the National Cancer Research Institute in Genoa, Italy:
It is likely that new studies directly comparing DNA copy number and gene expression will be performed in the near future on the role of aneuploidy in cancer, on what genetic events may induce chromosomal instability and on the validation of novel criteria for early diagnosis. It is predictable that these studies will vanish the conflicting views that either aneuploidy or gene mutations are a unique cause of the origin and progression of cancer negating the role of the alternative mechanism. Today, these conflicting interpretations are increasingly being abandoned to let a more complex mixed paradigm take over from previous concepts. In brief, ideas stemming from the old Boveri theory and from the modern theories may soon be seen as cooperative and equally important to cancer.
and notes that Giaretti's question, "Don't we have now enough experimental evidence that cancer originates and progresses with the contribution of both gene mutations and aneuploidy?" may ultimately have the answer, "Yes." - but Duesberg is dogmatically wedded to the answer being "No."
If one's goal is a genuine solution to cancer, there is no dog in the fight between aneuploidy and genetic mutation' the issue is really how much of a dependent role each of these and other mechanisms play, so that the global understanding of the system can be improved. Only that way lies the hope of a true cure.
Labels: aneuploidy, cancer
Wednesday, April 25, 2007
Congratulations to Matt Yglesias http://www.matthewyglesias.com/archives/2007/04/everlarger_media_matt/
Matt Yglesias is leaving The American Prospect, and will be working for The Atlantic Monthly. I think that of the triumvirate of liberal policy magazines (TAP, The Washington Monthly, and The Atlantic), this is the best fit for Matt who is a pragmatic liberal interventionist on the foreign policy front and an unabashed liberal on the domestic. In other words, very purple. I had the pleasure and honor of blogging alongside Matt for a while myself and he's a formidable wonk in his own right. I think that his blogging at TAM will do a lot to broaden the appeal of purple politics amongst the left-wing of american political discourse - a perspective that is almost wholly absent (or at least, drowned out) by the leading progressive policy portals like Daily Kos. The ultimate goal of any policy writer is to influence policy, and in that regard Matt's ascension is great news for everyone.
It's also worth remembering that the last merit promotion of this sort was when Blake Hounshell moved from American Footprints to become web editor of Foreign Policy magazine. This sort of thing is a great trend.
Congratulations to you, Matt. And congratulations to TAM, too.
(aside: IMHO TAM would be well-served by following the Washington Monthly/Kevin Drum model and having Matt's blogging be the primary content on their front page site).
via Ezra and Brian, both of whom I have also had the distinct honor of blogging alongside in the past.
It's also worth remembering that the last merit promotion of this sort was when Blake Hounshell moved from American Footprints to become web editor of Foreign Policy magazine. This sort of thing is a great trend.
Congratulations to you, Matt. And congratulations to TAM, too.
(aside: IMHO TAM would be well-served by following the Washington Monthly/Kevin Drum model and having Matt's blogging be the primary content on their front page site).
via Ezra and Brian, both of whom I have also had the distinct honor of blogging alongside in the past.
Labels: Purple
Sunday, April 08, 2007
a progressive manifesto? http://www.dailykos.com/story/2007/4/8/103855/9127
NYCO at DailyKos bemoans the lack of a unifying Manifesto under which to unite the progressive movement.
The problem with a manifesto however is that a manifesto is usually a statement of principles, followed by a statement of intended action or desired goals guided by those principles.
The principles that tie together the progressive movement are very general, universal ones. If I were to reduce it to a single sentence, I might say, "all people have an inalienable right to life, liberty, and the pursuit of happiness." But what are the roadblocks to these things?
a conservative will argue that government is the oppressor and that the market is the liberator. A liberal actually extends that, saying that govt and the market can both be oppressors, and both can be liberators. In essence, liberals allow for double-edged swords - which means now we have to take care which way we swing.
And in the decision to swing our swords of govt or markets, we will disagree. Consider the Euston Manifesto, deried by most proressives as a tool of neoconservative imperialists. I am a signatory. The principles underlying the Euston Manifesto are essentially liberal ones, not conservative ones. How then do we reconcile ourselves when we interpret the end products of the shared principles so differently?
At Nation Building I am an advocate of principled pragmatism and liberal interventionism. note the qualifiers: liberal, pragmatic. Therein lies the rub. I think that we need to focus on the principles, and recognize that they are universal enough to lead us on different paths. But as long as the tent is a big one, I dont think a true manifesto can ever be drafted. Nor does it necccessarily need to be if instead we think of the progresive movement as an encouragement away from mono-thinking and conventional wisdom and towards the grecian ideal wherein we are all philosopher kings, and the wisdom of the majority is fueled by the wisdom of the individual.
The problem with a manifesto however is that a manifesto is usually a statement of principles, followed by a statement of intended action or desired goals guided by those principles.
The principles that tie together the progressive movement are very general, universal ones. If I were to reduce it to a single sentence, I might say, "all people have an inalienable right to life, liberty, and the pursuit of happiness." But what are the roadblocks to these things?
a conservative will argue that government is the oppressor and that the market is the liberator. A liberal actually extends that, saying that govt and the market can both be oppressors, and both can be liberators. In essence, liberals allow for double-edged swords - which means now we have to take care which way we swing.
And in the decision to swing our swords of govt or markets, we will disagree. Consider the Euston Manifesto, deried by most proressives as a tool of neoconservative imperialists. I am a signatory. The principles underlying the Euston Manifesto are essentially liberal ones, not conservative ones. How then do we reconcile ourselves when we interpret the end products of the shared principles so differently?
At Nation Building I am an advocate of principled pragmatism and liberal interventionism. note the qualifiers: liberal, pragmatic. Therein lies the rub. I think that we need to focus on the principles, and recognize that they are universal enough to lead us on different paths. But as long as the tent is a big one, I dont think a true manifesto can ever be drafted. Nor does it necccessarily need to be if instead we think of the progresive movement as an encouragement away from mono-thinking and conventional wisdom and towards the grecian ideal wherein we are all philosopher kings, and the wisdom of the majority is fueled by the wisdom of the individual.
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About Nation-Building
Nation-Building was founded by Aziz Poonawalla in August 2002 under the name Dean Nation. Dean Nation was the very first weblog devoted to a presidential candidate, Howard Dean, and became the vanguard of the Dean netroot phenomenon, raising over $40,000 for the Dean campaign, pioneering the use of Meetup, and enjoying the attention of the campaign itself, with Joe Trippi a regular reader (and sometime commentor). Howard Dean himself even left a comment once. Dean Nation was a group weblog effort and counts among its alumni many of the progressive blogsphere's leading talent including Jerome Armstrong, Matthew Yglesias, and Ezra Klein. After the election in 2004, the blog refocused onto the theme of "purple politics", formally changing its name to Nation-Building in June 2006. The primary focus of the blog is on articulating purple-state policy at home and pragmatic liberal interventionism abroad.
