Tuesday, January 27, 2004

Update: Increasing Assets For The Poor

Ms. Frog of frogblog followed up on my post about Harold Ford's "American Stakeholders" proposal by pointing me towards the work of Michael Sherraden, a Washington University professor who studies asset creation policies.

You can read about his work here and here. I found it quite cheerfully encouraging - he's found that small, practical programs to encourage savings are highly effective, even among the very poor - people traditionally considered to be unthrifty and improvident.
the fact is that poor people can and do accumulate assets, and Sherraden has the data to prove it. Participants in programs of matched savings called IDAs, which resemble 401(k) retirement plans, have saved an average of $33 per month and 71 cents of every dollar that could be saved or matched. Interestingly, the 43 percent of participants monitored whose incomes are below the poverty line save almost as much as other program members, and save a much larger portion of their income.

Monday, January 26, 2004

Garance Franke-Ruta Gets It Right About Dean

If you've ever spent time in the medical arena you know that being a physician is something very different from being an attorney, which is what John Edwards, John Kerry, and Joe Lieberman are. Your stance to the world is simply different if you're a physician, because -- outside of a few specialties, like plastic surgery -- your power doesn't come from how you look or how you appear or even how you sound. It comes from your knowledge and the capacity to do things no one else is authorized to do in their daily lives -- to touch bodies, to demand of individuals, to prescribe courses of action -- and from the human power of interaction. You can't convince people to be healed, no matter how eloquently you speak about disease and suffering or what you wear. You have to actually do something to make a person better. You also have to do the right thing. And if you don't, the consequences can be dire and literally deadly. (from Tapped.)
As someone who works in medical settings and grew up in a medical family, this strikes me as absolutely correct. Howard Dean has the consummate physician's personality. He's brash, direct, impatient, and forceful. He's very, very certain about his positions. But he's also ready to change his mind if presented with convincing new data - at which point he'll be very, very certain about the new position. Doctors pretty much have to be that way.

It makes him stick out like crazy in a field of politicians and lawyers, because he doesn't place the same emphasis they do on carefully crafted nuances of language. I imagine that he's just plain baffled by the constant accusations that he's "flip-flopped" on this issue or that. For a doctor, there's nothing wrong with changing your diagnosis and your plan in the face of new information, or changed circumstances. But the other candidates and the media seem to see it as a cardinal sin.

Gov't Handouts For Demon Youth?

Harold Ford, Jr. had a thought-provoking op ed in Sunday's Washington Post, outlining a couple of proposals intended to build assets among people with moderate income.

His central proposal is to provide "American Stakeholder Accounts" of $1000 in investment funds for each child born in the United States ($2000 for children born into families below the poverty line). The accounts would accrue interest until the child was 18, at which point the money could be withdrawn tax-free and used for... well, whatever the kid wants to use the capital for, I suppose. Ford offers a list of sober, reasonable choices - "to pay college tuition, purchase a home, start a business or invest for retirement" - but his program is modeled after a British program in which, apparently, the 18-year-old recipient just gets free ownership of the money.

I don't think this program will ever get off the ground, if only because the primary beneficiaries are teenagers - one of the most despised groups in America. But it's an interesting prospect. My cynical initial reaction was that we'd see more 18-year-olds driving nice cars than ever before, but in retrospect, that may be unfair. Maybe kids who grew up knowing that they'd have a financial stake coming to them would think about money differently. Our society currently treats youth as irresponsible children who can't be trusted to make their own choices, and who can be expected to be dependent on adults until somewhere in their mid-twenties. Accurate perception, or self-fulfilling prophecy?

We'd certainly have to start raising and educating teenagers differently if we knew that, at the end of their minority, they'd all have full control of $6,000 or so. We could, of course, put heavy restrictions on how the money could be spent. It could be limited to the list of adult-approved uses Ford suggests, things like college tuition or job training. But it would be far more interesting to provide a mandatory high school course in money management - principles of investing, for example, and how to avoid scams - and then just turn young adults loose. Maybe they'd want to pour the money into world travel or political activism or the charity of their choice or a really nice ride. Maybe they'd waste it all on clothes and CDs, and in six months they'd be crying that it was all gone. Probably they wouldn't make the precise choices that adults would make for them.

But growing up conscious that, at a defined age, they'd be handed the adult-level status and responsibility that comes with a significant amount of money to spend or invest - that just might push back the ludicrously extended adolescence our society has imposed on young people, and prompt them to take themselves seriously, as adults. In turn, it might prompt adults to take them more seriously, as well. I'm all for that.

Friday, January 23, 2004

Euthanasia, Part 2a: Prospects At The End Of Life - Pain

A 2002 comprehensive state-by-state review of end of life care found that dying people in America have inadequate access to pain control and specialized support services. Seventy percent would prefer to die at home; only 25% do. Most do not have access to hospice care or don't receive the full suite of available hospice services. Dying people fare better with access to palliative care, which is treatment that focuses on relieving pain and suffering rather than attempting to cure disease. But only 17% of community hospitals and 26% of academic heath centers have specialty teams for palliative care. The American Pain Society reports widespread problems with insufficient pain control at the end of life.

It's no wonder that many of these people decide that they want to kill themselves. But it doesn't have to be that way.

State-of-the-art pain treatment is phenomenal. It encompasses narcotic and non-narcotic painkillers; slow-release narcotics that don't cause heavy sedation; medicines that increase the effect of painkillers, such as muscle relaxants or low-dose antidepressants; biofeedback; hypnosis; acupuncture; nerve blocks; nerve stimulation; and even the surgical implantation of tiny painkiller pumps near the spinal cord. The American Pain Society estimates that over 90% of dying patients can receive adequate pain relief without being overly sedated, and that pain relief can be accomplished with sedation in the rest. But most dying patients are offered only narcotic pills or injections, in increasingly larger doses. With narcotics come undesirable side effects: nausea, constipation, depression, over-sedation. And doctors may be reluctant to prescribe sufficient quantities of narcotics for pain relief, either for fear that the drugs will be abused, or for fear that they will depress breathing and perhaps hasten death.

Why is there such an enormous gap between the possible and the actual? Because specialty pain treatments are complicated and expensive. Not many doctors are experts in pain management, and patients may not be referred for pain services even when they are available - only 20% of patients with chronic uncontrolled pain are seen at specialty pain clinics. Costs are also a complicating factor: insurance companies would certainly rather pay for an inexpensive morphine injection than an epidural medication delivery system. In many states, funding for skilled home nursing care is limited; thus, patients who can benefit from, for example, patient-controlled analgesia pumps may need to choose between the desire to die at home and the desire for appropriate non-sedating pain control. This is despite the fact that dying at home, even with a visiting nurse in attendance, is significantly cheaper for the overall health care system than dying in a nursing home or the hospital.

Pain, and the fear of pain, are major justifications for Physician-Assisted Suicide (PAS). Proponents of PAS have assured me that pain often cannot be controlled in terminal illness. If that is true, it might be a legitimate argument for the availability of PAS - but the pain control available to most dying people falls so far short of adequacy that the proposition can't even be said to have been tested.

Adequate pain control will be more expensive. Increased access to palliative care will require expansion of the health care system in a direction that is not generally profit-enhancing. But ethically, can we as a society ask dying people to choose between suffering and killing themselves, in order to save the rest of us some money?

Good News/Bad News

Limestone's HIV-positive inmates admitted to education, work programs
Classes now open to HIV inmates

Buried deep in both of these articles is a one-sentence acknowledgement that this good news, this display of enlightenment, applies only to male prisoners. Female prisoners with HIV are still segregated in Alabama prisons, barred from attending GED classes, drug treatment groups, or job training. The Alabama Department of Corrections doesn't seem to see any pressing reason to change that policy, probably because, unlike the men, the women aren't suing in federal court.

This story's also been covered extensively in the gay press, for example, here. The gay press articles do mention in the lead sentence that HIV+ women continue to be denied access to education, but what they leave out is a lot weirder.

"Alabama still remains out of the mainstream in housing HIV-positive prisoners separately from others," cautions 365gay.com. Here's what they don't say, courtesy of the Birmingham News:
Less than a year ago, an AIDS doctor visited the facility and found deplorable conditions. Sick prisoners living in a vermin-infested warehouse were denied basic medicines and, at times, left to die by an overwhelmed medical staff, according to a report filed last year in the federal lawsuit.
The gay press usually does a great job of covering AIDS advocacy issues. So how come, reading their coverage, it would be easy to come away with the impression that the worst thing that was happening to those inmates was the denial of GED classes, and that their greatest lingering problem is that they're not being given HIV-negative cellmates?

Wednesday, January 21, 2004

Go, Otter, Go!

My Significant Otter is en fuego over in the comments section of Obsidian Wings:
I spent years preparing myself to give my life in the service of my country if necessary, and I believe that the least that my country owes me in return is telling me the truth when it comes to what we need, and what we spend our money on. Don't piss on my hands and tell me it's raining, for God's sake!

If we need to all shell out to make sure that we can check incoming cargo containers for hidden nukes, or to pay for draining a terrorist swamp in Iraq, then I'm OK with that. Just don't say that only those making less than some particular amount get to shell out more money to cover it. Don't tell me that gay people don't get the same rights as Britney Spears. Don't tell me that massive deficits and tax cuts go together like beer and pretzels. Don't tell me that we can get along with half-assed planning for rebuilding Iraq. Don't tell me that you think all of us out here in the 50 states are morons, who can't be trusted to follow whatever line of reasoning you want to provide for your actions.
There aren't individual comment links, but scroll down to the post from Michael N. at 2:04am. It's worth reading the whole thing.

Now That Iowa's Over

Calpundit linked to this nicely-presented site, which supplies poll data for upcoming primaries through Feb 3. Some of the data is pretty old (Oklahoma was apparently last polled before Christmas), and none of it, of course, is post-Iowa. But it does raise some interesting points:

Gephardt, of course, was killing in Missouri. He had 37% in the polls as of 1/11/04, compared to Dean's 19% and Clark's 15%. Now that he's dropped out of the race, where will his supporters go? My money says they don't go to Dean - the Dean/Gephardt rivalry in IA got too nasty. I would've had trouble crossing over to Gephardt if Dean had dropped out, and I'm guessing that the reverse will also be true. Kerry could really make out here, if he can convince Gephardt supporters that he's the closest equivalent. But it's definitely time for a new MO poll!

Kerry's definitely got a shot at winning New Hampshire. But in every Feb 3 state, he's trailing the leader by at least 10 points. In Arizona, Oklahoma, and South Carolina, he's trailing the leader by more than 20 points. How much will his IA win help in these southern states? I'm guessing that they don't really look to IA for their political guidance. On the other hand, if he also wins New Hampshire, there will begin to be a certain aura of inevitability about him that will probably influence voters in later contests.

Edwards' surprisingly good performance in IA could give him enough of a boost to take South Carolina. But he's nowhere right now in the other Feb 3 states, which are all about Dean and Clark. I don't think Edwards has a strong enough organization nationwide to be able to take advantage of his IA boost, but then again, I would've said that he didn't have a strong enough organization to get the IA boost in the first place.

The upcoming set of contests are all primaries, rather than caucuses. (Huh, wait. Apparently, New Mexico has a caucus. How come I've never heard of that before?) That should make the poll data more reliable, because polls are closer in structure to a standard election ("pick your favorite candidate, and then go home") than they are to the horse-trading and vote-shifting caucuses.

I wonder how long it will take for Lieberman to drop out.

Monday, January 19, 2004

Eighteen? Eighteen?

Well, sure shows you what I know, doesn't it?

This is so crazy, I don't even begin to know what to make of it. The polls as of yesterday showed a four-way tie, too close to call, but these results aren't close at all. This is a slaughter of the two candidates who seemed to have Iowa locked up between them.

I'm not even going to begin trying to analyze it. I'm just going to shake my head and be dazed for a while.

Euthanasia, Part 1: The General Argument

(See the prologue to this series here.)

I've struggled a little bit with how to put this series together, because my argument seems to me to be a vast edifice with a lot of intricate components. My current position has evolved over several years, through my psychological education, my political and social experience in the disability rights movement, my clinical work with incurably ill patients, and my personal experiences. It's hard to see how to convey all of those ideas and perspectives at once, in the short attention span theater that is the blogosphere. So I've decided to lay out my general thesis here, and to address the supporting framework of arguments and evidence in subsequent posts, as outlined below.

My argument is that euthanasia and physician-assisted suicide (PAS) seem to be good ideas only because society offers grossly inadequate care and resources to people who are severely disabled or terminally ill. Most people underestimate the degree to which it is possible to relieve pain, distress, and suffering in persons who are disabled or dying. Instead, people tend to see depression, despair, futility, and intolerable suffering as rightful and unchangeable elements of the end of life, rather than seeing them as reasons for intervention or as appalling failures of care.

I further argue that many people in western cultures are so personally afraid of disability and dependency that they see suicide as a rational response to incurable illness, but to no other human problem. As a result, evidence of depression is often overlooked in ill or disabled persons who are suicidal, and some incurably ill or disabled persons experience pressure to refuse life-prolonging medical treatment. Considering all of these factors, I believe that PAS cannot be safely administered.

Future posts in this series:
Part 2: Prospects at the end of life.
Part 3: Prospects for the lives of people with incurable illnesses or disabilities.
Part 4: Case study: PAS and euthanasia in the Netherlands.
Part 5: Screening PAS candidates for depression: what's a psychologist to do?
Part 6: I'd rather die: Fears of disability.
Part 7: "Mercy killings" in the courts and in the press.
Part 8: Another definition of death with dignity.

But first, before we continue, a few definitions:

Euthanasia is when a physician actively administers lethal drugs to a patient. PAS is when a physician prescribes a lethal dose of drugs for a patient to self-administer. PAS is legal in the state of Oregon, although contested by the federal government; euthanasia is legal only in Belgium and the Netherlands.

PAS is not the same as stopping medical treatment or refusing medical care, both of which are legal everywhere in the United States and Canada. Ill persons always have the right to request "no heroic measures" or a "do not resuscitate" order, and to refuse or stop life support or lifesaving treatments. (You can pro-actively spell out your preferences in an advance directive, so that your family and doctors know what you want. I recommend it.)

Sunday, January 18, 2004

It's Always Worse Than It Initially Seems

The Bush Administration's proposal to spend $1.5 billion dollars on marriage promotion is not just a condescending, wasteful, embarrassing nanny-state sop to social conservatives. It's worse than that. The $1 billion in federal money (the rest comes from the states) will be drawn from the Temporary Assistance for Needy Families budget. So that makes the marriage promotion bill a condescending, wasteful, embarrassing, nanny-state sop to social conservatives that takes food out of poor children's mouths.

Which, incidentally, makes Wade F. Horn, assistant secretary of health and human services for children and families, a liar:
Dr. Horn said this is all the Bush administration is aiming to do. "Marriage is not the administration's antipoverty program," he said, pointing out that no money was diverted from any other program to pay for the new proposal. "It's an issue of addition, not subtraction. This will add options and opportunities, not take away from them.''
I suppose that from Dr. Horn's point of view, marriage education is a form of "assistance" for needy families, and thus doesn't involve the diversion of funds from one program to another, but a happy new diversity in the types of assistance available.

Anyone else buying that?

Friday, January 16, 2004


As you probably have noticed, I've added an adorable picture of sea otters to the sidebar. I'm hoping that you're noticing because the otters are so cute, and not because it's messed up the way my blog looks in your browser. If it does look odd, could you please leave a comment telling me what browser and version you use? I'm pretty new to this whole HTML coding thing, but I'll try to fix it if it isn't working.

Update: Otters regretfully removed until I can get some advice about how to make them look good in non-IE browsers. Alas.

Three Hypothetical Situations

[1] Your house burns down, killing your wife and child and destroying all of your possessions. You've lost everything that matters to you, and you can't imagine starting over again with nothing. You can't go on living with the pain, so you decide that you want to commit suicide. Fortunately, your family, friends, and doctors are approving and supportive - they agree that it would be a mercy to end your life at once.

[2] You've never had a romantic relationship or even any close friendships, and you wouldn't even know where to start trying to establish one. You don't think you add anything of value to the world. You feel desperately lonely every day of your life. You can't go on living with the pain, so you decide that you want to commit suicide. Fortunately, your family, acquaintances, and doctors are approving and supportive - they agree that it would be a mercy to end your life at once.

[3] You've been diagnosed with an incurable illness. You can feel yourself getting weaker and less able to keep up with your normal activities, and you know that your condition is likely to worsen until you die. You hate the idea of depending on others. You can't go on living with the pain, so you decide that you want to commit suicide. Fortunately, your family, friends, and doctors are approving and supportive - they agree that it would be a mercy to end your life at once.

If you're like most people, you think that my first two hypothetical situations are appalling and sad, but the third one makes a fair amount of sense. What makes that third story so different? Over the next few weeks, I'm going to be exploring that question in a series of posts about euthanasia. Stay tuned.
Top Ten Reasons Why Bush Wants To Go To Mars.

Junk Science

[A] Bush administration plan would require new health and environmental regulations to rely more solidly on science that has been peer-reviewed.
Doesn't that sound like a good idea? Isn't peer review one of the major foundations of the scientific process?

Well, no. Or at least, not like this.

Research that's published in scientific journals has already been peer-reviewed. When a scientist submits an article for publication, the journal editor sends the article out to several experts in the field, who critique the method of conducting the study and the interpretations of the results, looking for flaws, errors, and overstatements. Typically, at least some of the reviewers are the author's major scientific rivals. Once the article appears in print, further peer review occurs in the forms of letters, commentaries, and review articles by other scientists. It's a brutal but thorough process.

But the Administration doesn't mean this system at all. They mean to set up a new layer of peer review, which will occur not in the independent community of scientists but under the auspices of the White House Office of Management and Budget. And they mean to heavily slant the peer review process towards industry-funded scientists.
It lays out specific rules regarding who can sit on peer review panels -- rules that, to critics' dismay, explicitly discourage the participation of academic experts who have received agency grants but offer no equivalent warnings against experts with connections to industry. And it grants the executive branch final say as to whether the peer review process was acceptable.
Governmental agencies are a major, dominant source of research funding in the United States. Excluding researchers who have received grants from the government quite simply means excluding most independent researchers.

Imagine a "peer review" devoted to the question of whether some chemical process increases cancer risk. Researchers funded by the National Cancer Institute and the National Institute of Environmental Health Sciences would be completely excluded from participation, and the task of reviewing the adequacy of the scientific evidence would fall instead to researchers in the pay of, for example, the American Chemistry Council and the National Association of Manufacturers. The White House would be the sole arbiter of whether the peer review was fair.

Rep. Henry Waxman has been doing a yeoman's job of documenting the distortion and perversion of science under the Bush Administration. This is a fairly subtle example, and likely to slip under the radar despite the number of scientists and former regulators who are opposed. They've hijacked an undisputed scientific good, peer review, and used that language to cloak their industry bias in respectability. If these new rules go into effect, you can expect to see forty years of environmental and health standards quietly rolled back. It will be a public safety disaster.

Thursday, January 15, 2004

Mission to Mars.

Hey, I'm a science fiction fan - of course I support the space program. And I've never understood how we could go to the moon and then just... stop. But I don't think I'm just being a sour-grapes Democrat when I say that I don't trust these guys in charge of the mission.

In so many ways it's a typical-Bush ploy to get credit through exploiting a symbol, without promising much of substance. $12 billion in space funding!! ...of which only $1 billion is new money, which works out to less than a 2% increase in NASA's budget. The other $11 billion will be taken away from existing space programs - most of which, I understand, were not exactly overfunded to begin with. (It reminds me of his often-invoked promise of $15 billion for AIDS funding. He acknowledged himself that $5 billion of that money would be taken from existing AIDS programs, yet he consistently gets credited in the press for the whole $15 billion.)

Of course, as Calpundit points out, no one thinks we can get to the moon and Mars with $12 billion dollars. Bush Senior's administration estimated the total price would be around $500 billion - and that was fifteen years ago. Bush will get the credit for his bold visionary strategy, and some poor President and Congress down the road will have to figure out how to pay for it - just as they'll be figuring out how to pay for his Medicare prescription drug bill and his tax cuts, both of which also delay their full impact until after he leaves office.

I know that at least one space scientist reads my weblog, so I have to ask... Bush says:
"Lifting heavy spacecraft and fuel out of the Earth's gravity is expensive. Spacecraft assembled and provisioned on the moon could escape its far lower gravity using far less energy and thus far less cost."
My question: does this even make sense? The way I figure it, if we're going to build the Mars vehicle on the moon, that means we'll have to ship all of the raw materials for the Mars vehicle, all the equipment used to build it, either all the fuel to power it or all the refinery equipment needed to extract and process fuels from the moon (I don't even know if that option is possible, but Bush says it might be), and all of the workers involved in building it - plus everything needed for those workers' life support. How can that be cheaper and more energy-efficient? Am I missing something?

I know that low-gravity space shipyards appear with great regularity in science fiction, but I don't see how they can possibly be superior to earth-based construction unless you're building an entire fleet and thus getting economies of scale - or unless you're establishing a full colony, such that all of those people would be up there and developing industries anyway.

Wednesday, January 14, 2004

Wednesday's Sunday Baseball Blogging

So Roger Clemens will be pitching for the Astros.

Roger Clemens, famous for his beanball... Roger Clemens, fourteenth on the all-time list for hit batsmen [1]... Roger Clemens will be in the batter's box facing Major League pitching every fifth day.

Hee hee hee.

[1] Actually, that statistic is a little unfair. If you look at the number of hit batsmen per inning pitched, Rocket comes out way ahead of guys like Cy Young (#6) and Nolan Ryan (#8).

A Simple Plan

Okay. I know that, like shooting fish in a barrel, going after obscure Bible-Belt state legislators isn't particularly sporting. There's no challenge. But I still can't help mentioning this:
[Instead of a constitutional amendment banning gay marriage,] Graves says Congress could implement a simpler process to accomplish the same thing.

"I think the way to handle that on the federal level is for Congress to curb the jurisdiction of the federal courts to handle such matters (as gay marriage)," he said.

"They could take away their jurisdiction to handle matters like gay marriages, prayer in schools and the posting of the Ten Commandments" in government buildings.
That's a great idea! Let's repeal Article III of the United States Constitution, because that will be simplest. At least no one can accuse him of thinking small.

(At first I thought that he just wanted the First Amendment repealed, but that wouldn't take away the federal courts' jurisdiction over gay marriage, which is usually based on the "equal protection" clause in the 14th Amendment and the "full faith and credit" clause of Article IV, Section 1. If his statement is to make any sense at all - which I suppose is a debatable question - it's got to involve the provision in Artlcle III that gives federal courts jurisdiction over "all cases, in law and equity, arising under this Constitution [and] the laws of the United States.")

Monday, January 12, 2004

Monday's Sunday Baseball Blogging

I'm delighted to report that "Take Me Out To The Ballgame" has been translated into Latin. The good kind of translation, too - faithful to the spirit of the original rather than slavishly devoted to word-for-word accuracy. And it rhymes both in Latin and in the back-translation to English:

Aufer me ad arenam.
Aufer me cum turba.
Da mihi glires sparsos melle.
Reditum domum non curo velle.
Pro leonibus exhortemur.
Nil refert hominum.
Duo, tria membra edent

Which, being interpreted, means:

Take me to the arena,
Take me out with the crowd.
Buy me some dormice in honeycomb
I don't care if I never go home.
So let's root, root, root for the lions
Not the humans they maim
Munching two, three more body parts
at our Caesar's game.

38 days until pitchers and catchers report, and then maybe you'll get some substantive baseball blogging. But seriously: I don't know what it is about fans of Latin that prompts them to translate just about anything into Latin, seemingly unprovoked. You don't see Ancient Sumerian hobbyists doing anything like that, do you?

(via Electrolite.)

Needle Exchange vs. Needle Legalization

New Jersey and California are considering proposals to allow IV drug users access to clean needles. These proposals come in two basic forms: setting up needle exchanges at which users can turn in dirty needles and receive clean ones, or allowing the purchase of clean syringes at drugstores, without a prescription.

Policy discussions seem to treat these options as essentially equivalent in their public health value, in that they both provide drug users with access to clean needles. Needle exchanges are backed up by a significant body of research literature demonstrating that they reduce transmission of blood-borne diseases without increasing drug use, and similar benefits are ascribed to the legalization of needle purchase. But there's no reason to believe that the benefits actually are similar.

Needle exchanges require a one-to-one trade: you get a clean needle for every dirty needle you turn in. The effect is not only to increase access to clean needles, but to decrease access to dirty needles. That's important because, if dirty needles are available, people who need a fix will use them - even if they could theoretically obtain a clean needle with a little more time, money, and effort. Dirty needles need to be taken off the streets. Legal needle purchase doesn't do that - it just increases the overall number of needles in circulation.

There are two other enormously important advantages of needle exchanges: they're free to the user, which makes them more likely to be used, and they offer a point of contact through which addicts can receive counseling and referrals for treatment. Drug users who use needle exchanges are more likely to enter rehab and more likely to get HIV tests, as well as other medical care. Legal needle purchase, on the other hand, doesn't provide the opportunity for counseling, and it assumes that people will spend money they might otherwise spend on drugs on clean needles instead. There are middle-class injection drug users for whom that might be true, but most street addicts - the ones at greatest risk for HIV and hepatitis - don't have that kind of discretionary spending capacity.

That's not to say that needle legalization has no benefits. It does increase the clean needle supply. It also increases the likelihood that users will carry their own needles. Right now, in most localities you can get busted for possessing an injection rig even if you don't have drugs on you - which makes people less likely to carry their own needles and thus more likely to share. If needle possession is legal, there will no longer be a disincentive to carry personal injection equipment.

But my cynical side says that the primary advantage governments see to legalizing the sale of needles is that it allows them to keep their hands clean. No one has to get personally involved in meeting the individual or public health needs of drug users - they can put the solutions out there and leave it to individual drug users to have the personal responsibility to access them. That's a nice ideal, but it's not what you do when you're really serious about fighting a public health threat.

Thursday, January 08, 2004

Dubious Electoral Math

Daily Kos reprinted a piece from the subscription-only Wall Street Journal, describing each of the Democratic contenders' strategies for winning the primary. Some of them are entirely plausible - for example, the Clark campaign hopes that Dean will knock out Gephardt in Iowa and that Clark will win a strong second place standing in New Hampshire, after which "Mr. Clark would move to friendly territory in the South and Southwest." That's a reasonable scenario, given that Clark's passed Kerry in the NH polls.

Kerry's supposed winning strategy, on the other hand, seems a bit further afield.
A second-place finish in the Hawkeye State would propel the Massachusetts Democrat, they argue, to parity in New Hampshire --where he now trails Dr. Dean by 20 points -- and, more than Mr. Gephardt, he could compete financially and politically in the political landscape ahead. Dr. Dean has raised twice as much money as Mr. Kerry, and the senator has been forced to dip into his personal wealth to finance some of the campaign.
Okay: Kerry's not going to finish second in Iowa. Iowa is a Dean-Gephardt race. But even if he did take second place in Iowa, it's hard to see how that would help him close a 20-point gap in New Hampshire. A "surprisingly strong finish" (as the press likes to call it) primarily boosts candidates who aren't very well-known, because they get more attention from the media and the voters. People in New Hampshire know Kerry already.

Finally, as harsh as that bit is about "Dr. Dean has raised twice as much money as Mr. Kerry," it understates the amount of trouble Kerry's in. Yes, Kerry's 2003 donations ($22.5 million, not counting the $6 mil he borrowed from himself) were about half what Dean raised in 2003 ($40 million). But quarter by quarter, Dean's fundraising has been surging ahead and Kerry's has been falling. In the first quarter of 2003, Kerry was the top Democratic fundraiser, leading Dean $7.5 million to 2.9 million. By the fourth quarter, Dean raised $15.3 million to Kerry's 2.5 million. That's more than six times as much. The trend is what really counts.

Around the Blogs

Now, this is what TTLB's new weblog showcase is supposed to be about: bringing our attention to things like The Greater Nomadic Council's explanation of the relations between advertising and "cool."

In the Liberal Coalition this week: the Invisible Library has a lovely eulogy for Emperor Norton, who died 124 years ago today. Edwardpig has more examples of Bush contradicting himself, which will be ignored by a press obsessively tracking accusations of Democratic candidate inconsistencies. Echidne of the Snakes passes on marital advice from Dr. Laura, and does a nice job of demonstrating that neither gender is well-served by the wife-as-geisha ideal. Gotham City 13 reminds us to get our talking points straight: no matter how much it might seem otherwise, Howard Dean is the angry one. (Bonus: there's a cute dog pic right below the linked post!) Also, did you know that Howard Dean supporters are terrorists-in-waiting? Thanks to And Then... for reading that stuff so I don't have to.

Dohiyi Mir has some interesting news I hadn't heard: Vermont Public Radio reported a partially mitigating circumstance for Dean's closed Vermont records. Frankly, I have trouble getting excited about the whole sealed-records thing. It shouldn't be an issue past the primary, since Bush's Texas records are also inaccessible. Steve Gilliard has the most interesting take yet on that ridiculous Club for Growth ad. (Kudos to the Atlanta Journal-Constitution for finding an Iowan who works part-time as a body-piercer in Des Moines, moonlights at a coffee shop, and is utterly unamused by the Club for Growth ad.) And Lambert at Corrente is following up on the stunning lack of national attention to domestic terrorism. Finally, more people should listen to Pen-Elayne talk about why that godawful "S-factor" meme should just be buried right now.

Good stuff all around. Check it out.

Wednesday, January 07, 2004

Hot Time In The Old Town Tonight

As avowed liberals, we here at Respectful of Otters live lives of wild and irresponsible hedonism. Tonight being the first Wednesday of the month, we're off to
a revamping of the "political love-in" from the '60s, where pot-smoking hippies would use politics as a guise for picking up dates. Now, Dean -- having "liberated" the gays of the state of Vermont by legislating civil unions, much in the same way he might imagine that Lincoln "liberated" the slaves -- is out to "free" every sex-starved, party-deprived Democrat and give them what they really want: a good time.
Seriously, if you folks have never been to boozy sex parties organized by precinct, you should give the Dean Meetups a try. I know there's nothing like letter-writing and phone banking to put me in the mood.

Unkind people might point out that Rachel Marsden, author of this fantasy, should perhaps not lecture others about sexual ethics. But that's beside the point. Marsden seems to be trying to set herself up as the next Ann Coulter, only with poorer copy editing. Given her already-demonstrated grasp of invective, innuendo, and distortion, I think she'll go far.
The problem is that the Howard Dean gravy train seems to be sputtering toward the end of its track. One can only play "rotate-a-date" for so long, even if it is for a political cause. Looks like they're running out of beer keg money on the Dean campaign trail. They've dropped the fun, playful pretense and are now resorting to flat-out desperation.

On Dec. 28, Dean's campaign manager, Joe Trippi, sent out a mass mailing to every poor sap who happened to give the "Dean for America" folks his or her e-mail address: "We need to raise $1.5 million before midnight on December 31 so we can win Iowa. With just four days left to go, we're $1.2 million short. Please take action right now, because these are the most critical days our campaign has ever faced."
That column was published three days after the Dean campaign announced that the $1.5 million goal had been exceeded by $300K - pushing Dean over $15 million for the quarter, yet another Democratic fundraising record. Doesn't sound like they're running out of keg money to me.

Now, if you'll excuse me, I'm off to pack up the bong, lube, and voter registration pamphlets. I'm due at the Meetup in six hours.

(Via Sisyphus Shrugged and others.)

More From Our Friends at Abbott

After I posted about Abbott Pharmaceuticals raising the price of one of their AIDS drugs, my Significant Otter did some poking around at Abbott's financials. They're crying poverty to the people who are now expected to pay 400% more for ritonavir, but that's not what they're telling their investors:
In 2002, Abbott achieved record sales and net earnings of $17.7 billion and $3.2 billion, respectively, with diluted earnings per share of $2.06, excluding nonrecurring charges. Abbott also recorded its 316th consecutive quarterly dividend to be paid to shareholders since 1924. In addition, 2002 marked the 30th straight year Abbott's dividends have increased. The company's Pharmaceutical Products Group - which includes U.S. pharmaceuticals, specialty products and international sales of pharmaceutical, nutritional and hospital products - generated sales of nearly $10 billion.
A nice spreadsheet summary of their 2002 finances can be found here. Note that research and development expenses represented 8.8% of net sales. Their gross profit margin was 51.9%. The return on investment to their shareholders was 28.3%. Sure, that's a lower ROI than shareholders in the late nineties could expect. You can't expect to get a 43% ROI these days, any more than you can expect to pay less than $26 a day for ritonavir. Things are tough all over.

Thanks to the fine Significant Otter and his mighty research skills.

Increasingly Misnamed Sunday Baseball Blogging

So Pete Rose finally admitted that he bet on baseball.

Most fans don't seem to care: two-thirds say he should be allowed to work in professional baseball again. On the other hand, baseball writers generally don't seem impressed.

The pro-Rose argument seems to go something like this:
If Rose admits his sins and seeks help, why should he not be allowed into the Hall?

Drugs, alcohol, drinking and driving, even murders and spousal abuse are routine headlines amongst today's stars. Where does betting rank on that list of crimes? [...]

We do live in a forgiving society. Once Rose admits his sins, it is time to forgive and elect him to the Hall of Fame.
The thing is, a lot of these folks seem willing to skim over the "Pete Rose confesses and is sorry" part. He doesn't in fact seem to be particularly sorry, or particularly aware that his actions were wrong. Look at excerpts from his ABC News interview - the rationalizations are thick on the ground. He actually tries to claim that most players barely know that betting on baseball is against the rules. He minimizes the seriousness of his offense, as Jayson Stark notes:
He speaks of how he never bet against his own team, and how he never placed a bet from the clubhouse, and how he never used "inside" information, and how he would never, ever fix a game -- no matter how much money he could have made. [...] You'll find words like "mistake" and "stupid" and "wrong" in there -- many times, in fact. But here is the only context in which he uses the word, "sorry":

"I'm sure that I'm supposed to act all sorry or sad or guilty now that I've accepted that I've done something wrong," Rose writes in the book. "But you see, I'm just not built that way."
It doesn't matter whether or not Rose ever bet against his own team. A manager who bets on some games and not others is going to make different managing choices when money is on the line. He'll use his resources differently. He might, for example, be willing to blow out his bullpen to get a win, regardless of the effects on the next few games. Rose says his managing choices were never affected by bets - as if he can make that argument credibly. No one could, but it's particularly unconvincing coming from someone who has been lying to baseball fans for fourteen years.

So what about the drug-use analogy? Darryl Strawberry doesn't have a lifetime ban, despite his sordid history of cocaine addiction, repeated arrests, and solicitation charges. Is gambling really worse than being a cokehead?

Yes. For baseball, gambling is absolutely worse than being a cokehead. Cocaine use harms the player; gambling harms the game. If you're a baseball fan, ask yourself this: Suppose that it were widely known that managers and players sometimes bet on baseball games. Suppose that when your home team lost, you could never be quite sure that they hadn't thrown the game. Would you still watch?

We still watch now, knowing that some players use steroids. We still watch, knowing that some players use illegal drugs after the games or in the off-season. Because as long as everyone on the field is doing his utmost to win, the game itself is still exciting and emotionally engaging.

If gambling on baseball is tolerated, we don't have that anymore.

Monday, January 05, 2004

2,500 Florida doctors will see their malpractice insurance rates go up by 45% in 2004.

If you're a conservative commentator, you're thinking "See? This is why we need tort reform that includes caps on damages in malpractice suits. Lawsuits are pricing doctors right out of business - here's your proof." Which would be fine, except that Florida already passed exactly that kind of legislation in August. Insurance companies were supposed to figure their 2004 rates based on the new caps.

The insurance company's justification is distinctly fishy.
``When you think about how medical costs will rise in the future, it becomes apparent that the costs of providing medical care to a plaintiff years down the road are astronomical,'' MedPro spokesman John Novaria said. ``In order to meet those costs, we have to ask for higher premiums.''
Aren't we always being told that spiraling malpractice insurance rates are largely responsible for rising health care costs? So now the insurance companies are using the prospect of higher health care costs in the future to jack up providers' insurance rates...which will increase the costs of providing care...which will lead to higher future medical costs for patients...which will justify still-higher malpractice insurance rates, because costs are expected to continue to increase.

I'm dizzy.
*clearing dust from the lectern*

This is a little technical, but stay with me.

On December 4, Abbott Pharmaceuticals raised the price of the drug ritonavir from $1.71 to $8.57 per 100mg pill.

Not many people take ritonavir in a full-strength dose anymore, and lucky for them - at the new price, it adds up to $102.84 per day even before the other two drugs in the three-drug AIDS cocktail are figured in. Ritonavir's real value is in enhancing the effects of other protease inhibitors - it keeps them in the patient's system longer, which means that the patient can take smaller amounts less often.

For example: the stand-alone dose of saquinavir is three to six 200mg pills three times a day, or 1800-3600mg per day. Combined with a couple of ritonavir pills, the dose of saquinavir drops to two 200mg pills twice a day, or 800mg - and the midday dose is completely eliminated. This is valuable partly because it increases the likelihood that patients will take all their pills, and partly because lower doses decrease the risk of side effects. It's even valuable to Abbott, because suddenly everyone wants to have ritonavir prescribed as part of their regimen or bundled with the new drug they've just invented.

Abbott markets a drug called Kaletra, which is a combination protease inhibitor (PI) that includes ritonavir. As newer PIs are approved, Kaletra's market share has been dropping. Curiously, the price of Kaletra didn't go up when the price of ritonavir went up, even though ritonavir is an ingredient in Kaletra. But of course, the effective price of every other combination of ritonavir-plus-PI went up. Patients and their doctors have three choices: they can pay extra for ritonavir; they can go back to enormous unenhanced doses of non-Abbott PIs; or they can switch to Kaletra, which hasn't risen in price.

Abbott's defense explains that they give a lot of ritonavir away (which is true) and that they've agreed not to raise prices to state AIDS Drug Assistance Programs yet. They mention their research costs, the traditional defense for high AIDS drug prices. (They don't explain how it is that their research costs have increased for a drug that's been on the market for seven years.) But their primary argument seems to be that the market will bear higher prices.
At the new price of $8.57 per 100 mg, Norvir is most often the lowest cost component of a protease inhibitor-based regimen. For example, when you combine Norvir with a regimen based on newly approved therapies such as Reyataz (atazanavir) at $22.08 per day, Norvir continues to represent a fraction, typically one-fifth, of the daily cost of therapy.
Some of the new HIV drugs are very, very expensive. Insurance companies and state programs are paying for it, and they'll eventually assume the increased costs of ritonavir as well. Kaletra will claw back a little more of the combination-PI market share.

There will be much less incentive for other companies to continue research into new PIs that would need to be combined with ritonavir. Their manufacturing costs will increase dramatically, because they have to buy ritonavir from Abbott, so they'll have to either cut profit margins or pass increased costs on to customers who are increasingly unable to afford higher AIDS drug prices. For example, Boehringer Ingelheim's prospect tipranavir needs to be taken with ritonavir. The tipranavir/ritonavir combo was expected to be priced at $20,000 a year, but with the increased cost of ritonavir, the price would be around $29,000 a year. Assuming that there is a ceiling to what consumers are willing or able to pay - and there is; the current high cost of drugs has led to waiting lists and medication rationing in many states - tipranavir may now be priced right out of the market.

And the patients? They should just remember that larger drug company profits are their only hope for the future.