EP-ology by Carl V. Phillips

Krugman on dealing with fools and frauds

2012-01-26T16:57:00.003-05:00

Paul Krugman is one of the greatest intellectuals of our era, though not because of that Nobel in economics (some total fools have won that), but because he is one of history's best callers of bullshit. I may be a bit biased, because his dispositions and fights remind me of my own. I sometimes assume that fame, being on television whenever he wants, a column at NYT op-ed, and one of the best-read blogs in the world makes it rather easier for him to deal with the bullshit. On the other hand, if I get frustrated, I can just ignore it all for a while with little harm done, while he has that whole weight of the world thing to deal with. I am not sure how it works out in terms of stress levels.

Anyway, for those who do not read him, I like to periodically collect some of his recent analysis of the nature of bullshit (just that, not the substance of the fights, which you can find in the original) that reminds me of the fights that I write about. For example, from his blog:

I view the primary race through the lens of the FOF theory — that’s for “fools and frauds”. It goes as follows: to be a good Republican right now, you have to affirm your belief in things that any halfway intelligent politician can see are plainly false. This leaves room for only two kinds of candidates: those who just aren’t smart and/or rational enough to understand the problem, and those who are completely cynical, willing to say anything to get ahead

.....So what you have are fairly dim types like Perry, on the one side, and the utterly cynical Romney, on the other. (Gingrich manages to be both a fool and a fraud).

Sound familiar, dear readers? That seems to be the same qualifications for being part of the establishment anti-harm-reduction tobacco regulation authorities, like the "expert" panel and other US FDA decision makers that I talked at last week. I wonder what would happen if I started a poll of who among those regulators is fool and who is fraud.

In another recent blog, Krugman reminded us of why (even beyond the above naming of names) he will never be a Senator or Secretary of the Treasury, even though he should be:

...this is an example of why policy debate is so frustrating, and why I’m not polite. The key thing about how the conservative movement handles debate is that it never gives up an argument, no matter how often and how thoroughly it has been refuted. Oh, there will be more sophisticated arguments made too; but the zombie lies will be rolled out again and again, with little or no pushback from the “respectable” wing of the movement.

In comments and elsewhere I fairly often encounter the pearl-clutchers, who want to know why I can’t politely disagree, since we’re all arguing in good faith, right? Wrong.

This came out at a time when I was trying to explain to a discussion board populated mostly be lefty activists why industrial wind turbines are so bad. The conversation, such as it was, ran like this (highly paraphrased and abbreviated obviously):

Possibly well-meaning person who might genuinely care about the truth: "But coal is so terrible."

Me: "I agree, but IWTs can do basically nothing to reduce the use of coal because.... The best way to reduce coal use right now is to replace it with gas. At best IWTs perhaps reduce the burning of gas a bit."

Now clearly doctrinaire, though perhaps still well meaning person: "If there is any benefit at all in reducing greenhouse gas emissions, it is worth doing."

Me: "The only studies I know that actually do the numbers suggest there is not such benefit, and if there is, it is tiny, comes at the expense of creating serious health problems and destroying communities, and costing a fortune that could be better spent elsewhere."

Now clearly not a genuinely well-meaning person: "Quit your whining about hurting people. Coal and global warming are terrible."

Zombie lies do not even require a few days or weeks before they pop up again. Sometimes they circle back just a day and few posts after they were refuted in the very same conversation. And as for the pearl-clutchers:

Me: "What part of 'does not actually address those problems to any significant extent' eluded you? I have made this as simple as possible."

Random person who has never bothered to join the substantive conversation, to me: "You are a complete arrogant asshole. How dare you tell people that you are right and they are wrong just because you are extensively citing the science based on your decades of relevant expertise and they are merely quoting from bumper stickers."

(Ok, I obviously added that last bit of subtext myself, but it does sum things up nicely.)

Dealing with zombie lies is like trying to reason with a three-year-old. And there is something about it that is much more bothersome than other forms of bullshit.

Consider: In this particular case, there is no push-back from anyone respectable, by which I mean that no environmental group I am aware of has had the balls to step up and say that installing IWTs is a bad policy that does little or nothing for the environment and clearly does more harm than good. They do not have to actively oppose it, but they need to explicitly dis-support it. Until they do, I (and lots of others, from what I can tell) will refuse to support the "green" agenda, by donating money, signing petitions, etc.

Why such a strong reaction? We all join, donate to, and cast votes for groups and people who have some policies that we tend to disagree with, and speak politely of some of our opponents. Why do I et al. change our politics and Krugman et al. lash out about these? I think it is because of how particularly maddening it is to try to deal with someone who should be an honest adult, but who is arguing like a petulant three-year-old who just cycles through his "arguments" while ignoring the responses to them. It makes polite disagreement impossible.

This is compounded by the violent reaction of some others to any attempt to treat the zombie lies with the disdain they deserve. As Krugman put it, some people...

...start from the presumption that when people...make strong statements, that they must have a defensible model behind their assertions. And so if someone...says that there is no such defensible model, we must be engaged in a “rant”, treating these people unfairly. .... So what purports to be a demand for fair-minded argument ends up, in practice, being a demand that we pretend to find a coherent position where none exists, that we basically invent a high-minded debate out of thin air.

As a final point, this has gotten me thinking about the much decried tendency of internet communities to separate people into like-minded subgroups who never talk to each other. Maybe it has less to do with a desire for reinforcement, as is usually claimed. Many of us quite like the opportunity to present our thoughts to people who do not agree. But we depend on them being honest and open-minded, or at least possessed of a deep enough position that they mount a valid argument, rather than being fools or frauds who just repeat zombie lies. Indeed, a large majority of people I present thoughts to are indeed honest and open-minded, I genuinely believe. But enough of the loud-mouths are not. And when you try to call bullshit on the fools/frauds, you trigger the pearl-clutchers who freak out about "rants".

At some point, dealing with that just becomes intolerable. So it just becomes easiest to stick to forums where everyone's views and intellectual capacities are fairly well aligned already. Indeed, I anticipate it is pretty likely I will leave the group that produced the dialogue above. Poor Krugman, though, has to stick with dealing with economic policy makers; at least the enormous speaking fees must be some consolation.

Unhealthful News 198 - Reporters think science is Magic: the case of the Iowa vote

2012-01-20T22:07:00.000-05:00

It seems that Rick Santorum actually won the Iowa primary for the Republican nomination for president. (And whatever you might think about him, at least he scored ok on his concern for animal welfare; on concern for people, well, not so good.) This is not a health news story, but it is a great example of dangerous innumeracy in the press, one that illustrates why decent science reporting is so rare.

I happened to catch a few minutes of Fox News yesterday morning after this broke, though I am sure this was not unique to them. There was a discussion among the reporters (or is that "reporters"?), which included near apoplexy about how terrible it was that the revised vote estimate changed the "winner". Rather than Santorum losing to Romney by a single-digit number of votes, as originally estimated, he actually won by about 30 out of the 120,000 cast. The press were blasting the clerks who count and record the votes and calling for an investigation about how an error could be made in such an important process. Granted, Fox News is more intent on stirring controversy out of nothing than the other networks, but I would be surprised if any of them offered a realistic perspective.

Notice that in the previous paragraph I used the word "estimate" rather than the typical "count". This was to illustrate that the process of figuring out how many votes were cast is a complex combination of human actions, not some kind of Revealed Truth or flawless mechanistic process. It should be obvious that there are many ways that errors can be made in counting, recording, and compiling over 100,000 observations.

(Note: In a deeper sense, it is not entirely obvious that there even is a True value for the number of votes. There are probably genuine ambiguities in the process. From that perspective the count does not reveal the truth so much as create it. But we can set aside that level of analysis and just stick to the version where we believe there is a truth, but errors happen.)

Another cut at toting up, or an audit, will almost inevitably yield a different number. Even some things that seem like "just counting" are attempts to measure complicated worldly phenomena using created methodologies (a combination of actions that is called "science"), and so involve scientific error, even if there is not the random sampling that some people think is the only source of error in science. (I wrote a paper about quantifying error in the absence of random sampling years ago, which was well received and is easy to understand, so you might be interested. It did not change the world of course -- it was widely read by people who probably already agreed with the main points, but who understandably do not want to go out of their way to actually act according to that knowledge.)

What the angry reporters were oblivious to is the fact that the most serious error was theirs, not the Iowa vote counters'. By presenting as it it mattered that the original estimate put Romney ahead by 8 votes rather than behind by a few, they are the ones who made it a problem that a revision changed that. That razor's edge only seemed to matter to the press because they are really only very good at reporting on sports, and so try to treat everything else as if it were sports. Iowa was a tie for all practical purposes. It was a low-stakes vote in a little state, but matters because it is a show of strength that might predict or influence the big votes later. In that context, a few votes more or less obviously do not matter.

If this were a winner-take-all process, then there would need to be a legal definition of who won, and then there would be genuine room for complaint if later audits showed that it was not assessed properly (as with Bush v. Gore, Florida). But that is not the case, so it was just the reporting itself that created the notion that the "winner" mattered.

The error that the reporters made is confusing a question like who won a game of football or tic-tac-toe or chess (based on rules, without error in the process unless someone is truly subverting the system) with a question of who won a war or who is more popular, which is sometimes obvious, but sometimes rather more complicated to assess, and involves no bright lines. The reporters were treating the Iowa vote was a football match, and in a football match if the initial declaration of who won is later reversed then then it both changes everything and may genuinely result from some unacceptably serious problem in the process.

What does this have to do with health science and science reporting more generally? Well if the reporters cannot even visualize how 0.01% errors cannot creep into a process of gathering data about a process they understand -- counting how many people moved to which side of the room to support a particular candidate in local community centers etc. across the state, and then gathering all of these notes together without losing any, and then adding them up without keying something in wrong -- then there is no way they can hope to understand how measurement, sampling, modeling choices, and countless other points of decision and possible goofs, along with confounding and faulty instruments (to say nothing of intentional political manipulation), introduce errors into scientific estimates.

Interestingly, reporters will occasionally use a phrase like "no statistical difference" or "statistical tie", but presumably only because it is fed to them. I suspect they have no idea that it means "the limits of our analytic abilities are such that this could be an exact tie, or it might go a bit in either direction, and we cannot tell". But reporters would never be willing to accept, "the vote in Iowa was a statistical tie" because they think that uncertainty only comes from some magical force called "statistics" (which I suspect most of them, if they think about it at all, think refers only to the concept of random sampling error).

Similarly, reporters think that "a relative risk of 1.92" is more scientific than "it doubles the risk", even though the latter is almost certainly a much better description of what we know because it does not pretend to knowledge that is much more precise than what we actually have. I cannot claim to be free of guilt in contributing to this. E.g., having calculated the point estimate that the epidemiology suggests that smokeless tobacco has about .01 of the risk from smoking, I often say "99% less harmful" and that estimate been picked up as the conventional wisdom. But what I really found was that there was not compelling evidence of any risk at all, that some not-unreasonable assumptions gave numbers in the range of 1% or maybe 2% of that from smoking, and (most important, really) there was no remotely plausible way to get a figure as high as 5%.

The proper statement of the risk would be most of the information in the previous sentence. But most non-scientists (e.g., science reporters) would interpret a precise-sounding assertion "it is 99% less harmful" as being more scientific than the rougher statement that is actually more accurate. They treat science as if it is some magical process that either is silent on a question or tells us an exact quantitative answer. There is a tendency for people to think that any method of inquiry that they do not personally understand must be magically perfect. But "method of inquiry they do not understand" is most everything; after all, reporters seem to not even understand the concept of a bunch of people writing down some counts and then trying to gather them all for tallying. If they did understand that, they would not be shocked to hear about 0.01% error.

My testimony at today's FDA tobacco center meeting

2012-01-19T23:29:00.001-05:00

[Update, 23 Jan 12: Official video is now posted at https://collaboration.fda.gov/p49817128/ I start just after 6:13. The other public comments start at about 5:22.)

Today I departed from my usual practice of fiercely avoiding any "science by committee" setting or engaging with government overlord-types, and gave some testimony at the Center for Tobacco Products TPSAC meeting. Greg Conley and Bill Godshall talked me into make the trip as an advisor to the tobacco harm reduction advocacy group CASAA. It was worth it -- there were several great presentations by harm reduction advocates in the "citizen comments" that our public ~~masters~~servants grudgingly allow because they have to. Greg recruited several people who had quit smoking by switching to low-risk products, and there were great THR presentations also by Greg, Bill, Elaine Keller, Jeff Stier, Gil Ross, and others. I was pretty pleased with mine too, given that I wrote it while sitting through the talks earlier in the day (something to do during the tedious and pointless presentations by the well-paid consultants and others who were invited to speak by the hosts).

To appreciate my talk, I need to offer some background (which kind of spoils the freshness, I know, so if you are familiar with all this, you might want to skip right to the text of my talk).

Background for those who know nothing about CTP etc.: The US FDA was fairly recently given authority over tobacco products. The unit that formed is dominated by dedicated anti-tobacco extremists who are opposed to harm reduction, and its external scientific advisory group (TPSAC) is stacked with extremists and junk scientists, and contains no harm reduction experts even though most of their role is to evaluate harm reduction products. There is a serious threat that FDA will substantially restrict, one way or another, low-risk alternatives to cigarettes. They are particularly notorious for playing the chemophobia game, obsessing (or pretending to obsess) about detectable chemicals in products, implying that these have health effects even though the evidence about actually effects suggests otherwise. No doubt they are annoyed about having to deal with public comments, because (in a complete perversion of the term) they consider the stakeholders to be the busybody activist groups and not include the actual primary stakeholders, the product users. Public comments also are a challenge to their preferred way of dealing with information they do not like, which is to declare it to not exist and claim we do not really have any information (they still do that, of course, but they probably momentarily feel worried that someone is going to realize they are bullshitting). Indeed, the defining characteristic of this whole process seems to be to pretend that evidence about THR does not exist, because it is not exactly the "right" form of evidence, or is not collected by the "right" people, or whatever. That is the same old game used by the anti-harm-reduction extremists for a decade, but now it is official government policy.

Bits of background on this meeting: Today's meeting was dedicated to dissolvable tobacco products, smokeless tobacco mixed with confectionary which dissolve in the mouth. These face particularly great existential threat from the regulators, probably because they compete with the almost identical products from the pharma companies who many of the extremists carry water for. The citizen comments period allowed for only 16 of us, and only for 3 minutes each -- "government for/by the people" in action! It was quite clear from various comments and questions from the floor that many members of the committee did not understand key points about THR, despite supposed expertise and a year on the committee, and even more clear that they had never talked to any actual product users. (They appeared genuinely astonished to hear one of the presenters say that he has kept using an e-cigarette, even though he is sure he could quit, because he likes it.)

In yesterday's session, the committee had been offered a lesson in the Swedish experience, about how smokeless tobacco use had caused the world's best reduction in smoking and had been shown to have trivial health risks. They then tried to make up every possible reason about why that is not a good reason to encourage (i.e., allow) the marketing of new smokeless products in the US -- because that is just not the same thing, so we really have no idea whether something similar could happen. Oh, and there was a trumped-up obsession with how children might get poisoned by these products (never mind that it had never happened, or the question of why they should be worse than existing pharma products that are almost exactly the same but much easier to unpackage, or other medicines) and resulting tangents about safe packaging.

Anyway, since (a) I figured several of the other presenters were already covering any basic information that I could communicate in 3 minutes, (b) Bill submitted 200 pages of written testimony (which they clearly did not read), and (c) the members of the Center and committee have had months to learn things, and if they did not already know them it was not because they had not heard them. In short, they either already knew what I could tell them as a THR expert, or the reason they did not know is that they were intentionally ignoring the information. So, I decided to go a different direction with my testimony. Here it is (in full -- 3 minutes is a very short time):

I speak today as an educator with an interest in the nature of science and its role in the functioning of our society, and from that perspective would like to say, "won't someone please think of the children?"

If an impressionable young mind stumbled across how science is often portrayed in this corner of our nation's government, he would be at risk of never becoming scientifically literate, let alone to wanting to be a scientist.

First, science is supposed to be an honest truth-seeking process that attempts to figure out the best possible answer to a question, often via methods that require innovative thinking. Our impressionable young mind, however, might come away:

-believing that science consists of just a few narrowly-defined recipes, rather than taking in all the information we have in myriad forms, available from many forums, and thoughtfully making the best use of it;

-believing that health science focuses on looking only under streetlamps and obsessing about easy but not directly informative work like chemistry, rather than trying to do the more difficult work to translate this and other information into what we really want to know about health effects;

-from today's session, he might believe that science involves such methods as manipulating children into giving the answers you want, speculation-laden anecdotes, limiting reviews of the evidence to exclude any evidence that you wish did not exist, and counting unsupported assertions by authors as evidence;

-and he would be taught that science it is not about identifying how we maximize our knowledge, but that it is involves declaring that we just do not know anything, when in fact we know quite a lot.

Our impressionable young mind is not going to think very highly of science, and he might reasonably conclude that the best way to get involved America's version of science is to go to law school. And, yes, that means that misguided ways of looking at science may be a gateway to more dangerous behaviors.

Second, this poor child would get the impression that a hypothetical cardiovascular condition or cancer 40 years from now will be just as harmful as a near-term case in a current smoker, a case that was caused because smokers are discouraged from switching to low-risk alternatives. Do we really want to tell that child that we expect so little of him, that his generation's health science will be so lousy that the 40-year-out cancer will be no more treatable that it would be today?

Finally, at the very least, I would urge this committee and Center to make sure that any such anti-scientific writing is kept in child-proof packaging, rather that being left laying around on the internet where anyone could stumble across it and damage their developing minds.

In case you are wondering, still more background re that third bullett (explaining the joke does not make it funny, but it can clarify): The "manipulating children" refers to the the Indiana Health Department who presented there and are the darling of the anti-tobacco extremist nutcase faction; their infamous "study" consisted of assembling some children, mixing dissolvable tobacco products (which the children had never seen or heard of before) in with some candies, and asking the children what they thought they were looking at. Obviously, they "discovered" that the kids thought the dissolvables were candies like the other items they were presented with. This is what passes for evidence for these people. I suspect it would be possible to convince the kids that the dissolvables were cats if you worked at it.

The "anecdotes" point refers to someone who presented statistics about thousands of tobacco poisonings which were meant to imply that dissolvable products were dangerous, but in fact showed the poisonings were from other products. Perhaps realizing how worthless her data was, she threw in a single story about a mild poisoning that might have possibly maybe been the result of dissolvables that someone had unpackaged and left around, maybe. The "unsupported assertions" referred to a really stupid report presented by someone from RTI (for which they probably got paid a fortune of our government's money) reviewing some of the studies on the topic; the report highlighted whatever random conclusions the authors asserted, regardless of the fact that most were unrelated to the evidence reported in the study. In other words, they did work at the level of a bad MPH student (which I suspect is exactly what most of the researchers were). The "limiting reviews" referred to that RTI report, in which they every-so-conveniently had reasons to not include all papers not written by opponents of harm reduction, as well as similar behavior in all the other reviews of the day.

Unlike some of the other presenters, I did not get any questions from the committee. What could they say? The one question/comment I thought might come was something like "do you think this committee is some kind of joke". I was prepared with an answer -- "well, if you really cannot understand the seriousness of what I was communicating, then, I guess the answer is yes". Alas, no one asked the question.

But I still wonder how many of them even began to understand what I was saying. I know that many of my THR-expert colleagues got it, but I kind of doubt a sufficient level of intellect is common among the officials and committee members. Long-standing science committees are generally populated by political hacks and former scientists who cannot or do not want to think hard any more. I was told that the top FDA guys looked like they were amused at least part of it (but whether that is a good sign or just a smug "yes, you caught us, but who cares -- we are still the ones in power" is not clear). I noticed that at least one committee member, Jonathan Samet, perhaps was also getting it, but he knows my style from crossing paths over the years and, though I am pretty sure he does not like me, he gets it. He a clever guy, albeit someone who has risen to seemingly dominate institutionalized American epidemiology, due to position and connections, not scientific skill, and then perverted it with politics, further damaging and already shaky field. (No mystery why he might not like me, huh?)

Anyway, I am pretty sure they missed my final bit of satire. Before the citizen comments, the chair read this ridiculously long statement about how we are encouraged to start by disclosing our conflicts of interest, who paid for us to be there, etc. This is in keeping with the "look for any excuse to dismiss what someone has to say" mentality. It is ironic, since that committee is notorious for being stacked with people with enormous conflicts of interest. Anyway, I was not about to waste time from three minutes with that, but since I spoke a bit faster than I expected, I had 15 seconds left at the end. So I added,

Oh, and no one has ever paid me for my work doing history and philosophy of science like this.

And CASAA paid the two-figure cost of me coming here.

I am guessing that they had no idea that I was ridiculing their conflict of interest obsession.

The meeting was painful, but it is good to be reminded sometimes: I generally know with how little wisdom the world is governed, but sometimes it is useful to remind myself of some of the details. It was just so absurd. The committee would ask presenters questions the presenter could not answer but which (a) everyone on the committee should have already known and (b) someone in the audience was clearly the top expert on. But we peons in the audience were not asked to solve the conundrum, because science-by-committee does not allow for stepping outside the box (or in this case, beyond the plastic chain with "no one past this point" signs that separated the audience -- I am not kidding). Several of the answers were in Bill's submission, but they could not be bothered with looking at that. My favorite was when the committee was asking about some details of what one company had reported and the speaker was not sure; representatives of that company who undoubtedly knew the answer were sitting in the room, and no doubt some or all of the committee knew that, but the people up front went around and around without being able to figure out the answer rather than actually doing the research (asking) needed.

This kind of consultation among the privileged ignorant, which never actually seeks data, passed for scientific inquiry in the Dark Ages. But dark ages never really die. They just take refuge in government and religious institutions. So try not to think too much about the children -- it is just too damn depressing.

[UPDATE: lots of typos fixed. Sorry -- it was a long day. And I cannot figure out what I did with the formatting, so it just has to stay as it is.]

Unhealthful New 197 - What do easy interventions against global warming have in common with e-cigarettes?

2012-01-17T20:19:00.002-05:00

I have a dozen big topics on my backlog list, but I will ease myself back with a simple one that showed up in today's news. In his column, John Tierney (aka one of the handful of writers at the New York Times who consistently reports accurately and with genuinely useful analysis) wrote about a book and a new study in Science, that suggests that the best (both effective and practical) strategies for reducing the threat of global warning are not the "ecologically correct" ones we hear about. The new study suggests focusing more on "black carbon" (basically, soot) and methane, which contribute more to global warming immediately than does the CO2 that we focus on (though CO2 lingers longer - a problem, but one we have more time to deal with). They advise:

encouraging a switch to cleaner diesel engines and cookstoves, building more efficient kilns and coke ovens, capturing methane at landfills and oil wells, and reducing methane emissions from rice paddies by draining them more often.

As an added bonus, moving those in the third world from dirty 19th-century-style techs to modern alternatives will reduce local health-affecting pollution too, and improve crop yields. And they are cheap interventions – indeed, they are estimated to be money-saving the near-medium term.

What makes this an Unhealthful News topic is not the coincidence that my previous post was a link to a talk I gave explaining why current wind power tech is terrible, no matter how much you are worried about global warming. Nor is it that Tierney is writes unhealthful news – quite the opposite. Rather, it is the subtext from all of the authors, sometimes not so subtle, suggesting that these ideas face an uphill battle because they do not demand meritorious sacrificial pain inflicted on rich countries, and because pursuit of theoretical perfect permanent solutions is the enemy of the good action that we can take now. Tierney observed the:

…lack of glamour: Encouraging villagers to use diesel engine filters and drain their rice paddies is less newsworthy than negotiating a global treaty on carbon at a United Nations conference. Another [concern] is the fear of distracting people from the campaign against carbon dioxide, the gas with the most long-term impact.

That should feel familiar to regular readers. There seems to be the same urge for sacrifice – imposed on others, of course, not oneself – and refusal to pursue favorable cost-benefit ratios that dominates "public health" nannyism. Encouraging active recreation, building sidewalks, and other welfare-improving and non-confrontational alternatives are not nearly as glamorous as trying to ban Happy Meals and tax soda. Encouraging the use of e-cigarette or smokeless tobacco as substitutes for cigarettes is violently opposed, and newsworthy global treaties and bans are favored, even though substitution is by far the most promising current intervention and has amazingly low costs. The "problem" is that dealing with the most immediate threats (protecting the health of today's smokers; climate change over the next few decades) distracts us: that is, it buys us time to develop better science and technology, distracting from the urge to pursue whatever half-assed, expensive, ineffective "solution" is in vogue right now.

There is a perverse preference for more costly solutions, even if they are not effective, so that people are forced to repent and suffer for the sins of modern decadence. Funny how the math works out: when the costs are added to the benefits as part of what is good about a policy, rather than being subtracted, then expensive and ineffective can score better than cheap and effective.

I find myself in the middle of numerous conversations following my talk and video about industrial wind turbines, some of which are productive, but many of which touch on some or all of these same themes. The upshot of many comments is that we should be willing to pay any price – or, more precisely, that other Americans (Canadian, Europeans) should be forced to pay any price – for anything that reduces global warming at all. We should not wait for good technologies that are just a few years off, or take advantage of increasingly cheap natural gas as a good substitute for coal. No, we have to do something that is really really painful, and never mind that it actually does not do any good at all.

Like Tierney and the researchers, I am not holding my breath waiting for those who claim to be so worried about climate change to jump on the black carbon bandwagon. Like, say, e-cigarettes, it offers huge benefits with little sacrifice, and gives us a lot of slack to make further improvements in the still imperfect situation, rather than desperately flailing around for a glamorous, top-down, immediate, perfect solution. We can't have that, now can we?

Back again (and video about why industrial wind turbines are so bad)

2012-01-17T08:34:00.000-05:00

Hi, everyone. Has it really been almost three weeks since I posted? Sorry about that. I got quite sick (which is to say, poorly -- I know about half my readers speak English rather than American) and just could not get better for two weeks. When I finally did, I was behind on everything. Not only did it make a mess of the holidays, but I missed a prime time for bloggers and feature writers, when we can look back over the year or prognosticate about the new one. I might do just a tiny bit of that -- after all, if I could not live with being late, I would not be able to live with myself.

I will start posting again this week. In the meantime, I will post a link to a talk I just gave and then recorded a voiceover slideshow version, an overview of the case against industrial wind turbines (which is roughly synonymous with "the case against wind power" given current practice). Caveats: it is long (50 minutes; it is not a topic that can be covered quickly), I cannot claim it is the best version of that overview available (there are others by people who specialize in making that overview, whereas I normally focus on the health effects), and there are bits that are for the specific audience (though that is explained at the beginning and should not be a problem). Otoh, I think it is pretty good, or I would not have recorded it, and there are some interesting things to learn about the topic. So if you are interested in that topic or just like the way I give talks, here it is: http://www.youtube.com/watch?v=EpzVgK5s1VU

Unhealthful News 196 - Reports on censoring bird flu research lack realistic context

2011-12-29T00:24:00.001-05:00

A lot has been written already about the recent request(?) by the US government for a couple of journals and researchers to censor the discovery of how the "bird flu" virus (influenza H5N1) can be changed to allow airborne transmission (it is currently believed that the only transmission vector to humans is contact with birds) and related research. The press has reported this being a case of "biosecurity" (which Phil Alcabes appropriately ridicules) concerns about an incredibly deadly flu, pitted against the problem of censorship and losing the free exchange of valuable scientific information. The thing is that almost none of these exciting motifs accurately describes the situation.

First is a point I have written about at greater length before, so I will offer just an abbreviated version here: People who write about infectious diseases, including most of the ostensible experts, never seem to learn that when a novel disease appears, there is a huge bias toward identifying only people who have gotten extremely sick from it. After all, who shows up in a hospital to get diagnosed, thus leading to the discovery of a brand new or rare disease? This is even more true in extremely poor populations where medical care is mostly limited to when someone is on the verge of death. So the observation that half the people who get the disease die from it (a common claim in the hype about H5N1 right now) really means that only half the people die from it among those who are treated after they are on the verge of dying from it, when combined with those diagnosed on autopsy who could not afford any medical care.

How many others got/have the virus, having suffered only an everyday bout of illness, or perhaps nothing at all? No one knows. Only the rarest of nasty diseases would not have 100 like that for every one that went to the hospital, and 1000 or 10,000 is quite plausible. A million is possible. So is bird flu an utter terror, that is deadlier than contracting Ebola, or is it a fairly typical disease of its kind that kills perhaps as many as one out of every 100,000 that get it? And for that matter, might it already be airborne in the wild, but just not virulent enough to notice? We really do not know.

On top of that, there is no evidence that there are any significant and capable international terrorists who are waiting to use information like this. (Indeed, the place to end the previous sentence might be before the qualifying phrase, "who...".) There are lots of ways to engage in untargeted random destruction, and no one seems to be employing them.

So, the possibly low risk might argue for protecting the tremendous value of communicating the new discoveries and avoiding the horror of censorship. Except that avoiding publishing the details represents be almost no loss of useful communication or genuine censorship. I would guess that there are a couple of hundred people in the world who could make good use of the information that is being kept secret, and I would bet that most of them will still have access to it if they want. In a matter of years, technology will evolve so that more people could make use of that information somehow, but by then it will inevitably be common knowledge.

As for censorship, this qualifies in only the most technical sense. Censorship matters when it results in suppression of information, not the mere suppression of someone's words. Everyone is being told the publicly relevant information, and indeed the dispute has called far more attention to that information than it otherwise would have gotten. It is government suppression of useful health science when, for example, the CDC quietly hides relevant data it has about the benefits of tobacco harm reduction, as they do, and people are widely misled. But if they reported the general result or the data and merely refused to tell us some highly technical detail about how they did the research, that would be a welcome relief from the self-censorship.

Or consider an analogy: It was suppression of the worst kind that the US military prevented any reporting about a gunship crew gleefully killing a group of civilians in Iraq until Bradley Manning (or if not him, whatever hero actually did it) leaked the video. It would not have been censorship in any important sense of the word if the they had allowed the incident to be reported, but prevented publication of some technical details about the weapons used that could benefit an actual enemy. All the useful information would be out there, and the withholding would have been explicit and purposeful.

So what we really have is a case of withholding information that probably is no threat, and that will inevitably be public before long anyway, but that is probably actually still available to those who really need it, and is a situation where preventing the technical information from being made public does not constitute the kind of censorship we should fear. Yawn. Now I forget why this seemed important to write about.

Unhealthful News 195 - "News" about effects of alcohol and the HPV vaccine: misleading readers while accurately reporting the science

2011-12-27T19:55:00.001-05:00

Two stories in this morning's New York Times inspired me to get back to Unhealthful News blogging. They are both great examples of bad reporting that takes something that is obviously true and manages to report it in a way that communicates something that is false, and not by misrepresenting the results. One story offered the headline, "Prevention: Beer and Martinis: As Healthy as Wine?" and the other, "Patterns: HPV Vaccine Is Not Linked to Promiscuity". They were both authored by Nicholas Bakalar.

So, you might ask, what is misleading about reporting the following?

Now an analysis in the January issue of The Journal of Studies on Alcohol and Drugs suggests that martinis and beer may be just as effective at extending life [as wine]. Wine may have appeared to be better only because the people who choose it are generally healthier.

and

A survey has found that girls ages 15 to 19 who are vaccinated against human papillomavirus, or HPV, are no more likely to be sexually active or to have more partners than unvaccinated girls.

The answer is that there is absolutely nothing misleading about these reports. What is terribly misleading is the implication that there was ever any question whatsoever that these claims were true.

The fact that alcohol, without regard to which of its many delightful forms it is served in, is beneficial has been well-established for about two decades. In fact, it was never the case that the evidence supported the claim that wine or red wine was more beneficial. There was, once upon a time, a hypothesis that red wine had some particular properties, offered as a possible explanation for the "French paradox" in which it was observed that the French were much healthier than their macronutrient mix would suggest they ought to be. (The real explanations: Fats, particularly milk fat, are not actually worse for you than carbohydrates as was believed for a while; the French eat reasonable portions, slowly, and mostly whole foods; and they are less often physically inert compared to their Anglo peers.)

The original research that discovered that alcohol was beneficial (reducing cardiovascular risk) was partially inspired by the that French non-paradox, but as soon as the epidemiology started coming in, it became clear that there was no measurable difference in effect between different sources of alcohol. A few bad studies, those that failed to control for the fact that in the USA wine drinkers tend to eat and otherwise behave healthier, sometimes did show an advantage for wine. But it was always clear that this was the confounding. More generally, there was the confirmation bias in which the studies that showed the opposite (random noise happens) were ignored. Sometimes in the history of a scientific discovery, there is a moment where the best evidence of the day strongly supports a claim that later turns out to not be true. This is not one of those cases.

For the case of the HPV vaccine, there was never any doubt that the vaccine would improve the benefit-cost tradeoff for having sex, but the effect would be slight. Very slight. When compared to the many huge benefits and costs of choosing to have sex, the very small risk of cervical cancer thirty years in the future and the even smaller though potentially sooner risk of oral cancer are absolutely minuscule. This is especially so when we consider that adolescents are not exactly focused on the distant future when making decisions, and that the more proximate oral cancer risk is pretty much never mentioned in the pro-vaccine information (if people realize that most non-geriatric oral cancer seems to be caused HPV, it will be difficult to blame it on smokeless tobacco, and the "public health" people do not want to risk that).

So, the vaccine ought to create a tiny increase in someone's probability of choosing to have sex with more partners, but nothing that could possibly be picked up in the data from a survey of 1243 girls/women. And that is even if there was not the huge confounding problem due to girls who get the vaccine coming from very different families from those who do not. The effect would have to be more than a 5% change in probability to have any hope at all of showing up in a study that small (even with impossibly perfect control for confounding). The availability of contraception and HIV prevention (i.e., condoms) ought to make that big a difference, but it would be irrational of girls to react to that extent to the HPV prevention (and irrational in the opposite direction from normal teenage irrationality).

So why were these study results portrayed as surprising discoveries, and why is it so non-surprising that Bakalar and the press more generally reported them this way? Because the press, science and otherwise, can be counted on to carry water for well-funded extremist liars, reporting their claims as if they had merit and never calling bullshit. Usually the dishonest extremism comes from what gets called the political right wing, like the economic claims of the Republican party or pseudo-Christians who oppose the HPV vaccine because they want to punish people for having sex. But what usually is thought of as the political left, "public health" people, can be equally extremist and dishonest. In this case the pseudo-Christians and the pseudo-public-health people have basically the same goal: To mislead people, and thereby keep their health risks greater, in order to support an abstinence-only agenda.

The good news is that manipulating people with lies like those is really tricky, and most of the prohibitionists are just not that smart. The playing up of red wine gave wine makers license (almost literally) to make health claims, promoting the category, without preventing knowledgable people from learning that other drinks are healthy too. When it became clear from Swedish studies that snus caused no measurable cancer risk, American anti-tobacco extremists tried to claim that this did not apply to similar American products, though the evidence suggested no difference. Finally the marketers realized they could not overcome that propaganda, so they just started selling "snus" in America. Truth that improves the public's health will usually eventually win out over its opponent in "public health".

Unhealthful News 194 - Public health terrorism, Pennsylvania date rape edition

2011-12-09T22:50:00.001-05:00

In my last post I wrote about (and plan to revisit) a pseudo-public-health campaign to vilify the common practice of parents co-sleeping with their infants, which might cause a net increase in risk when done properly, but might not, and the net effect is clearly very close to zero. I pointed out that this type of destructive extremist behavior by nanny-state actors seems to trace to anti-tobacco extremism emerging, since the 1990s, as the tail that wags the dog of public health.

Chris Snowdon recently posted a scathing takedown of an extreme (which is not to say rare) commentary that argued that since society has accepted policies that deny people the freedom to use tobacco, therefore government should take the same action with regard to other health-affecting choices. Not every health affecting choice, of course -- just the ones that a certain ilk of people does not approve of. As Snowdon has argued at length, this is one of the dangers of allowing an exceptional set of actions (government restrictions on free choice) to deal with an "exceptional" problem (the high risk from smoking). Granting such exceptions to the ethical standards of free Western society almost inevitably creates a situation where extremists want to use the same tactics to deal with any similar phenomenon that they declare to be a problem.

A related but slightly different concern about such disregard for ethical public policy, beyond curtailment of personal autonomy via prohibitions, is curtailment of autonomy via manipulative messaging. The worst of this, along with simply lying, is emotional violence that is designed to hurt people (for their own good, of course) and usually harms orders of magnitude more people than it causes to behave differently. The most obvious example is the disturbing, often gory graphics on tobacco packages, which proponents have managed to trick everyone into calling "graphic warnings", even though they are most certainly not. (A warning communicates accurate information that is not already known for the purpose of facilitating better informed decision making. The tobacco graphics fail the "communicate information", "not already known", and often the "accurate" bits.)

The authors of the anti-co-sleeping campaign clearly drew inspiration from (and maybe even apprenticed in) the lavishly funded anti-smoking emotional violence campaigns which adopted a mentality of "say/show anything that might accomplish the goal, regardless of whether it is true or what damage it does." In the case of the anti-co-sleeping, the damage includes the problem that it is impossible to offer advice about how to safely co-sleep (specifically, don't do it when you are under the influence of mind-altering drugs, legal or otherwise). When the over-the-top message that co-sleeping is as bad as putting baby to bed buried in covers and cuddling a large sharp knife, there is not room to say "but if you do, make sure to...." Further damage comes from making some of the many co-sleeping parents feel bad about their choice based on incorrect information. And for any parent whose child died while co-sleeping the message might as well be "nyah nyah, you were an idiot, you deserve to be grieving for the rest of your life".

Fortunately there are very few such parents. But, a lot more women have suffered date rape, and that is a lot of nasty flashbacks resulting from this (pictured) anti-drinking message that depicts a disturbing image of the legs and half-removed clothes of a young woman lying on what appears to be the floor of an low-quality institutional bathroom. The guilty organization in this case was the Pennsylvania Liquor Control Board, which pulled the ad after one day following an outcry by rape victims and advocates. At least that agency does not claim the mantle of "public health" in their title, though it is kind of annoying that the state secures for itself a monopoly over liquor and wine sales, and this agency that is the monopoly seller is using the profits for nasty messages like this. (Fortunately there is something of a free market for beer and, for those of us living in the southeast of the state, there is the state of Delaware, home of low price booze, only a few minutes away -- something that seems even more worthwhile given this fiasco.)

Is our state liquor monopoly an extremist "anti" organization that is just trying to twist women to their agenda. Well if you go to their webpage that is linked from the rape graphic, you will find such statements as:

Heavy drinking is usually defined as consuming an average of ... more than 1 drink per day for women

Also you will find such demonstrates of knowledge as:

...binge drinking is a pattern of alcohol consumption that brings the blood alcohol content (BAC) level to 0.08% or more. This pattern of drinking usually means 5 or more drinks on a single occasion for men or 4 or more drinks on a single occasion for women, generally within about 2 hours.

For most men and most drinks, less than 3 drinks in 2 hours is enough to get above 0.08%. My personal favorite, though, was:

The more alcohol you consume, the more intense the effects 11.

What makes it funny is that "11" there is a reference note. They felt the need to cite to some FAQ at the CDC website to make that claim. For amusement value, this just edges out this one, in their list of "myths":

MYTH: Alcohol is an aphrodisiac. Alcohol reduces inhibitions and may stimulate your interest in sex...

But apparently that does not mean it is an aphrodisiac or anything.

In short, the PLCB behave like the typical pseudo-public-health nannies when it comes to this messaging, both in terms of the message and the intelligence with which it is delivered. On the website, their message is the usual scattershot collection of claims about how terrible a behavior is; date rape risk is a minor part of the arguments they heap on. So why do they emphasize that in their graphic? Because it evokes visceral horror among many women, more so than does the threat of choking to death in one's sleep or dying in a car crash. The action being taken is ostensibly one of communication and warning, not prohibition or regulation. But the act is actually designed to terrify the audience, through creating fear and other emotional reactions to a memorable image, into being less likely to drink, regardless of whether they might make that decision based on a rational calculation of the risk. Even setting aside the practical problems with this (e.g., those most likely to be terrified are those who are already most cautious), this is not a legitimate role for government or anyone supposedly acting in the public interest.

In contrast with the anti-co-sleeping message, where the advice is not actually supported by the science, it is undoubtedly true that less drunkenness will result in less rape. But that does not justify a tactic that is designed to provoke as much reaction as possible (even if it is paranoid overreaction). As with the anti-co-sleeping message and tobacco, the prohibitionist approach makes it impossible to offer useful harm reduction advice. This is particularly striking since the text accompanying the graphic is actually addressed not to the victim, but her friends ("when your friends drink, they can end up making bad decisions...that leave them vulnerable...."). So here's a thought: If you see your friend drinking about to pass out, do not let her go unaccompanied toward the bathroom with a man she just met. Even better, the message could be "as with a designated driver, make sure someone in your group has the job of guarding against such occurrences (and avoid fraternity parties entirely)."

And speaking of that man, the ad campaign did not acknowledge his existence Due to the apparent lack of a perpetrator and blaming the booze, the rape can only be seen as the victim's fault entirely. The outrage about that is probably what got the ads pulled in a day, as reported by the Philadelphia Inquirer and via the Associated Press, though the stories also tell us of the outrage the victims of date rape expressed about having that imagery forced on them. It is tempting to say the news reports were good, because they report the complaints and the sensible outcome. But thinking about it more, the stories failed the basics of news reporting. There was no inquiry into what possessed those idiots to create this in the first place, or to think it was acceptable. The report is about one battle, without realizing that it is part of a war.

Returning to the message, why did the PLCB not offer advice about how to avoid date rape even when you are drinking? Because they do not actually care about date rape. Their mission was just to discourage drinking, by any means available. The typical current behavior of "public health" told them that exploiting the existence of date rape was ok. Yes, they folded when someone insisted that it was not ok, but their willingness to fold may have been because they were not quite as committed as the extremists are; the funding for the effort comes from the profits of the agency's liquor stores, after all. It is not difficult to imagine the extremists (the Milwaukee public health unit in the co-sleeping case, most everyone in the business in the case of tobacco, and quite a few in the anti-alcohol groups) arguing that the importance of their cause justifies terrorist tactics, blaming the victim, and causing flashbacks for thousands of previous victims.

I do not want to imply there is some huge divide between these tactics and direct government control over people's actions. Indeed, the prohibitionists depend on disinformation and emotionally violent messages to create the social situation where they can impose policy-enforced restrictions on behavior. Demonization and abuse of smokers would not be possible if a couple of generations had not been "taught" how evil they are and how they really all just want to quit but are too weak to do so without "help". But the two bits should not just be lumped together, if for no other reason because the messaging approach is commonly practiced by ostensibly respectable people. As a real and credentialed public health person, I am more bothered by them than by the prohibitionist extremists that they empower and cover for. It is like the southern "gentlemen" in Washington for over a century talked about states' rights and such to provide cover for lynchings and other acts of racism that they pretended to not support. There are always thugs out there for any cause; there are not always credentialed, skilled, and apparently respectable propagandists making it possible for them to act.

Unhealthful News 193 - Public health extremists try to arm babies with cleavers

2011-12-06T20:02:00.001-05:00

If you are reading this in a way that does not display pictures, you will want to click to the original to see the image. Yes, that is a real anti-public-service poster/ad from the city of Milwaukee's department of health, intended to inflict emotional violence on mothers who make the possibly maybe slightly risky (bear with me -- I discuss the evidence and other specifics of the message below) lifestyle choice to co-sleep with their babies, a radical behavior that is practiced by crazy cultists like... well, like the majority of humans alive today or who have ever lived.

Most of my regular readers who are familiar with my writings about tobacco harm reduction and its extremist prohibitionist opponents (and the related issue of the free-choice rights of smokers or other drug users) will find this hauntingly familiar. Those who are not familiar (and I have been told that writing on this topic will draw some new readers even though I am late to the story) need a bit of background:

Anti-smoking started as a legitimate and properly modest public health effort to educate people about risk and try to persuade them to reconsider their choice to smoke. But by the late 1990s, anti-tobacco had transformed into a multi-billion-dollar extremist industry, bent on eliminating not just smoking, but low-risk smokefree alternatives (which are about 99% less harmful), and willing to use any tactics, no matter how destructive. It became the tail waving the dog of public health, and the result has been terrible for public health's social and scientific reputation. Even though smokers in Western countries are well aware of the risks (indeed, most of them actually overestimate the risk) the extremists push for inflicting more and more emotional violence on them, in the form of general abuse and denigration, as well as disturbing ad campaigns and labels. If people will not choose to quit if they know the truth, the extremists will pursue other avenues to make them so miserable that they have to quit. For their own good, of course.

To those of you, dear new readers, who may be adamantly anti-smoking and may not have thought this through before, and so perhaps are thinking "yeah, that sounds reasonable", think about the classic "first they came for..." warning. As soon as it became acceptable, as well as a comfortable career path, to exaggerate risk and inflict emotional violence on people who do not conform to the demands of the "public health" community, it was no longer just about smoking. It metastasized.

There is little doubt that the authors of the nasty anti-co-sleeping poster drew their inspiration and got their tutelage from anti-tobacco propaganda. As anti-tobacco has trained a generation of activists who believe it is ethical to do whatever it takes to "improve" people's behavior, they have moved into other areas of what used to be public health. Various observers have done a good job of showing how anti-tobacco extremists are actively and openly tutoring anti-alcohol extremists to aid their prohibitionist efforts, and it is trending toward overweight and fast food. But even if you are not an aficionado of nicotine or alcohol or junk food, and so you do not feel like speaking up, because you are not among the targeted, they might well be coming for you if you do anything they do not approve of. Like eating salty food, or not exercising, or choosing to raise your baby in a particular way. So far, the decidedly dangerous act of transporting your baby by car, or crossing the street with him, is not in their crosshairs. So far.

In terms of justification for the cleaver graphic, every news story (examples) seemed to quote only one statistic, in various forms:

"Is it shocking? Is it provocative?" asked Bevan Baker, the Milwaukee health commissioner. "Yes. But what is even more shocking and provocative is that 30 developed and underdeveloped countries have better infant death rates than Milwaukee."

Should we be impressed? Center-city Milwaukee is a pretty awful place, as America goes. I would guess that 50 countries have higher average income and better health outcomes in general, and probably 100 have better educational attainment. So on a propensity score basis, the city might actually be doing better than expected on infant deaths.

But the biggest issue is that hyping the magnitude of a problem, the typical tactic of public health activists, is a fundamentally dishonest method of trying to justify a particular intervention. The intervention needs to be defended based on whether it will meaningfully contribute to solving a problem, not whether there is a problem. (Readers who are familiar with tobacco policies will be finding this to be quite familiar.) The high infant death rate in Milwaukee is mostly due to premature births to young poor mothers. Even if one accepts the morally dubious "ends justify the means" claims, there actually need to be some ends.

So, does proper co-sleeping increase infant deaths? The evidence supporting that claim is, at best, weak. There are definitely infant deaths that are directly caused by being in an adult bed. These seem to most often involve a parent who is passed out from drugs (be they FDA approved, legal, or illegal), or piles of fluffy bedding. That is where the "proper" in the previous sentence comes in; all advice about safe co-sleeping makes clear that these situations are bad. If we take out those cases -- which should be blamed on parents not knowing how to be safe or not being competent to follow advice, which bodes ill for their babies wherever they sleep -- it is not entirely clear what the net effects are. There are still some identifiable deaths caused by co-sleeping, even absent a stoned mother or inappropriate blankets. But there is also evidence that mysterious sudden infant death (crib death, cot death) is reduced by co-sleeping. The data is so poor (the stigma created by anti-co-sleeping campaigns makes it very difficult to find out the prevalence of incident-free co-sleeping) that it is difficult to be sure. But it is pretty clear that the worst that can be said about co-sleeping is that it creates a small risk, in the same range of such risky behaviors as running errands with the baby in his car seat. The only obvious candidate for the title of America's leading scientifically competent source of advice about raising babies, Barry Sears and company, recognizes co-sleeping as a very reasonable option and offers some recommendations for keeping it safe.

"But," gasp and sputter the self-appointed masters of our health-affecting decisions, "if even a single life can be saved, this is justified" (to paraphrase statements in many of the stories about this). Really? Would saving a single life justify a strict nighttime curfew for everyone in the violent city of Milwaukee? How about banning driving for a month -- that would almost certainly save some lives, including kids. Oh, what's that you say? There are other considerations that mean we should not blindly attack any freedom that might cause one person to die? Oh, I see. So the "if even a single life" game only applies when someone is doing something that you personally would not choose to do, Mr. Public Health Official.

Co-sleeping -- like nicotine use, drinking, other drug use, playing sports, travel, eating junk food, etc., or having a baby in the first place -- is a major lifestyle decision that involves health risk. Different people make different decisions, and some find that making one particular choice is extremely important, and worth the small risk. In the case of co-sleeping, there is not only the important choice about how to relate to one's child, but for some babies and mothers there are important health benefits (better feeding, mother or baby able to get enough sleep, etc.). Providing misleading information, like claiming co-sleeping is as dangerous as a baby cuddling with a sharp knife, will result in suboptimal decisions. Moreover, telling parents that they are being criminally irresponsible by making a particular (common, reasonable, culturally acceptable) choice will often not change their behavior, but might make them feel bad about what they have done, thereby inflicting gratuitous emotional harm. And in those rare cases where a death seems to be attributed to co-sleeping, this messaging starts to seem a lot like those who tell parents that their decision to vaccinate caused their infant's death -- nothing but harm comes from such lie-based sensationalism.

Moreover, there is the classic prohibitionist problem: If you try to prohibit something it becomes very difficult to regulate it. One result is that banned drugs are often contaminated or used in needlessly dangerous ways. In the present case, by staking out a position that co-sleeping is an unacceptable evil, it is impossible to offer the nuanced advice about how to do it most safely.

How did the unhealthful news handle this story? Badly, of course. As is typical, the health reporters presented random useless claims on both sides of the issue, typically the claims above from the "public health" people and the equally useless counter quoting one mother who co-slept with her babies without incident. Worse, many reported the story of one recent death in Milwaukee that was attributed to co-sleeping without ever mentioning whether the mother was stoned. Accompanying these uninformative factoids was absolutely no mention of the evidence of whether there was net risk, or even an acknowledgment that such evidence might be a bit useful in the discussion. This absence was glaring even in the few good articles about the incident and issue, like those in Time Magazine's health blog (which has somehow become one of the most complete sources of health news out there, exemplifying both the good, like these, and the bad, as in the link about overweight above).

The worst unethical behavior from anti-tobacco activists often traces to funding of the anti-tobacco industry by Big Pharma, which profits from selling their (almost useless) quit-smoking products. Could there be a Big Crib that is (ir)responsible for these ads? Strangely enough, the answer is sort of yes. The phone number printed on them rings to a QUANGO called "Cribs for Kids", which offers to provide cribs for those who cannot afford them (as if that lack is the main reason for co-sleeping!). Gee, I wonder who is paying for such giveaways and who profits from it (kidding of course -- there is no need to wonder). Presumably the Big Knife industry, though prominently featured, contributed nothing, since if we take away the misleading words we can just interpret the posters as suggesting "do not sleep with an armed baby". That seems like good advice.

[Update: The first comment by KMN and my reply have some content that I wish I had included in the original post.]

Unhealthful News 192 - "Public health" oligarchs trying to hijack anti-oligarchy movement

2011-12-05T22:28:00.001-05:00

A recent commentary by my friend Jeff Stier inadvertently called my attention to a disturbing behavior by some nanny state types, trying to imply they are akin to the Occupy movement, and how the media (including Jeff!) seem to be letting them get away with it.

In the commentary Jeff heaps justified ridicule on the "Food Police" who sought to ban Happy Meals in San Francisco by banning the giving away of toys with food. This rule affected only McDonald's, as far as anyone could tell, but in a bit of dishonest policy making was written to try to hide its targeting. So, since there was no actual ban on Happy Meals, McDonald's responded to the ban on free toys by charging a dime for the toys and donating that money to their own children's charity. This caused the law's proponents to go berserk about McDonald's subverting or skirting the law, which is to say, about McDonald's obeying the law. Personally, I think that it is a bad thing that people eat at McDonald's, but it is quite funny to see dangerous and destructive policy initiatives fall on their face. (Chris Snowdon also wrote about this humorous incident.)

Elsewhere in the editorial, Jeff stakes out a stance against regulations that require chain restaurants to post the calorie counts of their menu items, a rule that I think is pretty much a perfect public health intervention (information for better decisions; no coercion for those who do not want to change their decisions). But that is a story for another day. But the most striking bit was that the Food Police are trying to claim that their cause is somehow akin to Occupy, declaring their efforts to be #OccupyBigFood. It is easy to see why the Food Police might want to try to steal some of the legitimate cache of Occupy. It is not so obvious why the press and other commentators let them get away with it.

As far as I can tell, the only thing the Food Police have in common with Occupy is that they do not like something that is being done by some large institutions. Occupy is about protecting the 99% from the confiscation of the commonwealth by a growing oligarchy of barely-regulated financiers, the corrupt or otherwise mis-aimed government, and a few tens of thousands of other masters of the universe types. While it certainly attracts people who have various political views and plenty of radicals, the Occupy message itself is not opposed to the free market or supportive of particular regulations.

The nanny state wing of public health is mostly orthogonal to Occupy, but to the extent it runs parallel, it seems to run in the opposite direction. The nanny staters want to be masters of a tiny little universe and deny opportunities to the rest of us -- i.e., they are like those that Occupy is fighting. To put it most charitably, they want to "protect" the 99% from our own propensity to make "bad" decisions. The financial oligarchs and associated politicos inflict harm on people and our society that individually we can do nothing about, so muscular collective action is needed. No such action is needed for someone to avoid any harm that might be inflicted upon them or their Happy Meal-aged children by McDonald's food. Rather, those who would restrict choices are trying to exercise power, and some popular action is needed to keep them from banning salt and otherwise lowering people's welfare.

(Note that this analysis does not address arguments that particular foodways contribute to environmental damage, cruelty to animals, and other external costs, and should be regulated based on that. The "Food Police" activism is based on trying to enforce particular behaviors based on the health effects on those making the decisions, a restriction of freedom not an attempt to correct for external costs.)

A randomly related note is this news story about how some of those "just pour in boiling water" instant soup cups have a propensity to tip over, and how reported research shows that products on the market with other perfectly functional package shapes are much safer. Given the surprisingly large number of serious burns caused by spilling these cups, as reported in the story, this seems like a great candidate for regulation. Unlike unhealthy food, which someone might rationally choose because of other benefits (price, yumminess), no one wants a cup of soup that is more dangerous than it needs to be because of its shape, but few people are aware of the hazard so the market does not solve the problem.

So can we agree to intervene to solve an obvious simple problem? Probably not, because of how rare the clear thinking of the core message of the story is.

The comments posted on the story quickly degenerated into bickering about the healthfulness and naturalness of the instant soup itself. Given that inability to focus on the remarkable simple observation that is the story, I suppose it is little wonder that the press cannot tell the difference between activism that is about collective action to protect us from avoidable external threats and activism that is designed to prevent us from exercising our preferences. Meanwhile, it is probably a safe bet that if someone does propose a regulation on cup-of-soup container shapes, the usual suspects will start screaming about the oppression inflicted by Big Government, taking away our right to decide to needlessly risk severe burns. And when this hypothetical story is reported, you can bet they, along with those who want to ban instant soup entirely because it is salty, will be given as much ink as the sensible analysis about the tipsiness of containers.

I guess there is one thing that Occupy's calls for economic action and regulation and discussions of product regulation have in common: Both of them suffer from the widespread popular ignorance that is caused by the media reporting scientific information as if was a sporting match or a celebrity scandal.

Unhealthful News 191 - Absurd claims about the effects of smoking place restrictions, North Carolina edition (Part 3)

2011-11-28T22:51:00.000-05:00

(Links to Part 1 and Part 2. Sorry for the long delay in finishing this the series. First I was at the tobacco harm reduction sessions that were part of the TabExpo conference which I blogged about at the tobacco harm reduction blog, then my computer broke and I wanted to wait until I could access what I had written it rather than rewriting it, and then holidays.)

In the previous two parts, I offered a back-of-the-envelope assessment of the possible impact of a restaurant/bar smoking ban on heart attacks. I estimated that the effect, if it exists, would be in the order of 1% of the population’s total, and only that high if we take near-worst-case estimates of the effects of second-hand smoke and assume, without scientific support, that intermittent medium-term exposure accounts for much of the effect. Let us now set aside the latter parts of that sentence and just assume that we are trying to detect a 1% decrease.

Is it possible to detect a 1% change in something? Yes, of course, but only under the right circumstances. If we have a rigid object with a length X, and we are about to do something that we think will change the length to .99*X, then two measurements -- one before and one after -- would suffice to confirm this, assuming we have an accurate measuring device and were very confident in our ability to use it precisely. But, of course, for the heart attack case we are not talking about something that was fixed and constant for all time before the event and again after at its new value. The most important difference is that we are counting up random events that result in a series of realizations of an incidence rate that we are hypothesizing has dropped by 1%.

Is it possible to detect a 1% change in such a probability of a random draw? Yes, of course, but only if you have enough observations and that some other conditions hold. Imagine you have a coin that you have altered so that you hypothesize that when you flip it, it lands heads only 49.5% of the time, a 1% decrease from what it did before. Could we throw the coin enough times to detect the change with a good confidence? Yes, but the number of heads we would need to throw to have confidence in the observation would be greater than the number of heart attacks observed in the North Carolina results. What does this mean for those results? It means that even setting aside other complications, pretending that the pattern of heart attacks was as regular and reliable as flipping a single coin, we would still have enough random noise that it would be difficult to detect the signal.

In that scenario in which heart attacks are like coin flips, however, it would be extremely unlikely that we would err so much as to estimate an effect 20 times as great as the plausible true maximum. So what happened?

The problem was that the "some other conditions hold" caveat I stated was not met -- not by a long shot -- and the analysts tried to deal with this by forcing the data into a complicated model. Instead of just looking at before and after collections of a few tens of thousands of coin flips that vary only as a result of the one change, they were trying to deal with a series that showed lage changes over time that had nothing to do with the event they were trying to assess. In particular, there was a downward trend in heart attacks over time. So obviously if you just compare before the change with after, the latter will show a reduction. This is exactly what some of the lowest-skilled dishonest analysts have done over the years, effectively claiming that the impact of the downward trend that existed before the smoking ban was due to the ban when it continued afterwards.

More sophisticated dishonest analysts used complicated models to try to trick naive readers (i.e., policy makers, news reporters, and 99.9% of everyone else) into believing that they had accounted for this obvious problem. But before getting to them, what would an honest and sophisticated analyst do? The answer in this North Carolina case is:

Give up without even bothering to try.

As I already noted, merely being able to detect the hypothesized signal in the noise, assuming the ban is the only change between before and after, requires a bit more data than all that was used for this analysis. Using up some of the statistical power to model the downward trend, even if it were a very simply shaped curve and you knew the shape, would leave even less power to detect the impact of the policy shock. So an honest analyst who knew what he was doing would insist on getting a lot more data before doing the analysis. And as it turns out, honest analysts who have gathered such sufficient data, for much larger populations with longer periods for estimating the time trend, have found no measurable effects on heart attacks from smoking bans.

So what did the present analysts do? The only approach that would have any hope of working would be to assume that the downward trend was constant (in some sense, such as the percentage reduction from year to year was constant) except for the effect of the ban. But that option did not work for the government employees who were tasked with "proving" that their department's pet regulation had a big effect. Sadly for them, the time trend clearly flattened out, so the gains after were less than those from before. If the trend had accelerated they might well have claimed it was caused by the ban, but because it decelerated, they were not willing to do that simple analysis, which would blame the reduction in reduction on the ban.

So they set out to use other data to try to explain the time trend. This is not wrong in theory. After all, the time trend is being caused by something -- it is not just a magical effect of calendar pages turning. So if we had all the data in the world and knew what to do with it, we would not have to deal with the trend itself since we could predict the rate of heart attacks at any given time, however it was trending, with the other data. But here we run into the problem again of not having nearly enough data, not only not enough observations (events) but not enough other variables to really explain the changes over time. Very sophisticated analysts with lots of data might attempt to explain complicated phenomena like this.

Such sophistication is more common in economics, but there are a few examples in public health, like the attempt to estimate the mortality effects of outdoor air pollution: By collecting daily data on mortality, air pollution, weather, and many other variables from multiple cities for years, researchers attempted to estimate the effects of the air pollution. Unfortunately, this was extremely difficult because hot weather is strongly correlated with high air pollution days, and the hot weather itself is at least ten times as deadly as the worst case estimate for the pollution, so basically the estimate for the effects of pollution is determined by exactly what is estimated to be the effect of weather -- make the estimate for that a bit low and it will look like pollution is doing a lot more harm than it really is. The air pollution research is notorious for the researchers making a technical error in their first published estimate, and having to revise their estimate down by half. (Added bonus lesson for the day: Do not believe the oft-repeated claims about how many people are killed by outdoor air pollution. They are little more than guesses.)

In the case of the smoking ban, it is the time trend that has effects in the order of ten times the hypothesized effect, but the implication is the same: Unless you have a very good estimate of the effect of that other factor, or have enough data to figure it out, there is no way to estimate the effect of interest. So, once again, no honest analyst who knew what he was doing would attempt this.

A dishonest analyst, however, would find that he had all manner of options for getting the result he wanted by using different combinations of the variable he has and employing many different statistical forms. The analysts could experiment with different options and report only one of them, as if it were the only one tried and as if it were somehow the right choice among the many different models. This is the most nefarious type of what I labeled publication bias in situ, and is almost certainly what the smoking ban advocates have done in the various cases where they used complicated analyses to “show” that the effects of the ban are far greater than is plausible.

Finally, we might ask what an honest research might do if tempted to just give this a go, even realizing that the chances are that it would not be possible to get a stable estimate (i.e., one that does not change a lot as a result of whims of model details or the random sampling error in the data). One thing that would be required would be to do some tests to see if the estimate was sensitive to reasonable changes in the model or data, and most importantly to report the results of those tests. To their credit, the authors of the NC study actually did a bit of that. You would never know it from reading the political documents surrounding the study, like the press release, but they did one of the more telling tests: They took their model and calculated what it would estimate the effects of the ban were if it had been implemented at a different time. That is, they kept the same data and used the model to estimate the apparent effect of a new regulation that started at a different time from when it really did. The results for the two alternative times they report are a 27% decrease in heart attacks (recall that the touted “result” of the study was a 21% reduction) and a 12% increase. That is, during months when their estimate of the effect of the new ban should have been zero (since it did not happen then), the estimates ranged from bigger than their estimated effect from the actual ban to a substantial effect in the other direction. Put another way, their model is generating noise, and the 21% result is just an accident of when the ban was implemented and the details of their model; had the ban been implemented a month sooner or later, the same data would have "shown" a very different effect, though almost certainly one that was still far larger than was plausible, one way or the other. They could have just as easily have gotten any other number within tens of percentage points.

And maybe they did. That is, maybe they tried models that produced those results and buried them. But I am thinking maybe not. After all, the analysts would not have even reported the results of the little validation analysis if they were trying hard to lie. If they were ASH-UK or Glantz, they would have buried those results or, more likely, never done the test. If I had to guess, I might go with the story that the analysts tried to do an honest job and report that their model could not really find anything, but their political bosses insisted that they report something favorable without caveat. The analysts left in the information that shows the political claim to be a lie because they could get away with that in the text. The “public health” politicos are not smart enough to understand what that means, if they take the time to read it at all. If that is really the story, however, it is not so good -- anyone who would allow the politicos to claim that their analysis showed something that it clearly did not, and who stayed in their job and accepted the behavior, shares much of the guilt even if they tried to sneak the truth in.

So, that's pretty much the story. We can estimate how bit the effect might theoretically be, and that tells us that it is either very small or zero. We can observe that there is not enough data to see an effect that small. But some random luck will generate an impressive overestimate of the true effect a lot of the time, and intentional misrepresentation of what the data shows can almost guarantee it, we hear about bit "effects". Everyone involved in the exercise to show that bans of smoking in a few places have miraculous effects is either dishonest, clueless about basic quantitative analysis, or both. There is simply no other explanation.

Unhealthful News 190 - Absurd claims about the effects of smoking place restrictions, North Carolina edition (Part 2)

2011-11-14T15:21:00.000-05:00

In my previous post, I started commenting on the absurdity of a state of North Carolina claim that their recent ban on smoking in restaurants and bars caused a 21% reduction in heart attacks. I presented part of a generic analysis, from an unpublished paper I wrote a few years ago, that basically says "if you are claiming that a such a ban caused such a large reduction in a disease rate then you are obviously wrong, regardless of what your statistical model says, and anyone who gives it a few minutes' thought should understand this". In this post I make basically the same point, looking at it from a different angle, in case that might be clearer for some readers.

Start by considering the epidemiologic estimates for the increase in risk from second-hand smoke. The evidence, when assessed by someone who is not intent on promoting smoking bans, puts the risk at so close to zero that it is impossible to say from the data that risk definitively exists. (There are decent theoretical reasons to surmise that there is some risk, so it seems safe to assume that the risk is not zero. But it is small.) A few studies of people who have experienced the most extreme long-term exposure get numbers like a 20% increase in risk. As is inevitable with random sampling and publication bias, there are a few that go tens of percentage points higher.

So let us consider the possibility that the risk is a bit higher that 20% -- that is, a nonsmoker who is exposed to second-hand smoke is over 20% likely to have a heart attack, at all or much sooner, compared to that person not being exposed. (Re the "much sooner" point, see the observation from Part 1 that a very-short-term harvesting effect would wash out of the annual statistics.) This number is unrealistically high and at most might be considered a worst-case estimate of the risk for those with the highest accumulated lifetime exposure. But even if it were the average effect for those with passing exposure at smoking-allowed restaurants and bars, it would obviously be far higher than the effect of that exposure averaged across the whole population. Only people who were exposed in the first place would have that risk, and only those who go from exposed to unexposed as a result of an intervention can benefit from it.

How many people go from being exposed to restaurant/bar smoke to unexposed as a result of the ban? It is a bit fuzzy to define this since there will be a lot of people whose exposure is reduced, and a spectrum of how much it is reduced. But we can start with the observation that roughly half of everyone had approximately zero such exposure before the ban, never or almost never going out to eat and drink, or avoiding smoking-allowed venues when they did. (To really get this right, we would need to figure out the portion not of people but of total risk -- a 20% risk increase for an exposed 70-year-old would cause a lot more absolute risk than the same percentage would for the 25-year-olds who pack some bars -- but it seems likely this would strengthen the point I am making, since the older highest-risk people tend to go out to party less.) Thus, even if you believed that exposure at the level of visiting restaurants and bars causes somewhat more than 20% increase in risk, which is an absurd belief in itself, there is no possible way the effect of the smoking ban could be more than about half of the claimed 21%.

Not only are there a lot of people who were not exposed in the first place, but many of those who are exposed are smokers (where do you think the smoke comes from?). No one seriously claims that the minor increase in exposure from second-hand smoke dramatically increases the risk for a smoker, on top of the already substantial risk increase from smoking. Perhaps it does somewhat, but it is going to be a lot smaller than the effect on a nonsmoker. Many others who are no longer exposed in bars after the ban are still exposed at home -- perhaps more since their smoking spouses do more of their smoking at home or in the car before arriving at a venue. Furthermore, most of the people who experience a substantial reduction in their total exposure -- all but the nonsmoking workers and hardcore nonsmoking barflies, rather tiny percentages of the population -- experience a reduction of an exposure that was far less than the extreme exposures that sometimes generate measurable effects in epidemiologic studies.

This is enough to show that the 21% estimate is utterly implausible. Taking it further, what does this way of looking at it suggest would be a plausible maximum effect of a bar/restaurant smoking ban?

To start, even a 5% increase in risk from the bar/restaurant exposure would be a high estimate of the effect for everyone except the aforementioned workers and barflies. We can figure that half of the population was not exposed in the first place, that easily a third of those exposed were smokers, that many of those exposed had very minor and occasional exposure, and that many others that were exposed had only a minor reduction in exposure since most of their exposure was elsewhere. So it seems unlikely that even one-fifth of the population experienced a substantial reduction in exposure, getting the effect down below 1% of the total. Even if we allow for a greater effect for the small highly-exposed minority, as well as some small effect for those with a very small reduction in their total exposure, it is difficult to come up with any at-all-plausible scenario that results in a reduction of more than about 2%. (And keep in mind that this still depends on assuming the 5% increase in risk in the first place, something that is largely speculative. Thus the real figure could be much lower than even this.)

Perhaps the full details of this analysis might call for more than common sense, but I have to assume that most people who thought about it would realize that claims of 10% reduction, let alone 20%, are completely incompatible with reality. This brings us back to the question I asked in Part 1:

So, who would be stupid enough to believe this claim?

I suppose I phrased that too harshly to be a general statement: The average casual reader of the news does not have time to think through most of the claims that they hear -- about the benefits of wars, the causes of unemployment, or health claims -- so their failure to question the claim should not be attributed to poor judgment on their part. They just do not have time to judge. But I will not back off on the harsh accusation when talking about news reporters and other opinion leaders who spend more than a few minutes on the topic.

Several North Carolina local news outlets reported the story without a hint of questioning the result. Once again, it becomes apparent that the journalism curriculum for health reporters no longer includes the classes that teach governments lie habitually and that perhaps when someone (anyone) puts out a press release that claims "hey, everyone, look! statistics show that the decision we made was a good one and did everything we said it would" it is perhaps not best to just assume they are correct and transcribe their claims. Can you imagine if these guys were teachers? "Class, now that you have finished your quiz, I am putting the correct answers up on the screen. Please grade yourself and write your score on the grade sheet that I am passing around."

The good news might be that the national press was so bored of these claims (not critical, just bored) that it does not appear to have been picked up by any national news outlet. But that did not stop Stanton Glantz and his junk science shop at UCSF from posting about it (h/t to Snowdon for reporting that post), and you can count on it showing up in future national news stories where these hacks are quoted. We would not expect the thoughtful analysis like the above from these people; we can count on them to repeat (repeatedly) any absurd claim like the one from NC as if it were correct. Indeed, we could count on them to conveniently ignore any result that was down in the realistic range.

(Q: How do you know if Stanton Glantz is spouting junk science in support of his personal political goals, damaging both science and public policy? A: They have not announced his funeral yet. Interestingly, it is not entirely clear whether he spouts junk because he has not acquired a modicum of understanding about the science in the field where he has worked for decades, or because he is a sociopath-level liar; I am not entirely sure which is the more charitable interpretation.)

So that is the easy side of this analysis, wherein reporters transcribe claims that are obviously wrong and extremist activists embrace them because they are wrong. In Part 3 I will go into some details of the modeling that are beyond the abilities of reporters and junk-science activists, but that emphasize that those who reported the results are lying and/or are attempting analyses that are way beyond their abilities, and presumably know it.

Unhealthful News 189 - Absurd claims about the effects of smoking place restrictions, North Carolina edition (Part 1)

2011-11-12T21:21:00.001-05:00

I was asked to comment on a report from the state of North Carolina which claims that their early 2010 implementation of a rule that prohibited smoking in a few public places where it was previously allowed (bars and restaurants) reduced emergency hospital admission for MI (heart attack) by 21%. This story broke a few days ago, and Snowdon has already written about it, as has Michael Siegel. Both of them offered the observation that this claim is just an artifact of complex modeling that can generate any result you might want. Snowdon already pointed out that the downward time-trend in heart attacks actually flattened out after the ban (i.e., it was dropping over time, but dropped less after the ban than before). That is pretty much all you need to know. The time trend is by far the dominant statistic, and anything else has to be measured against it. It is, of course, possible that the ban saved some would-be MIs, but since the time trend lessened, there is no possible way anyone can claim to see the result in the data.

(Siegel added the observation that for women there was actually an increase in MIs after the ban (it was less than the decrease for men, so the net was the continuing decline), though it is not actually clear that this means much -- after all, if men were the ones primarily "saved" from second-hand smoke, this is what we would expect to see. I am not inclined to make much of this observation, since the report authors did not pull the obvious junk science trick of reporting just the result for men, trying to gloss over the result for women. Just as it is always possible to find a subgroup that exaggerates an observed/claimed population effect, it is always possible to find one that runs counter.)

So, the main message is already out there, but I think I can add two things to it to bracket it: (1) At a level that most anyone can understand, the NC claim is utterly implausible, regardless of what the statistical analysis says. This is in keeping with my goal of showing how thoughtful people can often analyze science -- and call bullshit on it where appropriate -- without needing to understand all of the arcane details. (2) I can also provide some additional insight into the statistical modeling, from the perspective of someone who can do statistics like that, and more important, has observed the behavior of other people who do it. This is kind of a big topic, one that I wrote a paper about once, though never got around to publishing, so I will start with this post and then continue it.

What does it mean to claim that a particular intervention reduced a disease by 21%? It sounds impressive. Indeed it is. It means that whatever it was that the intervention brought about -- in this case, the removal of second-hand smoke -- was causing one-fifth of the outcomes in question. (Rounding to "one fifth" is a much more accurate way to describe the statistic -- reporting down to the last decimal place is good evidence that someone does not understand the limits of their statistics.) So, second-hand smoke was causing one-fifth of all heart attacks? Really? That would make its impact roughly as great as that of smoking itself. This is not even remotely plausible. Right there is evidence that this result is wrong, and you do not need to know anything about how they did the calculation.

But, wait, it gets worse. The claim is not that the totality of second-hand smoke exposure causes as many heart attacks as smoking, but that the fraction of exposure that is eliminated by the bar and restaurant ban was causing that much. The more common and constant exposure in the home would not be eliminated; indeed it would probably increase as smokers gathered to drink somewhere they can smoke. So the claim must actually be that second-hand smoke causes a lot more heart attacks than does smoking, up around half of all heart attacks, and this intervention eliminated roughly half of those.

But, wait, there's more. The claim must be that exposure to second-hand smoke in restaurants and bars over a medium time period (roughly: measured in months) causes one-fifth of all heart attacks. Epidemiologic studies, even those by anti-tobacco activists, have only been able to sometimes find an elevated risk in life-long nonsmoking spouses of smokers, or long-term workers in smoky environments. But the smoking ban obviously did not eliminate lifetime exposure during its first year, the one year of data that was available.

Those who wish to defend this absurdity would undoubtedly reply with their "one puff" hypothesis, the claim that even a brief exposure to second-hand smoke can cause acute physiological effects that can trigger a heart attack in someone who is vulnerable. But even setting aside whether that claim is plausible at all, it does not work in this scenario. The claimed phenomenon is what is known, morbidly, as a "harvesting effect", triggering an event that is on the verge of happening a few weeks sooner. Someone who was close enough to a heart attack in March that being in a smoking-permitted restaurant would have triggered it, but who avoids that event due to the new ban, is still on the verge and will likely encounter a similar trigger by April, or undoubtedly in June when hot North Carolina weather kills many of the vulnerable. So, according to the story, some people are being saved from this trigger by a week or two or maybe ten.

If that were really the case, there would be a slight drop during the year after the ban, but it would be very slight since basically only a few weeks of heart attacks would be eliminated from the year: The ones from the first week after the ban would just be shifted to later in the year; those that would have happened at those times would be pushed later, and so there would be close to a wash; and only those that would have happened at the end of the year would be pushed beyond the range of the data and thus represent a reduction. It might be interesting to see if there was a drop in that first week, because that would be a good test of the "one puff" harvesting claim. But that would be only a matter of scientific inerest, not a substantial effect on public health.

So, for there to be a major reduction due to this intervention, it needs to be the case that many heart attacks are not caused by accumulated lifetime exposure (which is not changed much) or a immediate-term trigger (which is only delayed), but that exposure accumulated over the last few weeks or months causes heart attacks that never would have happened or would have happened much later. This story suffers from both the fact that there are no models or epidemiologic results to support it and because of the enormous portion of all heart attacks that would then have to be caused by second-hand smoke. The claim would be that medium-term exposure in restaurants and bars causes one-fifth of all heart attacks, and so trigger-term and long-term exposure in those venues cause more still, and exposure in the home and other venues must cause at least that many again, which totals to a substantial majority of all heart attacks. So if we can just eliminate the smoke, it looks like we can stop worrying about obesity and lack of exercise. Even smoking itself is looking pretty good, as long as you ventilate the ambient smoke.

So, who would be stupid enough to believe this claim?

Since this is Unhealthful News, you can assume it includes the press. More on that, and on the analysis, in Part 2.

Unhealthful News 188 - Follow-up on cigarette graphic warnings injunction: NYT chooses to burn its credibility

2011-11-11T10:20:00.000-05:00

I suppose it was just too good to be true. In my previous post, I praised New York Times reporter Duff Wilson, and by implication NYT reporting, for writing a story that was objective and factual about a politicized health issue. Specifically, he wrote about a US court injunction blocking FDA from requiring large gruesome graphic labels on cigarette packages, and did so without spinning it as a defeat for what any right-thinking person should want (he accurately presented the labels as representing the goal of a particular government faction, nothing more or less). He emphasized a basis for the decision, that these labels, while often inaccurately described as "warning labels", had no factual content and did not communicate information. Thus, they re not warnings), but are merely intended to emotionally manipulate.

Alas, the NYT could not allow objective and accurate reporting to stand when the topic involved one of its pet causes. So yesterday they published an editorial condemning the judge's ruling. They completely ignored the bases for the decision, that the labels violated free speech rights in pursuit of government advocacy of a particular behavior, did not fulfill some compelling responsibility of the government (like issuing genuine warnings), were not the minimal way to intervene in free speech in support of some competing goal (like genuine warnings would be), and perhaps most importantly that there was really no evidence the labels would change behavior. The editorial concluded:

The Obama administration should appeal Judge Leon’s preliminary injunction, which would put off the labeling changes for months, if not years. A delay on the labels would lead to more needless deaths.

So a bunch of write-about-anything, mostly political-beat journalists who have risen to the level of editor claim to know that these labels would reduce needless deaths. Hmmm, now how exactly do they know that? Are they privy to evidence that was not presented in the court case and that has not appeared in the scientific literature? Or are they simply relying on the deep insight that comes from having a strong belief in a subject one lacks technical expertise in?

The editors also asserted:

If his ruling stands, the government will not be able to warn against the hazards of smoking in a way that’s actually noticed.

Really. So by being limited to forcing cigarette manufacturers to print only those warnings that are, well, warnings, instead of adding images worthy of a slasher movie, the government has lost its ability to advertise, publish, pontificate, dictate "news" stories to the NYT and other papers that will be dutifully transcribed, and otherwise condemn smoking and smokers. Gee, this will probably mean that a whole generation will grow up without ever learning that smoking is bad for you. It is a good thing we have the NYT editors to warn us against this dire future.

It is no wonder that health reporting is usually so bad: The editors apparently demand that it be bad.

Unhealthful News 187 - Cigarette graphic "warnings" injunction, great characterization of the content, but too bad about the understanding of statistics

2011-11-08T22:14:00.001-05:00

Yesterday, a US federal judge ruled that the gruesome graphic labels that the FDA wants to mandate that cigarette manufacturers print on their packages would likely not stand up to first amendment scrutiny, and issued an injunction agains the regulation until the full constitutional issue could be litigated. (The text of the ruling was online this morning but the link does not seem to work anymore; you can link to my saved copy.) Since the litigation will likely take years, the judge ruled, requiring the labels appear until they are ruled unconstitutional, if that was indeed the ruling, would do irreparable harm. Thus the decision must be to not impose the regulation until and unless it was ruled constitutional.

The judge in question, Richard J. Leon of the United States District Court in Washington, was the same one who saved e-cigarettes from being banned in the US, making him the man of the year for tobacco harm reduction and maybe public health in general, though that honor, for which he will never get his deserved nomination for a Nobel Prize, was presumably not his motivation. He showed similar wisdom in the new ruling and that was very well reported by Duff Wilson in the New York Times.

The core basis of Leon's ruling was that the labels were not simply the communication of facts. That is, as I have pointed out a few times, they were not warning labels. Anyone who refers to them as such apparently has no idea what the word "warning" means. I have characterized them as "emotional violence", intentionally infliction of distress, and pointed out that they are designed to manipulate behavior in a particular direction rather than give people the facts they need to make an informed autonomous decision. Leon did not use the word "violence", but clearly argued that the graphics do not warn, but merely manipulate emotion; indeed, he emphasizes the legal evidence presented to him that this is what they were designed to do. He wrote, "they appear to be more about shocking and repelling than warning".

It is gratifying to see this recognition of the true nature of these graphics. I wonder if we will see anyone stop incorrectly referring to them as "warnings" as a result. Not the anti-smoking zealots, of course, or the World Health Organization, but maybe some of the people who try to write about this topic honestly will get the memo.

Another key basis for the ruling, a somewhat more technical, and thus not the focus of popular press stories (at least not when written by health reporters -- there might be some more thorough reports by law reporters out there), is that the large warnings, covering most of both sides of the package, clearly do not meet the standard for being the minimal infringement on free speech necessary to achieve the government's purpose. That part of the ruing actually included the seemingly sarcastic parenthetical, "...purpose (whatever it might be)". Indeed, the judge wrote about a previous ruling he was drawing upon and clearly agreed with:

the dimensions alone strongly suggest that the Rule was designed to achieve the very objective articulated by the Secretary ofHealth and Human Services: to "rebrand[] our cigarette packs," treating (as the FDA Commissioner announced last year) "every single pack of cigarettes in our country" as a "mini-billboard.,,26 Mot. for PI at 6 (citing a June 2001 press briefing with Sec. Sebelius, and an FDA Tobacco Strategy Announcement). A "mini-billboard," indeed, for its obvious anti-smoking agenda!

And, yes, that exclamation point was in the original -- apparently you are allowed two of those in a 29 page judicial opinion. Interestingly, Wilson's NYT article quoted the last few words and the punctuation, out of context, as well as another passage that characterizes the government agenda, without suggesting that the the agenda must be legitimate or even quoting some QUANGO activist endorsing the agenda. It was remarkable restraint and professionalism for a health reporter, since declaring fealty to the government agencies that feed them most of their stories is the standard practice. Wilson did include the mandatory QUANGO quote from Matt Myers, but chose a technical observation about how there will be an appeal of this ruling, rather than printing the self-appointed holy-man ranting that Myers no doubt also offered.

All in all, that was some pretty healthy health news. But I have to take a few points off for something -- being a professor is a profession and state of mind, after all, not a matter of who writes you a paycheck, and I should stay true to the titular theme of this series. Both Leon and Wilson did blunder when they wrote about the FDA's research on the effects of the graphic labels not addressing whether they would have a "statistically significant" effect on consumers' awareness of the risks of smoking, and specifically the research not being designed to be able to answer that. Health reporters have no more business writing about statistical significance than they do writing about legal nuances of the First Amendment of the Constitution, and this is a great example of why. (Judges might also want to shy away from using jargon from highly technical topics except by quoting its use by experts.) Since it was obviously impossible to study the effect of the labeling before it happened, it is not clear how a study could be designed to test the effect, let alone designed to achieve statistical significance in so doing.

As a more general point about their error, statistical significance is a property of a dataset -- or more precisely of a dataset and a particular hypothesis that is being tested -- not a property of the world. It has to do with the chance of seeing a pattern in the data due to chance alone, and relates to how sure we should be about the results. What people care about, and what the law should care about, is whether there is a substantial effect. "Substantial" and "significant" (without the "statistical") are rough synonyms in natural language. They have to be defined by context and basically mean "it matters". By contrast statistical significance is precisely defined (although only a small minority of those who use the term could actually give you the correct definition) and does not necessarily matter.

So, credit for recognizing that the proposed graphic labels are not warnings, and that they are emotional manipulation, and for genuine objective reporting that (contrary to the usual tone of the NYT) made clear that a particular goal of some people in government is just some people's preference, rather than some God-Given Correct Way. But points off for still, in spite of all that, not understanding some fundamental points about how science works.

[Update: The NYT undermines its good reporting with clueless editorializing -- has both irony and humor.]

Unhealthful News 186 - Cancer: screening is generally a bad idea; what about vaccines? (Part 2)

2011-11-06T21:18:00.000-05:00

In my previous post, I noted that there were several arguments made against recommending (or, for that matter, mandating) HPV vaccines for pre-sexual children, to protect against that sexually-transmitted cancer-causing virus. The one of these arguments that is actually fairly compelling, that the cancers the vaccine could prevent could very plausibly become easy to treat during the >30 years before they will occur. But since almost no one seems to understand this, it is interesting to try to understand what took so long to make the recommendation that boys get the vaccine. I noted that there was one misguided and two deplorable apparent reasons for that.

The first of those is that, in contrast with cancer screening, vaccines provide no stories of miraculous life-saving success. Well, actually that is true for screening too. There are lots of stories, but they are usually wrong. That is, most people who are uncritically quoted in the unhealthful news reports, in any story about a particular screening regimen looking like bad idea, sobbing "I am living proof that this screening saves lives!" are probably wrong. Most such screening tests detect many cancers that never would have led to morbidity, and others that would have been detected and successfully treated without that mass screening. In other words many, often most, of the "saved lives" were not. But they make a good story for the statistically illiterate decision makers, and are enough to let them be talked into funding/recommending/mandating the screens by those who stand to profit from that policy.

There is no such misguided constituency for vaccines. No one realizes that their life was saved from a disease they never got. Indeed, this is undoubtedly why vaccines for infectious agents that have other nasty effects are often forgone or even hated. News stories never report on the person who insists "I would have died without that vaccine", even though the speaker would be no less certain than someone making that claim about the screening test. Perhaps some of us should form a patient advocacy group as survivors of polio who never got it thanks to vaccination.

I will leave that for another day and move on to the even worse reasons the HPV vaccine has been only reluctantly embraced. HPV can be transmitted sexually even if condoms are always used. This means that, absent the vaccine, HPV risk is a reason to avoid even "safe sex". While it is obviously not a reason that affects behavior to any measurable degree, as evidenced by extensive journal peer reviewed... just kidding, I meant: as is obvious to anyone who is not totally clueless. But that incentive, or more accurately, that opportunity for anti-sex propaganda, is something that those who want to scare people into not having sex do not want to lose. Some have said as much, while others clearly share that sentiment but pretend to have other motives. They are quite willing to hurt people to save their souls or whatever.

If this sounds familiar to many of my readers, it should. It is basically equivalent to the anti-harm-reduction tactics used by anti-tobacco extremists. In both cases, prohibitionists actively oppose making the activity in question less risky because they want to maximize the incentives for abstinence. But that is not the only deplorable connection. It seems fairly likely that one reason the recommendation boys get the vaccine (rather than just girls, to protect against cervical cancer) was so long in coming was because of the refusal to recognize that for at least a decade the evidence suggested an increasing number of oral cavity cancers are caused by HPV. Indeed, many of the articles about the new recommendation have emphasized protection against anal cancer and anal warts, probably trying to create controversy by making it "a gay thing" and mention only throat (esophageal) cancer in addition to that, mysteriously not mentioning the dreaded oral cancer.

Why the failure? It is difficult to say for sure, but it is also difficult to not attribute it to the anti-tobacco extremists claiming oral cancer as "their" disease. They use it for misleading people into believing that smokeless tobacco poses substantial disease risk and is responsible for a growing epidemic of oral cancer. There has never been the slightest doubt that smoking causes far more oral cancer than smokeless tobacco, but the notion that "switching to smokeless just trades lung cancer for oral cancer" has been a major contributor to delaying tobacco harm reduction for years. The extremists -- pretending to be concerned with public health, just like the "Christians" who would intentionally avoid curing the lepers if leprosy was sexually transmitted -- got this myth so well established that it is quite difficult to communicate the causes of oral cancer.

There is a certain elegant symmetry in it. The lefty pseudo-"public health" sermonizers who despise the right-wing anti-harm-reduction sermonizers who oppose safer sex or needle exchanges have ended up working in tandem with them on this issue. Maybe it will be a wake up call to them and they will... just kidding again.

Finally, the symmetry extends to that one good argument I noted. Just as an 12-year-old who gets the HPV vaccine will be protected from a disease that will not occur for decades, and might be quite easy to deal with by then, a young person who picks up a dangerous behavior now might be saved by advancing medical science. The analogy is far from perfect: HPV-caused cancer is a specific cancer that, if fully cured or prevented at the last minute, might do no damage. By contrast, smoking damages lung and other tissue over time, and contributes to many diseases in complex ways, and that damage seems a lot less likely to be able to avoid or reverse. On the other hand, if smokeless tobacco causes an oral cancer in someone who starts using it now, the evidence suggests that this will happen many decades from now, making it again like the HPV case.

So, screening is loved based on non-evidence; vaccine-based harm reduction for sexually transmitted disease is embraced by the health authorities but suspect among some political factions; uptake of that vaccine is limited, though no one seems to be motivated by the one good reason for not bothering with the vaccine; the oral cancer vaccine is not being recognized as such; and none of this will affect the behavior of the various extremists and activists. The funny part, and the only reason this is not completely mortifying, is that a remarkable amount of the stupidity/naivety/dishonesty is canceling out other bits of the stupidity/naivety/dishonesty.

Unhealthful News 185 - Cancer: screening is generally a bad idea; what about vaccines? (Part 1)

2011-11-04T22:37:00.004-04:00

Yesterday, and several earlier times in this series, I wrote about how cancer screening tests have been shown to be inefficient (i.e., too expensive for the benefit they provide, as compared to competing uses of resources) or even more harmful than beneficial (a bad idea, even if they are free). This is not quite always true, and refers only to mass screening of people with no symptoms and who are otherwise not believed to be at higher than average risk. Cervical cancer screening is cheap and easy, and detects incipient cases of the disease rather than just finding growing cancers a bit earlier. Most other cancer screening looks pretty bad on close inspection. Maybe three or four mammograms between ages 50 and 65 are worthwhile.

Finding a vaccine for cancer and administering it to everyone is possibly a different story. About two weeks ago, the US government finally got around to recommending the HPV vaccine for boys. It has been recommended for girls for a while because it was recognized that just about all cases of cervical cancer are caused by sexually-transmitted papilloma virus strains that the vaccine can prevent. But beyond cervical cancer, it has long been recognized that HPV apparently causes many other cases of epithelial cancers (i.e., the body parts that are in contact with the outside world), specifically the bits that experience sexual contact, the oral cavity, esophagus, and anus. So some commentators have asked "what took so long?"

That is indeed a good question. There are a few answers that occur to me, one is fairly compelling, one is very compelling but no one seems aware of it, one is interesting and understandable but misguided, and two are deplorable.

The fairly compelling answer is that the vaccine is extremely expensive and prevention is probably of fairly little value. Recall that screening is usually too expensive to justify; this is primarily because it is expensive to screen millions of healthy people who do not have the disease to find the few who have it. It is also expensive to vaccinate millions of people who will never get cancer from HPV to save only the few who will. However, when the prevention happens, in contrast with screening, there are no costs of false positives, no further treatment cost, and no damage from the disease at all.

Can screening ever look so good? Not for cancer, given the high cost of treatment, but for other diseases it can. The example that comes to mind is syphilis screening, which is mandatory in the US for pregnant women, in the sense that if they do not get the recommended screen during pregnancy then it is a mandatory part of medically supervised delivery. Of all the screening tests I have ever done cost-benefit calculations for, this is the only one that came out clearly positive (note: I have never run the numbers for cervical cancer screening). The reason that it is done is that syphilis transmitted to a newborn, if undetected, can be devastating. But the benefits go beyond that, since non-symptomatic syphilis is unlikely to be detected, and so when it is detected the mother and her partner(s) are treated, eliminating those cases and all those they would cause in the future. This almost certainly lowers the equilibrium prevalence of the disease in the population by a lot, perhaps by half or more. But what makes this such a bargain is the treatment is relatively harmless and dirt cheap (a simple antibiotic shot), the cost of a false positive is equally low, and the cure is near certain and complete. Unlike most cancer screening, this is a very good deal.

But a problem with the current HPV vaccine is that even though it does not entail further treatment like screening does, it is still very expensive. It costs payers hundreds of dollars, in contrast with the few tens of dollars it costs to get a flu shot. Merck charges $300 for the drug itself, and there is clinical time for three injections, plus whatever markup the medics add. (Incidentally, the official claim is that the cost for vaccinating just the boys as they come of age would cost $140 million/year. But since there are 2 million boys in every US one-year age cohort, this seems low by about a factor of five. The estimate must be based on the assumption that few will follow the recommendations. Or someone is lying. I will leave the investigation of that discrepancy to the news reporters. Hahaha - just kidding. They will never pursue it, and probably not even think enough to realize there is a problem. Unfortunately, I will probably not investigate it either -- if anyone does, please clue me in with a comment.)

What almost none of the unhealthful news reports bother to mention, however, is that this huge total expenditure is mostly not real resource costs. That is, it does not consume actual stuff or labor, but rather just moves money from one entity to another. Because drugs always are priced at greater than their manufacturing cost, because the price has to amortize development costs, and especially because the US does not negotiate drug prices like every other country and thus allows monopoly profit on top of that, that $300 price undoubtedly includes a huge profit for Merck. While we might not want to give money to Merck, at least it is not an actual cost. The same is true for the physicians' fees for administering the injections.

A more important and compelling argument against the vaccine than purchase price is that this vaccine prevents cancers that, except in very rare cases, will occur at least 35 years in the future, and often decades more than that. Those of you who know a bit about these analyses might point out that any proper cost-benefit analysis discounts future costs and benefits, so this delay is already accounted for. But that process of discounting assumes that events will occur, and merely adjusts for the fact that we weight the present more heavily than the future in our decision making. But is that a reasonable view? Should we assume that oral cancer or cervical cancer (this observation applies to the girls too) will still be expensive or deadly disease that far in the future? I certainly hope not. Four decades might not get us to the point that a single injection will reliably eliminate the disease, as with syphilis now, but it seems safe to assume that there will be much better treatment than currently exists.

Remarkably, I have never seen anyone else make this observation, other than me and some of my students (who were thinking this through as an assigned exercise with the advantage, compared to most people writing about such topics, of having been taught what to think about). The strongest argument against this vaccine is that we should really hope it will not matter much for those who are currently young enough to benefit from it. Consider how much the value of an expensive syphilis vaccine for children would have been overestimated in, say, 1930 (it became easy and pretty cheap to treat once penicillin was developed and proven in the early 1940s).

That is the good argument against the vaccine. But I have never seen anyone make it, so it cannot explain what took so long. In Part 2, I will look at the not-so-good reasons that probably do explain it.

Unhealthful News 184 - The right answer about prostate screening, but as for the reasons...

2011-11-03T21:59:00.000-04:00

During my hiatus, Chris Snowdon asked for my opinion about a commentary by the Australian public health community's own keystone kop, Simon Chapman, which argued that screening for prostate cancer is a bad idea. Even though it was Chapman, the basic advice turns out to be good -- after all, a stopped clock is still right twice a day. (For more on why I am being so negative about someone who got the right answer, the above links go to Snowdon's and my analyses of some of Chapman's other "contributions".)

To see why it was good advice, we need only look to something that came out a few weeks ago, in which a US panel led by Virginia Moyer, a former colleague of mine whose clock keeps perfect time, recommended that the common practice of PSA screening tests cease. Here is Moyer briefly arguing for it in her own words. An even briefer version: Because most cases of prostate cancer are unlikely to grow fast enough to cause a problem before someone dies of something else, and perhaps the cases that will be deadly are unlikely to be prevented by screening, and because the treatment that results from screening kills some patients, it turns out there is no detectable mortality benefit from screening. Meanwhile, the treatment often causes nasty side effects (impotence, incontinence).

Following this recommendation, there was the usual outcry against any recommended curtailment in wasteful medical spending. It was the same as the reaction to scale back mammography that I wrote about before. As always, the most remarkable comments are the breathless testimony from cancer survivors who are absolutely sure that the screening saved their lives, when obviously they have no way of knowing that, and indeed the statistics show that it is almost certainly not true.

But what is a bit different about this case is how clear it is that the treatment, not the screening, is the real problem. In contrast with a mammogram, a PSA test is not harmful and will never cause the disease it is meant to prevent. Of course, the problem is that once someone screens positive, he is very likely to demand treatment even though it turns out to not be a good idea. Still, the last chance to avoid the cost comes not from the decision to test, but from the decision that is made afterward. Of course, if we agree that treatment after screening positive is a bad idea -- and obviously the same is true for treatment after screening negative -- then there is no value in screening other than to just know.

Those observations, in turn, led to a spate of occasionally interesting articles about whether it is better or worse to know. A lot of the discussion came back to how difficult it is to just live with the knowledge rather than acting on it, even if acting is not beneficial. The decision to treat is what actually causes the harm, but since that apparently bad decision is inevitable following a positive screen, the only way to avoid the mistake is to avoid the triggering knowledge. It makes sense, but it is still interesting that people cannot resist acting.

The above-pictured "In an emergency" sign from the London Underground is really amusing, with its major point of advice being "Do not take any risks". What it is really trying to say (I assume) is to favor inaction over action until advised to do otherwise, which is quite often terrible advice and obviously entails some risks. But someone apparently calculated that it is good advice, on average, for subway emergencies, and it turns out to be the right advice for treating the average detected case of prostate cancer.

To finish the story I began with, Snowdon's incredulity about Chapman's advice did not focus on the overall merits of the advice itself, but rather on how Chapman tried to support the claim: He made a wandering argument in which he suggested that screening and treatment does have mortality benefits, but since prostate cancer kills mostly old men who have already had a good life and might die of something else shortly anyway, they should favor quality of life (avoiding the damage from the treatment) over longevity. Snowdon pointed out the strangeness of this argument that men should not have the option of going for the supposed longevity gains, coming as it was from someone who is best known demanding the opposite choice. Or, more pointedly, known for his willingness to pervert science, abuse the social contract, and do pretty much anything he can think of that might keep people from choosing to smoke or even choose to be in smoky environments. He will ferociously fight to deprive people of the choice to take that risk, however much their lives might benefit from the choice, but then demands that men accept another mortality risk because he judges that their lives will benefit.

The funny thing is that, according to Moyer et al., it is reasonable to deprive men of this choice because there seems to be no upside. But Chapman claimed there is an upside to treatment, but that the choice to pursue it should still be denied. A slow clock, rather than being right twice per day, might only manage once per month.

Unhealthful News 183 - Greetings from the middle (of history (of science))

2011-11-02T21:29:00.000-04:00

Hello, everyone. I promised you 180-some more UNs, and while I will obviously not fulfill my hope of doing that within 2011, I will continue toward the goal. I will get started by including some general observations I have been wanting to write about, interspersed with the unpacking of recent news that is the central theme of the series.

This is hardly the first time this has occurred to me, but I have been struck over the last few months by how most people, notably including those with the experience to know better, seem to think that they are living at the end of the history of science. People who understand how Newtonian physics, which seemed doubtless correct for centuries, had errors that were fixed by Einstein's relativity are remarkably unwilling to allow for any possibility that the current theory has some flaws, such as the possibility that a particle could move faster than the speed of light. Of course, I am more interested in science and technology that is more immediately practical.

One place I observed the phenomenon of people not realizing they are living in the middle of history is with regard to "renewable energy". I have been in some interesting battles about industrial wind turbines, which regular readers will know cause serious health problems for nearby residents and are so incredibly inefficient that they arguably offer no benefits at all. I will come back to some details of what I have written and been dealing with there, but will start with my observation about what seems to be motivating some IWT proponents.

I have noticed that the well-meaning people (i.e., I am not talking about the industry and their hirelings) who argue in favor of building IWTs persistently fail to understand the technological reality that we are not at the end of history. Their view seems to be the following: The natural dynamics of the planet -- wind, waves, sunlight, temperature gradients -- contain plenty of energy that should be harvestable for electricity. Moreover, we will probably (they would say inevitably) come to need those sources of electricity. Typically they also point out that burning coal has huge environmental costs. But the erroneous syllogism is the next bit, where they argue, "...and therefore, since the only technology that harnesses those dynamics that can be built on a large scale right now is IWTs, must be a good idea to build them."

I assume the gaping failure of logic here is obvious. Decades or centuries before the Apollo Program, it was clear that it was possible to use develop technologies to send people to the Moon. But that did not mean that getting aboard the best rocket that could be slapped together in 1950, wearing a diving suit, would have been a bright idea. Yet when I or others point out that (a) IWTs are so incredibly inefficient that their net contribution to energy generation is quite possibly negative (i.e., installing new IWTs actually increases fossil fuel consumption), and even if the contribution is actually positive, the cost of that tiny benefit is enormous, (b) IWTs cannot affect baseline generation like coal or nuclear (which basically need to operate at full capacity all the time) because the wind is intermittent, and so only affect how much gas is burned (gas plants can be turned on and off -- it is not terribly efficient, but much better than it would be with coal), and (c) IWTs do terrible damage to local residents' health and the environment, I frequently get the response "but we cannot burn fossil fuel forever! and coal is evil!!!"

Translating that charitably (i.e., resisting the very strong urge to scream "what part of 'approximately zero net energy contribution' and 'does not replace coal burning' is too complicated for you to understand?"), I can only conclude they they are falling victim to the end of history fallacy. Since at some point in time we might be forced to get our electricity from "renewable" sources, and improving technology will make such generation efficient long before then, then doing so must already be a good idea. After all, how could something possibly be a good idea in the future, but not a good idea now? Aren't we the pinnacle of human civilization? The evidence-based truth, that renewable technology (except for damning rivers for hydroelectric) is currently not ready, and thus immediate installation is a terrible idea, simply cannot penetrate that prejudice.

A second version of the "end of the history of science" fallacy can be found in blind faith in the perfection of current health science methods and knowledge. This problem explains much of the unhealthful research and news reporting I have covered in this series. If only there were a bit of epistemic modesty and use of the phrase "the best we can do now" or "given the limits of current knowledge", there would not be nearly so many errors in health reporting.

Allopaths (mainstream Western medics) are particularly guilty of lacking modesty, epistemic and otherwise, and the tendency to mistake medics for scientific thinkers is particularly damaging to health science. For a profession that so recently engaged in such practices as therapeutic blood letting (which physicians of the time were absolutely positive it was a good treatment) and was quite likely to kill those it was supposedly helping because physicians refused to wash their hands (and were absolutely positive that doing so would be madness), medics and their enablers show a remarkable arrogance in insisting that everything they currently believe is absolutely, positively, beyond-and-doubt correct. What is worst, >99% of the time, the belief is not based on any scientific knowledge, but rather was just something someone was told. And so they believe it with certainty. If this this sounds a bit like another major social institution that has a history of being absolutely sure of highly destructive baseless claims on the basis of faith alone, you are not wrong.

I am not just talking about how many clinicians are absolutely positive that smokeless tobacco is highly risky and other areas where they are the victim of directed propaganda (though there is no excuse for that either). I am talking about things like medics whose education includes the equivalent of one semester of epidemiology, one semester of immunology, and zero semesters of nutrition making absolute pronouncements about the evidence about food allergies, and often being very wrong. I'll probably come back to that theme.

At a less dramatic level, the "end of history" mentality contributes to the reporting of every trivial, highly-technical research finding as if it were of huge practical importance by itself. This is not the only reason for that, of course, and I have written extensively about some of the others. But if consumers of the report (editors, reporters, consumers, policy makers) understood that they are sitting in the middle of history, they would not be so vulnerable to venal self-aggrandizement by researchers.

The metaphor that occurred to me is that this is like polishing roadway gravel. Gravel is very useful in a workaday way, making it possible to move forward over otherwise muddy terrain. But picking up a piece of gravel, polishing it to a high sheen, and putting it in a glass case does not make it a gemstone. In a way, the unpolished bit of the road forward was arguably contributing more to the world than a gemstone. But even if you do not take such an extreme workmanlike view of value, it should be clear that trying to polish and display a large portion of the gravel is a disservice to the value of both gemstones and gravel.

So, we should not polish the gravel, but should wait until we reach the end of the road where there will be a gemstone. (Hint for interpreting that: like a rainbow, the road has no end, so that statement, like the one about the pot of gold, is true because it is vacuously satisfied.)

Mic check

2011-10-26T06:14:00.000-04:00

Hi, everyone. I am declaring the hiatus to be over. Well, not actually today, but within a few days. I have been saving up topics to cover, and if I can remember what they are I will cover them. If not, every day brings new ideas. If any of you saw something over the last few months that made you think "I wish I could have seen what Phillips wrote about that at EP-ology", please let me know in the comments or via email and I will see if I can cover it.

Unhealthful News Hiatus

2011-07-02T22:52:00.000-04:00

Hi, everyone. I have completed a half year of daily Unhealthful News posts, but I am not going to finish the promised other half year. Not immediately anyway. I am also going to mostly go dark with regard to blogging in general, and perhaps other media. I will try to look out for direct messages and will probably not be completely silent on twitter and facebook.

To the health news reporters and the bad researchers and busybodies who are doing so much damage to public health, let me assure you that this does not come because I have discovered a shortage of unhealthful, unscientific, and unethical behavior to challenge. In other words, it's not you, it's me. I suspect most of my close followers have picked up on my professional frustrations and other difficulties.

I think I will probably be back, so see you then.

Unhealthful News 182 - Did Serious people seriously think FDA regulation of tobacco would go any differently than it has? Really?

2011-07-01T22:04:00.000-04:00

Sigh.

Yesterday Paul Krugman summarized someone else's comments as follows:

“Some people thought from the beginning that the stimulus should have been much bigger. Hahaha! Also, it turns out that the stimulus was too small, so we need some more.”

From this, he goes on to observe (a version of one of his points that may be as important has his economic theory):

This is actually a fairly familiar thing from my years as a pundit: the surest way to get branded as not Serious is to figure things out too soon. To be considered credible on politics you have to have considered Bush a great leader, and not realized until Katrina that he was a disaster; to be considered credible on national security you have to have supported the Iraq War, and not realized until 2005 that it was a terrible mistake; to be credible on economics you have to have regarded Greenspan as a great mind, and not become disillusioned until 2007 or maybe 2008.

Making the rounds lately is a piece from Tobacco Journal International by John Lauterbach, a nonvoting (industry) member of the US FDA's Tobacco Products Scientific Advisory Committee. In it he observes:

Congress did not intend to forbid adult use of legally manufactured and marketed tobacco products. Indeed, Congress gave the FDA (Food and Drug Adminstration) the authority to make sure that tobacco products were made under good manufacturing practices using tobaccos and ingredients that were free from contamination, and that such products were not adulterated and/or misbranded. …. Moreover, users of tobacco products would be given accurate information on which classes of tobacco products presented higher health risks to the user than did other classes of tobacco products. Furthermore, there would be active support by the FDA for reduced risk tobacco products. Finally, the CTP staff would include scientists and engineers who were as knowledgeable in the design and production of tobacco products as were their counterparts in industry, and there would be joint research on test methods for the characterisation of tobacco products and tobacco smoke.

Um yeah. It is not clear whether he really believes this, or if it is just a setup. If he does believe it, he seems to join a lot of others in qualifying as Serious, in the Krugman sense. He does take a tone of genuine surprise when he continues with:

So, why have the good outcomes that would lead to reduced tobacco-related disease not happened? Apparently, Dr. Deyton and others at the CTP and the FDA do not want them to happen. It appears that they want to continue the scourge of tobacco-related disease in the hopes that the populace will demand the elimination of the tobacco industry and tobacco use.

Hmm. Where have I heard that before? Oh yeah, that is how I have been characterizing this political faction for about five years, having coined, defined, and characterized the term "anti-tobacco extremists" because I was sick of hearing them erroneously referred to as "public health". It is what I predicted would be the outcome of FDA regulation when it was in the works. This was at a time when many others who are interested in tobacco harm reduction, as well as the industry, were optimistic about how it would go. It sounds a lot like what I was still pointing out a year and a half ago to anyone who would listen. I never changed my position, by the way, I just got quieter after getting sick of being pretty sure I was right and yet watching all the focus (and money) flow away from the areas I work on.

Quite frankly, some with interests at the CTP and FDA seem to believe that when Congress approved the Family Smoking Prevention and Tobacco Control Act, the “TCA“ for short, it ratified the World Health Organisation's Framework Convention for Tobacco Control (FCTC) treaty. …. This is very important because the WHO does not want to reduce the health risks associated with tobacco use. The WHO wants to eliminate all tobacco use, even use of tobacco products whose health risks are indistinguishable from those of medicinal nicotine.

I am shocked to hear that. Oh, except for the fact that my colleagues and I were among those who made exactly that point about WHO many years ago, and we have been following the FCTC follies with all of that treaty's implications for truly terrible public policy.

 What I want to focus on now is the TPSAC and the forces who want to take the word, "science" out of the Tobacco Products Scientific Advisory Committee. …. The three industry representatives on TPSAC have been a troublesome team for the FDA. We have been very professional in asking all the questions the FDA did not want asked. ….unlike the other scientific advisory committees that help the agency deal with difficult scientific issues, the real expertise on the TPSAC lies with the non-voting industry representatives, not with the voting members of the committee. Indeed, the difference in expertise between the industry members and the voting members is so great; the FDA has to hide our expertise. Our expertise is listed as "Industry Representative." If the FDA listed our expertise, it would make the voting members of the committee look weak.

I should make clear that I am not writing this to criticize Dr. Lauterbach's presentation. It is just a good example, and he certainly deserves credit for bits like that. My frustration is that he has to tell anyone most of this information at this late date. However, I do have specific disagreements. In particular, I take issue with the implications of this question:

So why doesn't the TPSAC have academics who are experts in tobacco science, tobacco chemistry, and tobacco toxicology?

Setting aside the answer, the question implies that those are the most relevant fields. But the matters being addressed by the Committee and the FDA are almost entirely about epidemiology, welfare economics (consumer preferences and such), and other social sciences. No doubt chemistry will have its role, but it is pretty minor so far. Indeed, where there has been focus on chemistry, that ignores much more important health and social science points.

….if we had such faculty members available to serve on TPSAC, the FDA would not want them on TPSAC, as they would ask the wrong questions. Tobacco and tobacco smoke are difficult materials, and those doing serious research soon learn to assume nothing and insist on proof before deciding the validity of a scientific proposition.

Right prediction about their opposition to experts, of course. They did not want, and carefully avoided including committee members who might ask tough questions about the relevant sciences. But the rest of that, ouch! It seems to play right into their hands, sounding remarkably like 1960s-70s style industry obstructionism. I am not saying that was what was intended, but the tough questions that are being ignored are along the lines of "how can low-risk smokeless products possible cause any measurable harm based on existing epidemiology and economics?" Questions like "how can we know what to do until we do more research about smoke?" are not only the wrong question but sound a bit contrived. I suspect the Serious people will come around on that too, eventually.

 Those who write anti-tobacco materials generally stay away from the mainstream journals that cover the sciences associated with product regulation even though scientists from other parts of the FDA publish in such journals. Why? They know that the reviewers and editors of such journals have little tolerance for pseudoscience. So, those opposed to tobacco publish in journals such as Tobacco Control, Nicotine & Tobacco Research and other journals that welcome less than accurate science as long as it is anti-tobacco.

A nice point. Of course, it is one that those of us who have been doing academic and academic-style research in the social sciences have been pointed out all along.

 However, when such pseudoscience has made it to print, the industry, for the most part, has not challenged the bad science. …. Fortunately, some of us who are not part of big tobacco, did the science, and got it published. I can assure you that you do not win friends when you write to a journal editor and show him that he let research into his journal that stated, if one took the experimental as it was written, the cigarettes were smoked well into the filter sections and that cigarettes were smoked under such variable conditions as to render the results useless.

How many times have I (and Rodu, and Enstrom, etc.) fought with publishers? A lot more than we have written about, and we have written about quite a few cases. I would contend that the social science side is far worse than the chemistry side, both in terms of publishing junk and censoring real science.

Action is required . Big Tobacco needs to step in and do its share to correct the errors in the literature and respond promptly to new ones. …. Unless someone acts, [an article he cites] is going to be used against dissolvable tobacco when TPSAC considers those products later this year.

Sounds right. Also sounds a big familiar.

 While we can hope that the FDA will learn from its mistakes and start using good science for tobacco product regulation, we have no guarantees that will happen.

Um, you might want to consider whether they believe they have made mistakes. I think agreeing to the premise that there were mistakes is a prerequisite for learning from them.

We know that our legislators do not look favourably on regulatory agencies that do not use good science as the basis for their regulations. We are fast approaching the point when we will need to solicit their help in getting the FDA's tobacco regulatory function back on the path that Congress intended. If we do not do it now, we may not have another opportunity.

So Congress is the best hope for defending good science? Oh that is good news. And it is because the regulators have acted the way some of us predicted that they would, and because no one is doing the science to push back against them because everyone decided to just trust the process. On top of everything else, Congress's role is predicated on their intent being enough different from what is happening that they are willing to micromanage it, as opposed to, say, exactly what those who were pulling the strings wanted and expected.

Some of us were un-"Serious" enough to have seen and discussed the impending problems from the start. All it took was a bit of science (economics, polisci, historiography, epidemiology -- chemistry was not so helpful).

As Krugman went on to comment today,

you might think that hippies like me were basing their views on some wild and crazy, unorthodox version of economics, while the wise, judicious people who thought that [what was actually done] was just right were using standard analysis. But actually it was the other way around. .... The hippies read the textbooks; the Very Serious People apparently rely on close analysis of entrails, or something.

It is an interesting question whether Krugman's observations about how the Serious People come around to our hippie reality (and then get more credit because took the Serious position in the first place) will soon come true, as Lauterbach is campaigning for. Or will it be that by the time they do, the whole matter will be buried far too deeply in the contents of those entrails.

Unhealthful News 181 - Avastin likely to be de-listed for treating breast cancer; if only they explained why

2011-06-30T23:12:00.000-04:00

This week there was some seriously unhelpful health news. One of the most talked about bits of health news of the last few days (example, example) is that an FDA committee concluded that the drug Avastin used to treat several types of cancer, is a bad choice for treating breast cancer. It is likely that the FDA will therefore withdrawal approval for that use.

I was curious about what was known, what the concerns were, what motivated the decision, what will happen, etc., so read some of the news and health pundit reports on the topic. I could have kept going, and probably pursued a more technical angle, but I started to find it more interesting to realize that I was learning almost nothing from what I was reading that was not contained in the headline.

The committee's unanimous judgment was that the risk outweighed the benefits. The only counter-arguments discussed were breast cancer patients who believe they have benefited from the drug begging not to lose it. Today it was announced that Medicare would still cover its use for breast cancer (because it will still be approved for other cancers, it will be on the market and FDA regulations do not prevent it from being used "off label"). This brings up some questions.

"Risks outweigh the benefits" can have rather different meanings. One of them is the subtle "if you use this drug rather than another then, adding up all the outcomes including cures and side effects, you are a bit worse off." That is a case where nothing much can be done except look at the overall statistics and go with them. But there are other variations, an extreme version of which might be, "this drug saves 5% more of those who take it for a year compared to the alternative, but it rapidly kills 6% of those who take it." There is no practical difference among these unless it is possible to figure out if someone is in the group that benefits or suffers from the choice, and presumably that has already been done based on demographics and details of the cancer to the extent currently possible.

There is one other possibility, where it is possible to start a treatment and figure out whether it is going well. I have no idea whether that might be possible in this case. You would think that after reading thousands of words analyzing the regulatory decision some information might have creeped in, but no. Some of the severe side effects mentioned (digestive system perforations, bleeding) are such that they can be detected and perhaps treatment can be changed, but perhaps it is then too late or changing the treatment is not safe. I am sure these are known, but no on reported them.

Some pundits complained that the news stories took many paragraphs to get to the most important point, that the studies show that the drug does not improve survival. I agree that this is the most important point. But I take issue with the implication that this is all that is useful to know. There is talk about continued research to find if there is a subset of breast cancer victims who might benefit; that is what pharma companies always want to do in cases like this. But it might be possible to identify cases that are benefiting. Or it might not. The news and pundits appear to be utterly silent on that point.

This is interesting because of the amount of attention devoted to women who were asking that the drug not be taken away from them because they believed it was helping. Not a single report or analysis I saw argued made the obvious point, that they have no way to know that because they have no idea what would be happening if they were not taking the drug. (There is evidence that the drug slows cancer growth even while not improving longevity, which would create the appearance of benefit.) On the other hand, no one suggested it might be the case that this subset is right about them being the ones who benefit (which would mean that others have been hurt because we know the balance is "no benefit"). Perhaps it is the case that if someone escapes the nasty obvious side effects then having the drug is better than not having it. That is kind of like the 5%/6% scenario I made up, wherein if it does not kill you early it is helping you. Presumably this information exists, but the allusions in the news to there being some slight prognosis improvements for some stages of cancer were not very useful.

This brings up a second question, which is why anyone expert would suggest continued use is a good idea. Individual consumers are often irrational, and mistakenly think that averages do not apply to them, and think they can see causation (that the drug is causing them to be healthier) when it is really too complicated to see. Individual medics are no better. But Medicare's policy decision implies that someone who is supposed to understand these things thinks it is wise to keep using Avastin to treat breast cancer. Yet to the news reader, there seems to be no basis for expert disagreement in the discussion. If there is no benefit, then there is no benefit. Again, presumably I could dig deeper into expert discussions and make sense of this, but how can it be that the news reports implicitly tell us there is this controversy, but no one thinks to report the basis of disagreement?

The only consternation reported was not about the challenge of scientific disagreement, but what to do with all of those poor women who are benefiting from the drug and testified in favor of keeping the indication. (Answer: Um, let them keep taking it if they really want it so much? It is not being banned after all.) The committee hearing was even called a "death trial" for them (as in "death panel"), because they were not just statistics. Some local news stories picked up individual examples of the human interest drama of those who will be deprived of this wonderful drug. Oh, where to start.

We expect superficial news reporting that emphasizes uninformative stories over useful statistics. In is pretty typical that the useful statistics are buried in the article. But in this case, nothing that was reported allows the reader to have any idea if the anecdotal claims have any basis, or should have any effect on decision making. There is the usual spate of statements like "the plural of anecdote is not data" from self-styled pundits, but that statement is not actually true. There are plenty of situations where anecdotes about the non-average cases are informative. There are cases where off-label use of makes sense for an identifiable subset, and so Medicare should pay for it. Is this one of those cases. Maybe someone understands these points and knows the answers, but they are apparently not among those writing the news and commentary.

Unhealthful News 180 - Study of "No Smoking Day" may be a new low in bad epidemiology and health economics

2011-06-29T21:31:00.001-04:00

Ok, that is probably not true, given how much other bad anti-tobacco "research" there is out there. But this is a really good one. It was so good I stole it from today's weekly readings in THR post so that I could expand on it here.

It was published in the quasi-journal Tobacco Control, of course. I will provide the entire abstract here so you do not have to bother with the link.

How cost-effective is ‘No Smoking Day’?

D Kotz, J A Stapleton, L Owen, R West

Participants: A total of 1309 adults who had smoked in the past year who responded to the surveys in the month following NSD (April 2007–2009) and a comparison group of 2672 adults who smoked in the past year who responded to the survey in the two adjacent months (March and May 2007–2009).

Main outcome measures: The number of additional smokers who quit permanently in response to NSD was estimated from the survey results. The incremental cost-effectiveness ratio (ICER) was calculated by combining this estimate with established estimates of life years gained and the known costs of NSD.

Results: The rate of quit attempts was 2.8 percentage points higher in the months following NSD (120/1309) compared with the adjacent months (170/2672; 95% CI 0.99% to 4.62%), leading to an estimated additional 0.07% of the 8.5 million smokers in England quitting permanently in response to NSD. The cost of NSD per smoker was £0.088. The discounted life years gained per smoker in the modal age group 35–44 years was 0.00107, resulting in an ICER of £82.24 (95% CI 49.7 to 231.6). ICER estimates for other age groups were similar.

Conclusions: NSD emerges as an extremely cost-effective public health intervention.

Taking this from the top, we have to start by observing that they are claiming that about 10% of all smokers attempted to quit each month. This indicates either some very faulty data or such an expansive definition of "quit attempt" (like "I woke up and decided I was going to quit, but I started again during my morning break") that it is meaningless.

Moving on, they assume that the entire observed difference is neither random nor the result of Easter/Lent, Passover, spring holidays, the misery of March, or anything else that might make April different from nearby months. It seems like these might make a wee bit more difference than an arbitrary declared day that most people pay no attention to. It is kind of interesting that they did not give us a month-by month breakdown, which we might have expected if the month with "No Smoking Day" were the global or even local minimum.

Beyond that, their interpretation of what NSD entails is quite silly. They treat it as if it is some kind of medical intervention that is independent of other causes of quitting, but really it is (at most, even if it really works) a focusing event, causing people who are considering quitting soon to say "ok, I am going to do it that day". So the effect, if there really is one, is to move quit attempts from May and June back to April. Perhaps not of trivial import (remember that smoking for just a couple more months is as unhealthy as using smokeless tobacco for your entire life), but not the same as causing quitting that would not have otherwise happened.

And this says nothing of their their magical ability to detect permanent cessation from a cross-sectional survey. Even if they have some standard prediction about permanence, quitting for different motivations, like say a focusing event, will inevitably have different permanency rates.

As if this were not bad enough, where they really jump the shark is the cost-effectiveness analysis. Reporting the cost of a declared focusing day per smoker is LOL funny. I wonder how much National Kale Week cost per meal at which kale was served; I will bet it was quite a bargain too.

That "ICER" is the "incremental cost effectiveness ratio", which measures the cost-effectiveness of an intervention as compared to an alternative it could replace that is more cost effective (so a better deal) but less effective in total. In other words it accomplishes an analysis like: "if we are going to take driver protections one step beyond seatbelts and add airbags, which are much more expensive but will save a few more people, we should make sure to not give airbags credit for the people that seatbelts alone would have saved anyway by comparing them to no restraints at all." What makes this funny is that they pretend to be using a somewhat complicated good measure, one that is often not done creating erroneous results (e.g., airbags are measured against no restraints at all; pharmaceuticals are measured against placebos rather than existing effective treatments), to look at something that they got totally wrong. In this case, the alternative that is crowded out by NSD (like airbags+seatbelts crowds out seatbelts-alone) is they same people quitting a bit later, which they completely ignore. So what they claim is ICER is really just the most basic, and misleading, cost-effectiveness calculation that pretends nothing would motivate quitting were it not for NSD.

So they go on to calculate the cost-effectiveness, not as £80/life-year-saved, but £82.24. Even if their estimate of the effect of the intervention were as precise as the 2.8 percentage points they report (which is not even possible given that they are basing this on only a few hundred events) they could not get precision even to the first significant figure, let alone the fourth: The guess – "estimate" would give it too much credit – about how many life years will be saved by someone quitting (again, even pretending that NSD caused it, and their estimate of permanent quits is based on anything, and that it would not have happened a month later even without NSD) requires assumptions about the next half-century of medical technology and other health effects. It cannot be reasonably guessed-at within a factor of two, let alone to one part in 10,000 as they imply. Someone develops a cure for cancer or emphysema, and the benefits plunge; some other breakthrough extends life by 100 years so long as you do not get cancer or emphysema and the benefits shoot up.

About the only thing that can really be said about their conclusion is that there is no doubt that NSD is more cost-effective than funding people who write articles for Tobacco Control.

Yes, this is what passes for science in anti-tobacco. Is it any wonder that they can reconcile "hundreds of millions of people are not quitting" with "a tobacco free world by 2030" or whatever? It would be humorous if it was not so incredibly damaging. Oh let's be honest: In spite of being incredibly damaging, it is frackin' hilarious.

Unhealthful News 179 - Getting molested by TSA is starting to look pretty good

2011-06-28T21:48:00.000-04:00

Oh it is going to be fun to watch this one play out.

A few blogs have started putting out various versions of the story that the new x-ray body scanner airport security machines that are increasingly installed in major US airports (which the bloggers call "naked body scanners", so they are making clear their opinion about them) are causing an elevated risk of cancer for the Transportation Security Administration officials who are operating them, and that the claims that they were safe were actually based on approximately nothing. The latter seems quite plausible. I am a bit doubtful about the former, but it is an interesting story.

In any case, it is a fun day for the Freedom of Information Act, which revealed some of this information, as well as the source of my previous post from earlier today.

There are definitely grounds for suspicion about the whole program. Some European airports have installed full body scanners that do not use ionizing radiation, and thus are undoubtedly safer, but there are rumors that the US is using an inferior product because the manufacturer is well connected. I am not sure about that, and it did not show up in anything I saw today, but I am sure it will come back into the narrative, so I will leave it to those who are better at that kind of investigation. Some of the points that came out this week were rather more interesting: Far from saying the machines are perfectly safe, as the US authorities claimed they had said, various researchers made clear to the government that they could offer no such assurances and they even suggested that TSA workers should avoid standing near the machines which, of course, is safer than being the passenger standing inside them.

The claims that the radiation dose is acceptable seemed to be based on the assumption that it was evenly divided throughout the body rather than being concentrated in the skin, creating a much higher local dosage that could cause skin cancer. However, a lower dosage spread more evenly might create just as much cancer, just at low levels in each organ, and most skin cancers are not that threatening, so this might be a good thing. It is quite a muddle. But what is clear is that the information given the public was inaccurate. It is also interesting that TSA agents asked for dosimeters (which measure cumulative radiation exposure and are common for lab workers, reactor workers, etc.) but were refused.

All of this information makes the government's behavior look very sketchy, and the charges against them are quite plausible. Meanwhile, no plausible response to the charges is apparent. From an epistemic perspective, the existing accusations and criticisms clearly put the burden of proof on those who are claiming safety, and they seem to have nothing.

On the other hand, the claim that will probably generate the most interest is pretty much groundless without further information. TSA screeners in Boston have complained about elevated cancer rates, and the allegation is that TSA authorities have dismissed the claim and tried to cover it up. This is a classic case of a cancer cluster, as I have written about in this serious previously. It is always the case, due to the random distribution of disease occurrence, that some group of people somewhere has a very high rate of some cancer or other disease. The fact that they self-identify does not tell us much because it is almost impossible to tell a chance cluster from one that is being caused by some exposure. Indeed, we cannot even be sure that there is an elevated rate in this case, since there seem to be no numbers forthcoming. Moreover, the claim is that there is also an elevated rate of stroke and heart disease, which are not plausibly related to the low-level radiation. Finally, the machines have not been in place long, and almost all cancers take much longer than that to manifest; the basal cell carcinoma that has been proposed as the greatest risk typically appears more than a decade after the triggering exposure (usually a bad sunburn).

So the Boston cluster probably signifies nothing, and the "cover up" – i.e., realizing that there is not a plausible causal relationship and not pursuing the matter – was a reasonable response. But in light of the real cover-ups that have occurred, and the general failure to understand the cancer cluster statistics problem, it could prove mighty embarrassing.

Oh, and for the record, a few days ago, before this story broke, I was directed to go through one of those scanners and refused, insisting on a manual search. This was not because I was intrigued by the thought of being felt up, but because I never believed the claims about the safety of those machines. Even though I am sure the risk is very small (and so I would not have done this if the cost to me were high, like I did not have a half hour to kill before my flight boarded anyway), it seems to me to be an obligatory act of civil disobedience, to demand the slow labor-intensive option as a protest against the dishonest way in which we have all been exposed to this bit of potentially dangerous security theater.

[Unrelated: Those of you who are working on learning the nuances of epidemiology by reading this series might want to check out my ongoing comments at this post, which currently focus on distinguishing confounding from causal intermediaries, but are expanding into other points.]

Ellen J. Hahn does not libel Brad Rodu so much as expose the ignorance of anti-tobacco "researchers"

2011-06-28T09:46:00.001-04:00

(A non-UN post)
Several people have sent me this FOIA-disclosed email, implicitly suggesting I write about it. In it, University of Kentucky professor Ellen J Hahn writes about my friend Brad Rodu, a prof at rival University of Louisville. The context was not reported, but the email seems to have been sent to some local health officials, and was presumably intended as an attack to try to prevent them from learning something (which was undoubtedly true) from Brad about harm reduction. Hahn wrote:

Please note the [sic] Dr. Rodu is on the Board of Directors for US Tobacco and has funding from the smokeless tobacco industry. He is a big supporter of use of smokeless tobacco to quit smoking.

Brad is quite proud of the latter characterization, and discloses his funding much more aggressively than anyone I know (and far far far more readily than the anti-tobacco people do). But the first bit, about being on a board, has been characterized as libeling him. The claim is false, but while I am no lawyer, I really do not think that merely giving someone credit for holding a position, grant, etc. that they do not have is libel. If we call that, or the false statement that someone has funding from industry, libel per se then we are implying if it were true, it would be crime or at least a terrible embarrassment. Neither of those is true. Perhaps if someone was well-known for stating that he does not take industry funding, and then someone claimed otherwise, it would be an explicit accusation of lying, which could be considered libel. But otherwise it is best not to fall into their trap of implying that corporate efforts to support honest research and THR are a bad thing.

On the other hand, Hahn probably thought such board membership was at least as bad as lying, so maybe its libel-ness should be judged by the standards of the writer. For example, if someone claimed:

Ellen J. Hahn, a University of Kentucky professor who actively opposes tobacco harm reduction, received competitive grants from a pharmaceutical company that makes nicotine abstinence aids and a cigarette company that is not moving into the low risk tobacco business, both of whom stand to lose business if the public health benefits of THR are realized

she might consider it libel even though it is merely giving her credit she does not deserve. Of course, I am not claiming that -- I have no idea if she has ever received such grants -- so, gee, I hope no one takes that paragraph out of context. Just in case someone wants to, I had better rephrase it using a trick I learned from the tobacco control people:

It is worth considering the possibility that Ellen J. Hahn, a University of Kentucky professor who actively opposes tobacco harm reduction, has received funding from pharmaceutical companies that makes nicotine abstinence aids and cigarette companies that is not moving into the low risk tobacco business, both of whom stand to lose business if the public health benefits of THR are realized. She certainly sounds like one of those people who is being paid to opposed legitimate public health efforts.

But I have not gotten the really important, and even somewhat funnier, bit. I noted that Brad would never have bothered to deny he was on the board of "US Tobacco". Among the very good reasons for that is that there never was a major company called "US Tobacco". There was "United States Tobacco" until 2001, when they changed their name to "US Smokeless Tobacco". Hahn's email was written in 2010, so even if she started writing about this back in the days of the old name (that she only got somewhat wrong) you would think she would have adjusted sometime in the 21st century. This might seem like a petty distinction, but keep in mind that this was not an ongoing correspondence about a topic in which abbreviations might creep in. It was a one-off statement of fact, intended as an accusation, and so obviously called for getting the statement just right. Presumably, then, the error reflects the fact that she did not know what she was talking about.

The bigger problem, that proves she did not know anything about the topic is that UST (their stock ticker and typical shorthand for that company) was acquired by Altria and integrated into that company and put under its board of directors; this was completed in 2009, as anyone writing in 2010 would have known. At least anyone with a modicum of knowledge about the world of tobacco would have known it, and Hahn signed her letter with "Director, Tobacco Policy Research Program" and "Director, Kentucky Center for Smoke-free Policy", so she seems to be claiming she is an expert in the matter.

So, Hahn did not commit libel. She just committed the usual factual sloppiness that is common among the scientific "experts" involved with tobacco control when trying to further their cause, ignoring science and other sources of fact and disciplined reasoning in favor of just saying anything they think might help their case. And furthermore, it is not even an exceptional case of that by the standards of the tobacco control "research" crowd. It is important to make this distinction, because these people do commit libel sometimes, and we should reserve the term for those occasions so it does not get worn out. As for accusing them of simply not knowing what they are talking about and saying anything they think will further their cause without regard to its accuracy, well, there is no way to avoid wearing those out.

Unhealthful News 178 - Why is it never a subsidy for healthy behavior?

2011-06-27T21:37:00.001-04:00

The battles over financially penalizing people for unhealthy behaviors seem to be increasing well beyond historical levels. After the triumphs there in the area of tobacco, which continue to amplify also, the battle has ramped up to punish people for soda, alcohol, and other unhealthy foods, and even to impose fines on recipients of public health care if they are overweight, and like tobacco, this has begun to include private lawsuits. (Important note to those of you reading too fast: Notice that the antecedent was punishing people for their behaviors, and thus "triumphs" refers to increases in punishing people, a triumph in the minds of people who think that is a good thing. I am most certainly not suggesting these are triumphs from the perspective of public health or any other humanitarian interest.)

Last week a data mining exercise revealed that consumption of fried potato products independently predicts more weight gain than does soda consumption. (Notice the phrasing there: Those foods are predictors of weight gain, not necessarily the cause, even though some other exposures are "controlled for" to some extent. Also, the simplistic analysis does provide useful quantification even though quantities were reported in the press by people who did not even understand that they do not understand what the study results meant.) In response, the LA Times half-joked about imposing a potato tax, to mirror the proposed soda taxes. It is pretty clear that if one is justified, then so is the other – both of these foods are a combination of energy (calories) and entertainment, with little other benefit. A parent would be wise to discourage young children from consuming them, as yummy as they are.

But what should we think about the government doing so?

Much has been said, but something occurred to me that is absent from that debate: No one ever suggests making such taxes revenue neutral, and there is almost no talk of using subsidies instead. There are plenty of arguments to be made that government has no business doing this at all, of course. But to test the honesty of the claims made in support of the taxes – "it is good for society", "it will save healthcare money" – it would be interesting to see if supporters were so excited if these proposals were not profitable.

Some would still be adamant supporters, of course. This includes some people who genuinely care about people, understand welfare economics, and genuinely believe that people make non-welfare-maximizing decisions – i.e., not in their own best interests, based on their own preferences – and so want to assist them in making better (as defined by their own preferences) choices. But this is a tiny minority of the supporters. Most government officials who buy into these schemes seem to be most interested in the promise of more money. Would they be on-board if it were just about supposedly helping people? And of course, there are the "health promotionistas" who believe they know best about what is best for people, and are willing to punish the people into conforming to their god-given knowledge. Putting them to the test is a little more difficult, but it could be done.

To take away the government coffers incentive, it is just necessary to make the policy spend at least as much as it takes in. It may not be trivial to figure out ways to spend money in the same direction as the taxes since, for example, we cannot subsidize tap water, already approximately free, as an alternative to penalizing soda. But the taxes are not exactly trivial either, so it is not all that much harder. (E.g., for a soda tax there are dozens unintended consequences and major complications like: Are they really going to ban free refills, and if not, how can they tax by unit volume? Are they going to forbid raising the prices of all non-taxed drinks to keep them all the same, as most every restaurant will prefer to do? Will clerks be required to police self-serve soda fountains to make sure someone is not evading the tax by lying about their soda being diet?)

Figuring out how to offer a subsidy for healthy foods might have to be a bit oblique compared to the soda or potato tax, like requiring that all of the tax revenue be given to grocery stores in proportion to how much broccoli they sell. But the main point is to ensure that those pushing for the taxes are all really motivated by the incentive effects of the price increase and not just wanting to skim some money for themselves. You have to figure that this is the real motive of governments; supporters in New York practically said as much. So let them prove they really are supporting these proposals for their public health benefits. Indeed, governments should even be required to kick in a bit more, to lose a bit of money from the policy, something they should be happy to do if they are really motivated by the wondrous predicted healthcare savings.

This has the added benefit that government will not become dependent on the revenues, like they have with cigarettes. Efforts to prevent tobacco harm reduction are inspired, in no small part, by the governments and activists who do not want to lose their cigarette tax gravy train. Yes, the broccoli lobby might try to keep people drinking soda to keep up their subsidy flowng, but if we spread the subsidy widely enough, no one will be in a position to want to make sure the behavior does not abate because they are now profiting from that market.

That brings us to the outside activists. You can be sure that anti-obesity (etc.) busybodies and their pet researchers are drooling at the prospect of getting their very own Legacy-like boondoggle of money. It will not be as big as the cigarette tax payoff, but it will still support all manner of useless activity for many useless people for the rest of their careers. So we should absolutely take it away from them by requiring the revenue be spent in a way that does not benefit them. In fact, we can make them pay for this. If they are so excited about incentives, let them experience some. The rule could be that major policy initiative that is onerous to people, like a soda tax, but will supposedly will reduce the health budget by x% should come with an automatic x% reduction in population research, advocacy, education, etc. funds for health promotion. After all, with that much of the problem solved, not as much money will be needed. Perhaps that would encourage a bit more honesty in these over-the-top predictions that never come true (they are generally off by approximately 90% of the predicted benefits), as well as some priority settings.

After all, we cannot let these people continue to gorge themselves on whatever they want without facing some repercussions. The expenses they impose on the rest of us are simply unfair.

Unhealthful News 177 - Prevention is better than cure, but preventive measures are often not

2011-06-26T22:14:00.000-04:00

I had planned to cover the news today, but I had one more overview thought I wanted to communicate. I have written some of this before, but I have a few new thoughts that I think are interesting. I will repeat enough to make it unnecessary to go back and read anything.

When major failures occur in a normally functional system, it is usually due to a combination of three causes, not just one as we often try to simplify it to:

operator error (e.g., pilot error; occasionally a failure would occur no matter what the proximate actor did, such as when the hardware just breaks, but usually some specific goof triggers it – otherwise it would probably have already happened)

hardware inadequacy (not necessarily that something broke, though that might be involved, but that it could have been designed to avoid the failure in question if that had been the goal)

systems failure (rules or patterns of behavior made the operator error more likely and did not guard against or mitigate the effects of this particular failure mode; e.g., making it easy to push the wrong button, not inspecting the tires often enough, not building in redundancies)

I commented yesterday about a novel that included the U.S. CDC fighting an all-threatening disease outbreak that required all of their abilities and major police powers, contrasting that with the current government practice of nibbling away at freedoms and pleasures to provide trivial health benefits at great psychological cost. "CDC" is, of course, the now inadequate abbreviation for the Centers for Disease Control and Prevention. And who can complain about the fact that they or any other government entity have prevention as part of their mission? How can prevention be bad?

It is bad when it lets a certain ilk of people try to make everything about operator error.

An illustrative example of focusing on the operator that you have probably seen is the card reader or gas pump that has multiple layers of hand-scrawled signs telling people which button to push or direction to slide, accompanied by clerks who get annoyed a few dozen times a day when they have to point out the sign to those who do not notice it and consistently guess wrong about what to do. This is a case of the operator being blamed for, and being forced to compensate for, hardware and systems failure: a device that was designed in a way that sufficiently defies expectations that many people's guess about how to use it, coupled with no better system for encouraging correct usage than yelling at the operator. Another favorite are the hotel key cards where the clerk repeatedly warns you to keep them away from your phone and wallet or they will demagnetize, which inevitably happens. These problems do not merely offend the engineer in me, but cause needless cost. They call for using better hardware (it exists in all of these case) or figuring out a way to gently guide people to avoid the problem.

Such solutions tend to be noncontroversial. No one complains about health researchers when they figure out a hardware fix to a problem, like a new drug. No one should complain (other than, perhaps, about the cost) when government improves infrastructure to give people the opportunity to behave in a healthier way, such as by installing bike paths, making sure that urban bodegas sell fruits rather than just chips, or requiring that restaurants list calorie counts. (Occasionally someone complains about such actions but they generally lack legitimate grounds to do so. Perhaps the predicted benefit does not seem to outweigh the cost, though seldom is that the justification.)

But "...and Prevention" becomes a problem when it consists of harming people in an effort to force them to change their behavior. That is, they put the onus on the operator. This is a remarkable combination of bad judgment and bad ethics. The ethical arguments, both libertarian and cost-benefit based, have been made here and elsewhere to an extent I see no reason to repeat them. The more practical argument is that in most arenas, the people running a complicated human system recognize that they must look for ways to improve the system, since bludgeoning people into being better operators is usually pretty useless. Pilots are not trying to crash after all. And if all of your troops are miserable to the point that they are not functioning well, you can try to whip each of them until they perform better, but there are much better solutions.

If your students are doing badly, you can admonish them to study harder, but if it keeps happening year after year, there is probably something wrong with the teaching, or the motivation, or the community, or something else beyond the individual. Yes, each student could save his own life, but if so many of them are failing to do so, we obviously need systems fixes, just like with a card reader where the users insert the card the wrong way most of the time. Imagine a task force assigned the job of improving the performance of schools proposing the policy, "ban televisions and video games, and institute corporal punishment and public humiliation for bad grades, and make sure there is no safety net for students who cannot get through school to make sure they have an incentive to do better." But that is basically what the "health promotion" people propose when tasked with disease prevention regarding drugs, diet, and exercise. They sometimes talk about making healthier communities, but a close look reveals that they are often just demanding that each individual behave differently.

When reviewing applications to public health school from the hundreds of indistinguishable Indian applicants trying to get into to American schools (usually with the intention of getting a foot in the door so they can become American physicians), their nearly identical application essays included the phrase "prevention is better than cure" in the opening paragraph. That sounds fine to a public health person, notwithstanding the pathetic repetition, until you notice that it is not always true. Preventing a particular case of a serious disease is almost always better than letting it happen, but that is not how things work. We cannot go back and prevent a particular event. We can only take prevention measures. Some of those are justified and efficient: clean water is definitely better than treating cholera, and the right vaccines and industrial regulations are appropriate and worthwhile.

But in keeping with my observations from yesterday, others represent cases of mistaking a prevention measure for an act of prevention. Just because it would almost certainly be a good thing to prevent a fatal smoking-caused cancer or accident does not mean that everything that might theoretically protect someone is a good policy measure. Preventive measures have broad negative effects and may not save anyone. I doubt that any honest intelligent person really thinks that emotionally violent pictures on cigarette packs are really going to cause many people to not smoke. But there is strong support for it because people mistake a preventive measure that seems like it might do something for a way of preventing a particular outcome. But it does not work that way. Whoever it was in someone's life who was suffered or died because of a risky behavior is not going to be retroactively helped. Preventing that would have been good, and curing it also, but that is not necessarily true for a prevention measure aimed vaguely in a direction that might have prevented that case. And implementing public policy rules is not a healthy form of therapy.

Unhealthful News 176 - But if you try sometimes, you just might find

2011-06-25T21:32:00.000-04:00

Last night, I finished reading Mira Grant's novel, Feed. It is about bloggers and a future filled with zombies. I trust that is enough information to polarize my readers into those who will absolutely not consider reading it and those who are intrigued. For the latter, I recommend it as entertaining moderately-light reading with some good deeper messages. (very minor spoiler alert) In it, the CDC has become a latter day military + police + homeland security for dealing with the biological threat of zombie virus infection that puts everyone at dire risk. I think one of the reasons I liked the book is that it is so refreshing to think of government public health people fighting a genuine major health threat rather than fiddling with soda, salt, and e-cigarettes. Of course, there are hints that they might be part of a power-politics conspiracy, and the author somehow randomly puts them in conspiracy with the tobacco companies, which is quite strange because she has constructed a future where people are protected from cancer and so smoking has become a popular and comparatively non-harmful activity. I guess she just has some personal pique about that one.

Anyway, perhaps we have people who are just wired to fret about risks and hazards and to try to do something about them, and this urge is not based on the actual magnitude of hazards that are faced. In a previous era they just would have inflicted that neurosis on their own kids, but now they have found ways to infantilize entire nations. In the zombie-filled future, they will have something useful to do. But right now they are like a large politically-powerful standing army during peacetime, an institution that tends to create the urge to fight pointless wars.

Today I went to the funeral for an old friend/classmate/roommate (so someone who was only my age). People cannot always be protected from the things they choose to do for fun. I have not changed my mind about that, even though we certainly see how sometimes a single event triggers some people – those with that wiring I mentioned – to direct their crusade in a particular direction. But most of the time that effort is something that can only make life worse, on average, and usually consists of waging war on some vice that would have turned out to have no effect, in this case.

Today, catching up on the lives people I had not seen or heard about in a while, I became starkly aware of how psychological health matters so much more than longevity by almost any measure. My friend had more total happiness in his foreshortened life than most people could ever hope to, but I was reminded of how many people do not manage to have much. In some never-turned-off circuit in my brain, it redoubled my disgust with what passes for do-gooder public health these days, actions that increasingly threaten to worsen people's psychological states for comparatively trivial physical benefits.

It also occurred to me that he probably would have been a great asset when the zombie war started.

P.S. This actually does make sense together, at least in my head. Also, just for today, I am closing the comments.

Unhealthful News 175 - You cannot avoid mosquitoes

2011-06-24T23:49:00.000-04:00

Pretty insightful title, huh?

Those of us who write about public health with a libertarian bent (or what I prefer to call a humanitarian bent – we treat people as people, rather than mere biological processes, and care about what they care about) often point out that the behavioral preventive measures that the "health promotion" types favor are often not worth the costs. But sometimes they are not even preventive.

I was just noticing the usual annual flurry of news stories about mosquitos and west nile virus (no link – I am not basing this on any particular story or claim). Many of them offer suggestions about avoiding being exposed (lots of repellant, staying indoors at certain times of day), usually in conjunction with a warning about WNV being detected in mosquitoes in the local media market. Some stories are about government efforts to eradicate the exposure vector with over-the-top chemical attacks on the local mosquitoes. The problem is that it is probably impossible to avoid exposure to WNV. Maybe I am thinking about this because I was just in northern Alberta feeding approximately 500 mosquitoes per day. No WNV there, but if there was, I would definitely be exposed. And during my time being outdoorsy in Texas, Minnesota, and other places, I have no doubt I have been exposed. And so have most of you who have lived in places where it is endemic.

At least that is my guess. The last time I followed the science on this topic was about five years ago, and at that time no one had a good idea of what portion of the population in areas with WNV had antibodies (which proves exposure, though people without detectable antibodies may have been exposed too). Maybe knowledge has improved since then, but I have not heard anything. Anyway, the point is that it is a better assumption that everyone in areas with lots of WNV mosquitoes is eventually exposed than to make the usual assumption implicit in the news reports (and the public policy).

What is that assumption? That only those people with diagnosed cases of west nile disease have been exposed. This is absurd, but it is remarkably common among those people who are supposedly expert on infectious disease. Think about numbers you hear, like 75% mortality rates for some exotic new disease. What that means is that if you look at only the people who show up at a hospital because they are in critical distress from SARS, bird flu, etc., lots of them die. Not exactly the same as what is being claimed, since thousands or millions may have gotten the infection but showed little or no symptoms.

So the precautions against WNV assume that most people who have never suffered a disease case from the virus must have not been exposed, so they should protect themselves (or the government should protect them) from exposure. But, again, there is absolutely no basis for this assumption. Frankly, it is kind of crazy. It is pretty clear that, among people in endemic areas, what keeps someone from becoming a disease case is much more likely to be genetics or other personal characteristics, not the absence of exposure to the virus.

This is a case where you might choose to let the press off the hook (though it would be good if they were better at what they do) because they are being fed a steady stream of nonsense from the supposed experts. You can avoid getting HIV by practicing safe behavior. But if a substantial fraction of mosquitoes where you live carry WNV, it will find you (unless you can get them all to use condoms). And as long as the experts keep up the fiction that avoiding exposure is the best way to prevent disease, we are unlikely to find a solution for the majority of people who are not willing to seal themselves up from bugs for months every year. This naive fixation is annoying and absurd, and yet strangely true to form for official "public health" people.

Unhealthful News 174 - Many results in journals are wrong, and that's ok

2011-06-23T20:01:00.000-04:00

I received the following observation via twitter. It looks like it had been RTed and perhaps MTed a few times, so I am not sure who first said it, and it does not matter. I also do not know whether it was facetious or serious. The suggestion was:

Maybe we shouldn't publish until results are replicated

The accompanying link was to a case of a researcher who fabricated data and the published papers have been withdrawn.

I can understand the frustration that causes a lot of non-scientists to complain that too much gets published that turns out to not be true. Rarely is this because of something as blatant as fabricating data, though it is quite often for actions that ought to be considered similar, like researchers intentionally fishing for a model that gets the result they want and hiding that fact. Sometimes, though, it is the completely honest and proper error that comes from random sampling or an unrecognized flaw in the study. Readers want simple right answers, like they learned in high school science classes. But science in action does not work that way.

Probably some of you immediately thought of the point I wanted to make about the above quote: How, exactly, can anyone replicate something that has never been published? They might stumble on the same analysis and do it themselves, but even then they would not know they had replicated something. Why? Because the way researchers let other researchers know that they have seen something that might be worth replicating is to publish it. Scientific publication is primarily designed to be communication among scientific experts.

The problem is, then, when research results that, to non-experts, are barely more understandable than raw data are communicated to people who do not understand what they are: They are just one cut at a question and might be different from the future received wisdom, or even the existing received wisdom. And this even ignores the problem of readers not knowing how to interpret the results in a useful way, even apart from what other studies might show.

Everyone in sight is guilty here. Researchers (and their institutions, and the journals) tout results to the press even when no one other than a few experts can really make sense or use of them. Most health reporters do not know enough to critically assess results or put them in context, except in the way they cover politics (which is to say, treating it like a "he said, she said" game and finding someone to just assert that the result is wrong). Science teachers create the mistaken impression that scientific results are always Truth. And the public demands simpler answers than can really exist (though perhaps all the blame there lies with the others on the list).

As you can surmise from my writings, I think the crux of the problem is science reporters who simply do not understand science, and health researchers who ...well… simply do not understand science. But no one is going to get those groups to refrain from publishing until they know what they are doing. And demanding replication of the errors will not help any -- there is no shortage of that.

Unhealthful News 173 - Believable information about nearsightedness (and why)

2011-06-22T23:38:00.000-04:00

I need a little positivity in my life today, so I am going to write it. Perhaps the most interesting health news story of the week was not in the news, but was an op-ed in the New York Times that argued that spending time out in the sun is the way to prevent a child from becoming nearsighted. The authors make a good case and it seems convincing. It is kind of interesting why it is convincing.

The authors clearly demonstrate that they are engaged in good scientific reasoning. This is not a case of a reporter blindly transcribing something he does not understand. (I should also mention that the authors are credentialed experts, but frankly that does not impress me. People with those credentials write a lot of garbage too.) They start with the observation that nearsightedness has increased dramatically in Americans over 40 years. But particularly insightful is that they observe that there is a strong genetic component, which is pretty much common knowledge, but allude to the fact that any highly nearsighted prehistoric ancestors would have been selected out of the gene pool. Thus, our ancestors must not have been nearsighted and so there is an environmental cause alongside the genetic cause (my words, not theirs, but they make the point precisely without the jargon).

They then point out a couple of studies that support the "playing outdoors a lot as a kid protects against nearsightedness" hypothesis. In a typical health news story, this is all you would see. You would then be left wondering if these studies really represented the most convincing body of evidence, or if the authors just like their results. It is still possible that these authors are pushing a pet claim that is really not so well supported. I know little about the subject, so could not judge.

So why do I trust them? Well, I understand evolutionary biology and gene-environment interactions in the abstract, and they explain those parts of the story correctly, with a precision that comes from simplifying without dumbing down. The do not explicitly point this out, but their explanation can explain the quantity of the effect that has been seen (because the changes in being outdoors are that great), unlike many such stories where something causes a large percentage increase in risk but still only accounts for a small fraction of the total. They also respond to the common belief and most obvious alternative hypothesis, that staring at books and screens caused the problem. The respond with a mere assertion that this is not true, which leaves the reader a bit dissatisfied. We can hope that if they could have afforded another few hundred words they would have explained the claim a bit. But the mere fact that they recognize what most people would think when told "nearsightedness has an environmental cause and is increasing in Americans", and they bring it up themselves, is a good sign. Acknowledging the best alternative hypothesis to their own does not prove they are credible, of course, but the typical practice – failing to even mention it, hoping readers will not think of it – would prove they are not.

On the critical side, they write the phrase "four times less likely". You know what they mean, but if you think about it, that phrase really does not work. It does not really hurt their scientific credibility.

So, good news for my baby, who may avoid sharing my experience of having to memorize where the soap before getting into the shower (no glasses) because I cannot see it. And it is good to see health science writing that inspires confidence, and to be able to sort out why that is.

Unhealthful News 172 - Reviews of expert analyses are not better than expert analyses

2011-06-21T23:57:00.000-04:00

Ben Goldacre is a blogger/columnist for the Guardian, covering much of the same ground as Unhealthful News. He writes some interesting stuff, and often makes a point I overlooked when writing about the same topic, though I often disagree with some of his points, usually because he falls into a trap of incorrect conventional wisdom about what something mean. Recently, he posted about a research paper that he and colleagues wrote to address the question of how often health claims in newspapers are wrong.

Ironically, though, the study has at least one serious weakness.

He reports:

Here's what we found: 111 health claims [about food that could be interpreted as advice] were made in [the 10 leading] UK newspapers over one week. The vast majority of these claims were only supported by evidence categorised as "insufficient" (62% under the WCRF system). After that, 10% were "possible", 12% were "probable", and in only 15% was the evidence "convincing". Fewer low quality claims ("insufficient" or "possible") were made in broadsheet newspapers, but there wasn't much in it.

Sounds impressive, until you ask "what could that possible mean?" (remember to always ask that!) He does actually explain much better than news stories usually do, and the explanation points out a certain contradiction in the reasoning.

I have a minor quibble with the characterization of the target population of stories. I think it is a bit misleading to claim that you can clearly define such statements, separating them cleanly from statements about food that are so obvious or obscure that they do not count as advice. But so long as they had a clear idea of what they were looking for, and worked hard to avoid choosing to include something because it made their results so impressive, then that is fine. A category can be systematic without being a clear epistemic object. Another minor quibble is their choice to take every paper for a single week, rather than gathering the same number of each newspaper from across a wider time period. This would help reduce random sampling error since health news stories tend to cluster.

The important concern, however, is how they decided what category to put something into:

a heroic medical student called Ben Cooper completed this epic task, researching the evidence behind every claim using the best currently available evidence on PubMed, the searchable archive of academic papers, and current systematic reviews on the relationships between food and health.

But this depends on the published literature, as interpreted by someone who is semi-expert, representing the best expert knowledge on the subject. It is remarkable how often that is not the case. I can think of numerous examples where someone reviewing the literature would come away with a conclusion that is very different from that of genuine experts. To name just three examples I have worked on that I have written about here and that come immediately to mind, someone naively reviewing the literature is likely to conclude: harm reduction using smokeless tobacco is not proven to be beneficial, H.pylori infections never go away without treatment, and routine screening mammograms at age 45 are a good idea.

In fairness to Goldacre et al., none of these are dietary choice, which tends to involve rather simpler claims and where most of what is claimed is based on one data fishing study (and thus is not well supported). So they kind of wired the result by choosing that particular topic. But there are still specific subject experts who know more than a simple literature review could tell you and cases where they recognize something is true though the literature has not caught up. Sometimes they are the ones making the statements to the press that get reported but do not appear to be supported by the literature, based on a naive reading. Moreover, the researchers who wrote those papers that Cooper reviewed are often the ones making claims to the press that are fodder for Goldacre's criticism.

There is no easy answer here. You have to figure out who to trust, and you cannot trust that the literature is accurate if you are not going to trust the authors of that literature. But if you are going to trust the literature and are really trying to figure out if a claim is supported, it is probably worth asking a few of the people you are trusting as experts for their opinion. Many systematic review papers are synthetic meta-analyses, which I have pointed out are highly flawed. But the others, that do not blindly follow a bad recipe, are heavily reliant on the expertise of their author, in both the subject matter and scientific epistemology, and there is no rule that prevents someone who is far from a top expert from writing the review (indeed, it is far more common than not). Many reviews just take sketchy information and repackage it so that it looks authoritative. Is this review of 111 claims such a case? It seems even harder to do this well.

Unhealthful News 171 - What the U.S. government is doing for our health

2011-06-20T23:44:00.002-04:00

Today in my twitter feed:

1. The FDA tobacco unit (@FDATobacco) sent out multiple tweets, seemingly once an hour, talking about how they are going to have an exciting announcement about new cigarette package rules tomorrow. Maybe I am reading too much into 140 characters, but they seem downright giddy about it. Whether you like the policy or not, there is something unseemly about the glee.

2. A story tweeted by @taz3cat reports that a man robbed a bank, demanding just $1, so that it would go to prison and thereby get health care.

3. Also, a reminder that thanks to the lack of effective stimulus effort, we are headed for a lost decade (high unemployment, people permanently lost from the world of productive pursuits, etc.), which will ensure that more people will need to rob banks to get health care.

But at least cigarette packages will be uglier (I assume). Maybe that will solve everything.

That is all. Sorry – I've had a very bad day.

Unhealthful News 170 - Followup on the benefits of smoking

2011-06-19T22:31:00.000-04:00

This is the first of what might be some posts with thin and/or recycled content.

Yesterday I finished the third of a series of posts examining a study that supposedly estimated the full costs (including health, etc.) of a pack of cigarettes. I used this to explain the concept of putting dollar values on the "invaluable", as well as the limits of doing so, and some other principles of cost-benefit analysis. I concluded with the observation that it is almost impossible to justify doing an analysis that counts up how a behavior takes away life's benefits (by costing life years) without including how it create benefits too (by improving their mental health, functioning, and happiness).

The "almost" in the last sentence refers to the one justification I can think of, if you are using the rest of that calculation to figure out the minimum benefit someone must be getting from the behavior. That is, if the calculation shows that the total cost someone pays per pack of cigarettes, netting out everything other than the day-to-day benefits of use, then those benefits must be greater than the caluculated cost. So since the study put that cost at $40/pack, the benefit to a smoker must be at least that. In the comments yesterday, Chris Snowdon picked up on this theme, and I wanted to expand upon what he wrote.

He noted,

smokers tell us how much they value smoking by how much they spend on the habit

in the form of what they pay for a pack of cigarettes (purchase price, including taxes). He points out that the benefit must be this and then some. In economist speak, we have a revealed preference, the gold standard in consumer economic valuation, because consumers show us that the value must be at least what they are paying or they would not do it. I will offer a friendly amendment/clarification to what Snowdon wrote: The purchase price is that absolute minimum floor value for this, because smokers will also consider the anticipated health costs, as well as any costs from social scorn, etc. Even if someone makes the utterly absurd claim that smokers are oblivious to the health effects, the absolute minimum benefits must still exceed the purchase price.

It is certainly possible to make some arguments about the nuances, but the point is that such arguments have to be made. If someone is going to claim that, unlike every other consumer good, where revealed preference is considered gold and we trust people to show a tendency toward rationality and have common knowledge, smoking is different, they face a rather steep burden of proof. But in the dominant discourse about tobacco use, such arguments not even asserted, let alone established. And no, simply saying "cigarettes are different" is not the statement of an argument – a wee bit more detail is needed.

For example, it is possible to argue that smokers discount the future so heavily that they effectively ignore the health costs. It seems likely that they irrationally undervalue the future to some extent, since most people discount the future too heavily about everything, but quantification is needed. Those who want to make this argument are obliged to recognize that smokers do consider some of the health costs, and some quantification is needed. With that, someone could claim that the revealed preference floor is merely the purchase price plus that fraction of the health costs, and not the true total cost. Of course they do not do this because, as Snowdon put it,

anti-smokers heads would explode if they tried to come to terms with smoking being pleasurable or having benefits to the user....

But this refusal to acknowledge simple bits of reality means that the only two numbers on the table for the floor revealed preference (minimum benefits): the full cost of smoking and zero. And zero is obviously wrong.

There are other arguments to be made. It is possible to argue that smokers feel that the benefits do not outweigh the costs in the long run, but the short term difficulty of quitting is beyond what they are capable of enduring. This seems to be what most people have in mind when they talk about addiction (except the ones who just use the word to mean "use", and the tiny odd minority who use the word to mean some biochemical process). This is theoretically possible, but it describes a very extreme situation. The obvious evidence – the fact that so many people quit when they really want to, the fact that many people get over the short term hump and then start again – argues against this. So if someone wants to craft this argument, they need a lot more than vague assertion to back it up. The closest anyone seems to come to actually trying to argue the point is claiming that most smokers say they want to quit, or try to quit, but it is pretty clear that this is about second order preferences or is just cheap talk, and is obviously not enough to establish what should be seen as a rather extreme claim about deviation from rationality.

Bottom line: Rhetoric can convince causal readers and impressionable children that smoking is somehow such an extremely odd experience that it defies the rules that describe 99.99% of consumption choices, that it challenges rational analysis as much as North Korean indoctrination or facing the decision to cut your own arm off to escape the wilderness, or at least as much as methamphetamine. But scientists and other honest serious people should know that this requires some extreme evidence. That does not merely mean showing that there is some deviation from perfect rationality, because that is true for most every decision – the argument being made is not that there is a deviation from perfect rationality, but that even the most basic rules of rational behavior do not apply. So,

(a) Extraordinary claims require extraordinary evidence. Hypothesizing extraordinary claims without having the extraordinary evidence is acceptable as long as someone admits they are doing this. But never trust anyone who want you to believe that an extraordinary claim is self-evident.

(b) Absent compelling evidence to support the extraordinary claims, we have to recognize that a group of health economists have argued that a pack of cigarettes provides over $40 worth of benefit, or at least more than a large fraction of this if we allow for deviations from perfect rationality.

Unhealthful News 169 - Flawed cost of smoking calculation, part 3: treating people like crops

2011-06-18T22:44:00.000-04:00

In two previous posts I commented on a calculation that purported to show that the total cost of a pack of cigarettes, considering the costs of everything including the material, medical, disability, and premature death, is about $40. Some people might claim that it is impossible to put some of those in terms of dollars, but as I explained in those and other posts, it is possible and necessary to do. It is implicitly done every time we make a policy decision that trades off market-traded resources (or, put another way, money) against health and longevity. However, I argued, that particular calculation was wrongheaded, but offered some useful lessons for putting dollar numbers to those goods and some legitimate criticisms about doing so.

I pointed out that about half of the $40 in that calculation consists of the smoker's own value for living longer and most of the rest is the cost of the cigarettes and foregone future income. All the rest, the external costs, is covered by excise taxes, again paid by the smoker. So this is basically a market decision, which makes this kind of calculation – based on a lot of shaky assumptions about assigning numbers to the "invaluable" – inappropriate. Such calculations are needed when we do not have markets, like for infrastructure or regulations, but not for consumer market choices where the externalities are minimal or paid for. Since these calculations are a basically a very rough, kludged substitute for a real market, it makes no sense to use them if the market is functional. As I explained in the first of my posts, the numbers for the "invaluable" do not really have a meaning apart from their role as a substitute for a market, and so the calculation represents the mistake of treating the numbers for having existential meaning.

In the second post I pointed out some apparent flaws in the calculation, including some apparent double counting. Most of that came from including a "value" for a person's own value for losing a life-year of $100,000, and then adding in secondary effects of that, like lost income. As I pointed out, when using a number like that, it is a practical necessity to include the secondary, tertiary, etc. effects. So the numbers we use are a bundle of positives (enjoying life, producing, being there for your family) and negatives (consuming resources) rolled into a single number because it is impossible to sort them all out. So taking such a number and then adding back in some, but not all, of the secondary effects makes no sense; it would have been fine to pick a bigger number since that one is on the low side, but the partial adding up is rather a mess. For example, it makes no sense to count someone's lost income as a cost without counting their foregone consumption as a benefit.

That leads to the promised biggest problem with the whole exercise, failure to use a consistent level of analysis. An ideal cost-benefit analysis, assuming a CBA is appropriate at all, includes all costs and benefits: expenditures, opportunity costs, health costs, mortality costs, time spent, pain, pleasures, etc. Many partial analyses do not look at all of this.

Some look only at impacts on government or other budgets. These are fine for what they are, but are often mistaken for having greater meaning. For example, it is reasonable to figure out how much, on net, it costs a health system to pay for a cancer screening test, which costs something up front and causes treatment, but occasionally averts greater treatment costs. But this is often badly misinterpreted, such as if the result shows that there is a net increase in expenditure and someone says "it is therefore not worth doing". But the calculation did not consider how many people's lives were saved, and other health outcomes. The expenditure calculation might come out on the negative side, but for most medical interventions the resource cost (money spent) is a negative consequence that is justified by the health benefits. So these "budget-based CBAs", which are not really CBAs at all, are an ironic construct wherein the CBA ignores most of the B, and health economics (the name of the subdiscipline that focuses on such calculations) ignores health.

Another place where we sometimes draw the line is in terms of market resources, ignoring health and happiness. Again, this should not be mistaken for a full CBA. Only a communist or fascist government, or a very impoverished society that is desperate about survival, would want to make public health decisions based only on consumption and production. That is how we decide about spending money to make crops healthier, where we do not care about the crops' for their own sake. Still, the results might aid thinking about a choice, so long as they are not over-interpreted.

One place that is tempting to draw the line, but that does not work, is between costs and benefits. It may seem that effects of a policy are pretty easy to classify intuitively, and some are. But since costs and benefits are just the same thing with or without a minus sign in front, the distinction is technically arbitrary and makes a mess in many cases. An obvious example in the cigarette calculation is characterizing the exercise as counting up the costs, but still subtracting foregone pension payments from the sum. This is the right way to do a CBA – it certainly makes no sense to include some of society's expenditures on a person (extra medical consumption) but not the equivalent offset (less other consumption).

Aside: This is something that seems to elude those who believe that demands like the one behind the Master Settlement Agreement are reasonable. The claim is that smoking costs the government money because it increases someone's medical costs. This ignores the fact that smoking contributes quite a bit more money to the government in the form of taxes and foregone retirement benefits, so there is no legitimate complaint about "costing society money". The only way someone gets to that conclusion is by arbitrarily ignoring some of the effects of one type while counting others. That makes no more sense as counting the just the costs of taking a new job ("I will lose the $60,000/year I make from the other job and have to commute ten miles to work") rather than netting out each category ("I will make $10,000/year more, and my commute will be shorter"). That analogy may actually be charitable, and perhaps it is more like a shopkeeper complaining about having customers because all of them walk away with some of the inventory (which obviously ignores the fact that they leave money in exchange).

This brings us to the fatal flaw in that analysis of the full cost of a pack of cigarettes. As I noted, they properly netted out some of the benefits, like subtracting pension savings. But they ignored others, a smaller example being inclusion of lost productivity from smokers (from smoke breaks and sick leave) but not the offsetting increased productivity (by making some people more functional). The big and fatal example is the authors including the loss of the value of a life year to the smoker himself, but not the offsetting benefits of making the years that are lived better. If the analysis is going to go beyond budgets and include what people care about, it has to include everything they care about. Cherrypicking some preferences does not lead to a legitimate analysis. This is well established in the field. For example, analyses like this are used to assess the net value of a treatment (say, cancer chemotherapy) that increases longevity but imposts other non-market costs, like making someone feel terrible for their remaining months. While some such decisions can and should be made based on an individual's personal tradeoffs, sometimes a policy decision needs to be made, and anyone who knows how to do this right knows we must put numbers to all of these considerations. What the authors have done is arguably even worse than treating people like crops, because instead of cleaning treating people only as producing and consuming engines, they arbitrarily count some of what people care about but not all of it.

There actually is one reason you might want to calculate everything paid by the smoker (which they basically do since taxes pay for what would be externalities), leaving out the benefits of smoking: It allows us to estimate the minimum value that smoking must have for the smoker herself. If she is willing to suffer $40/pack in costs, then the benefits must be greater than that. Of course, someone might then argue that the true minimum must really be lower than that because people do not understand how harmful smoking is (though this is pretty clearly false in educated societies) or that people discount the future too heavily (which is probably true, but requires some arguments and calculations to quantify – it is not good enough to just observe it is true). Or perhaps there is just some difficult hump to get over to quit that people cannot handle, even though they have decided the benefits are not as great as the costs (which is probably what most people mean when they say "addiction", notwithstanding the attempts to misdefine it in terms of biology).

The generalization of this point is something that I do not have to explain to anyone who has thought about nanny state issues: The "health promotion" types (the extremist loose-cannon storm-trooper wing that is often mistaken for all of public health) engage in political manipulation by adding up only an arbitrary subset of costs and benefits. Generally they ignore everything people care about in the world other than market expenditures and longevity/productivity, and effectively tell people that they are not allowed to care about anything else. This is the right analysis for agricultural scientists, but is indefensible for social scientists. The economists who did the cigarette study are respected researchers not political hacks like most nanny state supporters. But this particular analysis is fundamentally flawed, and that is perhaps most easily seen because it might cause an honest observer to think like a health promotionista.

Unhealthful News 168 - A followup and some amusing claims about smoking in Washington (state)

2011-06-17T22:54:00.000-04:00

Some clarification and followup. Yesterday I cited a blogger who took down a claim that driving is causing obesity, which was based entirely on the "evidence" that both were increasing almost linearly with time. His points were entirely right and quite clever, but I felt that he had understated a key point that could aid understanding of statistical analysis more generally. The point is that it is meaningless to describe two series as correlated if it is impossible for them to not be highly correlated, like if they are both constant or changing almost exactly linearly. It makes little more sense to say they are correlated than to say 1 and 2 are correlated.

But I think it is worth clarifying that it is possible that driving rates really do cause some of the obesity, but that just looking at the correlation is not the way to figure it out. The general point is this: There are right ways and wrong ways to seek evidence of a particular relationship.

In particular for the driving-obesity case, we would like to be able to control for all of the other variables that are causing the time trend in obesity, and then see if there is anything left that is explained by driving rates. This is not possible, however, so the next best thing is to just remove the time trend for obesity by just looking at deviations from the trend (blips off of the trend line). Following this standard approach, we would then look to see if the ostensible cause, driving, explains the blips. However, in this case it clearly does not, since it is linearly increasing and, since it obviously does not explain all of the upward trend in obesity, this evidence suggests it does not explain any of it.

As an aside, there are different ways to model a trend and thus control for it. The simplest is to assume the trend is a straight line on the graph, extended through time, such that the variable "remembers" where it is supposed to be and if it moves off the trend it tends to compensate and go back to it. Also reasonably simple is the "random walk" around the trend, in which any deviation from the trend creates a new point from which the trend resumes and there is no tendency to get back to the old trend line. The latter probably describes more variables accurately, and economics often models it; the former is what is almost always used in epidemiology, probably because they do not teach about the other in most epidemiology courses.

Before I wander too far, there is a concrete news target for this. It was reported this week that:

Washington, a state that has long boasted one of the lowest smoking rates in the nation, has taken a sizable drop from its third-place ranking, tying with Maryland this year for 11th place.

Sounds huge. Except,

Currently, 15.2 percent of adults in the state smoke, up from 14.9 percent last year, according to numbers from the U.S. Centers for Disease Control and Prevention (CDC).

The numbers from the survey that produces those results wander quite a lot, due to random sampling and other errors. (They also are substantially lower than other estimates for US smoking rates, but that is another story.) So the "change" reported there is better described as "no measurable change".

But in that article and an editorial, the Seattle Times joined the bureaucrats whose budget is threatened in seeking to blame this outcome, at least partially, on cuts to the anti-tobacco budget:

...may be attributed to funding cuts to the state Tobacco Prevention and Control Program, which is aimed at reducing tobacco-related disease and death, state officials say. In the past two years, the prevention program has seen major cuts — almost 60 percent of its funding — with even deeper cuts looming.

The particulars of this are pretty funny:

And in 2009, the Legislature ended the state's anti-smoking advertising campaign. Ads make a big difference, especially for teens and young adults who are influenced by plenty of pro-smoking ads paid for by tobacco companies peddling flavored cigarettes.

(For those who do not know, there are almost no pro-smoking ads in any influential media, and flavored cigarettes were never a major part of the market and have not been produced by any company with an advertising budget for over five years.)

Consider just one facet, the Tobacco Quit Line, a state-funded prevention program launched a decade ago. The phone service has provided expert advice and useful tools to some 150,000 people trying to kick the habit. But starting July 1, callers will no longer be able to get quit kits, over-the-phone help or nicotine replacement unless they are on Medicaid or have insurance.

(So in anticipation of losing the quit line, lots of people without Medicaid or insurance have started smoking??? Also, look at those numbers: "launched a decade ago" and "150,000 people" – that is about 1/10 of 1% of the smokers in the state getting advice every year. It seems unlikely that this made much of a difference, especially since I believe there are a few other ways to get information these days.)

Anyway, getting back to the point of the day, we could assess whether it really appeared that the budget cuts were affecting smoking rates. I realize that the anti-smoking people have neither the skills for nor any interest in doing good science. But it is possible. Probably the most useful thing to do would be to wait a year and see if the measured rate tics down again. In the context of the above brief bit about trend types, the real trend in smoking probably is closer to the random walk, but the measured rate has a tendency to bounce back from deviations from the trend because many deviations are study error.

For those who want to make an estimate now, they should look at whether budget changes coincided with smoking rate changes at other times, not just the latest politically convenient result. This is not perfect because there will be confounders, but it could be informative. I would bet that: most of the decrease in smoking was before 1998; the budget leapt up in 1998 and stayed high following that; there was some decrease in smoking around then, though much less than in, say, the early 1980s when the budget was very small; the smoking rate was flat for a decade despite the budget continuing to be high. If this is the case, then there is even less of a case to be made for their claim than there is for driving causing obesity. At least for the latter they really did track each other.

Finally, as another revisit to a previous post, recall how in UN163 I discussed the controversy over an apparently bad health economics study and wistfully imagined what it would be like if health science was held to such standards. Today, Krugman, who had commented at the outset, added:

So when the McKinsey alleged study made headlines, the firm was pressed to explain how the study was conducted. And it has refused to answer.

It’s hard to escape the conclusion that the study was embarrassingly bad — maybe it was a skewed sample, maybe the questions were leading, maybe there was no real data at all. Whatever.

The important thing is that this must not stand. You can’t enter the political debate with strong claims about what the evidence says, then refuse to produce that evidence.

Sigh. If only that were the standard. We know about as much about much of CDC's key data about smoking as we know about what McKinsey did in that study, and no one even complains.

Though I suppose maybe the grass is not entirely greener:

And it’s especially bad when the media give your claims lots of attention, while barely covering the furor over the refusal to explain where those claims come from.

Unhealthful News 167 - "Don't worry about it" is not sufficient advice

2011-06-16T21:34:00.001-04:00

The health information and advice business (which some would prefer to call the health scare business) is about 90% warnings and simplistic advice and 9% calls to dismiss the former because it is overstated or otherwise flawed. I am trying to build up the remaining 1%.

Actually, that is probably ridiculously optimistic – I doubt that the niche that I am trying to fill is nearly 1% of the discourse. That niche is trying to offer ways to understand the claims without just choosing to believe either the "worry" or the "don't bother about it" faction. You might think that the "don't worry" advocates would help with that, but they usually get it wrong.

For example, this AP article was an attempt to reduce the worry about two recent health scares (HT to @garyschwitzer for the reference). In her attempt to reassure people about the mobile phone and cancer scare, which I wrote a bit about in UN158 the reporter wrote that IARC

...said there is a possibility cellphones raise the risk of brain tumors. "The operative word is 'possibility,'" said [the American Cancer Society's deputy chief medical officer, Len] Lichtenfeld

Both the reporter and Lichtenfeld got that wrong. As I explained in UN15 the rating that IARC put on mobile phones was basically "code yellow" or "3 on a scale of 5". They label it "possible carcinogen" but that is really just an arbitrary phrase and does not have its natural language meaning. It is based on an unspecified combination of apparent level of risk and certainty of the estimate, both of which turn out to be low in this case, mingled with no small amount of worldly politics. But in the news story, the reporter and the ACS guy both managed to compound the confusion of that phrase by misrepresenting it as "it is a possibility", which clearly is a natural language statement that is very much not what the IARC report means. Their reassurances that we should not worry too much about this are valid (though they tend to overshoot and suggest "no one should worry at all, or even investigate further). But they do not seem to understand enough to offer the most useful possible observations about what IARC said.

The same article talks about the recently reported cancer risk from styrene, formaldehyde, and a few other chemicals, but offers reassurance from Linda Birnbaum head of the National Toxicology Program of the National Institute of Environmental Health Sciences, which issued the report of he risk. Of course this is not terrible reassuring given that this is the same unit that, as I pointed out yesterday, put out its current report about carcinogens with a section about smokeless tobacco that was roughly 2.5 decades out of date. But the message from Birnbaum and the reporter was that these warnings were based on occupational exposures (though the story does not actually use that standard term), which are much higher than consumer exposures. Fine. But then they go on to declare that consumer exposures therefore pose no risk. But we obviously do not know that. It would be fine to say that we have not detected a risk at consumer levels of exposure, but that is different. One of the advantages of occupational studies is that they lets us look at exposures that are very common at low levels when they occur at high levels, and that allows some guess as to whether they might be causing some problem at the low levels. If a problem is observed at the high levels, the guess is elevated to "its a possibility" (the real meaning of that term).

Saying "these chemicals are absolutely harmless" is a message that more commonly comes from pro-industry groups like ACSH, but what they wrote about today was what I wrote about two days ago, the new "study" about television watching and risk of diabetes. (They get really annoyed when people point out they are pro-industry, but it is pretty clear from a lot of what they write that they do not read my blog anyway.) They correctly point out that the study was of little value, but note only that the results cannot be distinguished from the effects of just being sedentary, regardless of the television. They suggest that this is the only limitation, substantially understating the limits of the research. I will not expand on that, since I already did (recall: snacking is up there with sitting still; the study method added no information to what we already had; etc.).

Finally (and the math phobic might want to just quit reading here), the Freakonomics blog takes on the recent suggestion that more driving is causing the increases in the obesity rate. The author points out that the supposed evidence is that both have been trending up, basically linearly, over time. He offers the clever counter that his age, which obviously trends up linearly over time, is just as good a predictor of obesity over time. He goes on to explain that in general, for a variable that follows a simple time trend, almost any other time trending variable will fit it. He goes on to note that the original authors concede that correlation does not equal causation, but argues that this is an understatement in this case.

He does not complete the explanation, however, and observe that there is not a correlation in a meaningful sense here. That is, this is not a case of a correlation with some other explanation, but it strains the term to claim there is a correlation. To try to explain:

You could observe that the height of the Empire State Building is a great predictor of the height of the Chrysler Building, always 62 meters taller, every time you measure them. But it should be obvious that it makes no sense to declare that they are correlated because they are both constants – each can be described by only a single number, so the variable does not vary. It takes a bit more thinking to see it, but it is also the case for linear trends, which you might say are a constant of sorts.

Any two series that can be described by only two values also cannot be described as correlated with each other in any meaningful way. Or to put it another way, they will always be perfectly related by a simple function, which means they are perfectly correlated so suggesting that their correlation means anything is nonsense. When something must be true, there is no information in discovering it is true. As an example, consider the two series x={1,3} and y={100,114}; they are perfect correlated, in that the first always perfectly predicts the second with the simple rule "if x=1 then y=100 and if 3 then 144" or if you prefer a linear equation, "y=93+x*7". But the same is true when the two values that represent each series are not just two observations, but a linear trend (a line can be described with two values in terms of either two points on it, or one point and the slope).

The point is that the driving-obesity result is silly at a much more fundamental level than is implied by "correlation is not causation", one that is not difficult to understand. The "correlation is not causation" phrase is used to describe situations where there is meaningful correlation between two variables that calls for an explanation (so, for example, it is not explained by "neither changes, so of course the difference is constant"), but the explanation might be some common cause that relates them (confounding) or perhaps causation in the other direction. But two curves that have the same basic shape will always be correlated if you choose the right scale, so there is no correlation that needs to be explained.

Failure to recognize this is what gives a lot of useful information a bad name. People see aggregate trend data and recognize it is not convincing but do not understand why. So they figure that all aggregate trends are uninformative (creating the fallacy that there is an "ecological fallacy"). This removes the ability to observe, for example, that mobile phones must not be causing many brain cancers because brain cancer rates are not trending up, or perhaps that television cannot explain much about diabetes because it exploded in popularity many decades ago and stayed up, while diabetes rates have changed dramatically over that time. The difference: several of those variables have some distinctive patterns, rather than just being straight lines over the whole range, so the bends in the curves should have matched, but did not.

Unhealthful News 166 - Last tango for salt shakers

2011-06-15T21:58:00.000-04:00

In the spirit of yesterday's q-and-a quick hit, another one.

CNN reported:

Salt shakers disappear from Buenos Aires tables

In an effort to combat hypertension, which affects some 3.7 million residents in the province -- nearly a quarter of the population, the health department reached an agreement with the hotel and restaurant federation to remove salt shakers from the tables at their eateries.

"On average, each Argentinian consumes 13 grams of salt daily, while according to the World Health Organization, you should consume less than five," Health Minister Alejandro Collia said when he announced the change last month.

….Collia said that if Buenos Aires residents can reduce their daily salt intake by three grams, it could save about 2,000 lives a year.

Will this reduce salt intake? Almost certainly. A lot of health affecting decisions, especially those involving immediate pleasures, are sufficiently influenced by convenience that little changes of availability can have an effect. Of course it is less controversial when that consists of adding a convenience (e.g., making sure snack packs of vegetables are as easy to get as chips) rather than removing one. The only conceivable way in which this might not decrease consumption is if chefs increased salt use in the kitchen to make up for it, and they overshot, which seems reasonably unlikely. Chefs might well prefer that people are not allowed to mess with their optimized seasoning.

Will this provide a health benefit? Ah, now there is the tough question. A social intervention like this is not like a drug, and things may not work out the way the drug addled think it will (and by drug addled, I mean those who think that drug trials are the right way to think about public health interventions). Among the proposed problems, the salt reduction might not really improve health (there is substantial legitimate controversy about whether salt matters for other than a small minority who mostly know who they are); people might overcompensate (thinking they are more deprived than they are, or perhaps as a act of rebellion), actually consuming more salt; or people might eat more unhealthful food because the salty food sated them sooner (as happened when people tried to cut down on fat intake). It is difficult to know.

Is this a good way to find out? It really is, assuming (a) they try very hard to get good longitudinal data that addresses the points from the previous paragraph and (b) you do not live in Buenos Aires and like salt. Sadly, I am afraid no one will gather good data (which requires some effort and skill, and especially an interest in honestly determining the effects). So this will probably be yet another triumph of "health promotion": Do something that sounds like it is healthful and make sure never to honestly study the effects so you can just declare that it did what it was supposed to do; ignore the social downsides, up to and including the downfall of the government; and ten port it everywhere else saying "it was proven in Buenos Aires and everyone should follow their example."

Is banning salt shakers the most patronizing bit of nanny-statism ever? Definitely not, because this clearly has it beat:

The measure is not as extreme as it sounds. Salt will be available by request, but only after the patrons have tasted their food.

The mind boggles at the thought of a steakhouse waiter refusing the premature request for salt, "lo siento señor, pero antes usted debe comer uno bocado" (and I am sorry for the barely remembered, and thus presumably mangled Spanish). Treating restaurant patrons like fussy toddlers ("no yummies until you eat at least one bite!") might actually be more amusing to see enforced than Nepal's proposal to ban tobacco sales to pregnant women.

Unhealthful News 165 - Applying some UN points to meta-analysis of TV watching

2011-06-14T22:56:00.000-04:00

I thought I would try to mix in a few shorter posts with simple summary points. Good teachers know that some quick quiz-like moments are useful amongst the monologues, and despite my current lack of a classroom I am a teacher to the core.

A recent synthetic meta-analysis of a handful of studies from the past four decades produced a flurry of news reports about the unhealthy effects of watching television, particularly type 2 diabetes and heart disease. The relative risks were in the 1.1 to 1.2 range for watching TV for 2 additional hours per day. The inevitable result was, of course, proposals for how to make people watch less television.

So...

Does that glowing screen mess up people's hearts and insulin systems? Of course not. Sitting still, not engaging in much exercise, snacking, gaining weight, and perhaps living a limited social life and other more subtle factors cause the outcomes. Television is what people do when engaged in those activities. Sometimes it causes them and absent television people would be out getting exercise and not snacking, but probably not usually. Many would be at a pub instead, or reading, or on the computer, or something else sedentary and snackable. You could argue that those are more worthy human pastimes in various ways, but that is a different point. As just one example, I usually have the television on when writing this blog (muting or pausing it for a while when I actually write – I am not some superhuman multitasker), and would not be getting much more exercise even if it were not on. (Right now I am not-really-watching the remake of "The Day the Earth Stood Still", redeeming feature of which is that someone figured out that Keanu Reeves's acting skills are perfectly suited for the role of an anthropomorphic alien who learned to speak only that week and does not possess human feelings.)

Did the meta-analysis tell us anything we did not already know? As is usually the case, no. It averaged together a small number of studies in a way that someone could basically do in his head. Though the usual fatal flaw with such syntheses – very different exposures that are treated as if they were the same – is largely absent, since television viewing is pretty much what it is, the populations varied radically due to the timespan if nothing else. Obviously the association with the outcomes is going to vary across populations based on how they are trending toward heavier body weight, for example, or the availability of cholesterol and blood pressure drugs. In other words, it seems rather unlikely that the knowledge value of the new paper was positive.

Why was the unit of exposure 2 hours of TV watching? Undoubtedly because the lower result for 1 hour was insufficiently impressive and presumably not "statistically significant", and 2 was the smallest number for which the results were statistically significant. Standard model fishing by people who mistakenly thing there is some magical importance to statistical significance, in other words.

What can we say about this comment, in the CNN story:

The increased risk of disease tied to TV watching "is similar to what you see with high cholesterol or blood pressure or smoking," says Stephen Kopecky, M.D., a cardiologist and professor of medicine at the Mayo Clinic

Nonsense. Two of the effects of sitting rather than exercising (whether in front of a television or not) are less healthy cholesterol and blood pressure. So the comparison to those intermediate steps does not make sense. It is like saying that the toll from traffic accidents is similar to what you see from unintentional trauma. As for smoking, not even close – two hours of smoking a day raises heart attack risk by a lot more than 20% (as does smoking in general).

Working on tobacco related issues, I had always thought that Mayo's junk science claims focused on opposing tobacco harm reduction. I guess they are equal opportunity spewers of nanny-state-supporting nonsense, and will understate the risks from smoking if it might help scare people about something else.

Unhealthful News 164 - Taking scientific advice requires some scientific skill

2011-06-13T21:37:00.000-04:00

On a slightly tangential note, but a quite critical point when it comes to health policy, the New York Times reported today that a quarter of US state legislators lack a four-year university degree. The report does not tell us how many more majored in highly non-liberal-arts and non-science fields (accounting, pre-law, business management, fraternity parties, etc.) that provide no basis for assessing scientific claims. But it is these legislators that make a lot of scientific, including health policy, decisions on behalf of people.

Yes, of course, a degree does not always correspond to knowledge and ability. Bill Gates did fine without a bachelor's degree, though some of the priorities of his foundation seem to suffer problems similar to those found in state health policy. And on the other side:

“I don’t think it’s imperative that you have a college degree to be effective,” said Mike Fletcher, a retired state trooper elected to the Arkansas Senate last year. “I think the most important thing is to have common sense.”

But there is a strong correlation between ability to make particular scientific assessments and the ability to finish a degree in a non-rote field. Common sense does not go very far when trying to figure out if the benefits outweigh the costs of making a meningitis vaccine mandatory. It does not even seem to help retired cops make sensible decisions about drug policy.

The obvious response is that they have people who figure out such things for them. The problem is that the further away someone is from understanding a scientific matter themselves, the more likely they are to believe someone who is not giving them accurate information, either out of ignorance or a hidden agenda.

You have to know something to even know who you should believe.

A policy maker who has absolutely no clue about scientific epistemology will depend on Wikipedia or 24-year-old aides (who will go to Wikipedia) to tell them what to think. Even if it is not literally Wikipedia, it is some other source at that level, like news reporters or a local advocacy group, that interprets science at the level of what shows up in the conclusion sentence of research papers abstracts. As readers of this blog know, such claims are not reliable in health science. Indeed, Wikipedia and most news outlets intentionally cultivate this kind of uncritical-acceptance-based behavior.

On a few occasions I have tried to correct errors in Wikipedia where something was once widely believed to be true, but was now shown to not be true (and, I think in all those cases, was never actually based on evidence – it was just one of those conventional wisdom problems). But even if I made the change in terms of "it was once believed that but now it has been shown/established that…. [source]", the editor who controlled the page quickly changed it back. I was informed, in effect, that most of what is out there on the web still presents the old view and does not acknowledge a controversy, and since science is democratic in the Wikipedia world, the old versions stands. Given that experience I choose to focus on forums where most readers know enough to recognize at least the basic credibility of what I argue, even if it is contrary to what they thought they knew and what others claim. My project in this blog is to figure out how to help people skip a few steps on this knowledge ladder, but that does not help much for those who do not even seek that knowledge.

The problem with knowledge at the news or Wikipedia level is that the people compiling it do not know who they should believe, or even how to distinguish when there is legitimate controversy. Wikipedia is truly great at what other non-expert encyclopedias were always quite good at, getting non-controversial factoids correct, and it dramatically broadens the coverage (from "when did Lincoln deliver the Gettysburg Address?" to "who were the finalists in American Idol"). It is pretty good with scientific controversies that do not have much of a worldly political angle ("when did humans arrive in the New World?" "what is the definition of 'species'?"). But it and newspapers fail when it comes to current controversies in active politicized sciences that public officials need to wade into.

The Wikipedia-level authors get their information from anyone who can publish an authoritative-seeming paper. This gets pretty close to maximum current expertise in many sciences, where people authoring study reports mostly know what they are doing and generally know who look to when they do not. There might be disagreement over ultimate conclusions and best methods, but not complete ignorance about best methods or who the leading thinkers are. But this is not the case in health sciences. Most people writing the epidemiology papers, the sources of the summary "knowledge" that is used in policy, have no idea what constitutes expert thinking in epidemiology. Thu there is yet another layer of not knowing enough to really know that makes uneducated faith in experts and "common sense" that much less likely to identify good advice.

For example, on the question of whether there are health effects from industrial wind turbines, the government of Ontario, Canada (a major hotspot in that fight) seems to put a lot of stock in the thin report on the subject by their Chief Medical Officer of Health. (CMOH is a strange Canadian institution wherein a physician administrator type is always the province's chief public health advisor.) I was reminded of this a couple of days ago when I saw a newspaper cite that report as if it were authoritative. The problem is that the CMOH and her staff were in way over their heads in writing the report, and not only did not know what constitutes the available evidence, but did not know whose analysis to believe.

Funny story: I was cross-examined by a lawyer representing Ontario at a proceeding where I had presented testimony that the CMOH report was a joke, albeit in a less combative and more detailed way, of course. She asked me something along the lines of, "since you know so much, did you ever contact the CMOH to try to provide useful input into the writing of the document?" It boggles the mind. I expect it would require more search and processing power than Google has to be able to identify any time someone is writing a supposedly expert report that is beyond their capability, and then direct the real experts to proactively contribute to it. It seems more promising for report writers to track down the experts and ask for input. Of course, they have to know who to even ask.

The situation in Ontario is that the lawmakers trust an authoritative sounding government official who knows more than they do but is far from an expert in science, and in turn she does not know who to believe or how to interpret it. Perhaps those who she believed know who are really expert, but they have shown no evidence of that. I am not sure whether Ontario legislators follow the same pattern of education as Americans, but it really would not take much scientific understanding, when coupled with a bit of partisan education (lobbying) in the subject matter, to realize that the CMOH report is worthless. But if the local lawmakers do not have the skills to understand (when given some information and advice about thinking in the spirit of what I do in this blog) when their "experts" are giving them bad information, it does not really help much that true expertise exists, merely a few layers away.

Unhealthful News 163 - Bad McKinsey study about health financing: it stooped to the standards of health science

2011-06-12T21:11:00.000-04:00

Last week, a report from the business consultancy McKinsey claimed that their survey found that 30% of American employers planned to eliminate health insurance for their employees when the "Obamacare" plan (the lame watered-down plan that will sort of provide a way to get health insurance for some people, though probably still leaving people like me screwed) finally takes effect. This claim, a number much higher than other research had suggested, created a minor flurry of news and then criticism.

To understand the importance of this, it is useful to understand that in the US there is an obsession with government action crowding out private sector provision of goods, coupled with the notion that it is universally bad. It is true that if government provides something with low or no charge it can take business away from beneficial private markets. Even if the market is providing a better product at a lower social cost, if the government starts giving it away people might abandon the private alternative. But crowding out can be beneficial since for many goods, like medical care financing, government can do a better job than the private sector. Frankly it would be great if employer-provided health insurance which is incredibly inefficient (in terms of both costing more than it would cost government and crippling many businesses with a huge competitive disadvantage) was entirely wiped out by a government alternative.

But the obsessive worry about crowding out is so crazy that there are those on the political right who argue that if only the government would just stop providing highways and schools the private sector could do a better job. So the press in the US, which skews to the right, picked up on the McKinsey study and touted it as evidence that medical financing reform was bad.

It quickly became apparent that McKinsey could not back up their claim. Greg Sargent of the Washington Post posted an early summary:

But as a number of critics were quick to point out, McKinsey’s finding is at odds with many other studies — and the company did not release key portions of the study’s methodology, making it impossible to evaluate the study’s validity.
There’s now been a new twist in this story. I’m told that the White House, as well as top Democrats on key House and Senate committees, have privately contacted McKinsey to ask for details on the study’s methodology. According to an Obama administration official and a source on the House Ways and Means Committee, the company refused.

Based on that, Krugman commented:

One has to assume that there was something terribly wrong with the study. At any rate, nobody should be citing it until or unless McKinsey comes clean. Oh, and if you ask me, this is a lot more important than some sex scandal.

Krugman went on to note Brian Beutler's post:

But multiple sources both within and outside the firm tell TPM the survey was not conducted using McKinsey’s typical, meticulous methodology. …. And that’s created a clamor within the firm at high levels to set the record straight. “This particular survey wasn’t designed in a way that would allow it to be peer review published or cited academically,” said one source familiar with the controversy. …. Reached for comment today, a McKinsey spokesperson once again declined to release the survey materials….

At The Incidental Economist blog (who I recently picked on in my not-yet-finished comments about the cost of smoking, but will quote positively here), one author called it "Dangerous faux research" and wrote:

Look, anybody can say what they like on a topic. They can put out a glossy report. They can claim they did a “survey” to make it sound scientifically rigorous. They can talk to the media all about it. They can stand behind their good name and reputation, if they have one. But when what they’re saying runs counter to previous experience and other credible estimates, they’d better have a good explanation. But, McKinsey has no explanation. None. They’re stonewalling.

….You know what would happen to me if I tried that? Suppose I sent my new results to a journal, results that were very different from that of others, and said, “Trust me. They’re good.” Well, my paper would be laughed out of the editorial office. And that’s as it should be. That would not be research. That would be the opposite of research. That would be indistinguishable from making things up.

The primary reason I am writing about this is not to point out a bit of bad research about health economics, but to contrast the reaction with the typical reaction to research in health science itself, which often produces results that are equally unexpected, and that consistently fails to report key bits of the methodology, and few authors are honest enough to respond to requests to fill in what is missing. You are familiar with the reaction to that: Nothing.

We generally have about as much idea about what produced health science research results as we do about what McKinsey did. And though I do completely agree with that last quote – there is plenty of junk science that is published in health economics journals, and lots of study inputs come from black-box sources, and a study with mystery methodology is not exactly the same as making things up, though we do not know for sure. It is certainly true that anyone can put out a glossy report, trade on their reputation, and make a bad survey sound like science – pretty much sounds like health science to me. The only thing missing in health science is that the apparent consternation of an institution concerned with it reputation that is evident in the previous quote; I can only think of a handful of such cases ever.

In fairness, the missing information from the McKinsey study is not as subtle as the problems with most health research. McKinsey omitted extremely basic information, given that their study was basically the answer to a single yes-or-no question. For a list, see this story in Time (which another Incidental Economist blogger quite amusingly described with: "Kate Pickert committed an actual act of journalism, and tried to get McKinsey to give her the necessary information. So far, they have refused. Her whole piece is worth reposting, so just go read it now.").

Still, sometime health science reports are missing this same information is missing and almost always are million equally critical information. Any expert can recognize this, but the reaction is pretty much nothing: Reporters just report the new bit of "truth". Subject-matter expert bloggers might point out that the result is odd, but they ignore the failure to report the methods. As for the government demanding more information, yeah right. The government is accepts black-box health analyses as readily as the press does and, indeed, produces more of them than anyone else. It seems the only time they bother to probe is when the study result has no practical implications but might affect their political bickering.

A more subtle point is just as damning. Notice that the fight over the McKinsey results comes from the fact that it is a substantially larger number than previously estimated. When health research is reported, this is generally not even noticed. The review of previous studies in a new research report, let alone in the press reports about it, almost never distinguishes between big and small. The common statement, "this result is consistent with previous studies that found an elevated risk…", might mean that the other studies estimated a completely inconsistent level of risk (much lower or higher), but only the fact that it is also elevated is considered. By the standards of health science, the McKinsey report would not have been controversial; it would have been "consistent with" previous studies that showed that some employers will cut coverage.

It is pretty clear that the current fight is being carried out by pundits interested in how we pay for health who have no clue that the problems with the McKinsey study are pretty much de rigueur for the studies used to decide what to do with that money.

Unhealthful News 162 - Total cost of smoking calculation, revisited

2011-06-11T21:24:00.001-04:00

A couple of days ago I wrote some general overview points about putting a dollar measure on the gain or loss of something "invaluable" like a life-year or a bit of nature. This is needed for doing cost-benefit analysis calculations that allow us to compare apples to oranges when making decisions, something that we absolutely have to do. As part of that, I commented on some economists' calculation of the total cost of smoking, measured per pack of cigarettes, adding up the health costs, the production costs, and so on. This was based on a 2004 book, but one of them was blogging about it this week. I suggested there were some serious problems with their approach, but I wanted to wait for the last in the series of posts about it to be sure.

In my previous post I mentioned that this whole exercise is inappropriate, and can only create results that are misleading, since smoking is a case of a consumer decision where the consumer is paying the costs. Those calculations where we try to assign values, as best we can (which is often not very good), to goods that are not traded in markets and perhaps are "invaluable" are a necessary evil for policy making where someone needs to make tradeoffs on behalf of society because individual market decisions are not possible. But it make no sense for private market decisions. If I calculated that the costs of riding motorcycles exceed the benefits, considering the health risks and assigning a number to the non-market goods that are someone's life and health, and told you that therefore you do not want to ride a motorcycle even though you think otherwise, I trust you would laugh at me. Why would you pay any attention to my calculations of the average costs and benefits, and in particular what value I think you should place on your own probabilistic death or injury, when you can make your own decision based on how you actually value the benefits and costs.

Smokers themselves pay the biggest single contributor to the cost of smoking, which is between 90% and 100% of the total health costs (depending on whether you believe anti-tobacco's claims about the effects of second hand smoke, or the claims of those who say there is no proof of any risk, or something in between). They also pay for the production and distribution of the product via the purchase price. Moreover, in most rich countries they pay taxes that more than cover the external costs – i.e., those that are foisted on someone other than the decision maker. The external cost is primarily the much talked about, but actually fairly small (and negative by some estimates) net additional health care costs. So, smokers are basically paying the total costs, and we have a functioning market; so a calculation aimed at making decisions in the absence of a market simply makes no sense. It makes no more sense than calculating the net costs and benefits of making a new computer game. This is something else that could be very roughly estimated if needed, but it is not needed – the market and consumers balancing their options in life can figure that out just fine.

There are some other glaring flaws in the calculation too. The costs that they claim are suffered by the smoker's family, predominantly the spouse's risk of earlier death, are estimated to be well over 20% of the health costs to the smokers themselves. But even the clearly overestimated party line numbers for the impact of second-hand smoke puts the total impact at only a little over 10% of that experienced by the smokers (e.g., the oft repeated numbers for the US claim about 450K people die from smoking annually, with about 50K of that being from the second-hand smoke). They also make claims about lost productivity from sick-leave and what is presumably smoke breaks. But they say nothing about the increased productivity that smoking provides for people whose brains work better on nicotine. Also, there is an important ethical question about whether someone "owes" society their maximum possible productivity, since employers choose to pay for only the actual productivity. Finally, as a commenter on my previous post pointed out, the cost of the smoke break is caused not just by the smoking but by the rules that force the smoker to travel to a distant place to smoke; however much those rules might be justified, they do cause this productivity loss.

But the point I wanted to expand upon a bit today is the double counting that comes from the estimate of $100,000 per life year lost prematurely. This is obviously not an actual price tag. In fact, despite the apparent confusion of people who use numbers like this a lot, it has no inherent meaning whatsoever. It is just a cutpoint for deciding when a policy is worthwhile and when it is not. If saving a statistical life year costs more than X then we can more efficiently devote our resources elsewhere instead, and $100,000 is an estimate for the right value of X. The math is such that this number can be used in cost-benefit analysis calculations as if it were a real price, but it is not. It does not matter that we use observations like how much people are willing to spend on safety or demand as a premium to work risky jobs – how they value their own statistical life, as it were – to reach a decision about the number. The number still exists simply because it is what we have decided to be the right way to make decisions, and while we call it "the value of a life year" it really does not have a natural inherent meaning.

This is a very good thing for those of us who want to use numbers like this, because figuring out everything an extra life year entails, and pricing out each bit, would be impossibly complicated. A life year is a complicated bundle of enjoying life, providing enjoyment to one's companions (these first two are by far the most important), as well as production that benefits society and consumption that takes away from society, further complicated by lower order costs and benefits (taking away a job from an unemployed young person, contributing to crowding and traffic accidents, imparting the wisdom of age, being a selfish old person with antiquated views who votes against public school funding and progressive policies). Obviously these vary dramatically by person. So instead of trying to figure all of these out, we take an aggregate number and just go with it. At the very least, using the same number across policy decisions (e.g., for both air quality rules and medical expenditures) makes our decisions more efficient, even if we might disagree about what number to use.

What the authors of the book and blog posts about smoking did, however, was take the number $100,000, and declare it to be just the value of the life year for its own sake, the enjoyment of life (presumably also including other people's enjoyment of that life). So they claim this justifies adding back in earnings, which increases this by about 25%. (Note: Earnings per se are not a benefit or a cost, just a transfer of money, but they are a proxy for productivity which is a benefit, and thus represent a loss when someone dies earlier.) But this really does not work. It is impossible to sort out the different components of the value of a life year, so you have to use an aggregate. If you are adding in salaried productivity, how can we not justify adding in the value of teaching your wisdom to your grandkids? If they wan to pick a larger number for the value of a lost life-year, fine, but they should own what they are picking and not try to sneak in more.

Furthermore, since the number is somewhat arbitrary it is necessarily extremely rough, so adding $100,000 to a calculation of productivity down to the last dollar makes no sense. If they want to just declare that they are using a value for a lost life of $125,000, that would be fine (the $100,000 is at the low end of what most experts consider reasonable). But what they did reminds me of the old joke, where a pupil asks his teacher, when they are visiting a natural history museum, how old those bones are and she replies "five million and three years old". When the kid asks how she could possible know that, she replies "I asked a museum guide that question when I first visited and she said 'five million years', and since that was three years ago…."

If the authors of the smoking cost study do not want to take the most practical course, to pick a single number, because they want to divide the figure between the smoker's own costs and what is externalized to others, they could do that. The biggest factors in each part would require a rough quantification of the "invaluable" – of loss of one's own life's enjoyment and others' loss of family/friend – so both would be extremely rough. But what they are doing by including the big number and then adding in others is (a) making a muddle of the fact that the big number properly includes those other values because it is impossible to separate them all, (b) making the "five million and three" mistake of calculating some values down to the last dollar when the biggest number is arbitrary with a factor of tens of thousands of dollars, and (c) trying to hide their important assumptions and value judgments behind a lot of seemingly impressive numerical details.

I guess this calls for another one of my "never trust anyone who…."

But you know what? Neither my previous post nor this one has explored the biggest problem with the whole exercise. I will come back to that sometime next week.

Unhealthful News 161 - Genes, environment, autism, and politics

2011-06-10T22:32:00.000-04:00

A lot of the misunderstandings in the press and among the public about studies of genetic causes of disease could be solved by a single observation: The answer to the question "is that disease caused by genetics or environment?", the answer is most always "both". There are very few diseases such that particular genes are necessary (that is, people never gets the disease absent those genes) and sufficient (that is, everyone who has those genes gets the disease). Even if we appropriately weaken these condition some – e.g., calling it sufficient even though there are exceptions if people do not live long enough or have the vulnerable body parts removed – there are still very few. Huntington's Disease is a well known exception, wherein a particular genetic pattern dooms someone, no matter their environmental exposures, unless they die from something else first.

There are a few health outcomes that can be considered entirely environmental (note that in this context, the term "environmental" refers to anything external that affects a body, including infectious agents, diet, etc., which is roughly the same as saying anything that is not genetic; it does not have anything to do with the "eco" sense of the word environment). Someone who is severely damaged by trauma or other major physical insult (plane crash, IED, engulfing fire) or severe chemical insult (getting no oxygen for a long period, ingesting a lot of poison) can be doomed from that environmental exposure. The particulars of his genetics do not matter, unless you really push the definitions to absurd levels (if it were not for his genetics, he would not have been a member of a tool-using species, so he never would have…). But even then, if someone is not killed immediately, chances are that genetic factors will affect whether he recovers.

Huntington's and trauma are the exceptions. For most diseases, someone's particular personal engineering (mostly genetic) and what they are exposed to in life both matter. With rare exceptions, studies of genetic causes of disease, just like studies of environmental cause, find that a particular pattern increases the risk, but very seldom is it 0% in the absence of the pattern/exposure, and even less often does it increase to 100% in the presence. Instead, the risk changes from something in between those two extremes to something else in between; the probability changes, but the particular factor does not fully explain the outcome. Other factors are also causal.

With that in mind, consider the recent studies that found some possible genetic explanations for some cases of autism, which were reported in the press, including good reports here and here. The new studies focused on genetic characteristics that are believed to be "spontaneous changes". That is, they are not something that is passed down through families, the type of genetics we usually think about, but are things that happen to one person's genes that may cause the outcome. (Note that I include the caveat "are believed" because despite the hype you read, the understanding of how physically inherited characteristics worth has enormous limitations. So it is possible that these genetic changes are pre-programmed by standard heredity, but in ways we do not yet understand. I wonder how many genetic epidemiology researchers actually understand that.)

The two news stories linked above were decent, though glaringly absent from the stories was a clear explanation that both genetics and environment are almost certainly a cause for most cases of all diseases. But anyone reading the articles with just that bit background knowledge would get a pretty good understanding of the appropriately modest claims. In particular the stories recognize that the more important genetic causes are inherited and unknown, presumably environmental, factors are more important still. The new studies and discoveries were largely basic science – that is, something that is a matter of curiosity that might prove important for some reason someday, but is definitely not where you would focus to answer applied science points about "why is there so much autism these days and what can we do about it?"

That brings up the question of whether these genetic changes are themselves environmental. The researchers are pretty sure that they come from changes the parents' sperm or eggs, but are not so sure about why they happen. As the news stories mentioned and most readers know, autism incidence has increased dramatically over a few decades. Standard genetic factors – those that are passed on from one generation to the next – cannot explain a trend like this because our collective genes cannot change over the course of a generation or two. Indeed, with only a few very unusual exceptions, genetics have not really changed within recorded history. Only environmental changes can explain trending like this. The LA Times story (first link above) did not reach that level of sophistication in their explanation, but they did pursue the point. They talked to Irva Hertz-Picciotto, an expert on the subject (and someone who was once a friend and colleague and editor of a journal I was the editor of, though I have not talked to her in years, and who I believe is one of the genuinely good epidemiologic researchers). She pointed out that the obvious conclusion is that the changes may well have environmental causes.

All in all, this is an interesting discovery, though with limited immediate practical scope (the numbers presented mean that these genetic changes could explain at most a few percent of all autism cases), and a perfect example for a tutorial in genes and environment. Of course, this being about autism, there had to be political spinning.

The American Counsel on Science and Health, whose melange of political positions include attacking any claim that there really is an environmentally-caused upward trend in autism, commented on the study. They seemed to suggest that the new studies help vindicate their preferred position that there are no environmental causes of autism, and thus the apparent trend is all a change in diagnosis. (Certainly some of the trend is that, but it seems very unlikely that explains all of it.) They criticize Irva for being "intentionally vague" about her observation, perhaps not realizing that the soundbite quotes that end up in newspaper articles usually oversimplify what someone told the reporter, to put it charitably. Exactly what was she supposed to do?

But they do have a point that it may be that there is no time trend in these particular genetic changes since they account for, at most, a tiny portion of all autism. The environmental causes of the change in autism incidence might exist only within the vast majority of autism cases that are not currently attributed to genetics of any type. Still, the reader of their comment is likely to come away thinking they new results argue against the environmental explanation, which they clearly do not. This is a case where the readers of mass media health reporters will actually have gained greater understanding than those who read the critical analysis (for the specific pieces I link here, anyway). In a role reversal, the former did real somewhat in-depth analysis, and the latter put out confusing statements following what seems like an over-simplified script.

Unhealthful News 160 - Calculating the dollar value of the invaluable is appropriate, except when it is not

2011-06-09T22:06:00.000-04:00

A week ago, Chris Snowdon posted a skeptical assessment of a monetization of natural goods and an estimate of the financial cost of smoking. I agreed with most of his criticism, but took some exception and promised to write more about it. I did a bit in the comments, a bit a few days ago, and will do more now, also commenting on some recent posts by Don Taylor at The Incidental Economist blog.

Setting aside the point that the environmentalists in question seem to be trying to bury their real motives rather than quantify their views, as I commented in my previous post, there is a good argument to be made for converting the value of non-market goods to a market currency. That is, many things may be priceless, but it is sometimes difficult to make policy decisions without converting them to a numerarie, which is economist-speak for a common currency, like dollars. The numeraire is arbitrary, and could be in terms of lives years or whatever, but since most things have a natural value in terms of currency (obviously the choice of currency does not matter) it is easiest to start there and convert the values of non-marketed goods to that.

Why would we want to do that? Well, I wrote a post on that so I will just summarize: If we need to compare two competing choices, we need them to each have a scalar (one dimensional) value for making the comparison. That is, if one option is worth two apples and five oranges, while the other offers three apples and four oranges, we need to know the relative value of apples and oranges to know which is best. Moreover, we do make such decisions: If we choose the first option in practice, we do not have an exact conversion rate, but we do know that oranges are worth more than apples. The same principle applies to decisions that affect whether or not we spend more to save lives or wetlands.

The problem with the two examples that Snowdon found were the people making the arguments were not doing this correctly. They were just looking at some expenditures associated with "priceless" goods (environmental and health) without doing the full calculation. The latter consists of adding up the all the values, both the priced and the priceless. So the value of saving a wetland park is the value it offers for recreation and aesthetic appeal (not too difficult to calculate, it turns out, even if there is no admission fee), the value in purifying water and other production values (the focus of what Snowdon wrote about, rather difficult to calculate but doable), and the value that comes from people just liking to know nature is being protected (an important real value, and theoretically measurable, but not really so in practice). This same principle applies to the natural world, taken as a whole.

Yes, that is right – it is possible to convert the value of the functioning biosphere into a single huge number of dollars, and it has been done. Why on Earth would we want such a number? It actually serves a useful purpose in figuring out how much we should be willing to spend to create some disaster-movie style defense against giant meteors impacting the planet and wiping out everything we care about. The chance of needing it in the foreseeable future is one in a billion, or ten million, or whatever the astronomers might calculate – I have no idea. Whatever that number is, we should multiply the big value number by it to get a rough estimate of how much we should be willing to spend on the space defense system. This is not an exact science by any means, but it has value. If the defense system costs a tiny fraction of that number, we should probably do it – giving up more immediate desires for something that might have tremendous value, but probably will not – but if it costs an order of magnitude more than the number then we should not make the effort.

Less abstract and much more significant for thousands of everyday decisions, we need to calculate a value like that for a year of life lost to decide when a public health, safety, or medical expenditure is too high a price to pay for what it provides. Because if we think that saving a life year is worth any price then we would give up way too much of everything else we value. And the same applies to environmental goods – we want unspoiled land and should not squander it, but sometimes we want crops more. Nothing has infinite value, and nothing important has zero value, so we need to figure out where in between to draw the line for practical decisions. We can call something priceless, but when we are calculating how much to spend to save it, in an abstract statistical sense, we need a price so policies can substitute for the economic efficiency that markets provide in most circumstances.

But having said that, we need to recognize that this is a necessary and useful tool for making certain types of decisions, and there is nothing right about it beyond that. It is a useful kludge, but should not be taken as Truth. Taylor takes it too far. He presents a calculation that each pack of cigarettes consumed imposes $40 worth of costs on the world. There seem to be various problems with is calculation including some double counting, but I am not sure since has completed only three of the four posts that form the calculation and I have not read his 2004 book that this is based on. I am pretty sure that he grossly overestimates the effects of second-hand smoke, and there may be other issues. But setting aside whether the calculation is accurate, I disagree with his implication that it is meaningful.

Half of the $40 consists of his estimate of the value of a statistical life year, which he puts at $100,000, a typical value for this. This is not someone's productivity (as measured by wages), but rather how much we think we should spend to save one statistical life. I.e., if we would decide it is worth spending $10,000 to put in a guard rail that has a 1 in 10 chance of saving one life sometime, but not any more, then this is the number we have decided is right. But there is no such decision on the line. No one is calculating the value of an anti-smoking policy by adding up the cost of producing and distributing cigarettes, plus the impact on disease, plus the changing in productivity and consumption, plus the "priceless" value of improving longevity. We do this for decisions about traffic safety or financing vaccines or mammography screening, but not for anti-smoking.

There are good reasons for that, such as the fact that smoking is a consumer choice, and in such cases we usually believe policies should only deal with any extra costs imposed on society (the justification for excise taxes, which more than pay for such costs). But it is not necessary to discuss why we do not do economic efficiency calculations for anti-smoking efforts. The simple fact is that anti-smoking policies are driven by people who feel that cost is no object, so there is no value in figuring out the limits of what we should pay. So Taylor's calculation is not useful. But these numbers – the value of a statistical life or planet – are, at best, only useful; they are never right. We may use the shorthand "each dose of vaccine delivered to Africa and used is worth $127, considering the lives saved and everything else" but what this really means is "we should be willing to spend up to $127 per dose to get them delivered and used", a practical statement, not an existential measure of worth. When health economists say "the value of a statistical life is $6 million", they are not assessing value (an implication that people quite reasonably object to), but what we should pay.

Taylor has fallen into the common trap of thinking that what his tools produce must be good. He used the economic tools that calculate an abstract number that can have practical value (though does not in this case), and reported it as if it were the actual value of a combination of some purchases and the "priceless". In addition to simply being epistemically wrong, this has the potential to lead to bad rhetoric and thus bad policy. It did not (I do not remember anything being made of this in 2004), but you could imagine people screaming "economists say that cigarettes should cost $40 per pack". The problem with this, even beyond his calculation seeming to err on the high side by a third to a half, is that most of the cost is already being paid by the smoker, so obviously having him pay it again makes no sense from an economic efficiency standpoint. And, again, achieving economic efficiency is the only justification for these numbers. I suspect that the reason that anti-tobacco did not pick up on this number is that they do not want to admit there is any finite limit to what we should spend to reduce smoking. They are doing just fine with the "priceless" tactic.

But it is worth noting that since people choose to smoke despite a huge cost like the one calculated, further economic modeling would show that the benefits are also huge, and the value can be estimated. Unfortunately this is too big a topic for a blog post and I did not get to it when I was still being paid to write research papers. Perhaps I will still get to it, but the argument still works in the abstract (though the calculations would be nice). This is fortunate since it is one of the best arguments for why tobacco harm reduction is economically superior to promoting abstinence.

Unhealthful News 159 - If you have a conflict of interest, you are not really doing research

2011-06-08T23:55:00.001-04:00

Occasionally, but surprisingly rarely, I wonder if I should have given myself a few personal days off during my 365 Days of Unhealthful News. I have no problem with High Holidays or even the day I had to post from my phone in the minutes before a plane took off, but it is really difficult to monitor the health news during Philly Beer Week. So today I will write about an observation made (over a few beers, naturally) by my friend and colleague, Igor Burstyn, a fellow refugee from the collapsed public health sciences program at the University of Alberta.

The observation (my paraphrase, interpretation, and substantial embellishment, so do not hold him to this) was that you do not do research to try to prove a point. You do research to try to figure out what is going on in society/the world/the universe/etc. If you are quite sure of what is true, and you are are just trying to demonstrate that, then you should be doing something other than research, like education or activism. Demonstrations are what the "experiments" in grade school science class are. It is not what real researchers do.

The immediate corollary is that researchers who set out to prove a particular point are not really being researchers. They are engaged in research kabuki, in which they act out a set-piece that uses the language of research, but is really glorified rhetoric. Note that this differs from someone who has a strongly held hypothesis that they want to test; such researchers are just as interested in figuring out if they are wrong, even though they strongly doubt it is true. I am not sure I can offer a simple explanation for spotting the difference, but it is easy to recognize when you are in and around it.

A more subtle corollary is that if someone has a major conflict of interest problem, chances are what they are doing does not really qualify as research. It is not merely that they might be biased in their methods or analysis. It is that if they are so biased about what they want the research to show, then they must have expected it to show that, and have just been trying to demonstrate it (if they were biased about what they wanted and they did the research, they must have been predicting they would get the particular outcome), and thus they were performing a demonstration, not doing research.

To tie this to recent news, rather than making it just an abstract discussion, I will suggest – in a blatant act of laziness and promotion – checking out today's tobacco harm reduction weekly reading list. The readings from Michael Siegel and Jeff Stier give some examples that exemplify the difference between research and advocacy that is posing as research, in contrast with the research by the Global Commission on Drug Policy that set out to really figure out whether the Drug War is working.

It would be overly simplistic to suggest an equivalence or otherwise over-interpret this. Someone who is genuinely curious can certainly still be biased by their worldly preferences, though the genuine curiosity should reduce any effect. And someone who is interested in proving a point might still act as an honest scientist, prepared to discover that the point is wrong. But it is probably not over-interpreting this line of reasoning to say that the bias deriving from conflict of interest manifests primarily at the study initiation and design stage, and not so much in the analysis. (Of course, many times the bias built into the design can only be recognized by looking at the analysis, since sometimes the design is "fish around until you find a model that best supports the goal".) By the time a researcher with serious conflict of interest – say someone who is seeking to show that an intervention they favored was effective – is analyzing the data, they have already set up the demonstration. Any study that would legitimately have failed to find the desired phenomenon if it did not exist – real research – would be designed differently from one that seeks to demonstrate something is true if at all possible.

For example, I was up most of last night finalizing proofs for a paper I posted about before. It was completely intended to be analytic, not research, arguing for a particular way of looking at the evidence that wind turbines cause human health problems. It is a research paper only in the sense that anything analytic that appears in journals gets called that: I knew what answer I was going to present from the start. So when I wrote my COI statement, I did not hesitate to describe, matter-of-fact, that I do work as a testifying expert on behalf of communities fighting the siting of local wind turbines. I had written a paper that was designed from the start to argue (sort of like demonstrating) how to think about the matter I worked on. By contrast, when I do research, I generally object to simply listing funding I have received as if that were COI. I will identify the motive for the study, but if that was not biased and the study was not designed to produce a particular result, then there cannot be a serious COI problem. Most "researchers" do not explain the motive for their study or really describe their methods, so they may well be hiding a genuine COI problem; it is all a matter of whether you honestly describe what you have done.

One easy lesson is never trust anyone who says "this research will show…". They are no more doing research than the presenters at a kiddie "science" museum are doing science when they demonstrate how to make something go boom. Demonstrations can be interesting, but they are not research.

Unhealthful News 158 - Brief observations about mobile phones and brain cancer

2011-06-07T23:31:00.000-04:00

A few days ago I wrote about how the flurry of news about mobile/cell phones causing cancer exemplified much of what is wrong with the IARC process. I have decided to not delve deeply into the scientific evidence about this, but there were two observations I though I would make about the discourse. For anyone who thinks that this is just not enough for the day (there must be one or two people out there who do not think that I "talk" too much :-), my more significant post of the day was at the tobacco harm reduction blog, in which I speculated as to whether the initiative to mandate plain packaging for cigarettes in Australia (which I have written about in this series) is actually a long con, where winning comes from losing.

At the height of the reporting about the mobiles and cancer scare, ABC News reporter Michael Murray floored me with the incredibly rare act of thinking like a health reporter should. Perhaps someone else wrote something similar, but I did not find it. Murray made that observation that if mobiles are bad for you, why have we not seen a spike in the brain cancers they supposedly cause, since heavy exposure to mobile phones has gone from about zero to over half of everyone in less than fifteen years? Why have most of the studies that tried to find a link found nothing, even though a few, with most focus on a single one, suggested otherwise (Aside: Yes, I am American, but I really think that "mobile phone" or "my mobile" are much better terms than "cellphone" or "my cell".)

Murray recognized the value of ecological data, which most health reporters and epidemiology researchers seem to not understand. If there is much increase in risk due to an exposure and there is a huge increase in exposure, they we should be able to see the results at the population level. But brain cancers are not increasing in incidence.

It is important to realize that it is not quite this simple. If the exposure causes only a small risk then even with the huge increase in exposure it might be hidden by a downward trend due to other changes, with the net effect being no change or even a decrease. As I pointed out in my previous post, the useless IARC process does not distinguish between important risks and trivial ones. It is also possible, as Murray points out, that the lead time for the cancer or the length of exposure required is longer than we have had a chance to observe. But he kind of muddles the point, because if this is true then there should be no evidence from the studies to date, and thus no IARC claim.

Of course, if one believes there is any genuine worry about the longer term, or that there is study evidence now, then it would not hurt to think about whether this calls for a change in behavior or technology. The risk seems to be really small – anything big would have shown up unless it always took decades to manifest – so the benefits of mobiles presumably swamp the costs. Indeed, this is clearly true despite the traffic fatalities they cause, a causal relationship which is very well established and that occurs at a greater rate than the speculated risks for cancer. Still, why not be safe and use a hands-free earpiece and microphone. It does not reduce the risks if you are driving (notwithstanding the completely clueless "drivers must use hands free only" laws) but at least it keeps your ear from heating up.

But the possible suggestion that this might be a cheap, easy, comfortable precaution to employ when it is convenient seemed to spark outrage among those that do not believe there is any risk (example). It is not as if anyone was suggesting that people curtail mobile phone use or do anything else that threatened industry profits, the usual motivation for feigned outrage. This must be real outrage. But why?

My only theory about this oddity: Ever notice that offering a constructive suggestion about how someone uses a software tool or a hammer, or even sexual techniques, generally elicits a calm response, even if there is disagreement. But suggest to someone they may be upshifting at too low RPMs, let alone that they should consider not feeding their baby that, and they go berserk. Somehow using a mobile phone has become one of those things that is so much a part of someone's life, like driving or child rearing, that they think that there cannot be anything they do not know about it, and that trying to provide new information is treated like a personal insult. That may be every bit as strange as the possibility that low-level microwaves can cause cancer.

Unhealthful News 157 - Never trust anyone who claims their policy is "science based", Drug Czar edition

2011-06-06T22:41:00.001-04:00

Oops. I should have waited a day on yesterday's "Never trust…" post, because today the US drug czar (officially, but never actually, known as Director of the White House Office of National Drug Control Policy), Gil Kerlikowske, posted a response to the Global Commission on Drug Policy. You cannot beat the drug warriors for examples of who not to trust and why.

Kerlikowske voiced the standard hard-line, tough-on-crime American party line. As I have noted before, contrary to stereotypes, the center-right US administrations – the current Democratic party as well as the Republican Nixon administration that declared the War on Drugs – are more hard-line than the right-wing administrations. This seems to be because center-right presidents are deathly afraid of being called leftist, so they appoint cops like Kerlikowske as their drug policy people and take a militant stand against drugs. (This is kind of ironic, since it is not even possible to say what a left-leaning administration would do, since there has not been one since the 1960s.) Tough drug policy is a great political game for politicians like Obama because it is a litmus test issue that older swing voters support, but that the politicos do not really care much about. Most people care more about drug policy than they do about most of what comes out of Washington, but since the ruling class can pretty much ignore the drug laws, they do not much care what they are.

Anyway, Kerlikowske objected to the Commission's call for decriminalization and other humane and sensible policies. Some readers might think he had a real case below the surface of bluster, but here is the clue that he really did not:

Our National Drug Control Strategy is science-based [sic].

That statement is a warning, and pretty close to compelling evidence, that the writer is trying to mislead you. First, there is no such thing as science-based policy. Policy can be informed by science, and should be, but cannot be based on science. It is ultimately based on objectives (which should be openly declared, as I discussed yesterday), ad these are based on preferences (call them "values" if you prefer). Science can then inform us about how effective a particular policy is at fulfilling those preferences. Anyone who claims that their policy is science based (that phrase, incidentally, should only have a hyphen in it when acting as a modifier of a noun that follows it) is trying to hide the true basis of the policy, their preferences. It is possible that they are so fanatical about their view that they do not even realize that there are other possible objectives/preferences, and so they actually think everything just follows from the science. But it is not clear whether such blindness is better or worse than just trying to trick readers into thinking that a particular preference was somehow scientifically determined.

The second problem is that activists with very partisan objectives, like Kerlikowske (or anti-tobacco extremists, or food police, or activists on either side of forbidding abortion, etc.), tend to employ science like a scavenger hunt, finding some support somewhere for what they have already decided they believe in. What he wrote after the previous quote was:

And science shows that illegal drug use is associated with specialty treatment admissions, fatal drugged driving accidents, mental illness, and emergency room admissions. Illicit drug use has huge costs to our society, outside of just criminal justice costs.

Notice that there is nothing in his "science" that tells us whether decriminalization and other liberal and humanitarian changes in policy would make things better or worse. Medical interventions might increase with increased usage, but they are more likely to decrease with quality control and use in controlled settings (as evidenced by Insite). Mental illness causes drug use and could be better dealt with if users did not have to stay underground. Driving under the influence might or might not be made worse by liberalization – it is certainly not obvious. There is nothing scientific about cherry-picking a few results that seem to support your objective, especially when even the cherry-picked claims do not really do so.

Lying with statistics is easy, after all:

...cocaine production in Colombia has dropped by almost two-thirds, and the very same U.N. World Drug Report cited by the Commission concluded that, “Demand for cocaine in the U.S. has been in long-term decline."

The US crackdown on cocaine in Columbia, which militarized that country, shifted production elsewhere. Demand for cocaine is down because methamphetamine – a drug that is nastier in most every way – emerged as a substitute as a direct result of import interdiction efforts.

Third, the myth of "science-based policy" is often used to declare that non-scientific points are science. In this case:

As I’ve often stated before, drug use should be addressed as a public health problem because we know drug addiction is a disease that can be successfully prevented and treated.

Drug use can be characterized as a choice, a disease, a desperate act of people with no options (which we might see as falling somewhere between choice and disease, with an element of structural social problems), or a crime, among other things. The supposedly enlightened drug warriors like Kerlikowske and Obama pat themselves on the back for declaring it is a disease rather than a crime. By doing this, they skirt around the obvious points that it is also a matter of liberty and a symptom of the miserable socio-economic state of so many Americans (who the Obama administration, catering to the right-wing and the oligarchs, refuses to help). They anchor this rhetoric on the pseudo-scientific claims about disease (which is whatever we define to be disease – science does not create definitions) and addiction (which is not even defined well enough to use in a scientific context).

Once again, the game is to use nonsense about "science" to trick the reader into not noticing the statements of preference/values. By discussing the concept of disease, Kerlikowske defines away the benefits of drug use and distracts the reader from noticing his failure to acknowledge the central issue of individual rights.

As an aside that does not offer any general lessons, it is kind of amusing that Kerlikowske cites Mexico's President, Felipe Calderón, as supporting US drug policy. This is the guy whose country seems on the verge of becoming a failed state due to the gang wars created by current US drug policy, so there is kind of a Catch-22: If he is crazy enough to support the policy, surely we should not trust his opinion.

Finally, you just cannot beat Kerlikowske's final paragraph as evidence that you should not trust anything this guy and this administration says about the subject:

It is, of course, tempting to opt for seemingly easy answers to the world’s drug problems. They appear intractable at times. But we have made real progress and the steps we take in the future must be rooted in science and evidence-based policies that will make our communities healthier and safer.

He makes the absurd claims that miserably failed policies must be best because the alternative seems easy (it really does not, but why would easy be bad?), he claims progress that does not exist, and makes an appeal to "evidence" while presenting no evidence that actually supports his case. Asserting that a policy is informed by science and evidence (setting aside the misuse of "based") is not like declaring that a food is "gluten and soy free". The latter is something that is a simple matter of fact that is best communicated by declaration. But the former is something that can and should be demonstrated, not asserted, presenting what the science shows and how that is being used to pursue a preferred objective. Absent that, the claim should inspire no more confidence than if he said the policy is the will of a deity. A simple assertion that a policy is evidence/science based is bluff and bravado, a lot like someone's assertion that he's got game: If he is telling you it is true rather than demonstrating it is true, it is probably not true.

Unhealthful News 156 - Never trust anyone who lies about their objectives, revisited

2011-06-05T23:40:00.000-04:00

Advocates of particular actions or policies are working in support of a particular objective. Whether you think you agree with it or not, there is no harm in hearing them out, listening to their statement of what they want and why they want it. Sometimes you might change your mind about something. Of course, usually you will not. You may have already thought about the issue, considered the arguments on the other side, and found them wanting. Or perhaps you find the premise to be completely without merit ("your god may demand that, but I do not believe in that"; "you think drug use is just per se bad, but I disagree").

But there is another possible advantage to listening to an arguments in favor of something you disagree with: If you discover that the proponents are making claims that do not seem to match their real objectives, you have good evidence of dishonesty. Moreover, it suggests that even they think that people would not support their cause if they really understood it.

The simplest example is anti-tobacco extremism. The advocates would like everyone to think of them as public health people, but they clearly are not. I will not belabor this because I and my colleagues have made this point numerous times. But I will point you toward what Dick Puddlecote wrote today, which is about as concise a case you can make for that particular point (though I have to point out that calling e-cigarettes merely 90% less harmful than smoking is so conservative as to be false – all the evidence suggests a point estimate in the order of 99% less and even the "it is clearly at least..." number is 95%, not 90%). It might well be that anti-tobacco extremists could get the people behind "we want to eliminate self-administration of any tobacco product or satisfying substitute, just because we don't think people should be doing that, even if it is very low risk." But they presumably realize that would likely be the end of their empire. Of course, if they valued honest and respected people they would give it a try, even if they even if they had doubts.

A quite different application of the principle today can be found in Gina Kolata's New York Times article about pharmaceutical warning labels. The content of these labels has become ridiculously broad, including many things that cannot be plausibly attributed to the drug, as well as concerns that are trivial compared to the reasons someone might take the drug. The result is long lists that contain so much that they have almost no information content. Of course, this is not news; every aware and thinking person knows that these warnings have become useless except as easy jokes for comedians. But what does this mean in terms of honesty and motives?

It is generally believed that the rampant warning labels exist merely to provide defenses for lawsuits. But this means they are not warnings, but are at best disclaimers and perhaps are better thought of as merely a formalistic maneuver that is more like a move in a sport or board game than anything practical. Ok, but so what: we know this is a game, so why should we care? Because of how the objective is misrepresented. They persist in implying that the these are warning labels, and thus claim that their objective is to offer warning -- i.e., useful actionable information. Warnings can be very useful, but someone who abuses the warning process is not trying to help their customers or the medics who serve as intermediaries. They are certainly not trying to contribute to public health, since polluting the world with pointless pseudo-warnings tends to diminish the value of genuine warnings. If the authorities would heed the advice in the title of this post, then "warnings" that do not genuinely function as warnings should not offer any legal defense. After all, if Bernie Madoff had posted a note, buried in some statement that contained everything that could possibly go wrong with financial investment saying "this investment house may be a Ponzi scheme" it would not have let him off the hook. Moreover, the regulators do not have to allow this pseudo-warning, so apparently their objectives are a bit skewed too, though it is beyond me what they might be.

The War on Drugs, which has gotten a a lot of useful attention in the last few weeks, due to the Global Commission on Drugs Policy and associated news and activism. (If you have not seen the AVAAZ petition yet, please check it out and sign on if you agree, as I would guess most of my readers do.) What is the objective of the drug warriors? It obviously is not to help users, or they would not be put in prison, forced to use inferior products, etc. It cannot be fear of crime and side effects, since most of those are caused by the War, not the drugs. But it is no longer plausible that it is to merely reduce drug use either, since it is clear that most of the tactics in the War do no such thing, with many of them pretty clearly increasing use of particularly bad drugs. Once again, whatever someone might think is the best way to deal with drugs in our society, they should not trust those who are part of the institutionalized drug war. Whatever it is they are trying to do (and it varies from one organization to another, of course) it is clearly not any of the stated objectives they use to mobilize public support.

Finally, and a bit more nuanced, I joined a very interesting conversation Snowdon posted over at Velvet Glove Iron Fist (and I plan to follow up on some other points about it later). One aspect of of the main theme was whether environmental activists are being disingenuous when they talk about the value of environmental amenities that can be translated into GDP-type measures, though what they are really worried about is some other concern entirely. If someone claims "I am devoting my life to worrying about the environment because I care about the value of wetlands in filtering drinking water and insects in pollinating marketable crops, so you are all with me, right?", then they should not be trusted. On the other hand, if they say "I believe we should care about nature for its own sake, and/or for its greater not-immediately-monetizable contributions to humanity", and then add, "but even if you care only about GDP-type values, you should consider the following contributions….", then they have done nothing wrong or unreasonable.

If there are many arguments that genuinely support the same conclusion, go ahead and make them all, just do not try to hide which one(s) you personally believe in. There is nothing wrong with appealing to others' motives, so long as you are honest about your own motives and about the arguments (making dishonest arguments just because they might appeal to someone triggers the "when you find out someone is lying about one thing, don't trust their other claims" test). Indeed, that is the essence of grassroots coalition building: Those concerned with freedom to take a particular action should appeal not just to the value of that action, but to concern about liberty in general, and those who share that general concern should recognize the common cause; similarly, we can substitute "concern for oppressed minorities", "desire to help the downtrodden", etc. for "concern with liberty". Since those who are dishonest about their motives, often claiming the very motives from the previous sentence, tend to have better coalition building tools (most notably, money), we need all of that we can get.

Unhealthful News 155 - I wonder if NYT reporters read the NYT

2011-06-04T22:15:00.000-04:00

A recent New York Times story by Nicholas Bakalar, of their better health writers began by giving examples of different ways of communicating the same statistic regarding the value of an intervention: a 50% reduction in risk, a reduction in risk from 2% to 1%, or one of every hundred people getting the intervention is saved from the outcome. He points out that the choice of which of those to tell someone will affect what he thinks of the intervention. This is one of those facts that is well known to those of us who do research on risk, but that guru consultant types who half understand it charge a fortune to teach to corporate types (not that I am bitter or anything). Bakalar does a decent job of explaining it and getting it right, though he uses some awkward terminology.

The story was motivated by some new review study of the research that demonstrates this phenomenon, but that is not at all interesting because, as I said, those of us familiar with the subject already knew the information. Perhaps the review includes something new, but such articles usually do not, and I am doubtful enough to not want to even bother to look it up. More interesting is Bakalar closing the article with a quote from the study author,

Journalists have to be careful about press releases with ‘new’ or ‘groundbreaking’ studies presented with relative risk reductions. For example, a study might claim a risk reduction of 50 percent. If the risk goes from 20 percent to 10 percent, that’s impressive. If it goes from 4 percent to 2 percent, it’s not. And both of them are 50 percent reductions.

The latter part of that is wrong in the sense that it is overly simplistic, suggesting that the study author does not really know what he is talking about, another good reason to not bother to read the study. If the risk of, say, having one's BMI increase to 25 sometime in the next decade goes from 20% to 10%, that is quite likely not consequential for health outcomes. If the risk of having your brain eaten by zombies in the next week drops from 4% to 2% I would say that is tremendously important good news.

But the first bit of the quote is good advice. It is one of the many reasons to not get too excited about "groundbreaking" research. Even better advice would be to consider the risk in terms of overall health risk, rather than in terms of one disease in isolation. Increasing the risk of brain cancer by 20% (which sounds more impressive than a relative risk of 1.2, which is why they put it that way) caused by using a cell phone at an extreme level has a very trivial effect on someone's overall risk of getting a fatal cancer. But I doubt that NYT reporters are going to pick up on this advice from their own paper, let alone more complicated points like the one I made.

Of course, Bakalar himself might have been more cautious about how "new" the study he reported on really was, given that it seemed to contain absolutely nothing new.

Of course, maybe reading The Onion would be better still, since it recently reported the headline,

Study: All American Problems Could Be Solved By Just Stopping And Thinking For Two Seconds

That really could eliminate a lot of bad health reporting, in ways that I have noted in this series ("what does that even mean?" "is that really possible?"). It might, however, have gone a bit far in claiming:

"We found that in 93 percent of cases, a positive outcome could have been achieved if Americans simply splashed a little water on their faces.… Our data indicate that when U.S. citizens don't take a second to compose themselves, they typically charge in like maniacs and hurt either themselves or several million Iraqi civilians." Mallory said a good rule of thumb for Americans is to think of a plan, stop, and then do the complete opposite.

This advice is probably far too harsh even for health reporters, though maybe it is about right when NYT reporters are writing about anything Bloomberg says about health. Though the same is true for their counterparts in the UK are reporting about alcohol, or those in India are writing about tobacco this is clearly an international problem).

Unhealthful News 154 - Three random thoughts on bad epidemiology

2011-06-03T22:42:00.000-04:00

(1) It was reported today that the indoor smoking ban in Britain might have motivated an uptick in pharmaceutical nicotine medical prescriptions during the period leading up to it, but the rate returned to baseline by about the time the ban was implemented. One possible explanation is that smokers were trying out the pharma products in advance to see if they might be an adequate substitute for cigarettes when they could not get outside to smoke. The reporter and researchers seem to have overlooked that possibility, and attributed all the purchases to quit attempts.

The story did, however, include the sensible suggestion that perhaps those who attempted to quit were just those who were on the verge of quitting anyway, given a little extra push by the impending ban. The implication of this is a recognition (by a hardcore tobacco control person, btw) that active anti-smoking (or anti-tobacco or anti-nicotine) interventions may well produce a large "harvest effect". That term refers to causes of death that are technically the proximate cause of someone's death, but that only kill people who are quite sick or old already, so should not be treated as other causes. Peak air pollution events is a good example of this.

If anti-smoking interventions mostly just harvest those who were going to quit soon, they are not working nearly as well as they appear. It is quite remarkable to see a hint that someone understands that most epidemiology of smoking cessation is junk science. Among the multiple reasons for this is that it does nothing to measure whether they are really changing someone's preferences and behavior rather than just harvesting. (Note that I am not suggesting it is ethical to take actions to make people change their preferences and behavior, especially without their consent. I am just saying that the cessation researchers consistently claim that this is what they have done, and they are quite likely wrong.)

I am currently having a discussion in which I am trying to convince a friend that interventions like telephone "quit lines" are not nearly as effective as is claimed because they are mostly just selecting for and aiding the focus of the almost-quitters. I actually had a thought about this when I was doing university research: I could send out a few of my students and researchers – perhaps the best looking ones – to walk up to smokers and say "we are working on encouraging cessation, and it would really make me happy if you would quit; here is my card, and can I get your contact information and check back with you in a month to see if you have quit". My hypothesis was that this would be about as effective a cessation intervention as any other, because most of the effect of most tools is to just provide a reason to those who are seriously considering quitting soon to quit now rather than getting around to it sometime.

(2) A story today in the New York Times about teenagers getting into bicycle accidents in the San Francisco area was one of the most absurd examples of leaving out the denominator and similar errors in anything I have seen recently. The headline is:

In Bay Area, Youngsters Are More Prone to Bicycle Accidents

The evidence?

The analysis shows that in the Bay Area cyclists ages 10 to 19 were involved in more traffic collisions — more than 3,200 from 2005 to 2009 — than any other age group.

That would be a lot more interesting if (a) we knew what the age groups were and (b) we knew how many cyclists there were in each. The best they offer is:

In a region filled with thousands of adult cyclists, including daredevils who barrel through congested cities at high speeds, data showing that youngsters are most prone to accidents surprised even bicycle advocates.

That suggests the denominator is larger for the older groups, so the rate is higher for the kids. But it does not actually say that. Can we get some numbers?

According to the data, San Jose had 434 collisions involving teenagers, the most of any Bay Area city. Oakland was second with 193.

Yes, those are numbers, but no, that is not useful at all. Can we get some numbers about how many riders there are?

“I would have thought it would be males in their 20s” who would have the highest accident rates, said Renee Rivera, head of the East Bay Bike Coalition. “Anecdotally, I see mostly young adults cycling.”

I will take that for a "no". So you really do not know if the the kids are suffering disproportionately, do you? Perhaps it is just that the older cyclists spend their time observing places that have few kids, like, near campuses and business districts rather than residential neighborhoods. So, can the reporter tell us anything about older riders?

In fact, cyclists in their 20s had the second-most collisions with motorists — about 3,100 from 2005 to 2009.

Well at least we have a hint (not an actual statement) that the age groups are all a decade of ages. At least that is something. But we also know that the headline was just saying that the kids were ahead by just 100, far lower than the measurement error we would expect for a statistic like this. The article goes on for another web page and a half, but no further numbers are forthcoming.

So is this a problem we should be worried about. Yes: Innumeracy among health reporters is a serious problem that demonstrates a "need for early education", as reported in the article. Well, that was actually reported about the need for childhood education about traffic laws, but I think I have better evidence on my side.

(3) I have been keeping this one on file since I just had to say something about it. A little over a week ago it was reported,

Italian government officials have accused the country's top seismologist of manslaughter, after failing to predict a natural disaster that struck Italy in 2009, a massive devastating earthquake that killed 308 people. …. Enzo Boschi, the president of Italy's National Institute of Geophysics and Volcanology (INGV), will face trial along with six other scientists and technicians, after failing to predict the future and the impending disaster.

You might be thinking this was a joke – I was not sure I should believe it when I read it – but here is an independent report from another news source.

It is not entirely clear what to say about this in Unhealthful News other than, perhaps, to note how good a job the reporters did in going on to explain why this was scientifically absurd: No one is capable of predicting earthquakes with enough certainty to offer timely warnings. If you want "sometime in the next twenty years, you might not want to be standing near a large window in San Francisco" they might be able to help, but acting on such information is not all that practical.

But it is even worse because these guys are not going on trial for reporting something that was wrong (even though no one else could have done any better), but rather for merely not reporting the right information. That is, they did not issue an incorrect report or warning; they merely issued no warning at all. Even if they had thought that the earthquake was somewhat likely to occur that week and failed to report it, they would have, at worst, been uncaring people who let down their countrymen. But failing to be a good samaritan is not criminal, so long as you did not cause the problem yourself, unless you are some kind of official acting under a duty to provide real-time service. Italy is a bit strange, but I cannot imagine that the geophysics people there swear an oath to protect their country against all enemies, foreign and tectonic. Indeed, you can see why they would not want to issue an incorrect warning even if they were 10% sure (which would be very impressive), which would cause a costly panic they would be condemned for when they were wrong.

Yet as troubling as this is, it would be just so cool if someone would indict health scientists for getting things wrong in a way that killed a few hundred people. I would not suggest it for honest mistakes or impossible demands like the seismologists faced – we could just restrict it to those who were overtly dishonest in their analysis, or at least grossly negligent with regard to modern methods. Better still, we could indict health reporters on the same grounds.

Yes, I realize there would be some unforeseen consequences. But one of them might be a positive: we would probably have to end the War on Drugs to free up enough prison space.

Unhealthful News 153 - An odd collision of politics and science

2011-06-02T22:19:00.002-04:00

Usually when politics and science collide, it is a case of the politicos overruling what the scientific evidence suggests is best. This week, there was the odd event of a US Congress committee trying to define what science is. They did not do so well.

The story was reported by the Washington Post as one of the dozens of legislative events that happen everyday and that most Americans have no idea about. But this one was picked up by various bloggers, interested in agriculture and especially tobacco.

House Republicans are pushing back against a series of public health measures, including school lunch standards and tobacco regulation, teeing up a confrontation with Senate Democrats and the White House over the reach of government in daily life.

The action was a committee vote about restrictions on what the Food and Drug Administration can do. The WaPo headline emphasized stopping Obama from trying to make school lunches healthier (horrors! this dictator must be stopped!!), but a lot of observers focused on the implications for tobacco regulation. In particular it seemed to be about (and was widely interpreted as being about) stopping the possible ban of menthol in cigarettes. It is not exactly clear to those of us reading the public record that it was really mostly about that. But the insiders seem to have interpreted it that way, and since this is all about insider politics and the games played by those who want to rule our lives, their assessment is probably accurate.

The most intense reaction was generated by a provision offered by Rep. Denny Rehberg (R-Mont.) that would block the FDA from issuing rules or guidance unless its decisions are based on “hard science” rather than “cost and consumer behavior.” The amendment would prevent the FDA from restricting a substance unless it caused greater harm to health than a product not containing the substance.

The phrasing there definitely seems to fit the menthol question. For those who do not follow the issue, the FDA advisory committee issued an opinion (which, in a huge surprise to many of us given the blatantly political committee, was scientifically accurate) that there is no strong evidence that smoking menthol cigarettes is any better or worse than smoking non-menthols, but that because menthol makes smoking more attractive, its presence increases the number of people who smoke. The enabling legislation for FDA regulation of tobacco allowed action if something caused health harm at the population level (which would include by increasing exposure by attracting, on net, at least a few users who would otherwise be abstinent) even if it did not matter for an individual user, given that he is using. For months, pundits protested that menthol did not cause harm (in the second sense) and therefore FDA could not ban it. They did not seem to pay any attention to my observations (what else is new!) that the "population level" criterion meant that they could ban anything that increased the quality of cigarettes to the user or, similarly, mandate anything that lowered the quality, like ugly packaging or requiring a minimum content of spider legs.

Ok, so fine. The legislature has the right to decide that the population health standard is cancelled and "less healthy" has to mean less healthy for any given individual user. That is what our primary branch of government can do: Change the rules if they do not like them. They also could have just said "you cannot ban menthol", but they probably thought this was slicker.

Oh, but wait. What is that about "hard science". Uh oh. I fear they are getting in over their heads.

“The FDA is starting to use soft sciences in some considerations in the promulgation of its rules,” said Rehberg, who defined “hard science”, as “perceived as being more scientific, rigorous and accurate” than behavioral and social sciences. “I hate to try and define the difference between a psychiatrist and a psychologist, between a sociologist and a geologist, but there is clearly a difference,” he told the committee.

Yup. They are getting in over their heads. I think the lawyers are going to have a difficult time figuring out how to implement that "hard" and "soft" bit. This starts to border on a legislature defining pi to be exactly 3.0 because it is more convenient.

Some people who are not scientists or scholars of science tend to think that anything they are told that sounds scientific and is completely baffling to them must be right. So you could tell them pretty much anything about geology, acoustics, or nuclear physics and they would probably believe you. But the real problem is that for the sciences that they think they understand – just because they know the words, I suspect – they think that the information must be weaker. Or worse still, they think they understand enough to critique the specifics.

But in this particular case, it is the social science that is much clearer than the natural science (which is what those of us who study science itself call what some lay people call "hard science"). The economics is that there is absolutely no doubt that the existence of menthol causes some people to smoke who would not otherwise do so. Most people who smoke menthols would smoke non-menthols if there was no other choice, but a few would not, and even one is sufficient since obviously no one avoids smoking due to the existence of menthols. Case closed; hooray for "soft" science. By contrast, the epidemiology (let alone the completely sketchy toxicology) about whether menthol causes extra health problems for the individual user, either by causing physical damage itself or changing how people smoke, is fairly unsure. Undoubtedly smoking menthols is either better or worse than non-menthols (the chance of being exactly the same is zero), but we are not sure which. In fairness, we do know a lot: that the difference is not great, and so is probably smaller than the "soft" effect from raising the quality of the product.

He did get it right when he said that some sciences were perceived more rigorous and accurate (I am not sure exactly what it means to be "more scientific"). He just may not grasp which ones are more rigorous and accurate.

As for the difference between a psychiatrist and a psychologist, it is a prescription pad and attitude. As for sociologist vs. geologist differences, I have dated both (notice that he made this about the people, not the disciplines) – and no, I am not going to give an answer.

In addition to protecting menthol, the new amendment:

would also prevent the FDA from restricting the widespread use of antibiotics in feed for farm animals, which many public health experts believe has led to the development of antibiotic-resistant bacteria that threaten human health. …. Groups including the American Medical Association and the Infectious Diseases Society of America have called on the FDA to ban the feeding of antibiotics to healthy animals.

Well, the AMA does practice a rather "soft" version of science much of the time.

Agricultural interests oppose those limits, saying there is no scientific proof that farm animals are the problem.

Here is another observation: There. Is. No. Scientific. Proof. Period.

Sigh. We need a press corps with enough education in science to not allow such nonsense to pass without comment. And such a Congress too.

The banning of menthol, or not, will probably have a trivial effect on public health. Mostly a ban would just fuel a black market to supply the higher quality (and tax free) product that could no longer be sold legally. Banning antibiotics in animal feed, however, could help preserve the few remaining effective antibiotics we have, possibly averting the public health disaster that would occur if much more resistance develops and someone does not develop some new antibiotics soon (there have been few successes for a very long time). I find it surprising to find myself agreeing with Congressman Henry Waxman (who has vowed to defeat the amendment once it is out of committee) and anti-tobacco extremist Matt Myers, who led the outcry about this. If they succeed, though, they might actually strike a blow for public health due to the antibiotics and other implications of the amendment. They might even do something I am not sure they have ever done before: Strike a blow in favor of good scientific thinking.

Unhealthful News 152 - The biggest problem with IARC's statement about cell phones: IARC

2011-06-01T23:35:00.000-04:00

A somewhat superficial one today because I spend hours working on the THR weekly reading (which has some interesting bits of how to interpret science, so even those of you who are not so interested in the topic might find it interesting reading). I might end up writing something about the current flurry of press about whether mobile/cell phones might cause brain cancer. Probably the most interesting aspect of that is how those who are skeptical of health scares get so apoplectic and angry – I fear they would start throwing punches if the debate were face-to-face. Today, though, I will just comment on the instigator of the current furor, the WHO's International Agency for Research on Cancer (IARC).

The biggest problem with IARC is that it exists. More precisely, the problem is that it is a research think tank that is no better or worse than most think tanks or university departments, but that its status implies that it is something more than this. In its role as arbiter of what causes cancer, more than anything else, it is basically a convener of committees. Committees make lousy scientists. But when the committees finish their reports, they become The Word of IARC, and the press and pundits take them way too seriously. Even worse, so do governments of countries that do not have enough research infrastructure of their own to form educated opinions.

IARC issues its proclamations by convening a small subset of the researchers working on the topic, usually missing most of the experts who could contribute the best analysis (that is true for all cases I have been able to judge). They do not include experts on how to make sense of a complex body of evidence, because they do not even seem to understand that this is an issue in itself. This semi-random group of reasonably knowledgeable people come to whatever conclusion they can hash out, and the result becomes Official Truth about the carcinogenicity of an exposure. But the quality of analysis is, at best, about the same as you would get from the faculty and students of a decent academic department that was studying the subject in question (and far less good than many focused learned studies – for example, there are quite a few studies of smokeless tobacco that are far better than IARC's).

That leads to the second major problem: IARC is not a neutral think-tank. WHO has turned into an activist organization on many topics, and IARC carries the water for them. I referred to the IARC committees as semi-random – the semi part reflects the fact that it is easy to choose a committee that will come to the conclusions that those in power want, and IARC does just that.

The third problem, exemplified in the mobile phone controversy, is that the form of the judgments that IARC makes are remarkably close to uninformative. I realize that pointing out that the opinions are far from the best possible expert evaluation, and are quite politicized, but also are reported in an uninformative way, is kind of like the old joke: the food at a restaurant was terrible, and even worse, the portions were too small. But the lousy rules under which the committees operate probably make their work worse, and they certainly hide how weak that work often is.

One of the first things learned by anyone studying epidemiology…. You know, it is never accurate to say that, so let me start again. One of the first things that someone learns in epidemiology, if they have one of the minority of epidemiology teachers that knows what they are doing, is that it is a science of quantification, not of yes-vs-no, and of circumstance. In physics, if a particular theorized particle is shown to have been created in a particle accelerator just once, it is a meaningful discovery. But in epidemiology (rough definition: the science of quantifying what causes diseases in humans), it matters what population you are talking about, at what point in time, and the details of an exposure, and most of all, how big the effect apparently is.

IARC looks at none of these. In short, the premise under which IARC operates would not earn a passing grade on a second-semester epidemiology exam (again, with the caveat that the professor was actually competent to be teaching second-semester epidemiology in the 21st century).

If you noticed the news, the official declaration was that using a mobile phone is "possibly carcinogenic for humans". It is a symptom of the underlying problem that this is such a dumb monicker. No, not the "for humans" part – we should be concerned about dogs using cell phones too. The terminology is dumb because you know what else is possibly carcinogenic for humans? Everything! It turns out that the meanings of the words does not really matter because they are just levels on a five-point scale. It is kind of like the US terrorism threat level, and is sometimes it is even portrayed with the same color scheme. Three of the rankings are better labeled than "possibly" (definitely carcinogenic, "probably", "probably not"), though one of them is actually worse ("unclassifiable"). What is worse than the names used for five point scale, purely a cosmetic problem, is the absence from such a simplistic measure of most everything that is important in epidemiology: What is the magnitude of the risk? What level of exposure are we talking about? Indeed, exactly what exposure are we talking about? And what population are we talking about, because something that caused a noticeable risk of cancer in, say Inuit people in 1950, might not cause measurable risk for people who eat enough vegetables and have 2010 medical care.

To explain the importance of this, if there had been a couple of epidemiology studies that showed that very intense use of one particular type of mobile phone, perhaps one that does not even exist anymore, seemed to cause a "statistically significant" increase in the risk for one rare cancer, even at a trivial level, then they would have declared mobiles a probable or certain carcinogen. Actually, I take that back – they would be supposed to declare that, but depending on the politics of this particular committee and what WHO wants the verdict to be, they might not have said this.

To further illustrate the fundamental problem with this system, IARC declared smokeless tobacco to be a certain human carcinogen. Though they wrote a very thick report, the conclusion was based on only five studies of oral cancer, one of an archaic US product that perhaps no one uses anymore, and the others of the hodgepodge of products (that are not entirely or even mostly tobacco) used in India by a population with one of the world's most usual distributions of oral cancer. The committee was so politically stacked that if these studies did not exist, they would probably have dug up another excuse to reach the same conclusion. But their opinion is still used to imply that modern Western products definitely cause cancer, just like cigarettes, even though the evidence does not support that. Because the IARC method is "hunt around for evidence of any version on the broad category of exposures apparently causing cause one cancer in some population", there is really very little useful information. But it makes great propaganda and an effective way to trick lazy health reporters.

In reality, though, the ratings clearly do not even represent the any-vs-none scale that is claimed. They really represent unspecified mix of a lot of vague considerations, as determined ad hoc by a committee. Consider: It is safe to conclude that any exposure that subjects the human body to any of many stresses (exposure to a carcinogenic chemical, even if very low doses and even if in an otherwise healthy food; heating the brain with low-level microwaves; etc.) has caused or will cause, if it happens a lot, at least one cancer. So saying something "probably does not" cause cancer must mean that there is no conceivable way that it could (the existence of Neptune's moons probably will never cause a case of cancer – at least until someone goes there). But in reality a committee reporting that assessment is not making the impossible claim that there is evidence that the exposure will probably never cause a single caner. Rather, they being fuzzy and probably really are saying that the risk is so low that we will never be able to measure it, or perhaps just that we cannot measure it in any population we currently know of. So really IARCs ratings are a random mash-up of certainty and quantity, which includes an unknown degree of considering extreme exposure scenarios rather than normal ones. All of this, along with what we people really should want to know, is hidden by the simplistic form that the summary reporting takes.

The US terrorism alert level was a running joke from the start, and a purely political concept. It was embarrassing how long it took them to cancel it. Sadly, I doubt we will soon see a similar cancellation of the IARC system. This is in part because the WHO is even less good than the US at getting rid of bad ideas, but also because few people seem to realize it is just as much a joke.

Unhealthful News 151 - Logic and proportion have fallen sloppy dead

2011-05-31T23:01:00.005-04:00

I figure I need to do a tobacco example since this is World No Tobacco Day, brought to you by the UN's champions of UN (that is, United Nations' and Unhealthful News, respectively), the World Health Organization. Over at the tobacco harm reduction blog, Paul Bergen wrote a great translation of this year's WHO statement about WNTD (one might call it a parody, but that would understate how fundamentally accurate it is). We started TobaccoHarmReduction.org five years ago today, in response to WHO's anti-harm-reduction WNTD that year, and if anything they have only become more unhealthful since then. Almost as funny was WHO doling out WNTD awards to its own peeps, funny because I saw it reported on twitter with the hashtag #mutualmasturbation.

Today, in keeping with the anti-tobacco extremist mission – attack all forms of nicotine use except smoking, because the popularity of smoking helps support their abstinence-only agenda – their pet reporters seem to have focused on low-risk smokeless alternatives and hookah smoking. I am writing about the New York Times's "contribution" to this, mostly because it is a great example of the WHO myths, as well as the funniest.

The humor commences with the human interest hook in the lead, about a physics major here at University of Pennsylvania who has become such a fan of hookah smoking that he bought one for his fraternity. He was quoted:

[He] believes that hookah smoke is less dangerous than cigarette smoke because it “is filtered through water, so you get fewer solid particles.”

Let's think about that. "Filtered" by moving fairly large bubbles through a couple of inches of water. Yes, some of the particles will touch the surface of the water and stick or dissolve, but most of them do not. It is more efficient than trying to clear the smoke in your kitchen from a cooking mishap by running water in the sink, but the same basic idea. Perhaps physics is not the strong field at our local supposed-part of the Ivy League. I guess we can hope he specializes in quantum theory rather than something that would educate about everyday physical chemistry. Or maybe the bit about the fraternity explains the problem.

Anyway, his conclusion that hookah smoking is less harmful than cigarettes is a reasonable guess, though we do not know enough about the risks to say for sure. But if so, the main reason would be that it is mostly a heat-not-burn system that products fewer combustion products.

After that hook, reporter Douglas Quenqua takes over the misleading claims himself. He starts with the WHO propaganda (pdf) that an hour-long session of hookah smoking is like smoking 100 cigarettes. Really? It is bad enough that NYT (and most other) health reporters do not fact-check, but it is pretty sad when they do not think. What the WHO report is claiming is not about health effects, because no such information exists, though that is what they are trying to imply. It is really just about total amount inhaled. But think about what it would take to inhale the equivalent of the smoke from 100 cigarettes. About ten breaths a minute times sixty minutes is 600 breaths. It is hard to smoke an entire cigarette in only six puffs, let alone 100 in a row, so it would be almost impossible to inhale that much in an hour. And that does not even take into consideration that hookah smoke is usually far less concentrated.

The WHO numbers seem to be based on the total amount of inhaling that someone does in an hour, as if the hookah were being used as a scuba hose. It might theoretically be possible to smoke a hookah as intensely as the WHO claims is typical, but it would be very difficult, and you would have to have a Nascar-style pit crew to quickly change the tobacco and charcoal when they ran out, several times. This certainly is in no way similar to actual hookah smoking, by well over an order of magnitude, and probably more like two, as would be obvious to anyone who had bothered to witness it before writing a news story about it. If he had gone as far as to try it, he would have discovered that each hit from a hookah is far less intense than one from a cigarette. Doing all of your inhaling for an hour by drawing on a hookah would be unrealistically extreme, but doing it by drawing on cigarettes is completely absurd.

The report goes on:

That study also found that the water in hookahs filters out less than 5 percent of the nicotine.

Well, that is good news, since nicotine is the good part of smoking, not the harmful part. Though apparently the New York Times is not aware of that, since this is presumably intended to suggest that a bigger number would be better.

Moreover, hookah smoke contains tar, heavy metals and other cancer-causing chemicals.

It might have been useful for the reporter to look up "tar" before writing that conjunction, so that he would know that it refers to the particulate phase of the smoke/vapor – i.e., the bit with the heavy metals and other cancer-causing chemicals.

An additional hazard: the tobacco in hookahs is heated with charcoal, leading to dangerously high levels of carbon monoxide, even for people who spend time in hookah bars without actually smoking, according to a recent University of Florida study.

It is plausible that there is lots of CO produced, but "dangerously high levels" tends to imply acute poisoning, which readers presumably understand, having heard about it occurring in household accidents. But this scare tactic ignores the lack of any reports, to my knowledge, about adverse acute effects (not that CO is good for your heart and the rest of your body in the medium term). It would be nice if someone offered some non-propaganda analysis of this, but the press is certainly not going to help with that.

And because hookahs are meant to be smoked communally — hoses attached to the pipe are passed from one smoker to the next — they have been linked with the spread of tuberculosis, herpes and other infections.

Practices vary certainly, but I have only seen situations where everyone has their own mouthpiece they insert for their turn. In any case, tuberculosis? If that is floating around the Penn student body (or the other American youth that were the focus of the story), transmission by hookah is not exactly the major concern.

Paul G. Billings, a vice president of the American Lung Association ... calls the emerging anti-hookah legislation a “top priority” for the lung association.

You would think they would be a bit more worried about the cigarettes that certainly cause (as opposed to the weak evidence about hookahs) lung cancer and COPD, and that remain about a thousand times more popular. But since the ALA is opposed to the use of smoke-free THR products to reduce lung diseases (and other diseases) it is clear that they are not really about lungs, or public health. They are just pursuing a political agenda that their donors are being tricked into supporting. Funny that reporters do not know how to probe, as I learned in middle school journalism class, perhaps asking the lung guy how much evidence there is that casual hookah use causes serious risk of lung disease, or maybe why it is the top priority.

The balance of the article goes on to recount how various localities are pursuing various forms of hookah bans, particularly focused on hookah bars, to eliminate what is slowly becoming a more popular pub-like center of social gathering for some young American adults. Banning is, of course, the preferred and most effective solution when young people are doing other than what they are told. If the trends and the bans are both popular enough, maybe it will lead to a generation that has a healthy distrust of the honesty and motives of those in power. Maybe a few of them will become reporters.

(Oh, and in case that title was too obscure, it is a lyric from the Jefferson Airplane's Go Ask Alice, the song with a hookah smoking caterpillar. The current discourse on tobacco has far too much in common with Alice's adventures.)