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Over-Prescribing of Antipsychotic Drugs: How It Happens

March 3, 2015

Here’s a quote from a New York Times article published yesterday that explains how excessive drug prescribing happens:

A Chicago psychiatrist pleaded guilty last month to taking illegal kickbacks of nearly $600,000 to prescribe an antipsychotic drug for his patients. The doctor, Michael J. Reinstein, also agreed to pay $3.79 million to the federal government and the State of Illinois to settle a lawsuit asserting that he had been involved in the submission of at least 140,000 false claims to Medicare and Medicaid. Law enforcement officials said he had prescribed clozapine for thousands of older and indigent mentally ill patients at 30 nursing homes and other sites.

The lawsuit said drug companies had paid kickbacks, consulting fees and entertainment expenses for Dr. Reinstein as part of an effort to induce him to write prescriptions for clozapine.

Last March, Teva Pharmaceuticals Industries and a subsidiary, IVAX Pharmaceuticals, agreed to pay $27.6 million to settle allegations that they had violated federal and state False Claims Acts by making payments to Dr. Reinstein.

Investigators from the Government Accountability Office said in 2011 that Medicare officials were doing little to monitor the use of prescription drugs by Medicare patients. But Medicare also designates antipsychotic medications as one of six “protected classes,” meaning that drug insurance plans must cover all or substantially all drugs in that therapeutic class.

The article can be found at: http://www.nytimes.com/2015/03/02/us/psychiatric-drug-overuse-is-cited-by-federal-study.html

Why do drug insurance plans have to cover all drugs in the class of antipsychotics?  Is there evidence that all such drugs are vitally necessary in the treatment of anybody, particularly the elderly?  In fact, there is evidence for the opposite: elderly patients who receive antipsychotics have higher death rates than those who do not.

The General Accountability Office(GAO) (the one branch of government that tries to ensure our tax dollars are spent wisely) has said that Medicare officials are “doing little to monitor the use of prescription drugs by Medicare patients.”  That means that there are no controls on drug prescriptions to the segment of the population that uses the most drugs: the elderly and disabled.

Congress should listen to the GAO and force Medicare to do more to monitor and control the use of prescription drugs; tolerating the behavior of drug companies revealed by this lawsuit is criminal negligence.  The psychiatrist who admitted to receiving huge kickbacks for prescribing antipsychotics is only the tip of the iceberg.   The GAO and the Justice Department should get together and enforce some rational behavior by Medicare.  Congress should establish a department within Medicare devoted to the study of the rational use of prescription drugs.

 

The Cost of the Destruction of 1500 acres of Land in New Jersey

February 28, 2015

According to a report in yesterday’s New York Times, the New Jersey prosecutor has settled a ten year environmental damage case against Exxon Mobil when the case was on the verge of being decided by a judge.  The settlement is for a small fraction of what the state had originally demanded: $250 million as against $8.9 billion.

This settlement seems odd, when the judge in the case was almost ready to announce his assessment of damages.  However, the governor of New Jersey is Republican Chris Christie, long known for his bizarre behavior.  Just last year, he shut down most of the entrance lanes to a heavily used bridge into New York for four days, creating massive traffic jams that tied up commuters for hours at a time.  He denied responsibility for this action, blaming high level staff members, but it seems obvious that it could not be done without his express approval.   The reason: the Democratic mayor of the town at the entrance to the bridge had refused to endorse him.

No direct contributions from Exxon to Christie have been uncovered, but they did contribute $500,000 to the Republican Governor’s Association last year while Christie was serving a one-year term as its chairman.

Some observers would suggest that Christie would be willing to do Exxon a favor for free, considering the possibility that he will be without a job soon and his prospects for a Republican nomination for President have been poisoned by the bridge scandal.  But that would be cynical.

All this information is not really public, but has been based on anonymous sources who learned of the amount of the settlement recently.  Read the story and decide for yourself: http://www.nytimes.com/2015/02/28/nyregion/exxon-mobil-settles-with-new-jersey-over-environmental-damage.html

The “Global Warming Conspiracy” for Fun and Profit: Dr. Willie Soon

February 28, 2015

Wie-Hock (Willie) Soon, who is a PhD in aerospace engineering and a part-time employee of the Smithsonian who works at the Harvard-Smithsonian Astrophysics Center, has been publishing papers that try to cast doubt on anthropogenic global warming (AGW) for over a decade.  A week ago, the New York Times published a piece based on disclosures made by Greenpeace and the Center for Climate Investigations.  These groups made Freedom of Information Act requests for disclosure of Dr. Soon’s correspondence related to his employment by the Smithsonian, a government body.  The letters reveal that he has had over $1.2 million in funding over the last decade from groups with vested interest in industries that produce carbon dioxide.  These groups include a company that holds numerous coal-fired power plants and the notorious Koch brothers (who made most of their money from oil-related investments.)  In addition, he has recently begun to receive money from a group that was organized specifically to anonymize money donations from wealthy individuals and groups who are mostly conservative in outlook.

Dr. Soon’s “scientific” papers attempt to show that the sun is responsible for most of the global warming that has been observed over the last 200 years.  In fact, objective scientists estimate that the sun may be blamed for perhaps 10 percent of observed warming, while human activities are causing at least 50 to 80 percent of the changes we have seen.  The sun has in fact gone through a period of reduced heating related to very low sunspot activity over the last fifteen to twenty years.

The problem with Dr. Soon’s funding is that he has published at least 11 papers since 2008 that attempt to cast doubt on AGW, papers that omit any information about his funding sources.  At least eight of those papers directly violate the disclosure policies of the journals in which they were published.  This sort of behavior could have the following consequences: the papers could be retracted, and Dr. Soon could face sanctions from his employer.   The Smithsonian Institution being a government entity, there is considerable red tape involved in his employment there.  There will of course be investigations by his employer, and these processes could take a lot of time.  The investigations could even reveal more dirt about Dr. Soon and his funding.

The reason this is particularly entertaining is that Senator James Inhofe, a loud critic of AGW, has repeatedly cited Dr. Soon as a reliable skeptic who is brave enough to beat back against the “global AGW conspiracy” that the Senator has been trying to “expose.”

The Senator is a thorn in the side of environmentalists and other proponents of action against AGW, and his speeches in the Senate and elsewhere are loaded with references to those scientists who publicly cast doubt on AGW.  Most, if not all, of those scientists are beholden to industry sources for their livelihoods.  There is little to respect in the Senator’s claims, and little to respect in these scientists.

Russia

February 19, 2015

There has been much news of late describing how Russia under the rule of Putin is slipping back in to a totalitarian, aggressive nation.   There’s a great article in the NYT today by an ex-Russian who spends a week in a hotel room watching nothing but Russian television.   In order to get through this ordeal, he is forced to be half-drunk most of the time and susbsist on a mostly meat diet.   Here is a quote from his entertaining experience, about a guest on a Russian television show reminiscent of “Jerry Springer”:

“In her own way, she is a model citizen for Putin’s new Russia. She knows to keep her trap shut while being continuously shouted at by persons in authority.”

It’s either that or the rubber hoses applied forcibly to the soles of your feet, where they don’t show and you can’t walk afterwards.

A link to the article:

http://www.nytimes.com/2015/02/22/magazine/out-of-my-mouth-comes-unimpeachable-manly-truth.html

The title refers to the “out of my mouth comes unimpeachable manly truth” tone of voice in the presentations of the news readers on Russian TV, which is even worse than Fox News (if that is possible.)

Suffering

February 18, 2015

Patient suffering is the most difficult thing that doctors have to deal with.  Most of the time, we don’t deal with it.  We just try to avoid it.  But when we connect with a patient one on one, we cannot avoid the suffering.  Think about how it feels to suffer.  That is the thing that makes disease intolerable to us, suffering.  We try our mightiest to avoid or relieve suffering, especially our own.  When a patient reaches for a Vicodin, it is because of suffering (it may not be physical pain, either; it may be “psychic” or mental pain.)

Here is a quote from an article in yesterday’s New York Times (NYT):

“But now, reducing patient suffering — the kind caused not by disease but by medical care itself — has become a medical goal. The effort is driven partly by competition and partly by a realization that suffering, whether from long waits, inadequate explanations or feeling lost in the shuffle, is a real and pressing issue. It is as important, says Dr. Kenneth Sands, the chief quality officer at Harvard’s Beth Israel Deaconess Medical Center in Boston, as injuries, like medication errors or falls, or infections acquired in a hospital.”

The article goes on to list several types of incidental suffering, usually caused by medical workers: poor communication is one.  “Blurting out, ‘Oh, you have cancer’ can cause suffering.”  Loss of a personal valuable item can make a patient suffer, such as when a nursing aide misplaces (or even steals) a patient’s wedding ring.  Losing one’s sense of privacy can hurt, such as when a patient overhears others discussing their illness.

Another form of suffering is just waiting.   Having to wait for a late appointment when you are sick, or busy, or just tired can make you suffer.   Waiting to get treatment when you know that you have a serious illness can make you suffer.  Imagine learning that you have cancer, that it is growing, that it will eventually kill you, and then having to wait two weeks to get a treatment that you have been told is lifesaving.

The NYT also references an article in the New England Journal of Medicine that is titled, “The Word that Shall Not be Spoken.”  The word is “suffering” because it so well covers all the aspects of illness that are painful in any way.

We avoid facing suffering in many ways.  We can deny it, stall it off, or just wall ourselves off from it.

One doctor mentioned in the article learned that he could reduce suffering dramatically and gain patient satisfaction just by “slowing down and listening” to them, “answering their questions.”

Of course, spending more time with a patient usually helps them, but there is only so much time and there are always so many patients.  The doctors (and nurses) are constantly being bombarded with conflicting demands on their time and on their attention.

The most difficult part is that when you are closely connected to a patient and watching them, the feeling of empathy with them can make you feel just as sick and depressed as the patient is.  That can cause suffering for the doctor, which when multiplied by so many patients in a day, can be truly draining.

The article can be found at: http://www.nytimes.com/2015/02/18/health/doctors-strive-to-do-less-harm-by-inattentive-care.html

 

Some Thoughts on How to Compete with ISIS

February 17, 2015

We do have a superior, and brand new, cultural system over that of the Islamic State: our Constitution requires strict separation of church and state, and demands freedom of speech, of the press, and the freedom to worship (or not) the G-d of our choice.  Islamists, in theory at least, demand the opposite: a theocracy, church and state combined, and literal submission to the rules laid down by those who claim to interpret “the will of Allah.”

However, we are in danger of being over-run by the Islamists because we are not using our resources to best advantage.  Here are a few things we should do in order to strengthen our defenses against those who think they have the right to take over the world for Allah by whatever means necessary.

First, we should pull back from an aggressive military posture into a strictly defensive one.  We need not station troops in any country controlled by Muslim governments.   We need not ensure that any one faction is able to keep any particular plot of land in the Middle East.  For example, we can and should denounce al-Assad of Syria as a murderous dictator.   But we don’t need to spend precious resources trying to overturn him.   Humanitarian aid to the refugees would be enough.  At times, when our intelligence indicates that one group is on the verge of massacring another, the Libyan treatment would be about all that we should apply.

We have all the land we need to live on now.   All we really need to do is effectively defend our own territory.  The territory that ISIS currently controls is some of the worst in the world: mostly barren desert.  It’s not worth fighting over.  However, when the Islamists threaten to massacre the Yazidis, we should send our B-1 bombers (it’s really a lovely plane, a true beauty, unlike the B-2, which is just butt-ugly.)

Second, we should change our prisons so that they  are not breeding grounds for extremists of all kinds.   Prison should be a place where people are reformed; they should come out reconciled to living in society, with a job that pays a living wage.  It should not be a place where criminals learn how to perfect their craft and teach each other to hate society more.  This is a difficult proposition, but it would be extremely profitable, especially in the United States, which has the largest per capita prison population in the world.

Third, we should beef up our social welfare system.   As I mentioned in my last post, ISIS claims to be obligated to provide free housing, food, clothing, and medical care to everyone who submits to its caliph.  How can we compete with an offer like that, with our dog eat dog system of capitalism?  Let everyone be protected from want, suffering, hunger, and disease, and let those who wish to work enrich themselves to whatever extent they want.   Income inequality is not  a problem because it is unequal: it is a problem because the people at the bottom are plagued by inability to pay their bills and just live like a normal human being.

As an aside, we should really try to avoid committing human rights violations such as those that occurred at Abu Ghraib and elsewhere.  These violations are not only disgusting to anyone who observes them, they are stimulants for extremists.  Those who are subjected to this kind of treatment, and then eventually released, inevitably become radicalized and have good reason to hold a grudge against their oppressors.  The new caliph is a good example: he is said to have been imprisoned in Iraq by American troops for a time.

A final note is that we would be well advised to stop buying oil from these countries.  Some of their profits go towards supporting the very people who want to destroy us.  We must become energy independent by the most advanced means we have available.

With a realignment of our priorities, we should be able to adequately defend ourselves from those Islamists who want to take over the world by whatever means necessary.  We have a superior cultural rule system and we need to defend it with maximum strength and minimum collateral damage.

About the New Caliphate, Mecca, and Stonehenge

February 17, 2015

Rather than go in to a long, and probably mistaken, explanation, of what the caliph and the people of the “Islamic State” (ISIS) REALLY want, I will direct the reader to an article in the Atlantic, which is probably the best-informed short article in English that I have read.  The reason it is well-informed is that the author spoke at length with several advocates of what I will call the “New Caliphate” who live in, and are trapped there by the governments of, Australia and the United Kingdom.  

Their passports have been confiscated, and they are under investigation and surveillance by government agencies and agents.  Because of specific laws in these countries, these advocates refuse to openly state that they have declared allegiance to the new caliphate.  The fine line here is that urging, or helping, others to immigrate to ISIS territory is also illegal.  Others have managed to immigrate to this territory, which is controlled by a man surnamed al-Bagdadi, who is the new caliph.

The Ottoman caliphate was abolished by Mustafa Kemal Atatuerk in 1924, when he declared the establishment of the modern state of Turkey.   However, that caliphate was not wholly legitimate for several reasons; the last really legitimate caliph probably died about 10 centuries ago.   The idea of the caliphate was proclaimed by Muhammed in the seventh century of the common era, and Sharia (the law and the social/economic structure of the state) was also set in stone by him.

There are several points about the Islamic State that most people do not fully realize.  First, it attempts to re-establish the Sharia (explained below) that Muhammed declared exactly as it was written in sacred documents like the Koran.  Second, it looks forward to an Apocalypse or perhaps, an Armageddon, in which all unbelievers will be killed (that means you.)  Third, it is unapologetic about its adherence to certain practices which sound really barbaric to Westerners: slavery (imposed especially on infidel women), traumatic punishments (which I will not mention because you know precisely what I am talking about), and the payment of a tax by Christians (who will be required to acknowledge submission to its rule.)

You might think that Saudi Arabia is a country in which Sharia is fully implemented.  This is not the case.  There is another aspect of literal Sharia which cannot be ignored: the obligation to provide “free housing, food, and clothing for all, though of course anyone who wished to enrich himself with work could do so.” (Quoted from the Atlantic article.)  This social and/or economic aspect is supposedly implemented in the new caliphate.  Free health care is included (apparently with vision care, which is not covered under the social policy of the United Kingdom.)

At the moment, the territory controlled by the new caliphate is some of the worst on Earth: mostly barren desert in the region of Syria and western Iraq.  There has recently appeared a satellite territory in eastern Libya.  Here were theatrically murdered (“brutally” is such an overused word) “over a dozen” (possibly 20 or 21) Christian Druze people (who had been immigrant workers from Egypt in the oilfields of Libya.)  A video produced by ISIS is available.  The government of Egypt retaliated and sent airstrikes against an eastern Libyan town said to be controlled by ISIS.  A spokesman on Egyptian TV stated that some “40 or 50″ people were killed in the airstrikes.  (These quotes are from the New York Times.)

In a nutshell, what we have is a group of people who are fanatical adherents to a literal interpretation of a social policy as well as a “religion”(I use quotes because to these people, their faith is more than a religion; it is an obsession) which was established in the seventh century and cannot be changed.  Furthermore, these people seem to believe in a “Last Days” scenario, reminiscent of the proclamations of American Christian evangelists who deny global warming, some of whom seem to support the Tea Party.  Notice that I am not advocating nor denigrating any of this insanity.

This brings me to another point: Islam is supposedly the second most populous and the fastest growing religion in the world, with some 1.6 billion adherents (they are said to be outnumbered by Christians, with 2.2 billions.)  The vast majority of these people consider ISIS to be “un-Islamic.”  The foremost secular authority on Islam in the US, Bernard Haykel of Princeton, is quoted in the Atlantic article describing them as having “a cotton-candy view of their own religion” which ignores the historical and “legal” facts.

There is no single dominant authority within Islam; multiple interpretations are available from imams (learned Islamic men.)  An imam may issue a fatwa (proclamation) stating that, for example, jihad means to try to topple the US government.   In most countries with a Muslim majority, the government is explicitly religious, although here again there is no agreement as to the exact implementation.

This mixing of religion and government is explicitly outlawed by the United States constitution and the constitutions and governments of most Western countries.  The separation, or blending, of church and state represents probably the fundamental controversy between Islam and Christianity.  In other respects the two are basically monotheistic religions.

The penalty for apostasy is death.  However, before someone can be declared an apostate, she/he must be warned and educated about the “true religion” (that is, the beliefs of Muslims, as they are interpreted by whoever is in control at the moment.)  In fact, to declare another Muslim an apostate is dangerous; Mohammed apparently said “If one Muslim declares his brother an apostate, one of them is right.”

I am ignorant of these matters, and no one has shown up at my doorstep to warn or educate me.  So I will probably die in ignorance, that is, I can’t go to Heaven or Hell, but presumably will wind up in Limbo.  I can tell you bluntly that anyone who comes to my house and tries to convert me to any religion will be shown the muzzle of a twelve gauge shotgun and invited to leave immediately.

If you really want to know more about this (and I certainly don’t) read the Atlantic article at:

http://www.theatlantic.com/features/archive/2015/02/what-isis-really-wants/384980/

A footnote: the most holy mosque (house of worship, or masjid) in the world is in Mecca, and it contains a unique structure called the “Kaaba” (cube in Arabic.)  This is a roughly cubical stone building about 42 feet high, featuring a black stone which is said to be a meteorite which fell in the hills nearby.   The structure is associated with Abraham, who is said to have rebuilt it, and dates to at least 2000 years before the common era (BCE.)  The Abrahamic structure was not cuboid: it included a rounded portion on the eastern side, which is still preserved as a three foot high curved stone wall outside the current structure.

The structure has been repeatedly rebuilt; in 1979, golden doors were installed in the entrance.  It is apparently only entered twice a year for a ritual cleaning by chosen dignitaries.  During the hajj (pilgrimage), which the faithful are required to perform at least once in their lives (if possible), a ritual walk around the Kaaba is made, currently by about 6 million people a year.

It is interesting to me particularly because its sides are aligned with certain astronomical landmarks: at the north, the rising of the star Canopus, and at the east and west, the setting of the sun at the winter solstice and the rising of the sun at the summer solstice.  These astronomical alignments remind me strongly of another structure: the Stonehenge in Britain.

I am informed by Wikipedia that the earliest stones at Stonehenge were radiocarbon dated in 2008 to between 2400 and 2200 BCE, although other parts of the Stonehenge complex probably date to 3000 BCE (there are some 700 individual architectural features contained in the World Heritage Site, which is 24 square km in size and nearly 30 miles long.)

These dates make an interesting coincidence, which I prefer to explore as it antedates all this fuss about the Koran and the way we were supposed to live in the seventh century CE.

(All statements of “fact” are sourced from Wikipedia unless otherwise designated; in particular, the part about the shotgun is a personal observation.) (way too long–sorry.)

 

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