On smuggling.

On smuggling.

While I was working in a research laboratory at Stanford, my advisor mentioned that she was waiting for a package from ________.

“Oh, we got something from him,” said our technician John, “but it was just an Invitrogen catalog.  Their rep brought us a newer copy last week, so I threw it out.”

“What!” my advisor shouted, causing him to jump.  “Which trash can?!” 

She and John rooted through the garbage together.  Luckily the package had arrived that day.  The now-gooey catalog (I was smashing a lot of cow brains in those days, and the bleached muck went into the trash) was still there.

We didn’t need another Invitrogen catalog.  But it’s illegal to ship DNA through the mail, so researchers often smuggle it by dotting some onto paper then circling the spot.  When you receive DNA this way, you cut out the circle, dip it in water, and then add bacteria.

The bacteria make more copies of your DNA.  Antibiotics kill off any bacteria that aren’t helping.  And the U.S. post office is none the wiser.

Then you can throw out the useless catalog.


I’ve been volunteering with the Midwest Pages to Prisoners project for about a decade.  We ship books to people who would be otherwise deprived.  Occasionally, though, administrators at a prison will instruct their mailroom staff to return all our packages.  Or, worse, quietly pitch them into the trash.  Months might pass before people inside let us know that our books aren’t getting in.

Usually, the administrators will relent and let us send books again, but it might take a few years of phone calls.  During one such frustrating episode, I wrote a poem.

Sympathy for the Devil

I am a writer as in a vulture, plucking words from

others’ pain. & sing penance, but never loud enough:

we feast upon this world of hurt we’ve made.

Words might salve even the poor, so we send free

books to inmates. At one prison, packages never

arrived. We called & were told we impregnated

literature with suboxone. We lacked both will &

way: we have no budget; drugged pages wilt &

yellow; no one would read. Later I heard the state

was shunting sex criminals there. Books were

a privilege, underhandedly revoked.

                                                               Gangs rule

inside: Aryan Brotherhood for whites, Gangland

Disciples for black men. We are free to believe in

post-racial America: in prison, meals might mean

a stack of trays sloughed inside a then-locked door.

Some men take two. Others will go hungry. The

ache of want sends us seeking for what symbols

of solidarity we find, hoping for allies against the

world.

             AB oft allies with the guards. Members reap

cushy jobs, access to visitors, untrammelled mail.

At the prison binning our books, gang & guards

were very close, COs inked in crosses, runic letters,

shields & shamrocks. Yet AB, there, was weak. So

they were fed sex criminals – easy, friendless kills.

A guard outs the doomed man’s past – everyone

lies, asked why he’s doing time – and members

murder him in the shower.  They look tougher

than they are.

                         A dozen deaths. No indictments.

Activists began to smuggle phones, hoping to

document abuse. That’s when our packages ceased

to be received.

                           I’ve no deep love for these men –

friends of mine were abused.  But if those who molest

should be punished by death, let’s force judge & juries

to say it. Not read a shadow sentence of 10 or 20 years.

We should say what we mean:

I sentence you to a cruel and unusual death.  It will

come suddenly in a shower stall, faux-Odinist skin-

head slamming your head against the tile until your

bruised brain ruptures from repeated trauma.  Your

eyes will loosen from their sockets, your skull will

crack, blood will whelm through your nostrils.  In a

final indignity, bowels relax.  You will know the brief

hell of hoping to live when you cannot.  Your limp

body will drop while the water runs, cascading over

your corpse.  Although news of your death will not

reach those who sentenced you, they will know that

justice has been done.


Quite likely, drugs were being smuggled into that prison.  I’ve been told that it’s easier to buy drugs in prison than out on the street.  Which is rough – people who are recovering from addiction often relapse after being sent to prison.  In those bleak environs, there aren’t a lot of other ways to occupy your time.

The drugs weren’t coming from Pages to Prisoners, though.  We always embalm our packages in tape so that correctional officers can’t tamper with them (as easily) on their way in.  And, seriously, our organization doesn’t have the budget for drugs – we’re shipping donated books wrapped in old grocery bags!  I’ve never tried to buy opiates, but I assume they’re expensive.  Guys in jail sometimes mention how many thousands they were spending on their habits each week, which helps explain why they’re broke.

I understand why prison administrators worry, though.  Scientists use books to smuggle DNA; you could illicitly ship a variety of drugs that way.

Although our organization ships books to people incarcerated in twelve different states, local prisons are the only ones that ban us.  Which is sad.  From a community perspective, we’d like to help people locally.  We can recruit volunteers by mentioning that the people inside will be coming back to our community.

From a health and safety perspective, though, prison administrators would prefer that books come from out of state.  Then they can feel more confident that packages are being sent by people who’ve never met the inmates. 

The recipients would be like my colleague John, evaluating each book based solely on its title: an Invitrogen catalog?  We don’t need that! 

Or, after receiving one of the packages sent by Pages to Prisoners recently: sweet, advanced Dungeons & Dragons!

Prison administrators have good reason to keep drugs out.  People’s tolerance wanes during their time in jail – somebody might take too much and die.  Whereas they’re unlikely to OD on D&D.

 Of course, prisons don’t have to be so bleak & punitive, let alone violent & PTSD-inducing.  Prisons like we have in the U.S. don’t need to exist at all.  And then organizations like Pages to Prisoners wouldn’t need to send books.

On loneliness.

On loneliness.

Most laboratory animals live in bleak environs.  With mice, each cage typically contains a single animal.  There is bedding, food, and water.  There is very little space.

A lab mouse will be illuminated for many hours each day – sometimes twenty-four, sometimes slightly fewer – by fluorescent lights.  It will hear the constant thrum of ventilation fans and refrigerator compressors.  At least once a week, an apex predator – wafting stress-inducing smells, especially if it’s male – will reach into its home and grab it.

Chances are, it will see other mice.  A rotating cadre will fill adjacent cages during its tenure in the lab.  They will never touch.

Our cruelty makes for bad science, too.

When social animals are stored in isolation, their bodies and brains decay.  Neuron growth slows, which impedes learning.  Lifespan is curtailed.  Obesity rates increase.

Lab_animal_careIf we stop mistreating laboratory animals, though, new research might be inconsistent with past results.  When describing mice, scientists don’t say that deprivation stunts brain development.  Instead we write things like, “If a lab is studying the impact of stress on the growth of new neurons, for example, and then it lets mice exercise on a running wheel – which has been shown to spark neuron growth – the study could be jeopardized” (from David Grimm’s recent news article for Science magazine).

4117496025_8024f879d6_zWe give ourselves a very skewed view of neurology if we let ourselves think that a creature’s normal habits are stimulating neuron growth, rather than admitting that deprivation stops it.  For decades, most researchers thought that neuron growth ceased in adults.  Even in the 2005 paper demonstrating structural plasticity, the authors wrote that “such changes are only seen in response to external perturbation,” because brain development is sluggish in lab mice housed in normal conditions, i.e. those little cages.

Of course, some scientists do care about the well-being of their furry test tubes.  For instance, biologist Daniel Weary, who told Grimm “Our dream is that our animals live a better life with us than if they had never been born.”  Animals in Weary’s lab get to touch actual dirt.

Maybe not the highest bar, but the lives of most animals on our planet are worse than if they’d never been born.

Vivek_Murthy_nomination_hearing_February_4,_2014Most social animals – like mice, rabbits, and humans – aren’t going to be very happy when they’re housed in isolation.  Former U.S. Surgeon General Vivek Murthy considers loneliness to be a public health crisis, leading to health risks as bad as smoking or obesity.

Unfortunately, most biomedical research is done with research animals amongst whom pervasive loneliness is standard.  And our political system gives outsize influence to wealthy corporations that earn more money when people feel lonely.

We shunt humans into jail when we feel that their behaviors are unacceptable for the world at large.  Incarceration sends a message: don’t beat your family; don’t steal; don’t sell drugs; don’t take drugs; don’t be late for an appointment with your parole officer; don’t be too poor to pay your court fees.  To my mind, some of these offenses are worse than others.

The hope is that either the threat of incarceration deters people from these things, or that the experience of being incarceration cures them of the inclination.  (Or a third rationale – that seeing offenders punished will pacify others’ sense of fairness – which seems to encourage the evolution of cooperation, but, like many other evolved behaviors, seems unnecessarily vicious for the modern world.)

We’ve known for years that punishment doesn’t work well as a criminal deterrent.  And the experience of incarceration seems to make most people worse, not better.

Instead, we’re imposing loneliness on people who most need the help of friends and neighbors to turn their lives around.  Somebody screws up?  We store that person like a lab mouse.

10490113913_e3a697bdca_zI was recently chatting with somebody who’s done nine months so far for a parole violation – and is still waiting for his court date, which keeps being rescheduled.  (He’s already told the judge that he’ll plead guilty, and the prosecutor wanted to send him to rehab, but his PO nixed the deal.)

“It’s a lot better now, in J block.  Everybody said, you don’t wanna move from A block, you’ll get no bingo, you’ll get no … I don’t care about any of that.  We can look out the window, see people walking on the street.

“I spent almost an hour, the other day, watching this leaf blowing back and forth in the wind.  I was staring, thinking I’d say to the judge, ‘you can pile on whatever other charges you want, I’ll still plead guilty, I’ll plead guilty to all of it if you just let me out there to look at that leaf blowing around up close.  Just five minutes, just lemme see something!

“In D block, that was the worst.  All we could see was the parking garage.  On weekends, we’d see nothing, not even cars.  So I was starting fights every day.  I’d be like, hey, turn the TV to, I don’t know, some channel I don’t even like, just so I can start something with somebody.  Cause a fight would at least be something to do.”

John-Michael Bloomquist’s poem “The Prodigal’s Return,” about teaching poetry in jail, ends:

                                      Each day that I visit

the jail full of men, who hug me the way

their families cannot, write poems about childhoods

I couldn’t imagine, I feel the love of my father.

After nine months inside – un-touched, un-hugged, un-loved, under-slept – perhaps our man will finally be released.  Surely his time there will have cured him of his addiction!

On Sci-Hub, the Napster of science.

On Sci-Hub, the Napster of science.

Here’s a story you’ve probably heard: the music industry was great until Napster came along and complete strangers could “share” their collections online and profits tanked.  Metallica went berserk suing their fans.  It was too late.  The industry has never been the same.napster

Sci-Hub has been called a Napster equivalent for scientific research papers, and the major publishing companies are suing to shut it down.  The neuroscience grad student who created it faces financial ruin.  The original website was quickly shuttered by a legal injunction, but the internet is a slippery place.  Now the same service is hosted outside U.S. jurisdiction.

[Note: between writing and posting this essay, Sci-Hub has lost another lawsuit requesting all such sites to be blocked by internet service providers.]

The outcomes of these lawsuits are a big deal.  Not just for the idealistic Kazakhstani grad student charged with millions in damages.  Academic publishers will do all they can to accentuate the parallels between Sci-Hub and Napster – and, look, nearly a quarter of my living relatives are professional musicians, so I realize how much damage was wrought by Napster’s culture of theft – but comparing research papers to pop songs is a rotten analogy.  Even if you’ve never wanted to read original research yet … even if you think – reasonably – that content producers should be paid, you should care about the open access movement.  Of which Sci-Hub is the most dramatic foray.

My own perspective changed after I did some ghostwriting for a pop medicine book.  Maybe you know the type: “Do you have SCARY DISEASE X?  It’ll get better if you take these nutritional supplements and do this type of yoga and buy these experimental home-use medical devices!”  Total hokum.  And yet, people buy these books.  So there I was, unhelpfully – quite possibly unethically – collaborating with a friend who’d been hired to ghostwrite a new one.

Central_core_disease_NADH_stainI read huge numbers of research papers and wrote chapters about treating this particular SCARY DISEASE with different foods, nutritional supplements, and off-label pharmaceuticals.  My sentences were riddled with un-truths.  The foods and drugs I described are exceedingly unlikely to benefit patients in any way.

Still, I found research papers purporting to have found benefits.  I dutifully described the results.  I focused on the sort of semi-farcical study that concludes, for instance, that cancer patients who drink sufficient quantities of green tea have reduced tumor growth, at which point newspapers announce that green tea is a “superfood” that cures cancer, at which point spurious claims get slathered all over the packaging.

Maybe nobody has written a paper (yet!) claiming that green tea ameliorates your particular SCARY DISEASE.  But there’s also turmeric, kale, fish oil, bittermelon, cranberries… I’m not sure any ingredient is so mundane that it won’t eventually be declared a superfood.  Toxoplasma gondii has been linked to schizophrenia, but low-level schizophrenia has been linked to creativity: will it be long before cat excrement is marketed as a superfood for budding artists?

cat-shit-2-flat-1.jpgAs it happens, enough people suffer from our book’s SCARY DISEASE that many low-quality studies exist.  I was able to write those chapters.  And then felt grim.  The things I’d written about food weren’t so bad, because although turmeric, coconut oil, and carpaccio won’t cure anybody, they won’t cause much harm either.  But the drugs?  They won’t help, and most have nasty side effects.

My words might mislead people into wasting money on unnecessary dietary supplements or, worse, causing serious damage with self-prescribed pharmaceuticals.  Patients might follow the book’s rotten advice instead of consulting with a trained medical professional.  I’d like to think that nobody would be foolish enough to trust that book – the ostensible author is probably even less qualified to have written that book than I am, because at least I have a Ph.D. in biochemistry from Stanford – but, based on the money being thrown around, somebody thinks it’ll sell.

And I helped.

Whoops.  Mea culpa, and all of that.

But I didn’t perpetrate my sins alone.  And I’m not just blaming the book’s publishers here.  After all, the spurious results I described came from real research papers, often written by professors at major universities, often published in legitimate scientific journals.

It’s crummy to concentrate all that slop in a slim pop medicine book, I agree, but isn’t it also crummy for all those spurious research papers to exist at all?

Maybe you’ve heard that various scientific fields suffer from a “replication crisis.”  There’s been coverage on John Oliver’s Last Week Tonight and in the New York Times about major failures in psychology and medicine.  Scientists write a paper claiming something happens, but that thing doesn’t happen in anyone else’s hands.  That’s if anyone even bothers to check.  Most of the time, nobody does.  Verifying someone else’s results won’t help researchers win grants, so it’s generally seen as a waste of time and money.

Still, the news coverage I’ve seen hasn’t stated the problem sufficiently bluntly.  Modern academic science is designed to be false.

This is tragic.  It’s part of why I chose not to stop working in the field.  I became a writer.  Of course, this led to my stint of ghostwriting, which… well, whoops.

Here’s how modern science works: most research is publishable only if it is “statistically significant.”  This means comparing any result to a “null hypothesis” – if you’re investigating the effect of green tea on cancer, the null hypothesis is simply “green tea does nothing” – then throwing out your results if you had more than a one in twenty chance to see what you did if the null hypothesis were true.

If you have a hundred patients, some of their tumors will shrink no matter what you do.  If you give everybody buckets of green tea and see the usual number of people improve, you shouldn’t claim that green tea saved them.

Here’s a graphic from Wikipedia to help:

pvalue1pvalue2

Logical enough.  But bad.  Why?  Because cancer is a SCARY DISEASE.  Far more than twenty people are studying it.  If twenty scientists each decide to test whether green tea reduces tumors, the “one in twenty” statistical test means that somebody from that set of scientists will probably see an above-average number of patients improve.  When you’re dealing with random chance, there are always flukes.  If twenty researchers all decided to flip four coins in a row, somebody would probably see all four come up heads – doesn’t mean that researcher did anything special.

Or, did you hear the news that high folate might be correlated with autism?  This study probably sounds legitimate – the lead scientist is a professor at Johns Hopkins, after all – but the result is quite unlikely to be real.  That scientist hasn’t written about folate previously, so my best guess (this new study is currently unpublished) is that pregnant women were tested for many different biomarkers, things like folate, iron, testosterone, and more, and then tracked to see whose children would develop autism.  If the researchers tested the concentrations of twenty different nutrients and hormones, of course they’d see one that appeared to correlate with autism.

[Edit: these findings were recently published.  Indeed, the data appear rather unconvincing, and the measurements for folate were made after the fact, using blood samples – it’s quite possible that other data was gathered but excluded from the published version of the study.]

This is not science.  But if you neglect to mention how many biomarkers you studied, and you retroactively concoct a conspiracy theory-esque narrative explaining why you were concerned about folate, it can do a fine job of masquerading as science.  At least long enough to win the next grant.

Which means that, even though the results of many of these studies are false, they get published.  When somebody checks twenty nutrients, one might appear to cause autism.  When twenty scientists study green tea and cancer, somebody might get results suggesting green tea does work.  Even if it doesn’t do a thing.

In our current system, though, only the mistaken researcher’s results get published.  Nobody knows that there were twenty tests.  The nineteen other biomarkers that were measured get left out of the final paper.  The nineteen researchers who found that green tea does nothing don’t publish anything.  Showing that a food doesn’t cure cancer?  How mundane.  Nobody wants to read that; publishers don’t want it in their journals.  But the single spurious result showing that green tea is a tumor-busting superfood?  That is exciting.  That study lands in a fancy journal and gets described in even briefer, more flattering language in the popular press.  Soon big-name computer CEOs are guzzling green tea instead of risking surgery or chemo.

I generally assume that the conclusions of research studies using this type of statistical testing are false.  And there’s more.  Data are often presented misleadingly.  Plenty of scientists are willing to test a pet theory many ways and report only the approach that “works,” not necessarily because they want to lie to people, but because it’s so easy to rationalize why the test you tried first (and second, and third…) was not quite right.  I worked in many laboratories over a decade and there were often results that everybody in the lab knew weren’t true.  Both professors I worked under at Stanford published studies that I know weren’t done correctly.  Sadly, they know it too.

This subterfuge can be hard for outsiders to notice.  But sometimes the flaws are things that anybody could be taught to identify.  With just a little bit of guidance, anybody foolish enough to purchase the pop medicine book I worked on would be able to look up the original research papers and read them and realize that they’re garbage.

There’s a catch: most of those papers cost between twenty and thirty dollars a pop.  The chapters I wrote cite nearly a hundred articles.  I’d describe a few studies about the off-label use of this drug, a few about that one, on and on, “so that our readers feel empowered to make their own decisions instead of being held at the paternalistic mercy of their healthcare professionals.”  A noble goal.  But I’m not sure that recommending patients dabble with ineffectual, oft-risky alternative medicines is the best way to pursue it.  Especially when the book publisher was discussing revenue sharing agreements with sellers of some of the weird stuff we shilled.

So, those hundred citations?  You could spend three thousand dollars figuring out that the chapters I wrote are crap.  The situation is slowly getting better – the National Institute of Health has mandated that taxpayer-funded studies be made available after a year, but this doesn’t apply to anything published before 2008, and I’m not sure how keen sick patients will be to twiddle their thumbs for a year before learning the latest information about their diseases.  Plus, there are many granting organizations out there.  Researchers who get their money elsewhere aren’t bound by this requirement.  If somebody asks you, “Would you like to donate money to fight childhood cancer?” and you chip in a buck, you’re actually contributing to the problem.

1403798100_f4ba200fe0_z
Photo by diylibrarian on Flickr.

I was only able to write my chapters of that book because I live next to a big university.  I could stroll to the library and use their permissions to access the papers I’d need.  Sometimes, though, that wasn’t enough.  Each obscure journal, of which there are legion, can cost a university several thousand dollars a year for a subscription.  A few studies I cited were published in specialty journals too narrowly focused for Indiana University to subscribe, so I’d send an email to a buddy still working at Stanford and ask him to send me a copy.

If you get sick and worry yourself into looking for the truth, you’ll probably be out of luck.  Even doing your research at a big state university library might not be enough.

That’s if you keep your research legal.

Or you could search for the papers you need on Sci-Hub.  Then you’d just type the title, complete a CAPTCHA on a page with instructions in Cyrillic (on what was until recently http://www.sci-hub.cc, at least), and, bam!  You have it!  You can spend your thirty dollars on something else.  Food, maybe, or rent.

Of course, this means you are a thief.  The publisher didn’t get the thirty dollars they charge for access to a paper.  And those academic publishers would like for you to feel the same ethical qualms that we’re retraining people to feel when they pirate music or movies.  If you steal, content producers won’t be paid, they’ll starve, and we’ll staunch the flow of beautiful art to which we’ve become accustomed.

The comparison between Napster and Sci-Hub is a false analogy.  Slate correspondent Justin Peters described the perverse economics of academic publishing, in particular the inelastic demand – nobody reads research journals for fun.

With music and movies, purchasing legitimate access funds creators.  Not so in academia.  My laboratory had to pay a journal to publish my thesis work; this is standard practice.  It costs the authors a lot of money to publish a research article, and “content producers” only do it, as opposed to slapping their work up on a personal website for everyone to read free, because they need publication credits on their CVs to keep winning grants.

With music and movies, stealing electronic copies makes content producers sad.  With research articles, it makes them happy.

In fact, almost everyone believes research articles should be free.  At the European Union’s recent Competitiveness Council, the member states agreed that all scientific papers should be freely available by 2020 – these  are the governments whose enforcement is necessary to maintain the current copyright system!  The only people making statements in favor of the status quo are employed by the academic publishers themselves.  Their ideological positions may be swayed somewhat by the $2 billion plus profit margins major publishers are able to extract from their current racket.

Academic publishers would argue that they serve an important role as curators of the myriad discoveries made daily.  This doesn’t persuade me.  The “referees” they rely on to assess whether each study is sound are all unpaid volunteers.  Plus, if the journals were curating well, wouldn’t it have been harder for me to fill that pop medicine book with so much legitimate-looking crap?

Most importantly, by availing yourself of Sci-Hub’s pirated material, you the thief no longer live in ignorance.  With our current healthcare model, ignorance is deadly.  The United States is moving toward an a la carte method of delivering treatment, where sick people are expected to be knowledgeable, price-sensitive consumers rather than patients who place their trust in a physician.  Most sick people no longer have a primary care physician who knows much about their personal lives – instead, doctors are forced for financial reasons to join large corporate conglomerates.  Doctors try their best moment by moment, but they might never see someone a second time.  It’s more important than ever for patients to stay well-informed.

Unless Sci-Hub wins its lawsuit, you probably can’t afford to.

On medical spending.

On medical spending.

Trepanation_-_feldbuch-der_wundartzneyBack when doctors were curing headaches by drilling holes through people’s skulls, or slapping on a few leeches to drain out the bad blood when sick patients came stumbling through the door, medical spending wasn’t a big deal.  There weren’t any serious political considerations attached.  If you were wealthy, you might visit a doctor and get yourself killed.  If you were poor, you’d probably go without medical care.  You’d live or die according to the virulence of your disease and the quality of your diet.  Maybe you’d buy a small amulet representing one of the healing saints, or pay a witch to bury herbs in an auspicious location near your house.

I haven’t done an extensive review of the historical data, but to the best of my knowledge no ancient kingdoms were bankrupted trying to provide leeches to all their sick citizens.

Now, though, the situation is different.  Medical care is better.  Doctors know enough that patients receiving care fare significantly better than those left untreated.

There are dramatic economic consequences of improved medical care, though.  Leeches and bloodletting and trapanation were ineffectual, but they were cheap.  Modern medical care actually saves people’s lives, but it comes at a huge cost.  In the United States, health care spending is about a fifth of the total economy, and rising.

US_health_costs_GDP

Albrecht_Dürer_-_Death_and_the_Lansquenet_(NGA_1943.3.3611)Death is scary.  For people who started learning philosophy with Camus (which is not something I’d recommend — this can result in an excessively bleak world view and is probably appropriate only for incurable depressives), inescapable death seems to be the major quandary in our attempt to ascribe meaning to life.

The fear of death fuels medical spending.  Also our spending on biomedical research.  Medical care is pretty great currently, especially if you’re comparing statins and anti-retrovirals and insulin to leeches.  But people still die.  We haven’t reached the singularity yet (thank goodness).

Leeching-largeBiomedical research spending makes the population as a whole sicker, though.  Most research innovations — and certainly the most lucrative ones — are for managing chronic conditions, not curing them.  People who would’ve died — how many leeches do we prescribe for atrial fibrillation? — survive instead, lowering our population’s average health.  And raises average age, since those first few maladies aren’t killing people as often.

It’s not so difficult to imagine that, if these biomedical research trends continue, people might survive until a hundred and fifty, maybe two hundred years old … and health care spending will rise until it’s a third of the U.S. economy, or fifty percent, or more.

That could doom the country.

But the real tragedy, to my mind, is the way that health care money is being spent.

9781250044631I think a passage from Damon Tweedy’s Black Man in a White Coat gives an elegant summary of the problem.  The whole book is great — I’d highly recommend it to anyone who cares about either racial inequality or the U.S. medical industry.  Tweedy’s writing is so compassionate, always looking to describe the best in people even when his narrative compels him to shown them at their worst.

The passage I want to quote appears just after Tweedy describes a preventable medical tragedy brought on by poor lifestyle choices.  Tweedy grabs a hasty meal with some of his colleagues and is still mulling over what more could’ve been done to help the patient.  Ironically, this leads to a conversation about counseling patients to eat better, but Tweedy and the other doctors are scarfing extremely unhealthful meals.

It really is a great book — big-hearted and earnest, with Tweedy always clear-eyed about his own failings.  His descriptions of his own struggles with poor lifestyle choices really dramatize his efforts to address other black men’s unhealthy lifestyles.

(Oh, and, I fixed a minor typographical error in the following quote without marking it — I always think  sic erat scriptum sounds snarky, and Tweedy’s book was good enough that I’d feel like a total jerk if I made him look bad for what was probably someone else’s mistake.)

pizza
Medical doctors should know better than to eat hospiteria (hospital cafeteria) pizza.

I asked them their thoughts on counseling patients about nutrition and exercise.

“That’s the responsibility of his outpatient primary care doctor,” he said.  “We’re here to deal with the life-and-death stuff.”

This focus on biomedical treatment over preventative care is not limited to Duke or similar schools.  Indeed, outpatient primary care physicians — the doctors that Mike felt bore the responsibility for counseling patients on diet and exercise — are often no more inclined than other doctors to have this discussion, even for diseases where these interventions are vital.  There are many barriers, among them money (dietary counseling is reimbursed poorly compared to medical procedures), time (physicians often see patients every ten or fifteen minutes), and the sense that nutrition talk is better left to dieticians, and that doctors should focus on their expertise (prescribing medications, interpreting tests, and performing procedures).  In addition, experience has made many doctors cynical about patient behavior and the likelihood for change.

The tragedy of U.S. health care spending isn’t just that we shovel too much money into it, which limits what we can spend on other, more important causes, but also that we pour huge sums of money into end-stage therapies that don’t increase quality of life nearly as much as cheaper, earlier interventions.

My father-in-law’s treatment is a great example.  By the end of his life, the federal government was spending hundreds of thousands on his care.  Medication for cholesterol and diabetes, high-tech surgery to replace arteries & restore nervous function in his hands after they’d been numbed by diabetic neuropathy, installing an internal defibrillator once his heart began to fail…

Those treatments helped.  Sure.  They kept him alive longer.  He was incredibly happy after the hand surgery — for months he’d been unable to play guitar because he couldn’t feel anything and could barely exert enough pressure to fret the strings, and after that surgery he could play again, invited everyone he knew for another potluck & jam session.

When K dropped her father off after that surgery, she realized our government’s medical spending on him was actually helping dozens of people — all his neighbors were outside waiting to greet him, and once he could use his hands well enough to cook again he resumed baking loaf after loaf of sourdough bread to give to them.

21878315985_6f3c3023f3
I couldn’t find an image of any breads that look quite as dense as the whole-wheat loaves Mike used to bake for everyone, but David Jackmanson‘s seems close.

At the same time, our government could’ve brought K’s father — and everyone he helped — more joy by helping him earlier.  They spent nothing on him until his untreated conditions left him too disabled to work.  Only then, and even more so after he reached sixty-five, could he get help.

It’s crummy knowing that he would’ve been happier, and would’ve been able to give more back to his community, if he’d been helped earlier.  His childhood was rotten, but nothing was spent to overcome the scars left from hostile parenting.  Our government didn’t help him get counseling after a traumatic event in his early adulthood, either, and that was the root of so many of his later problems.  A few thousand spent to help him then could’ve kept him from becoming indigent. A few thousand spent on psychiatric counseling then would’ve staved off the need for the hundreds of thousands in medical care that were provided later.

This bizarre state of spending priorities is reflected very clearly in our federal budget.  For instance, there’s no money set aside for universal pre-K education.  This would only cost on the order of $10 billion dollars, though, whereas we spend something like $500 billion on health care for the elderly.  But if our goal is to produce good health, childhood education accomplishes much more than surgery and pharmaceuticals for the elderly.

As Tweedy wrote, simply teaching people to eat better would obviate the need for a significant percentage of our medical spending.  Maybe we’d need to spend some money subsidizing real food so that a better diet was within more people’s reach, but, still… that’s much cheaper than the life-and-death medical care that Tweedy was trained to provide.

After an education worth some hundred thousand dollars, after two decades of hard work & studying on his part, Tweedy served as part of a care team working arduous thirty-hour shifts … all to save people who might’ve stayed away from the hospital entirely if they’d been eating vegetables.