Wednesday, December 30, 2009

Fallout from the lap bomber


We are very lucky that Abdulmutallab's device malfunctioned and hundreds of lives were spared. Yes it's unfortunate that intelligence agencies couldn't share information more freely (8 years after 9/11), and red flags weren't raised by his father's concerns and his cash purchase of an airline ticket. The media are going bonkers over this with 24-7 coverage and nonstop speculation, outrage, snap judgments, finger-pointing, or a combination of those. But for the millions of airline passengers who enter and leave our country every year, it's impossible to conduct thorough background checks and body searches, or run them through million-dollar scanners, unless we want our homeland security costs to eclipse our health care spending (and our civil liberties to be trampled). Plus it's quite a challenge and maybe foolhardy (or illegal) to investigate the millions of people who browse violent, religious, or anti-Western content on the Web, or are affiliated with someone who does. The Secret Service doesn't even have the manpower to fully investigate all the threats against Obama (up 400% vs. Bush).

Bad driving (not wearing seat belts, DUI, cell phone use) and medical malpractice claim more lives each year than terrorism, but we accept those ills to a certain extent, or at least we acknowledge that a "zero tolerance" mandate is impossible. We do what we can to minimize the risks with legal penalties and technology safeguards, but we concede that some lapses will occur. But with terrorism, why do we have to be so irrationally rigid? Now many air travelers are worried that they will be next, and even Des Moines airport is on high alert. But each time we drive to work, do we fear that we will become the next roadkill? Instead we're probably speeding because we're late, or calling a loved one, which ironically increases our chance of dying. So why the paranoia over terrorism? I know premeditated murder out of hatred or an extreme agenda is more jarring to the soul, but all preventable deaths are equally tragic. I think in risk consulting, they calculate the risk level by multiplying the likelihood of occurrence by the magnitude of harm (simplified I know). A driving death is higher on the former and lower on the latter (globally), and terrorism is the inverse. Maybe the actuaries can determine which one we should be more scared of, but I doubt it's terrorism.

Yes it's true that a major, traumatic event like 9/11 can disrupt the global economy and set our country back for years, not to mention all the lives and resources lost. We should do our best to prevent the big attacks, but independent "lone wolves" like Abdulmutallab (assuming he was not helped on scene) are impossible to thwart 100% of the time. We didn't stop the home-grown Unabomber and DC snipers until it was too late either. It is disconcerting that terrorists seem fixated with air travel instead of the other more vulnerable soft targets (smuggling a bomb in ship cargo, attacking commuter trains like in India, even cyberwarfare). Probably the fact that we are so obsessed with air safety makes them more motivated to defeat us there. Clearly our enhanced surveillance and tighter visa restrictions have helped keep us safe (though also created major headaches for innocent immigrants and students), and the proof is zero Americans killed on US soil by terrorists since 9/11. Even our hundreds of foreign missions abroad haven't been attacked (apart from our 2 war zones). But the blowback from our foreign military actions may take another decade to fully develop and sting us.

Americans are obsessed with guarantees and control. We expect our stock portfolios and home values to rise indefinitely. We expect to get promoted if we work hard. We expect that our flights will be on time and our cars won't break down. We expect that our government will keep us safe. Much of the time those things happen, but life is unpredictable. Several Americans just died from freak accidents while I typed this paragraph. But because we demand such flawless performance and guarantees of life, liberty, and happiness, we may over-react and resort to extreme measures in a futile attempt to maintain our values through adversities beyond our control. Afghans and Iraqis live with the very real possibility of a fiery death each day, but they are not paralyzed by fear, obsessed with security, and violent towards any perceived threat. The Serenity Prayer reads, "God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference." I think America's counter-terrorism efforts, while so far successful in keeping us safe, are lacking in all three. Maybe the last portion of the Serenity Prayer should read, "And when I fail in those attempts, God grant me luck to survive my shortcomings." Those survivors of the Northwest flight are alive today more due to luck than our counter-terrorism efforts.

In keeping with tradition, when the US is attacked (or almost attacked) from abroad, we respond by bombing some poor bastards within a month. As we speak, the Pentagon is making a list (and checking it twice) of potential Yemeni targets. The Muslims spoiled our day to celebrate the birth of the Prince of Peace (even though more people were murdered in Jesus' name than Muhammad's so far), so now Santa has a big lump of coal for Al Qaeda and any bystanders in their vicinity. CNN reported that we have a classified agreement with the Yemeni gov't to fly cruise missiles, fighter jets, and armed drones against targets in Yemen. So we have even more leeway than Pakistan, and in fact have bombed a suspected Al Qaeda camp there in early December. Well, Obama is sending 30,000 more Marines to Afghanistan, a nation with fewer than 200 original, Arab Al Qaeda members. Yemen, on the other hand, may have several hundred Al Qaeda fighters as well as high-ranking leaders, so I suppose an attack there would be more justified. But as many analysts have already warned, the Somalia and Pakistan examples show us that brash military strikes by a foreign power (even against legitimate, dangerous targets) may provide some strategic gains, but ultimately undermine the fragile local government and actually make failed state conditions more likely (an eroded rule of law and increased violent extremism against foreigners and their local allies).

http://www.cnn.com/2009/WORLD/meast/12/29/us.yemen.strike.targets/index.html

Thursday, December 24, 2009

Comparing the House and Senate Health Bills


Kind of funny (or not): in order to get conservative Dem. Senator Nelson from Neb. to vote for the health bill, Reid and Co. cut a deal.

"The Nebraska compromise, which permanently exempts Nebraska from paying Medicaid costs that all other 49 states must pay, may violate the United States Constitution — as well as other provisions of federal law," Texas Attorney General Greg Abbott said.

... [The Senate] bill was amended to shield Nebraska from the expected $45 million annual cost tied to expanding Medicaid programs.

Comparing some aspects of the House and Senate bills:

http://buzz.yahoo.com/buzzlog/93274

http://www.bloomberg.com/apps/news?pid=20601070&sid=aim3g2AJwUHI

Obama's (d)evolution on the public option:

Candidate Obama, 2008: The Obama plan will establish a new public insurance program available to Americans who neither qualify for Medicaid or SCHIP nor have access to insurance through their employers, as well as to small businesses that want to offer insurance to their employees. And again in another statement.... For those without health insurance I will establish a new public insurance program. (though he never once verbalized this in a speech)

President Obama, July 2009: I am pleased by the progress we’re making on health care reform and still believe, as I’ve said before, that one of the best ways to bring down costs, provide more choices, and assure quality is a public option that will force the insurance companies to compete and keep them honest.

President Obama, Aug-Dec 2009: [The public option was only a] sliver of my health care proposal.... I didn't campaign on the public option.

http://salon.com/news/politics/barack_obama/index.html?story=/politics/war_room/2009/12/22/obama_public
http://www.whitehouse.gov/the_press_office/Statement-from-the-President-on-Health-Care-Reform/

Wednesday, December 23, 2009

Got Merck? A day in the life of Big Pharma


Move over milk... Merck is so determined to help your grandma maintain strong bones that you won't believe the lengths they've gone.

With our female family members nearing retirement age, I am sure you've seen a bottle of calcium supplements or other bone-promoting medications on their kitchen table. Clearly osteoporosis is a health concern (especially for women, who lose bone more rapidly than men due to hormone changes after menopause), and we all know of a senior citizen whose quality of life was really impacted by broken bones from a fall (even 1 in 5 elderly women will die a year after a broken hip, due to other health complications associated with their disability). In the last decade or two, new specialty drugs have emerged that proactively reduce the chance of osteoporosis, and have blossomed into a multi-billion-dollar industry (since the trick with preventative drugs is you never know if you'll truly be at risk, so you better take them for the rest of your life to be safe).

Obviously osteoporosis doesn't occur overnight; there is a gradual loss of bone tissue, like how mild senility precedes dementia and Alzheimer's. So the "onset" of osteoporosis is named osteopenia, or bone thinning. But like senility, humans lose bone mass normally with age. So when is bone loss pathological? When do women reach the osteopenia zone (I'll refer to it as OP from now on)? Well, the cutoff point was literally decided arbitrarily by a room of bone experts at a WHO summit (they drew a line on a graph and that settled it). Unfortunately, many human diseases are not understood and merely classified by a set of symptoms that reach an arbitrary degree of severity, with clinical depression being an obvious example. Getting back to OP, the "disease" was decided to apply to people who were hovering near the osteoporosis cutoff.

Merck happened to have a bisphosphonate drug (later marketed as Fosamax) that inhibits the cells that digest bone. So without those cells' normal or pathological activity, osteoporotic people will lose bone slower. The problem is that bone is like a highway. It needs to be maintained and repaved occasionally from all the wear and tear. Those cells don't eat bone to be mean. They clear out old or weakened bone so other cells can lay down new, stronger bone. The renewing miracle of life. And the bone-laying cells do so very messily, like a kid with paint. The bone-eating cells are critical to remodel the bone, repair micro-cracks, and make it more structurally sound. Addition by subtraction. So actually a femur with more bone mass may be weaker than a thinner femur that is remodeled correctly by the bone-eating cells. So it's good that Fosamax stops over-active bone-eating cells from making a person's bones dangerously thin, but then over time the patient also loses some ability to maintain the strength in their bones through normal remodeling. In addition, Fosamax-type drugs are implicated in dozens of side-effects, and over 400 lawsuits were filed against Merck for the disease ONJ (in brief, wasting away of the jaw due to inability of that bone to heal after dental work, etc.).

But no bother, Merck wanted to sell Fosamax to the droves of aging people who were living longer, and would need to pop these pills for decades. Their major problem was people weren't using Fosamax, because they weren't getting diagnosed with osteoporosis until after they'd had an accident and doctors could examine their bones. Old people get more frail and reduce their activities. No one thinks that could be the sign of disease. Whole-body DEXA bone scans did exist in the 1990s, but they were costly ($200-300, and not covered by insurance) and there weren't many clinics that had the bulky pool-table-sized devices (~200 in the entire US). So Merck hired a team of consultants to fix the dismal situation. Bone scanners would be in every town, and older people would get scanned often (if they were successful).

So Merck set up a shell nonprofit called the Bone Measurement Institute (that employed an entire one person), and some top orthopedists became affiliated. They pushed doctors to use a peripheral, portable bone scanner that measured forearm or heel bone density, in order to extrapolate that to spine and hip bones (the bones that, if broken, would cause the most trouble for an osteoporotic patient). But doctors were hesitant: bone is highly dynamic and responds to the specific local loads upon it, and a vertebra is a lot different than a mandible (so you can't know the weather in London by looking out your window in Paris). The manufacturers of the traditional bone scanners were irate about this new competition in their niche market. Since they sold few traditional scanners per year, they needed to make them very expensive to recover costs. When Merck's portable scanner project didn't pan out, they decided to buy a traditional bone scanning company instead. Merck then slashed the cost of traditional scanners, forcing competitors to do the same or go out of business (and some did). So Merck won two-fold: they got revenge on the scanner companies who obstructed them, and cut the cost of scanners to facilitate their dissemination across the country (and reduce the scan costs to patients, making it more likely that they would seek one). They closed their scanner company soon afterward.

Merck funded clinical trials and submissions to the FDA to also get the peripheral scanners approved as diagnostic tools. They literally went door-to-door and even organized leases with doctors. Such measures to get more patients on their drug. Just imagine if they invested all that effort and resources into science, to actually understand human diseases better and design drugs more intelligently. But they're not a charity after all. Though of course better drugs will sell themselves and cost the company less in failed multi-million-dollar clinical trials and litigation. Anyway, Merck didn't stop there. They funded some third-party org's to lobby Congress to pass the Bone Mass Measurement Act in 1997, which made bone scans eligible for Medicare reimbursement (and some private insurance did the same). Now pay-for-service physicians could make good money on simple-to-perform bone scans. But for all its inefficiencies, Medicare conducts periodic cost effectiveness analyses, and they have wizened up to the game. In 2007 they decided to cut bone scan reimbursement from $140 to $60, based on expectations that the scanners should get cheaper with scale, and the procedure was much less laborious to doctors than previously assumed.

Of course those groups and the bone-related medical community were outraged, and the decision may get overturned. They want every woman over 65 to get scanned yearly, and maybe some men too. But mass screening is a double-edged sword. They help identify truly needy patients, but also flag many false-positives. That is why the NIH recently changed its mammogram guidelines for women, raising the recommended starting age from 40 to 50. This decision is controversial, but their complex data suggested that the scans don't improve public health enough to justify their costs (worrisome specks on a scan require the patient to get a biopsy, which ends up causing stress and revealing nothing).

Merck also won approval for a low-dose version of Fosamax targeted for potential OP patients. So even though their risk of a debilitating bone break was no different than their general demographic, they could be put on a daily regimen just because a bone scanner reported that they were in the vague OP risk zone. Even some athletic, pre-menopausal women were classified as osteopenic (though that is no guarantee they will be osteoporotic later in life). "Mild bone thinning" isn't so bad, like graying hair or wrinkles. It's part of aging. But "osteopenia" sounds scary, right? Gradually wasting away, and maybe losing your freedom and mobility from a sudden fall. No one wants to die like a zombie in a hospice facility. So take this magical pill every day and rest easy. And of course Merck blitzed the media with direct-to-consumer advertising, and word spread among seniors. From 1994-1999, the number of bone scans performed in the US increased from 77K to 1.5M (yet still only 13% of women over 65 get the scan, so Merck has more work to do), and orders for scanners went up 500%.

This is great news, right? There are several positive Fosamax papers published, but a recent study from the Univ. of Washington concluded that Fosamax was only effective in reducing the risk of spinal fractures (especially for patients who have already had a break), which is only a tiny subset of total fractures for the elderly. That makes sense, since your bones respond to a fracture by dumping a bunch of new, low-quality bone on the injury site (like a quick and dirty spot-weld), so Fosamax's mechanism of action should preserve that from deterioration. Though the injury site may never recover to original strength with impaired bone-eating cells. For the prevention of more common hip or leg breaks, the drug was no better than placebo. So even though it results in denser bones biologically, if that doesn't translate into better clinical outcomes, then what's the point? If grandma falls on her driveway, probably 2% more bone density won't save her. Unfortunately no studies are planned to examine the long-term effects of Fosamax, which bewilders me because I thought the FDA requires that. But researchers are concerned that the drug may actually increase fracture risk over time, since it impairs micro-damage healing. If you just dump a bunch of steel onto an already craggy bridge, you may be doing more harm than good (as we in the SF area know).

In closing, the Fosamax story mirrors many drugs out there in your parents' medicine cabinet. Fosamax sales doubled from 2001-2004, and are now over $3B/year. It is on the top-10 list of all-time blockbuster drugs. Although Merck's patent recently expired, brand-name Fosamax costs $90/month, which translates to $16.2K for a patient taking it from age 70 to 85 (excluding medical labor costs). Yes it's true that the drug does help a subset of patients who really need it, and has allowed some seniors to enjoy life longer. But the caveat with preventative drugs is we'll never know if the patient would have been relatively okay without them. The drug has also sickened and killed others. Eating right, weight-bearing exercise, and vitamins also promote bone strength (and don't have side-effects). And to be clear, Fosamax doesn't generate more bone for seniors, it just slows normal or pathological bone loss (so it can't "reverse" OP). But don't worry, the industry took notice and next-generation bone drugs are in development. The "business of medicine" is not so altruistic. Sometimes pharma will persuade doctors, device makers, and the government to tailor diagnoses (or even invent diseases) to fit their drug. And if demand isn't high, they will make it so with marketing campaigns, lobbying, and low-dose or "preventative" formulations for people who "could be at risk". Too bad nothing exists in the 2009 health reform bill to expose or regulate this.

http://www.npr.org/templates/story/story.php?storyId=121609815
http://en.wikipedia.org/wiki/Fosamax

Monday, December 21, 2009

Health care bill making progress


By DAVID BROOKS
Published: December 17, 2009 NYT
Times Topics: Health Care Reform
Readers' Comments

Readers shared their thoughts on this article.

* Read All Comments (190) »

The first reason to support the Senate health care bill is that it would provide insurance to 30 million more Americans.

The second reason to support the bill is that its authors took the deficit issue seriously. Compared with, say, the prescription drug benefit from a few years ago, this bill is a model of fiscal rectitude. It spends a lot of money to cover the uninsured, but to help pay for it, it also includes serious Medicare cuts and whopping tax increases — the tax on high-cost insurance plans alone will raise $1.3 trillion in the second decade.

The bill is not really deficit-neutral. It’s politically inconceivable that Congress will really make all the spending cuts that are there on paper. But the bill won’t explode the deficit, and that’s an accomplishment.

The third reason to support the bill is that the authors have thrown in a million little ideas in an effort to reduce health care inflation. The fact is, nobody knows how to reduce cost growth within the current system. The authors of this bill are willing to try anything. You might even call this a Burkean approach. They are not fundamentally disrupting the status quo, but they are experimenting with dozens of gradual programs that might bend the cost curve.

If you’ve ever heard about it, it’s in there — improved insurance exchanges, payment innovations, an independent commission to cap Medicare payment rates, an innovation center, comparative effectiveness research. There’s at least a pilot program for every promising idea.

The fourth reason to support the bill is that if this fails, it will take a long time to get back to health reform. Clinton failed. Obama will have failed. No one will touch this. Meanwhile, health costs will continue their inexorable march upward, strangling the nation.

The first reason to oppose this bill is that it does not fundamentally reform health care. The current system is rotten to the bone with opaque pricing and insane incentives. Consumers are insulated from the costs of their decisions and providers are punished for efficiency. Burkean gradualism is fine if you’ve got a cold. But if you’ve got cancer, you want surgery, not nasal spray.

If this bill passes, you’ll have 500 experts in Washington trying to hold down costs and 300 million Americans with the same old incentives to get more and more care. The Congressional Budget Office and most of the experts I talk to (including many who support the bill) do not believe it will seriously bend the cost curve.

The second reason to oppose this bill is that, according to the chief actuary for Medicare, it will cause national health care spending to increase faster. Health care spending is already zooming past 17 percent of G.D.P. to 22 percent and beyond. If these pressures mount even faster, health care will squeeze out everything else, especially on the state level. We’ll shovel more money into insurance companies and you can kiss goodbye programs like expanded preschool that would have a bigger social impact.

Third, if passed, the bill sets up a politically unsustainable situation. Over its first several years, the demand for health care will rise sharply. The supply will not. Providers will have the same perverse incentives. As a result, prices will skyrocket while efficiencies will not. There will be a bipartisan rush to gut reform.

This country has reduced health inflation in short bursts, but it has not sustained cost control over the long term because the deep flaws in the system produce horrific political pressures that gut restraint.

Fourth, you can’t centrally regulate 17 percent of the U.S. economy without a raft of unintended consequences.

Fifth, it will slow innovation. Government regulators don’t do well with disruptive new technologies.

Sixth, if this passes, we will never get back to cost control. The basic political deal was, we get to have dessert (expanding coverage) but we have to eat our spinach (cost control), too. If we eat dessert now, we’ll never come back to the spinach.

So what’s my verdict? I have to confess, I flip-flop week to week and day to day. It’s a guess. Does this put us on a path toward the real reform, or does it head us down a valley in which real reform will be less likely?

If I were a senator forced to vote today, I’d vote no. If you pass a health care bill without systemic incentives reform, you set up a political vortex in which the few good parts of the bill will get stripped out and the expensive and wasteful parts will be entrenched.

Defenders say we can’t do real reform because the politics won’t allow it. The truth is the reverse. Unless you get the fundamental incentives right, the politics will be terrible forever and ever.

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I've gone back and forth on this bill; but in the end, I come out with Krugman and Victoria Kennedy. It's far, far from ideal, but the system it will create is better than what we have now. The fight for a better and democratic (note the lower case "d") health care system will have to continue. For now, the corporate/insurance interests are still controlling the democracy through 'divide and conquer' techniques based on misleading information and arguments. The fact that Palin's 'death panel' arguments (or Glen Beck's idiocies) can resonate with any appreciable segment of the U.S. population tells us all we need to know about the failure of our basic (K-12) education system to teach critical thinking. In the meantime, the fact that 30 million more Americans will be able to get health insurance is no small matter, nor is the fact that a person, who now can't get any insurance because of pre-existing conditions, will be able to (even if the premium will be higher, so long as it can be paid, it beats a family losing everything it owns in order to pay for health care for a sick or injured family member). - - -


Paul Krugman: Pass the Bill
http://www.nytimes.com/2009/12/18/opinion/18krugman.html?_r=3&scp=3&sq=krugman&st=cse

Victoria Kennedy: Health bill 'imperfect' but necessary: Kennedy widow
http://www.google.com/hostednews/afp/article/ALeqM5j0m7LbkCWtIOGK-kQWO3bZQDnuug

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even without lowering the cost, of course the whole point to the health care reform was to extend health care to millions of "healthy" americans without healthcare so that we can keep them healthy and keep them from having catastrophic events that could have been prevented earlier.... this is the biggest way to save healthcare spending in the decades to come. But if we were to simply lower the medicare age, we lose on this point because now we are enrolling younger retired age population who may already have catastrophic event, only now on medicare. without lowering the cost then truly, where is the benefit besides more "old=potentially sick but yet undetected" people get sick on government plan and increase our health care spending. then we fall back to our last weakest point of passing health care reform, we just pass something so that it is easier for us to modify this one in the future than try to write the whole thing from the beginning and also have the pop get used to the idea so that next modification comes around ppl are less scared.. so we hope...

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I see where Krugman is coming from, and if I was a Senator (heaven forbid!), I would be forced to support the bill too. But it's tragic that our legislative system allows one or two senators to take a major historic reform hostage, and it's unfortunate that there is so much misinformation and so little support for single-payer reform and inevitable health care rationing.

Surely passing this bill is preferred to the status quo, and yes some incremental improvements can be made to the legislation over time, but I think the bill squanders our current rare opportunity (with all the stars in alignment) for fundamental reform of cost-incentive-accountability structures that is truly needed. Obama and others have said that if we don't pass health reform now, we'll have to wait another generation as costs continue to rise. Politically that is possible (hard to get a fillibuster-proof majority in the Senate to coincide with an administration of the same party), but I think the huge economic pressures of pricier care, plus the retiring Boomers, will compel us to revisit the health debate more frequently. Who knows if future presidents will be more Bush than Obama, and when the next Ted Kennedy will emerge to keep the Senate morally grounded? I think many progressives are disappointed that this is the best "change" we can get with Obama at the helm and a solidly Democratic (though still centrist-conservative) Senate.

The House version has the public option, foreign drug imports, tougher abortion restrictions, and more mandates for insurers (85% of premiums must be paid out as benefits, more oversight, less monopoly). All of those are toxic to Senators, so they'll probably be scrapped. But without the abortion amendment, I don't know if the Blue Dog House Dems will be on board with 2010 midterms around the corner (does Pelosi have a majority without them, Joseph Cao notwithstanding?). Liberal Reps have a right to be pissed about this bill, but I think they will end up voting for the Senate version rather than causing trouble and fragmenting their own party that is desperate for a political win. The Senate wants to tax Cadillac health plans and curb the wasteful Medicare Advantage program, but both are very unpopular with the rank-and-file, pro-union House Dems. So I guess it's not a sure thing Obama will sign this sucker by Christmas, and of course the GOP will do everything they can to stall and let the holidays sap momentum away.

What sucks is that the "party of no" GOP more or less walks away clean. The right wing spin suggests that they were the "patriots" who fought to protect the "good ol' American values of freedom and small government" in health care from a radical Obama who hates white people, but really they were just boulders in the road of inevitability. They'll declare victory because they killed the public option and "socialized medicine". If we want to go broke continuing to over-medicate patients, over-pay doctors/insurers, and under-perform in this country, then by all means do nothing. But the GOP literally didn't offer any constructive alternatives during this whole 6-month process. Obama should have never tried to take the bipartisan route - he'd have better luck negotiating with North Korea. Did he really expect them to cooperate on making him look good? The minute the right started mouthing off and misbehaving, he should have put them in their place. If he came down on them in the bold, righteous manner that he delivered his Nobel speech, we'd be in much better shape now. But instead the Dems were timid all summer while the tea parties and talk show hosts sowed the seeds of confusion and misplaced anger.

Thursday, December 17, 2009

Importing foreign drugs?


Here's another disappointment that isn't totally surprising: there was an amendment under vote in the Senate yesterday on whether to allow cheaper foreign drug imports to the market to keep US drug pricing more honest. But the measure failed 48-51. Sponsored by Sen. Dorgan, he estimates that the provision would save $10B and also includes some rigorous safeguards. A similar measure is already in the House health bill that passed. As you would expect, the Senators who voted nay to block cheaper imports received on average 70% more funding from pharma-related sources than the yay votes (see list in first link at the end). But maybe the vote is a moot point anyway, since the Obama administration already cut a boneheaded deal with PhRMA that I previously emailed about (http://worldaffairs-manwnoname.blogspot.com/2009/08/health-care-overhaul.html), and the Dorgan amendment would violate that agreement.

I know there are safety and quality issues associated with drugs from any origin, but we currently allow imported food, vehicles, toys, building materials, and such - all of which can and have sickened and killed Americans. European laws enabled drugs to cross their borders to different markets for the last 20 years, and their safety record is no worse than ours. Even according to Pfizer's (biggest pharma in the world after merging with Wyeth) former marketing VP Dr. Peter Rost, drugs that are made at the same plant and have the exact same safety profile are sold in the US for prices up to 10X higher. Why? He was fired from Pfizer soon after he made these claims on "60 Minutes". I find this issue ironic because those "socialist Europeans and Canadians" actually maintain a mostly free market for drugs and private insurance, while capitalistic, laissez-faire America practices protectionism and monopoly. And then they play the "safety" card any time their profits are challenged.

Safety huh? Foreign-made stuff is always worse than American (tell that to Detroit). Let's not forget that some "American" drugs are already manufactured overseas for cost savings and tax evasion (but still are FDA-approved as if the plants were on US soil). Pfizer alone has plants in Belgium, France, Germany, Ireland, Japan, and Puerto Rico. In fact they may not have any US manufacturing, or due to the Wyeth merger it will be heavily downsized. Plus plenty of American-made and FDA-inspected drugs have hurt people too (Vioxx, Yaz, Celebrex, heparin, and most recently a recall of H1N1 youth vaccine that isn't toxic but sub-potent).

If the laws are written intelligently and regulators and manufacturers cooperate on due dilligence, then threats to public health should be minimal, or at least not much worse than at present. 6% of the world's people live in North America, yet our region accounted for 43% of global drug sales in 2007. And I don't think most of those drugs went to people in Chiapas or Winnipeg. We are the drug maker's cash cow, so obviously they will do everything they can to preserve the status quo.

http://maplight.org/dems_senate_pharma_prescription_drugs
http://www.seniormag.com/canadianpharmacy/articles/safe-medications.htm
http://www.tmcnet.com/usubmit/2009/11/13/4479586.htm
http://www.cbsnews.com/stories/2005/06/03/60minutes/main699606_page3.shtml
http://www.drugrecalls.com/

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Unfortunately, this is all about what you describe as 'the boneheaded deal with PhRMA.' For some reason, and maybe he was right, Obama felt he had to cut the deal (caveat: I don't think this has ever been officially admitted to) in order to get national health care reform. The deal was apparently intended to get PhRMA on the side of "reform" and not use its vast resources to lobby and advertise against it. A deal with the devil, perhaps, but there's nothing pure or angelic about politics.

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But that's what worries me. Obama stated that he would make the health bill negiotations transparent and even broadcast the Congressional discussion on C-SPAN. That hasn't really happened. I think it's unrealistic to expect lawmakers to go on camera with their various proposals and deals anyway. But there shouldn't be such secrecy with the industry reps either. You're right that the White House initially denied any PhRMA deal, but the Huffington Post obtained a leaked memo, and later the WH eventually admitted to it, as reported by the LA and NY Times.

http://www.nytimes.com/2009/08/06/health/policy/06insure.html?_r=1

It shows disrespect for the public when he claims to shun lobbyists and keep the people first, yet he practices politics as usual (well, not as bad as Cheney and the oil companies at least). Who knows what deals are going on with doctors and insurers now? As you said, Obama needed to get PhRMA on his side of the health debate (or at least not fighting him tool & nail), but that hush-money comes at a huge price. He claims $80B in drug savings over 10 years (meager vs. the total cost of the health bill), but he's also protecting PhRMA's $1 trillion/year (and rising) bloated revenues. Like loan sharking, getting a little now, but paying a lot later. And obviously no business would agree to a deal unless it was a net gain for them (AOL-Time Warner notwithstanding haha). PhRMA's financial analysts are a lot better, and better paid, than Obama's.

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"The FDA has stated that it does not have the funds nor bear the responsibility to inspect on a regular basis overseas manufacturers of active pharmaceutical ingredients such as heparin."

Currently the FDA expects companies to inspect their foreign subcontractors or facilities, and report findings to them. The FDA only has the resources to inspect US sites like once every 1-2 years anyway.

The Chinese case was just plain counterfeiting. They usually sell heparin derived from pig blood, but in the case of Baxter's subcontractor, they diluted the heparin with cheaper, heparain-mimicking chondroitin sulfate from shellfish. So there were allergic reactions and deaths of patients who can't handle shellfish proteins or chondroitin.

http://www.cbsnews.com/stories/2008/03/01/eveningnews/main3896578.shtml
http://www.drugrecalls.com/heparin.html

Monday, December 14, 2009

More on health reform


The Democrats have to be very careful if a health insurance 'reform' bill is passed and Americans (majority, at least) don't like it. Social Security and Medicare have passed the test of time; that's why to tamper with the benefits is considered to be a political "third-rail." What finally emerges and Obama signs has to have the same positive and enduring reception by the people as social security and medicare. We'll see. I am for a robust public option not any public option (actually, I'm for single payer, but that's off the table due, in my opinion,to the vast sums of money that have been poured into the fight against it and the public option by the health insurance companies). But I'm with Obama on the point that the object of the exercise isn't a public option, per se, but an effective mechanism to control price (premium) gouging by the insurance companies, and to make sure people are insured for all (including pre-existing) conditions with no lifetime maximums imposed. As the saying goes "the devil is in the details," so let's see.

Offhand, it is the older Americans who will have more pre-existing conditions, so taking them into Medicare and out of the pool that the private insurance companies have to insure, will lessen the costs to the private insurance companies since younger people, thankfully, will have fewer pre-existing conditions. This may turn out to be a win-win compromise. The Republicans get to say they like and are supporting the expansion of Medicare (even though it is in fact a public option) while at the same time saying they've defeated the public option. The Democrats get to say they've expanded Medicare to a large segment of our population (and, by the way, while it may not be said - have opened the door to future expansion of Medicare to the entire population, perhaps incrementally, but nevertheless opened, and if Medicare one day becomes open to all, that's the end of the private, for-profit, insurance companies -- that in itself is a hammer that can be dropped if the private companies don't do right by the American people).

But let's see what finally emerges; we're getting closer, but all of this can go down if one of the so-called 'fiscally moderate' (read 'in the pocket of the insurance industry') Democrats doesn't stay on board.

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Yes I agree that single-payer can be the most efficient system if administered properly. Some commentators I heard thought that the leftist Dems should be happy with the Medicare extension to 55-and-overs, because Medicare is America's single-payer plan, and now at least it's available to more Americans. And if the bill passes, insurance will be more or less mandatory, so insurance companies will gain millions of new customers. So everyone is happy? I guess the real trick is how to pay for it, since unions fought the Dems to remove the "Cadillac plan tax". Maybe there will still be a tax on the rich? But I think the administration and CBO think that the savings from not having to treat the uninsured will pay for expanded coverage for all?

I just don't think there is much in this legislation to control the costs of premiums and fee-for-service doctors. I thought in big bills like this, everyone has to give back a little, and then get a little. Insurers won't be able to turn away sick people any longer, but in return they get more customers. I don't know if they will still maintain their regional monopolies or not. But what have doctors had to give up? Maybe with a cap on lawsuits, they can pledge to charge less for services, and not turn away Medicaid/Medicare people because reimbursements are lower than private customers. As a legal professional, how do you feel about the medical malpractice situation?

Yes as you said, the voting is so close that just one senator can derail it all - might be Lieberman. But I also think the Dems and the administration should not just throw all sorts of proposals and amendments out there and hope they get their 60 votes. As you said, a good bill needs to stand the test of time and be well researched to have a meaningful positive impact, and can't just be an exercise in throwing darts until you get a passage. The Medicare plan seemed to come out of thin air, and I don't think it was publicly discussed in the fall. I worry about these last-minute desperation ideas. If the negotiations aren't public, that leaves even more room for industry lobbyists and the like to tamper. And when you're in a hurry, you make mistakes of course, like the rushed TARP plan and Wall Street bailout. They were necessary (I suppose), but obviously flawed.

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All I can say is the details are not all public and we don't know what the final version will look like. As for me, I'm disgusted with the thought that we have a for-profit health insurance industry. I'd like to simplify this with single-payer and extend medicare to everyone. I agree with you completely as to last-minute, ill-conceived deals and the influence of lobbyists. But I voted for Obama because I had confidence in his judgment and so for now I have to assume he will not sign off on any legislation unless he believes it will indeed benefit the vast majority of Americans and not turn out to be a debacle which will hurt the country (and the Democratic Party).

As to the medical malpractice situation, in my opinion at least, the tort system is what keeps the powerful in check, and having financial incentives for lawyers to take cases for plaintiffs is important to justice in our country. "Tort reform" is code for the insurance industry (again!) wanting to maximize its profits. The fact is that insurance companies and major U.S. corporations have armies of lawyers working for them at very high hourly rates. And these armies of lawyers at the top corporate firms are typically the top legal minds coming out of law school (law students usually go for the gold upon graduation, and those who get it are usually the top 10% of the graduates from the top law schools in the country. (Obama, by the way, was one such graduate, but he resisted the temptation and became a community organizer -- talk about taking the long view, 'out of the box' thinking' and deferred gratification.) The average person cannot afford to pay a lawyer in anything resembling a major case. He/she must find a lawyer willing and able to take cases on a contingent fee basis and have pockets deep enough to advance costs and expenses. A big case is usually hard fought by the companies being sued. It's not uncommon for a lawyer to take a case and put in a thousand hours and have many thousands of dollars in expenses paying for depositions and expert witnesses. Since the plaintiff can't pay for this, the incentive has to be there for the lawyer to take the case and take the risk of coming up with nothing in the end. Thus you have the typical contingent fee of 33 or 40% of the recovery. If you cap damages, say in a medical malpractice case, it means lawyers don't take them unless they're potentially huge cases, and they pass on cases that may in fact be meritorious but where the potential damage recovery will not justify the expenditure of the attorney's time and expenses to be incurred. Take a look at this link for an example of the injustice of capping pain and suffering damages in medical malpractice cases in California: http://www.lectlaw.com/files/lit13.htm. I had a professor once who was adjunct faculty and took a plaintiff's antitrust case on a contingent fee basis. He was up against many corporate lawyers. He came in one morning after being up all night working on a brief in the case, and said he'd like a rule that limits the number of hours any side can put into a legal brief, but without it he had to just work harder to be able to meet the arguments of 3 or 4 lawyers on the other side working against him. The insurance companies may want tort reform by limiting damages, but I can guarantee you they would oppose a rule limiting the number of lawyers, their pay, or the hours they invest or in working on a case for them.

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Thanks for writing. I think even if McCain won, there would be some sort of health reform now because the status quo is just so unsustainable (16% GDP on health spending and rising). He might have some crazy GOP ideas about health spending accounts (can be more efficient than Medicare if regulated properly and used wisely, though I doubt Americans are up to the challenge), but they would pass something. So I don't think it's a great accomplishment if Obama just passes some watered-down token bill, as any American president now should be able to do at the minimum (a lot of urgency and political momentum). I think if health reform was a heavyweight boxing match, it's Round 7 and the Dems are down 64-68. Though as you said, a lot of details remain unresolved so it is possible to turn things around. But sad to say that the GOP hate and misinformation campaign seems to be working, as usual. Public option would have changed the playing field in the people's favor, but I guess for now that looks doubtful. Lieberman said he wouldn't support the P.O. or the Medicare-to-55 plans, and without him the Dems don't have the 60 votes. Though maybe he can still be bribed?

But after so much media coverage, fighting, and PR blitzes, each party needs to leave the health care issue claiming that they won. The Dems will pass some version of health reform by February or so, and they can claim a victory for the people. It will cover more of the uninsured poor and make private plans more accessible to people, so I don't want to make light of those gains. But the bill won't likely contain any sweeping reforms, so the GOP can claim victory that they didn't let America go socialist, and all the while the insurance, physician, and drug industries are fat and happy as always.

As you said, for-profit health is borderline immoral, if not completely obscene. I know medical workers should be paid fair compensation for their services, but insurance companies reap huge profits while not really providing us with any service at all (just headaches mostly). But like the prison system, now these behemoth bureaucracies are "too big to get rid of" (or even regulate it seems), and they have billion-dollar legal and PR teams to lobby Washington and fight any challenges to their earnings. Actually working for a large biotech/pharma (even one rated highly in the field), I am tired of seeing the mismanagement, propaganda, and decisions based on profits rather than patients. I plan to switch careers this year and am applying for a "green MBA" program to work on business development for biofuels or green engineering in the future. I hope it works out better, but I am sure there will be plenty of hypocrisy and BS there too.

I agree with what you said about tort reform. It's pure lies how the doctors & HMOs claim they need to keep raising fees because of the "rising" threat of malpractice. As the attachment shows, malpractice payouts per capita have remained flat in the last decade, while medical costs have gone up sharply, so they're uncorrelated. But aren't most malpractice cases settled without ever going to court? Like the MD's malprac. insurance basically tells him to settle, and he has little choice since fighting a court battle will take him away from his practice for months, thereby costing even more money (even if he is innocent). I guess in the single-payer health care nations, malpractice suits are much less common and for less money? Maybe that is due to better quality of care, but probably also fewer ambulance chasers? Lawyers should have financial incentive to take on these cases, but if the incentives are too great, they will over-pursue cases, like fee-for-service doctors over-prescribing procedures. Obviously doctors need to be held accountable for mistakes, but they can't be "practicing scared" and prescribing care based on lawsuit paranoia. It's not good for the doctor or the patient. Medicine is not exact and some people will die even if the doctor goes by the book perfectly. Angry patients and grieving families have a right to be upset, but of course we can differentiate between honest mistakes and negligence. Though if the industry favors settling out of court, then the truth will never be able to come out.

Wow, I didn't realize CA had a cap that was so low and enacted so long ago. It's just a tough situation because obviously HMOs, MDs, and hospitals pass on the costs of malpractice protection onto the government and customers. Yes as you said, maybe it would be more fair to not have lawsuit caps, but instead a cap on legal hours per side. Not just in malpractice, but I think it's terrible if one side can afford an "OJ-sized" legal defense All-Star squad, while the other has an overworked rookie public defender. It would be hard to regulate and enforce of course. Or maybe doctors shouldn't just fear the financial repercussions of malpractice, but fear losing their license instead. Too many repeat-offender doctors still practice and make lots of money. If an independent agency can evaluate malpractice cases, like the Trustee's Office for debt cases, and bar guilty doctors from practicing medicine (either a fixed time period or permanently), then doctors will be more careful for their own career's sake. And then they won't have the excuse of needing to charge more to cover their malpractice insurance, because they won't be financially liable for any damages. Maybe the agency can make payments to victims, funded by a tax or modest penalties to offending doctors. I don't know, just brainstorming. It's a frustrating situation for everyone I think.

Friday, December 11, 2009

Obama's Nobel speech


From Obama's Nobel acceptance speech in Norway this week:
http://www.mcclatchydc.com/homepage/story/80410.html
http://www.npr.org/templates/story/story.php?storyId=121304855

First of all, it's probably a really bad sign when Sarah Palin praises your speech on war, peace, and realism vs. idealism.
http://www.twincities.com/politics/ci_13970425?source=rss

Commentary from Newsweek's chief political correspondent, Howard Fineman:

Well, I said in many ways that's true. Yes, the tone [of Obama's speech] was humble. Yes, it was philosophical. Yes, it was complex. He talked about negotiations and banning torture and so forth, the importance of diplomacy. But I was struck, as somebody who covered the Bush administration, by how fundamentally he accepted some of the premises of George W. Bush's view of the world - the existence of evil. The president used the word terrorism several times. That's a word he's avoided in some recent speeches. He said no jihad could ever be a just war. No holy war could ever be just, but he said that in essence the war in Afghanistan was. Those are all notes I think that George W. Bush might well have struck.

In his very long speech, Obama once again showed that he is really gifted in articulating what every high school freshman should vaguely and abstractly know about war, humanity, and morality. He never really communicated how America's current wars (that he is continuing instead of ending) will lead to more peace in the future, vs. other less violent security precautions. He spoke in absolutes like Bush - a pacifist world where dictators can push us around because they know we will appease, vs. the "real world" with ugly war. But of course America only fights when it's just and necessary (even though he and everyone else have already admitted that Iraq didn't qualify). The problem with his and Bush's "just war" argument is that even if a war's cause is just, its prosecution is always messy and fraught with abuses. War is too confusing and humans are too flawed to conduct a just war justly. That's why we must seriously try (and try harder than we are!) to avoid any war, no matter the moral spin. Sure even Palin would say that America hates when it must march to war, but our track record suggests otherwise.

Obama said that no holy war can ever be just, which is true. We already know about the crazy Crusaders and the crazy Muslim terrorists, but what about America's holy war of Manifest Destiny that helped the US become a world power? Wasn't it our divine right or White Man's Burden to put blacks to work for no pay and conquer the lands between the two oceans, by displacing, raping, or killing any natives or Spaniards in our way? Or how about the Monroe Doctrine that basically compels our government to militarily intervene in small conflicts in the Western Hemisphere any time foreign "colonialism" is suspected? How hypocritical to claim to combat colonialism with colonialism. What about "Remember the Maine" when we declared a vengeful war against Spain (just like Afghanistan) that was actually a territory grab (we got the Phillipines and Gitmo). We had to attack Spain to prevent them from attacking us again, right? And it wasn't even proven that Spain sank the Maine, just as we have very sketchy evidence linking the Taliban to 9/11.

Even the most just war of them all, WWII, ended with American bombs massacring over a million defenseless Japanese civilians who were not at Pearl Harbor and who meant us no future harm. Japan was already on its knees and possibly ready to capitulate, but we had to nuke them twice anyway, just to flex our muscles to the Soviets that East Asia is ours. Obama also claimed that the fall of the USSR signaled a great victory for freedom and self-determination, and of course our side won. No one misses the USSR, but how exactly did freedom win the day when American forces slaughtered millions (or backed dictators who did) in Korea, Southeast Asia, and Latin America in the process? How did those "just wars" lead to the Soviet collapse and help people win their freedom? And if the Cold War was all about freedom and human rights, then why after the wall came down did American businessmen penetrate the former Soviet satellites faster than US aid and diplomats?

To me, the worst war is not the horrible Jihadi actions of Osama, Zarqawi, and his kind (they are bad but not the worst), but instead the much bloodier and deceptive large-scale Western-perpetrated war wrapped in the flag of freedom and peacekeeping. If Obama understands this, he didn't articulate it during his many war-themed speeches this year, which is moral cowardice on his part. And no coward deserves the Nobel. As one of only 3 US presidents who have received this prize, I think Obama not only missed a precious chance, but also shirked his moral duty (and better judgment as a thinking man), to cut the crap about America always being the noble world savior, and come clean about our past abuses and ulterior/selfish motives for war that relate more to power than security. We're in the 21st Century now, and many world polls show that people think America is a bigger threat to world security than Russia or Iran. Obviously, the rhetoric only goes so far and even slick Obama won't be able to persuade others who can see the writing on the wall, even if we refuse to out of "patriotism". I think we would make more friends and marginalize our enemies better by coming clean rather than perpetuating the status quo. We are America, and we do err and sin too.

Obama gave token credit to peace figureheads MLK (Obama would not be president if it wasn't for MLK) and Gandhi, and excused himself from their tenets because he is a head of state and commander-in-chief, so he doesn't have the luxury of idealistic pacifism. Maybe that is true, but Gandhi was also a political leader in the newly-formed India (albeit not a very good politician - not a profession for a decent man). When Hindu-Muslim tension turned to street violence after independence, did Gandhi crack down on them in the name of national security? And did he side with his fellow Hindus against the outsider Muslims? No, he staged a hunger strike and prayed for both sides. That sent such a powerful message, and because of his great reputation, the warring groups took just 5 days to broker a ceasefire, because they loved Gandhi and his life meant more than their conflict. Gandhi didn't have to make a single threat or send a single young soldier to kill or be killed to restore peace. That is what leadership is all about. Plus, Gandhi was eventually killed by a Hindu radical, not a Muslim. He was betrayed by his own people, like Rabin. That should remind us that the greatest threats to the state are usually internal (like the lobbyist-Congress revolving door, and right wing radio nuts), not Taliban bogeymen hiding in caves. I know Obama fasting will not stop Al Qaeda from fighting us, but maybe if America acted more like Gandhi in the last 100 years, Al Qaeda would have never been created.

"America's commitment to global security will never waver," Obama said. I guess that's why we have done or continue to do next to nothing positive for the tense, unjust, and/or atrocious situations in Burma, Kampuchea, Rwanda, Congo, Korea, Iraq (when Saddam was killing Kurds), Sudan, Georgia, Israel/Palestine, and such? In fact, our pro-Israel actions in the UN have prolonged wars and suffering there. We fight when we want to increase our influence, and when our economic interests are at risk. Sure that may coincide with humanitarian concerns, but that is obviously not our chief priority. We're just like any other army or state (actually worse than most), and not anointed with some higher moral status. So cut the crap Obama, or you really are the foreign policy infant that the GOP and Hillary labeled you as during the campaign.

We're stuck with Afghanistan now because we can't change the past. But our role is really janitor instead of policeman. We are obligated to try to fix the mess we've caused (huge poppy production, Taliban resurgence, spillover to Pakistan, etc.), and then get the hell out.

More Afghanistan concerns (some already mentioned in the last email):

http://www.salon.com/opinion/feature/2009/12/01/afghanistan_surge/index.html

Top Ten things that Could Derail Obama's Afghanistan Plan
1. Obama's plan depends heavily on training 100,000 new soldiers and 100,000 new policemen over the next three years. It has taken 8 years to train the first 100,000 soldiers fairly well, and the same period for the Europeans to train a similar number of police badly. Can the pace really be more than doubled and quality results still obtained?

2. Obama's plan assumes that there can be a truly national Afghan army. But the current one is disproportionately Tajik and signally lacks troops from the troubled Helmand and Qandahar provinces. Unless the ethnic tensions are eased, training a big army could well provoke an anti-Tajik backlash in Pashtun regions that feel occupied.

3. Obama's goal to "break the Taliban's momentum" may well fail. Only 20 percent of insurgencies in modern times are defeated in a decisive military manner.

4. The US counter-insurgency plan assumes that Pashtun villagers dislike and fear the Taliban, and just need to be protected from them so as to stop the politics of intimidation. But what if the villagers are cousins of the Taliban and would rather support their clansmen than white Christian foreigners?

5. Obama is demanding that Pakistan help destroy the Taliban movement, a historical ally of Pakistan in Afghanistan. While Pakistan now has good reason to attempt to wipe out the Pakistani Taliban Movement, which has committed a good deal of terrorism against the country, Islamabad has no reason to attack the Afghan guerrilla groups fighting Karzai. They are fellow Muslims, and are Pashtuns (as are 12 percent of Pakistanis), and dislike India. The Northern Alliance elements in the Karzai government, which have recently grown stronger, are pro-India. Obama is asking Pakistan to betray its national interests, which is not realistic in the absence of some much bigger carrot than a few billion dollars in foreign aid.

6. Obama asserts that although the Afghan presidential election was marked by fraud, the results (the victory of Hamid Karzai) are legitimate within the constitutional framework. But isn't it possible that Karzai has decisively lost legitimacy among broad sections of the Afghan public, wounding him as a partner in working for a recognition of the legitimacy of a greatly expanded foreign occupation army in the country?

7. Obama is demanding accountability from cabinet members in Afghanistan and offering agricultural and economic aid. But 15 present and former cabinet members are under investigation for massive embezzlement, and 7 key ministries were only able to spend 40% of their budget allocation last year. Isn't Obama counting on a culture of official probity and a governmental capacity that simply does not exist in Kabul? What happens when there is more cabinet-level corruption and when the Ministry of Agriculture once again just can't spend the money Obama gives it?

8. Obama assumes that the US is not fighting a broadbased insurgency in Afghanistan. This assumption is true in the sense that there is zero support for Taliban or Sunni extremists among Tajiks, Hazaras, Uzbeks, and a majority of Pashtuns. But if we looked at the equivalent of counties in Helmand, Qandahar and some other Pashtun provinces, we might find substantial swathes of territory where the insurgency is in fact broadly based. Moreover, Pashtun guerrillas can count on a certain amount of sympathy from other Pashtuns in their struggle against foreign forces-- including the 20-some million Pashtuns of Pakistan. If the issue is not the "cancer" of extremist ideology, but a form of religious Pashtun anti-imperialism, then that could be the basis for a broadly based movement.

9. Obama maintains that the "Taliban" have in recent years made common cause with "al-Qaeda" in seeking to overturn the Karzai government. But although the Taliban control 10-15% of Afghanistan, there are no al-Qaeda operatives to speak of in Afghanistan. That does not sound like much of a common cause. By confusing the Taliban with al-Qaeda, and by confusing the Taliban with other Pashtun guerrilla groups such as Hikmatyar's Hizb-i Islami, Obama risks making the struggle a black and white one, whereas it has strong regional, ethnic and nationalist overtones (see 8 above). Black and white struggles are much more difficult to negotiate to a settlement.

10. The biggest threat of derailment comes from an American public facing 17 percent true unemployment and a collapsing economy who are being told we need to spend an extra $30 billion to fight less than 100 al-Qaeda guys in the mountains of Afghanistan, even after the National Security Adviser admitted that they are not a security threat to the US.

Monday, December 7, 2009

Top climate scientist slams Copenhagen and cap/trade


http://www.guardian.co.uk/environment/2009/dec/02/copenhagen-climate-change-james-hansen
http://www.kqed.org/epArchive/R912070900
http://www.columbia.edu/~jeh1/

NASA and Columbia's Dr. James Hansen, the preeminent American global warming scientist since the 1980s (Al Gore is the figurehead but Hansen is the brains), has really come out against the Copenhagen summit (boycotting it in fact), the big nation's emissions reductions targets, and the whole concept of "cap and trade". While heads of state seek to reduce carbon emissions to 1990's levels by 2020 or so, Hansen thinks we need doubly aggressive reductions to even have a chance of averting climate disasters. Like we can live with the inevitable 1 meter sea level rise as a consequence of our past pollution and climate trends, but a 10 meter rise (if we do nothing) will be thoroughly disruptive to human kind. And despite the cheerleading and positive spin, it doesn't look like China and India will be of much help. They have agreed to reduce their "carbon intensity" by 20-40% by 2020, but not actual emissions. Intensity only refers to carbon emitted per unit of energy/commerce, so intensity goes down as GDP grows anyway (which India's and China's will obviously do). Therefore nations can reduce their intensities without ever doing anything about carbon. So while the US and China are the top carbon polluters (42% of total CO2), their carbon intensities are far below those of Congo or Kampuchea (<1% of global pollution), so obviously something is amiss.

Cap and trade (establishing total emissions limits and allowing low-polluting businesses to sell their carbon credits to high-polluting ones, or back to the government, which is in effect in Western Europe as we speak) is also inherently flawed according to him (though not for the reasons that Glen Beck believes). He even goes further to say that it is just a smoke screen to conceal, or at least prolong, business as usual (quite plausible considering the Washington-business relationship). We capitalists stubbornly believe that the "miracle of the market" will save us every time. A "carbon exchange" will incent less pollution while funding innovation. But is it the fairest and most efficient way of doing so? For a potential cap and trade industry, imagine the bureaucracy and costs associated with establishing such a complex, dynamic, lawsuit-fraught commodity exchange.

Just as investment houses nickel and dime us year after year for "managing" our 401(k) accounts, cap and trade will be run (or at least manipulated) by big Wall Street banks, who will also take their "service fee" cut of the pool. We've seen what happened with savings & loan, energy trading, telecoms, mortgage derivatives, and credit-default swaps, so can you just imagine the tricks that Goldman Sachs and others are scheming up for this nascent market that gov't is not equipped to properly regulate? The big banks have hundreds of people working on this already, and no bills have even reached the Senate floor yet (but they smell blood in the water with a carbon exchange expected to be worth a cool $1T). Already big polluters like energy companies and factories are threatening that they will have to pass costs onto the consumer due to the carbon fines from their business operations, and more than likely the banks' service fees for maintaining the carbon exchange will also get passed onto us. Yes some of the money will funnel into green research (mostly "clean coal" that will never be as clean as nuclear), but rest assured that Wall Street will extract its pound of flesh first.

In addition, "carbon offsets" will grant polluters more room to pollute, while not truly offsetting their actions, so it's really cheating the cap. Like Exxon could earn x more carbon credits for paying to protect y acres of forest from deforestation. That sounds very kind of them, but really what has it done? Since all forests are not protected, loggers and ranchers will just level another tract of land instead. And all the while Exxon gets to spew more carbon for pocket change (which will obviously benefit Exxon financially, or their bean-counters wouldn't have approved it). Another concern is "grandfathering". When sulfur limits were imposed by Congress to address acid rain pollution in the 1980s, coal power companies persuaded regulators to exempt older plants constructed before 1970. Maybe that explains why so few new power plants have been constructed, while demand has steadily grown. So despite the cap, it was business as usual, and the same might occur with carbon (you can imagine the companies whining about the huge costs of retrofitting old plants).

Hansen suggests that on the other hand, why not just impose a fee on carbon for a fixed amount, like we do for air travel and cigarettes? Like water, energy is artificially cheap in America, so that the social and environmental costs of wasting those resources are not directly felt by the waster. The reasons for this are varied, but clearly due to gov't policy. But just as the cost of used motor oil or car battery disposal is factored into the garage fees you pay, the costs of carbon pollution to the environment should be included in the carbon-emitting products we buy and the carbon-emitting business practices of most or all companies. But of course industry lobbies hate this idea because it will make their operating expenses rise while reducing revenues/productivity. A carbon fee would fund green projects and research, just as part of the cigarette tax funds gov't health programs like S-CHIP. If we were to tax $115 for every ton of carbon (or $1 for every gallon of gas, 8 cents per KWH electricity), we would net $670B each year for public use. Imagine what good that would do - we could even bail out Wall Street again during the next bust. Some of that money could even be paid back to the public to offset the higher costs of carbon-based goods or subsidize green retrofits/products (up to $250 per legal US resident per month). So instead of cap and trade (where the public gets nothing, and could even be shafted), we should implement "fee and dividend".

Wednesday, December 2, 2009

Obama's Afghanistan escalation


For the first time since 2001, according to polls, a majority of Americans believe that the war in Afghanistan is "not worth fighting." Fifty-seven percent of independents and nearly three-quarters of Democrats oppose the war — and overall, only 26 percent of Americans support the idea of adding more troops. Indeed, if Obama were to escalate the war, his only allies would be the Pentagon, Congressional Republicans, an ultraconservative think tank called the Foreign Policy Initiative, whose supporters include Karl Rove, Sarah Palin and a passel of neoconservatives and former aides to George W. Bush.
- R Dreyfuss, Rolling Stone Oct. 28

I was disappointed with our Nobel Peace Prize laureate's rhetoric during this week's Afghanistan speech (he plans to send in 30,000 more Marines for ~18 months, many straight from Iraq, which must be demoralizing for their families). NATO may add 5-10,000 troops too, but I am skeptical. He can argue that this course of action is the best choice of dismal options, and remind us that he inherited this conflict, but don't feed us the same tired War on Terror crap. Public opinion is majority against a troops surge, partially because Americans feel that Afghanistan is not "winnable", nor critical to our security anyway, and they're probably right. Even the worst-case scenario of a Talibanized Afghanistan is not like North Korea or Iran. The country is mostly illiterate, dirt poor, internally divided, and geographically isolated, like Somalia with poppies instead of pirates. They may export some petty criminals and terrorists from time to time, but their ability to do harm is greatly diminished vs. 2001.

Obama did not heed the protests of Congressional Dems, VP Biden, and Karl Eikenberry (US ambassador to Afghanistan and a retired general who served in Afghanistan from 2005-2007) in this decision. He caved to our rock star generals instead (McChrystal and Petraeus, the latter rumored to seek a run for political office, assuming we are successful in Afghanistan?). Eikenberry's protest is especially noteworthy since he was part of the McChrystal/Petraeus/Odierno clique from West Point, and Army chums place a premium on loyalty. But his experiences in-country have soured him to the possibility of working with the Karzai regime towards victory. I hope President Obama hasn't forgotten the man he was as Candidate Obama. I understand that he must represent the Office of the President now, respect the conservative mainstream, and placate Pentagon interests. But if JFK deferred to the hawks during the Cuban Missile Crisis, probably none of us would be here. Sometimes the bravest thing to do is not to fight.

Biden warned that the world will test a young, idealistic Obama the minute he assumes office, and maybe Obama wants to show the world that he is a tough war president too. Maybe he fears that weakness on Afghanistan will create an opening for the GOP in the 2010 midterms. But after 8 years of fumbling and violence in the Middle East, it's disrespectful to the American people and the people of the world for him to re-hash the same tired Bush arguments for prolonging and even escalating a frustrating war. Ironically, many of the arguments he made on the campaign trail against Bush's Iraq Surge could equally apply against him here. Change we can believe in?

First of all, we were NOT attacked on 9/11 from Afghanistan, and not a single hijacker was Afghan (or Iraqi). Osama and other Jihadists did receive sanctuary in Afghanistan from their days as fighters in the Mujahadeen against the Soviets. But the Taliban government under Mullah Omar had little inkling Al Qaeda was planning 9/11, and probably would have tried to stop them if they found out (because obviously it would trigger a Western invasion and the toppling of their fragile regime). Why do you think Sudan expelled Osama and even offered him gift-wrapped to Clinton? The old Taliban was more interested in retaining power than attacking America. Where did the 9/11 attacks come from then? First, it came from our oil rich "buddies" in the Persian Gulf - suicidal fanatics and rich financiers in Saudia Arabia, Yemen, etc. Second, it came from within. The 9/11 hijackers were granted entry into the US months prior to the attack, and learned to fly, evade authorities, and infiltrate airport security. You can't really get that training in the remote terrorist camps that Clinton bombed. Maybe at best the 9/11 terrorists learned basic combat tactics, explosives, and weapons training in Afghanistan - skills that were not pivotal in accomplishing the 9/11 attacks. But the panic and mania immediately following 9/11 allowed NATO to justify an Afghanistan invasion and Taliban coup to the UN, and the rest is history. So just because the war is sanctioned by the UN and 43 nations have contributed to the effort doesn't make it a righteous or necessary war (see Kosovo conflict).

And then Obama claimed that we can't allow the "same people" who perpetrated 9/11 to regain a foothold in Afghanistan to launch new attacks against us. The same people are not in Afghanistan now! Our initial special forces operations in Afghanistan in 2001 decimated much of Al Qaeda (some estimate up to 85%), and improved international surveillance has greatly reduced Al Qaeda's ability to travel, communicate, and obtain resources. By our Nat. Sec. Advisor's own admission, there are fewer than 100 "real Al Qaeda" inside Afghanistan (meaning Arabs directly connected to Osama's network and acting as his agents). Mullah Omar's Taliban no longer exists, and he is probably not even in country (same with Osama, who is quite ill by some accounts and only serves as a symbolic figure for terrorism). The "new Taliban" (or so we call them) are groups of Pashtuns, Uzbeks, Tajiks, or other dissident minority groups who are conducting an insurgency against foreign occupation and the Karzai regime, which is widely and accurately viewed as illegitimate and corrupt. Taliban means "students", as in those who have attended fundamentalist madrasas and subscribe to that form of Islamic doctrine. Most of the current "Taliban" have not even attended such schools (and are illiterate in fact), and they are definitely not unified and cohesive. Just as we lumped all communists together during the Cold War to our peril, we can't label everyone who is not friendly to the NATO presence as Taliban. At least Obama offered the olive branch to any Afghans willing to lay down their arms, but I am not sure how that offer will be received by the insurgents and Karzai.

Pakistan is a different and more delicate situation, so I will limit this discussion to Afghanistan. Clearly those nations' fates are intertwined, but does anyone really think that the Pakistani Taliban would be so belligerent today if we were not across the border in Afghanistan and killing Pakistanis with our drones (thereby undermining the Pakistani government that is supposedly critical to winning the War on Terror)? Whereas Al Qaeda ostensibly fight us because of who we are, the Taliban fight us because we are there. They have little interest in a global caliphate or the destruction of the West. They may not complain if those things happen, but they are not dedicated to achieving those goals. They fight because a foreign force is occupying their country (and a force with a history of imperialism, hostility, or at least disrespect to the Muslim world). So if we boost our military presence there, shouldn't we expect the insurgents to do the same? And let's remember that Bush/Obama already sent 21,000 new troops earlier this year to launch new offensives, and since then violence has only gotten worse and the Taliban have made shocking gains (they now "control" or roam freely in 15-25% of the country).

What will 30,000 more troops do for a rugged nation that is bigger than Iraq (both acreage and population, and a more diffuse rural population at that)? South Vietnam was a much smaller state, and the US had nearly 1M troops there, as well as 0.5-1M better trained and better equipped South Vietnamese forces. McChrystal's people want to copy as many successful Iraq techniques as possible, but the two wars are not interchangeable. As part of the "clear, hold, build" strategy, US forces will embed themselves with the local population to better protect them from insurgents. But many villages (especially in the volatile Helmand Province and Pashtun areas) do not want more Marines in their lives. They may not love the Taliban, but that doesn't mean they'll welcome us with open arms and offer aid (especially when collaboration with foreigners may provoke Taliban reprisals). It's not like the Iraqi Sunnis who were sometimes happy to have a US presence to prevent Shia takeover.

The hope is that we can train enough Afghan security personnel to assume ISAF's duties, so we can start our "victory withdrawal". Obama's plan is to train 400,000 more Afghans in the near future, which is a pipe dream. We probably couldn't even train 400,000 new American cops in a year. And as we've seen in Iraq, rapid recruitment of armed forces leaves us vulnerable to infiltration. Another problem is most Afghans don't trust the security forces, who often shake people down like thugs and are not trustworthy (or even participatory) in difficult combat situations. Plus it is quite challenging to develop a unified national army and police there, built from the remnants of the brutal Northern Alliance and local warlords. We have very little expertise in nation-building and peacekeeping in tribal/communal societies (see our great record in the Balkans and Africa). Afghanistan's forces are comprised of a dozen distinct ethnic groups, each of which is chiefly concerned with protecting its own population and probably won't risk themselves for anyone else (or may even be rivals with each other).

Obama is a young president and I'm sure a little awed or intimidated by the dashing senior brass at the Pentagon. He is not a pushover, but I think he is also very conflict and risk averse. He doesn't want the wars to overwhelm his other foreign and domestic policy initiatives. Generals always say they need more men/resources, and always believe that victory is not only possible, but assured, if they get what they need and we get out of their way. Heck, what manager doesn't ask for those things at work? In other words, the Pentagon's advice will always be biased, even if chickenhawks like Feith and Wolfowitz aren't directing traffic anymore. Our military leadership loves America and wants to keep us safe, but they are also arrogant and career-minded. Insurance companies resist health reform, so it should be expected that our generals resist withdrawal plans. Some hypothesize that McChrystal's force request was deliberately leaked early to the press to make it even harder for Obama to reject it. If Obama spurns the generals' request and Afghanistan continues to deteriorate, things will be very bad for him and his party. But the generals aren't car salesmen, and Obama and the American people shouldn't be shmoozed or pressured into buying an extended warranty and DVD entertainment system that we don't need.

I know we can't just pack up and abandon Afghanistan tomorrow, but after 8 years of spinning our wheels (at best), we really need to act with caution. If our objective is to stabilize and modernize Afghan society (the humanitarian mission that our NATO allies are more concerned with), as well as containing or hunting down those committed to international terrorism (the military mission that the US is more concerned with), then our actions should not destabilize the region or create new terrorists. I know I was pessimistic about the Iraq Surge and my fears did not really materialize, but most experts agree that Afghanistan is a much more difficult challenge. What is wrong with Biden's strategy of de-escalation? He believes that a surge would be counter-productive and we should actually reduce our footprint, shifting to surgical strikes against Al Qaeda and obvious Taliban targets. If we can't trust Karzai and we don't have the troops to really execute the Counterinsurgency Manual (and we don't), then what is the point of taking the McChrystal/Petraeus approach that will probably require a decade of more commitment to Afghanistan? Just because we're too ashamed of possible defeat?

To conclude, I was hoping Obama would declare a plan something like this (which also has a chance for success):

"My fellow Americans, fighting is not the only way, nor the preferred way, to defeat Al Qaeda and international terrorism. With UN backing, we invaded Afghanistan to bring to justice the perpetrators of 9/11 and those who protect them. While that objective still remains partially unresolved, we have gravely wounded Al Qaeda since then, and their ability to threaten our homeland, or even wire money to each other, is much reduced. For that, we all owe thanks to the Bush administration, our allies, and those in the armed forces and intelligence. It is true that Osama's inner circle roams fairly freely in the border region with Pakistan, and I am not happy about that. I pledge to constructively and respectfully work with the Pakistani government to address this problem. But as long as we maintain diligent surveillance, take good opportunities for surgical strikes with minimal civilian casualties, and support friendly military, economic, and democratic development in the region, I am confident that Bin Laden and his network pose minimal danger to us.

It is true that Taliban-like insurgents in Afghanistan threaten our allies in the Karzai government and our interests in the region. But unless we have a clear, quantifiable, plausible strategy and milestones for assessing and containing that threat, then it is not worth more American lives and resources to police a nation the size of Texas and as rugged as Alaska. Our armed forces are the toughest in the world, but they are stretched thin and not being used efficiently. By gradually and rationally drawing down US forces in Iraq and Afghanistan during my presidency, our men and women in uniform will be able to spend more time with their loved ones, receive improved training back home, and focus on small-scale counter-terrorism rather than state-scale counter-insurgency, which are two distinct missions. Withdrawing from a fight can also increase our security, because it will permit us to recuperate and be ready when the next serious fight emerges. We will still maintain a lean presence in Afghanistan to assist in the training of Afghan security forces, execute counter-terrorism operations, and aid the Karzai government to improve transparency, prosperity, the rule of law, and basic services to the Afghan people.

America is a great nation, but we have our limits and must respect the other peoples who share the planet with us. We cannot and probably should not intervene every time there is civil strife, and we should be aware that our extended military presence overseas may cause resentment and play into the hateful rhetoric of our enemies. Sometimes we must be humble and let other nations take the lead in attending to their affairs. Yes there will be delays and failures, but America did not become a global power overnight either. Let me be clear that we are not retreating like cowards or throwing our friends in the Middle East to the wolves. America will always be there when we are called upon and there is critical need, to friend and foe alike. While we may not be surging troops to Afghanistan, we will make a diplomatic and development surge. Under military protection and rigorous standards of accountability, we will greatly increase our aid projects. We will listen to our allies, deliver what they need, and offer our input while respecting their wishes. But our assistance is not unconditional and open-ended, and I will ensure that every taxpayer dollar spent on Afghanistan is an investment in real progress for the future, or it won't leave our shores. We can also defeat terror and extremism by being good global citizens and peacefully improving life in needy countries, so that the conditions which spawn hatred and violence never materialize. Thank you and good night."

http://www.kqed.org/epArchive/R912020900
http://news.yahoo.com/s/ap/us_fact_check_obama_afghanistan
http://www.rollingstone.com/politics/story/30493567/the_generals_revolt
http://worldaffairs-manwnoname.blogspot.com/2009/08/problems-with-our-afghanistan-approach.html
http://www.npr.org/templates/transcript/transcript.php?storyId=120346497

Wednesday, November 25, 2009

The Family


"Jesus didn't come to take sides, he came to take over." - member of the Family and US congressman

"We desire to see a leadership led by God," reads a confidential mission statement. "Leaders of all levels of society who direct projects as they are led by the spirit." Another principle expanded upon is stealthiness; members are instructed to pursue political jujitsu by making use of secular leaders "in the work of advancing His kingdom," and to avoid whenever possible the label Christian itself, lest they alert enemies to that advance.

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No, this is not about the mafia, but it's not that far off either. There is a secretive fundamentalist Christian group headed by Doug Coe named "The Fellowship" or "The Family", founded in the 1935, which makes Scientology or the K Street Gang look like Boy Scouts. Members of the Family include US senators, cabinet members, and state governors, and they seek to use their business/political connections to advance their views. They help organize the Congressional National Prayer Breakfast in Washington that sitting presidents also attend.

Their agenda is quite bizarre and hard to even call Christian. They believe that the New Testament's emphasis on helping the poor, humility, love, and compassion is all wrong. In fact, the Bible's secret message is all about worldly power, and they use free market capitalism, anti-gay, and anti-abortion issues to rally support. Yes, I know, Dan Brown is taking notes as we speak. Ironically for US lawmakers, they believe that American democracy is doomed to fail and totalitarianism is the way to go - the way Christ intended for us. Like many US elites, they were enamored with the European fascists (rising from nothing, their manipulation of the masses, uniformity of thought, and rapid industrialization/militarization), but after WWII they had to tone it down of course. Though even today, their leaders including Coe have used the examples of Hitler, Mao, Stalin, and Pol Pot to instruct and describe how the Family seeks to embody and propagate total fanatical commitment to absolute power for Christ and his "true message".

They could be described as "elite fundamentalism". They also believe that Jesus has a special message for the chosen few, and his parables for the masses were just Spam, because we can't really handle the truth of his grand plan. Of course the high-ranking members of the family are the chosen. Strangely, the Family has both Catholic and Evangelical members. I suppose they put their dogmatic differences aside to join forces for the Culture War.

Their prominent members:
- Congressmen (some potential 2012 GOP presidential nominees, and some Dems too): Coburn, Prior, Grassley, Pitts, Stupak, Wolf, Ensign, Shuler, Nelson, Enzi, Thune, Inhofe, Wamp, McIntyre, Clinton (while she may not be an official member, Family head Doug Coe is an intimate spiritual advisor to her since her husband was president).
- Governor: Mark Sanford (yes, the guy who was caught using state resources to go to Argentina for a booty call).
- Other notable alums: Strom Thurmond, Charles Colson (Nixon's hatchet-man who went to jail for Watergate but after became CEO of big defense contractor Raytheon), Pat Robinson's father, David Kuo (Dubya's head of Faith-Based Initiatives).

Maybe leftist journalists are just trying to tar these conservative politicians with shady, unproven connections to a religious cult (like how douchebag Glen Beck tries to connect Obama to ACORN to the end of the world). But many of the Congressmen listed above live at C Street residences while in Washington owned by the Family, and rented to them at below-market rates. Probably the only reason the mainstream knows of the Family is some of their members were caught in embarrassing affairs (Ensign, Sanford, Pickering). I guess sometimes God wants you to break one of his commandments in service to the greater good.

Maybe you think that this is just tabloid and doesn't really affect our lives, but look at some of the Family politicians' recent actions. The last-minute abortion amendment to the House health bill was called the Pitts-Stupak amendment. Mother Teresa was not an outspoken critic of abortion until she met Pitts in the 1970s. Family members have used government funds to go on overseas missions in support of cruel dictators and corrupt regimes who happen to endorse pro-Family policies. They helped get weapons and money to Indonesian dictator Suharto, supported Christian militias in Lebanon, and currently back Yoweri Museveni, the despotic leader of post-Idi Amin Uganda (a nation with some of the most draconian anti-gay laws in the world). Before Museveni, they also armed Somali strongman Siad Barre during the Reagan-Bush years, who contributed to thousands of deaths. I have no idea how those Third World, war-torn nations and their pathetic leaders factor into God's plan for the world, but apparently the Family does. But what's the big deal, since other politicians take trips sponsored by companies or special-interest groups all the time? Well, it undermines US foreign policy and credibility when US legislators travel to speak with foreign leaders, advancing a private agenda that may or may not be aligned with official Washington policy (I would hope it isn't). One thing we have to thank Abramoff for are 2007 Congressional reforms that allow these trips and their funding to become public knowledge.

So to close, I know the Family is probably less of a risk to global stability than Al Qaeda or H1N1, but the fact that they are out there, that they believe what they do, and occupy very high positions of US power is cause for concern. If they are doing God's work and mean no harm as they say, then why be so secretive? Level with us and lead the masses on the path of righteousness, like the dictators they admire. Hopefully government transparency and accountability will grow, and constituents may find out if their leaders are affiliated with and executing the agenda of private groups that don't have the people's or America's best interests in mind.

http://www.npr.org/templates/story/story.php?storyId=120746516
http://www.youtube.com/watch?v=LVrQkunIZXo&feature=related
http://en.wikipedia.org/wiki/The_Family_(Christian_political_organization)
http://www.worldmag.com/articles/15778 (a criticism of the Family from a Christian right source)
http://www.democracynow.org/2009/8/12/sharlet