Proud Men Die Young

People who most believe in a culture of honor -- who agree that "A real man doesn't let other people push him around" or that aggression is a reasonable response to being insulted -- told the researchers they were quite willing to engage in risky behaviors, such as bungee jumping or gambling away a week's wages. This willingness to take risks might well translate into an early death[.] . . .

Honor cultures are more powerful in rural areas, where the influence of personal reputation is higher than it is in cities. Although honor states had a 14% higher accidental death rate in the cities, they had a 19% higher rate of accidental death in more rural areas, compared to non-honor states. More than 7,000 deaths a year can be attributed to risk-taking associated with the culture of honor in the USA.

From here.

FWIW, it could also have something to do with the fact that "cultures of honor" also have disproportionate shares of blue collar workers whose jobs are more dangerous. But, the urban-rural comparison casts some doubt on that economic as opposed to cultural interpretation.

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Virtue Doesn't Pay (In The Very Long Run)

Virtue is an old fashioned term that used to be applied to morality but that way of thinking now seems mostly confined to issues of personal health. If you virtuously eat right, excerise, don't drink too much, floss, and so on, you will live a long and health life. Right?

Well, maybe not. It turns out that people "who live to 95 or older are no more virtuous than the rest of us in terms of their diet, exercise routine or smoking and drinking habits."

At age 70 the long lived had lifestyles not much different than others at that same time of life.

Overall, people with exceptional longevity did not have healthier habits than the comparison group in terms of BMI, smoking, physical activity, or diet. For example, 27 percent of the elderly women and an equal percentage of women in the general population attempted to eat a low-calorie diet. Among long-living men, 24 percent consumed alcohol daily, compared with 22 percent of the general population. And only 43 percent of male centenarians reported engaging in regular exercise of moderate intensity, compared with 57 percent of men in the comparison group.

Then again, it isn't as if the recommendation for diet and exercise come from nowhere. On average, these things have been demonstrated to help a lot in studies that have extremely large sample sizes and statistical significance, although the habits that have the highest work reward ratios (e.g. low dose asprin regimes and moderate alcohol consumption) are not all those one might naiively expect. Smoking, however, as expected, has a huge impact on life expectency, on average, as do little tips we would expect like not getting exposed to radioactivity above certain doses or to highly toxic chemicals like asbestos at work.

But, genes and luck, rather than diet and exercise, appear to be the key to making it from merely old to very old. And, there appears to be a pretty hard wall beyond which women just don't survive no matter what they do at about 114 to 115 years, and the absolute maximum lifespan of a man seems to be a bit shorter than it is for women.

There are a couple of competing theories as to why there is a maximum. One is that a small number of processes like telomere shorting and senile systemic amyloidosis eventually kill almost everybody that other mishaps didn't kill by that age.

If this is true, a small number of pills or magic bullet treatments might be able to significantly increase maximum human lifespan, although not necessarily average human lifespan. life expectency might increase only modestly (perhaps into the low 80s), but maximum life expectency might increase from 115 years to 130 years or more and a lot more people would live past 110.

An alternative narrative builds on the quip, "I'll bet they'll feel dumb when they get old and are dying of nothing." Maybe the causes of death that get most of us are front loaded, the very old are the people who escape those earlier onset body failures (mostly a few kinds of cancer and cardiovascular system collapses like heart attacks and strokes). Those people who don't die of those causes see more and more body systems that last just a little bit longer start to fail one after the other, until pretty sooner a person has multiple body systems that are all in trouble and one or the other of them catch up with them.

If this is true, comprehensive pre-failure life extension treatments of a large number of body systems would be necessary to meaningfully expand maximum life expectency, but a breakthrough on a small number of conditions might greatly expand average lifespan short of the maximum that is practically possible, which would be followed by multiple body system collapse later in life. Many more people might live to 90 instead of 70, but not many more people would live past 110 than do now.

READ MORE - Virtue Doesn't Pay (In The Very Long Run)

Overall new U.S. HIV cases stable

The most recent report from U.S. government health officials reports that 50,000 new HIV cases were diagnosed in the most recent year, stable compared to four years ago overall. About two-thirds were men who have had sex with men, about 9% were IV drug users, the rest were classified heterosexual cases, something fairly typical of prior years.

Cases were up for adult men who have had sex with men and are under thirty years old, including an increase of 48% for black men in that category compared to just four years ago, and since the overall numbers were down, presumably down in many other demographics compared to four years ago.

The media has reported the 48% increase for black men who have had sex with men and are under thirty years old as "gay men." But, I suspect that a significant share of those cases reflects men who were raped by other men, probably mostly in prison. Why? The numbers are much larger relative to the size of the population involved than in other demographics and following completely different trendlines. There is no particularly good reason to think that the black men are that much more likely to be gay than other men. While it wouldn't be surprising if the unsafe practices rate for gay black men engaged in consentual sex outside prison was higher in black men than for other men, the differences in rates of HIV infection and other serious STDs is so much higher in young black men than in demographics with much lower incarceration rates. There may be racial divides in the 2010s gay social scene, just as there are in other parts of American life, but the numerical gap is what you would expect if Jim Crow were still in full force in America; while my perhaps naiive take is that young gay men are no more segregated by race, and perhaps a bit less so, than other American demographics. Also, the numbers seem to suggest that significantly more black women receive HIV from black men who have had sex with men than in other demographics, which would suggest, at a minimum a larger share of men who have had sex with men who also have sex with women in this demographic than other demographics. If would take only something on the order of 0.5%-2% of the black male prison population to have new HIV infections each year to account for the discrepency, which would not be out of line with these cases making up a minority share of all estimated for prison rapes of black men each year. An indepth analysis post from 2005 on the subject at this blog is here and there have been several posts in between.

However, my conclusions are based only on numbers and I haven't seen an in depth non-statistical analysis, despite its importance from a public health perspective. For example, focusing public information campaigns on bars frequented by young middle class African American gay men is not going to solve the problem if most of the new cases are coming of young African American men who have had sex with men are coming from prison rapes (or, for that matter consentual sex in a prison environment by gay men who don't have access to basics like condoms and have a limited choice of partners).

The good news, however, is that people who are infected with HIV are living about twice as long and at greater levels of health as they did when the outbreak started, roughly twenty years instead of ten, in round numbers, mostly due to new drugs, but perhaps to some small extent also because most new infectious diseases grow less virulent in subsequent epidemic waves because the most virulent strains tend to die out with the people who are infected while having caused fewer new cases in the meantime.

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Physiological Test Predicts Effectiveness of Talk Therapy For Depression

[A] quick, inexpensive, and easy to administer physiological measure, pupil dilation in response to emotional words, not only reflects activity in brain regions involved in depression and treatment response but can predict which patients are likely to respond to cognitive therapy[.]. . . activity in the brain's cortical emotion regulatory systems is strongly related to pupil size when people are viewing emotion-laden words . . . It is because of this relationship between eye and brain that pupil measurements predict the response to cognitive therapy."

Cognitive therapy is a type of psychotherapy designed to help individuals overcome difficulties by modifying negative or irrational thoughts and behavior, which, in turn, can improve mood and reduce stress. It is usually completed in weekly sessions, with 10-20 sessions being effective for most individuals who benefit.

From here, citing Greg J. Siegle, Stuart R. Steinhauer, Edward S. Friedman, Wesley S. Thompson, Michael E. Thase. "Remission Prognosis for Cognitive Therapy for Recurrent Depression Using the Pupil: Utility and Neural Correlates." Biological Psychiatry, 2011; 69 (8): 726 DOI: 10.1016/j.biopsych.2010.12.041.

The abstact of the paper provides more details:

Although up to 60% of people with major depressive disorder respond to cognitive therapy (CT) in controlled trials, clinicians do not routinely use standardized assessments to inform which patients should receive this treatment. Inexpensive, noninvasive prognostic indicators could aid in matching patients with appropriate treatments. Pupillary response to emotional information is an excellent candidate, reflecting limbic reactivity and executive control. This study examined 1) whether pretreatment assessment of pupillary responses to negative information were associated with remission in CT and 2) their associated brain mechanisms.

We examined whether pretreatment pupillary responses to emotional stimuli were prognostic for remission in an inception cohort of 32 unipolar depressed adults to 16 to 20 sessions of CT. Twenty patients were then assessed on the same task using functional magnetic resonance imaging. Pupillary responses were assessed in 51 never-depressed controls for reference.

Remission was associated with either low initial severity or the combination of higher initial severity and low sustained pupillary responses to negative words (87% correct classification of remitters and nonremitters, 93% sensitivity, 80% specificity; 88% correct classification of high-severity participants, p < .01, 90% sensitivity, 92% specificity). Increased pupillary responses were associated with increased activity in dorsolateral prefrontal regions associated with executive control and emotion regulation. For patients with higher severity, disruptions of executive control mechanisms responsible for initiating emotion regulation, which are indexed by low sustained pupil responses and targeted in therapy, may be key to remitting in this intervention. These mechanisms can be measured using inexpensive noninvasive psychophysiological assessments.

The small study obviously needs to be replicated in a larger sample before being used on a widespread basis, but the 88% rate at which this simple test determines if high severity depressed patients will respond to cognitive therapy, compared to a 60% response rate in the absence of screening, is a major improvement for a technique that requires no investment in drugs or equipment and only minimal additional training for mental health practitioners. This test could spare more than half of severely clinically depressed individuals time and misery trying cognitive therapy that is unlikely to be effective for them, allowing them to use alternative therapies like drug treatments that are likely to be more effective for them immediately, while allowing about half of severely clinically depressed individuals to receive cognitive therapy, knowing that it has a very high probability of being successful, and avoiding the need for them to undergo a psychiatric drug treatment regime that is unnecessary for their recovery. The fact that the benefit is statistically significant at the 99% level in this small study also makes a study calculated to replicate this result look like a promising good investment.

Given that clinical unipolar depression is one of the most common mental health conditions, and is by far the most common one that is not typically congenital, which makes it disproportionately likely to be a condition dealt with by a primary care physician as opposed to a specialist mental health care professional, this kind of advance has particularly great practical relevance. Also, since unipolar depression is so common, the cost savings to the health care system of a diagnostic tool for determining what kind of treatment will be most effective could be an evidence based medicine technique that could make a material dent in the overall cost of mental health care.

Since this is a diagnostic approach, rather than a drug or device, it also doesn't need a long and costly approval process from the Food and Drug Administration. Funding of a simple large scale replication of this study which could be completed in a year or two, would be enough to include this diagnostic technique as part of the standard by the book treatment regime for unipolar depression nationally. Of course, since this isn't an approach would have a biotech company backing it, this kind of study almost necessarily would need to be funded by the public sector, for example, through a National Institute of Mental Health (NIHM) grant.

The real value of treatment effectiveness prediction tools as a means to improve the quality of patient care while reducing health care costs, a field which is coming into its own as a subfield of psychiatry and psychology, also suggests another funding possibility. Health insurance companies have historically viewed themselves primarily as financial institutions and as institutions through which patients can collectively bargain for provider health care pricing. But, the health insurance industry might be well advised to develop and fund a non-profit research foundation to develop treatment effectiveness prediction tools that do not have drug companies or medical equipment makers to fund them, as a way to promote health enhancing quality control.

The benefits of this little study aren't just practical in an immediate sense either. This is some of the hardest empirical evidence yet that there are medically relevant subtypes of unipolar depression in existence, with some indication of what the underlying neurological basis of that subtyping might involve. One of the deep issues in psychiatric classification of mental health conditions, for which the DSM-IV is the current industry standard, is that diagnosis of psychiatric conditions is almost entirely based upon non-physiological symptoms. It is entirely possible that some common DSM-IV conditions are really a cluster of separate conditions with similar symptoms but different causes (and hence different courses of treatment that are likely to be effective), and that other common DSM-IV conditions currently viewed are in fact merely distinctive syndromes that arrives when separate co-morbid conditions are present.

For example, this study shows that there are at least two types of unipolar depression, one of which is talk therapy responsive and one of which is not. This very likely indicates that the causes of the two types of unipolar depression are different. If this insight in incorporated into prior research on the causes of unipolar depression, the sometimes muddy and contradictory theories about what causes unipolar depression and how it can best be addressed might be clarified. One leading theory regarding the cause of unipolar depression conceptualizes it as a situation where prolonged stress and anxiety cause the body's normal responses to stress to shut down and try the new strategy of becoming depressed to deal with the situation. This might be a primary causal mechanism in one but not the other of subtypes of unipolar depression. If so, somewhat muddy data linking this cause to depression might become much more definitive with regard to the relevant subtype of depression, while clearing the decks for a search for one or more alternative causal mechanisms for the other subtype of depression.

Another possibility is that the pupil dilation response to emotion laden words may be a congenital element of a person's personality that is present even in the absence of unipolar depression. If this is the case, this trait might be one of many that is routinely tested for in children or young adults along with traits like blood type. Children with the trait might be at higher risk for the cognitive therapy responsive subtype of depression. Similarly, medical records could indicate which children are at risk for non-responsiveness to cognitive therapy as a treatment for unipolar depression. Since the physiological test for this trait is quite objective and easy to administer on a mass basis, it might also be possible to see if this trait corrolates with other mental health conditions, particularly those which are often co-morbid with unipolar depression (a co-mordidity pattern that might be more stark when restricted to a particularly subtype of depression), and to determine if it has a hereditary component. Patterns of co-morbidities associated with a particular subtype of unipolar depression might shed insight into the causal mechanism of a variety of mental health conditions which in turn might shed light on the kind of treatment regimes that are likely to be effective for those co-morbid mental health conditions.

Indeed, it might even be possible to provide these children or young adults, on a prophylactic basis, the kind of cognitive training that people with unipolar depression receive after they are diagnosed to help these individuals deal with situations that could lead to clinical depression before they happen.

There is no obvious reason that the benefits of cognitive behavioral therapy, which boils down to teaching people habits of thinking and mental tools for coping with certain kinds of problematic cognitive habits or tendencies, in general, can't be almost as effective when administered in advance as they are when administered as therapy after the fact. It might be possible to put together a set of empirically validated cognitive behavioral therapy regimes into a comprehensive set of coping skills that could be transmitted on a mass basis in a manner not unlike the model by which we instruct people in first aid, CPR, rescue breathing, the use of abdominal thrusts to respond to choking incidents, the proper way to respond to house fires, tornados and tsunamis, or suicide and bullying prevention programs. People who experience cognitive behavioral therapy responsive conditions anyway may benefit for refresher instruction and may be able to make more sense of what these therapies involve when they actually have the conditions that they are designed to alleviate, but it isn't unreasonable to think that this kind of public health preparedness model could materially reduce the overall incidence and impact of many common mental health conditions, some of which are subclinical or would otherwise never be diagnosed as such.

READ MORE - Physiological Test Predicts Effectiveness of Talk Therapy For Depression

Misery suppresses suicide

The happiest countries and happiest U.S. states tend to have the highest suicide rates[.] . . . "This result is consistent with other research that shows that people judge their well-being in comparison to others around them. These types of comparison effects have also been shown with regards to income, unemployment, crime, and obesity."

From here.

The relationship is strong and statistically robust, but theories to explain it are merely guesswork.

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Prenatal Environmental Exposures Produce Mental Health Harms

Researchers found that within a sample of 215 children monitored from birth, those children with high levels of a pollution exposure marker in their cord blood had more symptoms of attention problems and anxiety/depression at ages 5 and 7 than did children with lower exposure.

The researchers measured a biologic marker or "fingerprint" of exposure to polycyclic aromatic hydrocarbons (PAH) and other combustion-related pollutants in newborns' cord blood. When inhaled by the mother during pregnancy, these pollutants can be transferred across the placenta and bind to the DNA of the fetus, forming "adducts" in blood and other tissues and providing a biologic measure of pollutant exposure. Mothers completed a detailed assessment of their child's behavior.

In urban air, traffic emissions are a dominant source of the pollutants measured in the study. The authors accounted for other sources such as environmental tobacco smoke and diet in their analyses. None of the mothers in the study were smokers.

From here citing Frederica P. Perera, Shuang Wang, Julia Vishnevetsky, Bingzhi Zhang, Kathleen J. Cole, Deliang Tang, Virginia Rauh, David H. Phillips. PAH/Aromatic DNA Adducts in Cord Blood and Behavior Scores in New York City Children. Environmental Health Perspectives, 2011; DOI: 10.1289/ehp.1002705.

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Deconstructing the Concept of Health Care And Options For Dealing With It

The convention of lumping all of the issues that fit under the rubric of health care is necessarily somewhat arbitrary. As we look to improve ways to control costs and find better ways to finance care, which is a never ending process despite the passage of the Affordable Health Care Act, which makes major reforms, it is worth examining ways to break the overall field of health care into parts, and to see if there are things that we commonly don't define as health care that are appropriate to address with the same tools.

Group health insurance plans and Medicare define health care quite broadly, but exclude certain procedures and treatments commonly deemed to be cosmetic or recreational or fitness related; long term care in nursing homes or with home health care services; and sometimes abortion. Medicaid often includes a broader definition that includes, for example, nursing home care.

Individual health insurance plans, out of concerns about moral hazard in the purchase of health insurance, have narrower definitions of covered health care. Routine services are often covered by a deductible on the theory that the tax advantage that applies to group health care plans creating an incentive to include as much as possible in the plan coverage scope for tax reasons does not apply in individual plans of employees who are not self-employed where risk management and price negotiation with providers, but not tax minimization is the goal.

Individual health insurance plans also usually exclude, or include only at prohibitively expensive rider rates (far more than this kind of care contributes to the whole in group health insurance plans) types of health care for which moral hazards exist because patients can know that they will need coverage in advance and buy it only if they need it. These conditions include pregnancy related care, mental health coverage, and coverage for pre-existing conditions (mitigated by a variety of devices to allow pre-existing condition coverage where moral hazard risks are not as serious, such as quasi-group COBRA continuation coverage).

Pregnancy is very expensive to insure against in individual health insurance plans because it is highly controllable by the insured, even though the lifetime costs of pregnancy related care frequently don't vary much from one woman to the next.

Mental health coverage has been further divided into categories that look more or less medical (biologically based conditions). There is dispute over whether some treatment regimes such as non-allopathic medical approaches (such as chiropractic, aromatherapy, herbal remedies, psychological therapy, acupuncture, personal training, and massage therapy remedies) are really health care in the sense intended, and over whether treatments such as fertility treatments are genuinely necessary as opposed to recreational.

Long term care coverage is an example of a very expensive, high probability event, with moderate risks regarding duration and costs, that is further complicated by the fact that long term care typically covers not only medical-like expenses but also non-medical-like expenses such as rent and food costs for the resident. Similarly, loss of income due to disability, or the disabilities presumptively inferred from old age called retirement, are typically handled separately from medical care.

We make distinctions between "emergency care" which everyone who comes to an emergency room is entitled to regardless of ability to pay, at least until stabilized, and other kinds of medical care.

We have different financing regimes for dental care, vision care, work related injuries (worker's compensation or the equivalent), non-work related accidental injuries (tort remedies and casualty insurance), health care for foster children, health care for Medicaid v. non-Medicaid patients, health care for the uninsured who can and cannot pay in cash, health care for certain veterans, out-of-pocket and insurance paid care, over the counter and prescription treatments, and so on.

Within the area of Medicaid covered health care, there are two groups of beneficiaries whose care is very expensive: older people who need nursing home care, and people with disabilities, and another, poor people who are not disabled or old served by the minority of providers willing to accept new Medicaid patients for below market rate reimbursements, for whom it is very inexpensive to provide health care.

A large share of all people covered by health insurance or governmental health care programs are entitled to that coverage not in their own right, but by virtue of their status of dependents of someone else. Medicare is one of the few programs that does not cover the entire family (although individual policies and CHIP enrollment in Medicaid for children only in a family are another).

The Affordable Care Act has made several strategic choices, which made political sense at the moment, but may not be the best long term solutions. One is to focus on a scope of care similar to bare bones group health insurance plans. Group plans are encouraged. Individual plans are made more like group plans through prohibitions on pre-existing condition denials, through mandatory coverage, and through expanded scope of coverage, in order to address moral hazard issues. The scope of Medicaid is expanded to include the near poor. And, tax credits and incentives ease the ability to pay problem for both group and individual plans.

There are other ways that the task could have been divided.

We could have chosen to deliver some or all health care services to children (and even college students) through educational institutions. Most school districts have school nurses and psychologists already, administer a few routine screening tests, provide health education (mostly, but not entirely sex education and illegal drug use propaganda), and refer children who seemed to be in need of medical attention but are denied it to social services authority. But, it wouldn't have been hard to establish a system of comprehensive, single payer health care for children through the school system. This would prevent the current system from suffering strain from the fact that large families do not fully bear the cost of their own care in many cases (particularly with more generous employers), and would in some ways reinforce the notion of connecting health care to one's place of employment - extending the idea to school aged children.

Colorado until recently, and some other states, have experimented with no fault automobile accident medical coverage, in which care for automobile accident injuries are financed through the injured person's car insurance, with particularly severe cases to be settled via subrogation actions by the insurer who pays for the care. There have been proposals to make such no fault coverage universal and finance it with a gas tax or other excise tax that functions as a "pay at the pump" user's fee. Worker's compensation, in theory, at least, covers work related injuries and diseases without regard to fault.

With a universal health care system, it would be possible to remove health care payments from the domain of automobile insurance, casualty insurance, tort judgments and worker's compensation entirely, by making health insurance the primarily responsible party for all health care, with legal responsibility for medical expenses related to fault in accidents or on the job injuries or diseases limited to subrogation actions. This would take a great many personal injury cases outside the tort law system entirely, and narrow dramatically the scope of the issues presented in these cases. Even more dramatically, we could decide that compensation for lost income due to disabilities that arise from injuries or diseases (or perhaps otherwise) ought to be entirely the province of insurance or social safety net programs, rather than the courts, perhaps via a more robust version of Social Security, or mandatory comprehensive disability insurance, in lieu of separate regimes for work related injuries, general tort cases, sick leave policies, and cases covered partially by private disability insurance policies and social security. Subrogation cases could allocate fault in cases where it was necessary to provide the proper incentives not to engage in negligent conduct (although in a society where everyone is adequately insured, this is harder to justify, particularly for small cases where the burden of the risk faced by different insurance companies can be expected to average out over time). In a regime like this one, only "pain and suffering" and dignitary injuries would be left to litigate.

Less radically, health insurance companies would process all health care claims, regardless of the nature of the injury, and then would be reimbursed by casualty insurance companies, with their actual costs entitled to presumptive validity. Tort lawsuits might establish liability for medical costs, but simply order the insurer for the tortfeasor to pay those costs as they come due, avoiding litigation involving expert witnesses over the validity of medical costs incurred and the estimated future medical costs involved in a personal injury case. Casualty insurers and health insurers could resolve medical expense disputes in individual cases through intercorporate arbitration.

We could have had a single payer system for some conditions, perhaps mental health care, or pregnancy care, or congenitally disabled people whose high cost of care is a certainty at the outset, that are hard to deal with through individual insurance due to moral hazard issues, while utilizing the Affordable Health Care Act insurance regime approach only for more ordinary cases. Mental health care or pregnancy care could be quite affordable to provide via a single payer system since they are a small part of the total national health care expense.  Failure to provide adequate mental health and/or pregnancy care has immense externalities for the rest of society as well, so perhaps these need to be redefined as public health issues.

We could have medical care in all trauma cases handled by one program or insurance regime, and handle non-trauma causes in another regime.  The public interest in universal trauma care is greater than the public interest in many kinds of universal non-trauma care.
Pregnancy care could be insured not through employers, but on a basis similar to universal life insurance or long term care policies, with premiums made over a lifetime or many years, to cover a lifetime of coverage. Rather than expiring for want of premium payments, these policies could create non-dischargable debts, a bit like student loans, which insurers could collect with bad debt figured into their pricing. Alternately, we could have a system of guaranteed pregnancy care loans that is directly analogous to the student loan regime, allowing births to be paid for over the course of a decade or two, rather than all at once, and could focus on transparency in pricing as a way to control costs in this area.

Guaranteed medical care loans also make sense as a back stop to a regime with catastrophic coverage in which not all patients have funds in a health savings account or otherwise sufficient to pay their current out of pocket costs.

We could distinguish between catastrophic care, which might be handled by a government program or secondary tier of insurers (a bit like umbrella insurance), and ordinary health care which would de-emphasize risk sharing and emphasized price negotiating and cash flow management. The greater ability of patients to pay for non-catastrophic care would make more ordinary market-like arrangements such as those seen in the area of dental health, seem more workable.

If coupled with a system of guaranteed medical loans, non-catastrophic care could be optional, and only catastrophic care would have to be universal either because it is mandatory in some form, or is a tax financed government program. The downside of making this a mandatory form of insurance, is that compliance can be difficult to secure for a program that actually makes insurance payments to the people who pay the bills only very infrequently, while accounting for something on the order of half of the cost of health insurance. But, catastrophic care on an umbrella insurance model would have very low administrative costs relative to premiums, and relatively few of the really controversial insurance coverage issues involve catastrophic care cases. This could give a government program a fairly large economic role in health care without having much of a day to day administrative role in it that people would fear would interfere with doctor-patient relationships.

Medicare and Medicaid are currently mostly programs that pay providers directly on a fee for service basis, but could be organized to pay for a menu of health insurance options, or to pay providers on capitation or similar basis. The Ryan plan that would provide mere flat dollar vouchers to buy health insurance would be problematic standing alone, but if there was a core set of coverages that could be purchased with the voucher without additional expenses from a vendor of last resort who was required to provide it, this would not be worrisome.

It would be possible to structure health care claim processing a bit like the way we structure credit card progressing today, where cooperatives like Mastercard and Visa process claims and adjudicate billing disputes, but the loans are extended by member banks that set interest rates, set credit limits, and establish their own reward programs. The vast majority of health insurers could be united in a small number of cooperatives, which would receive claims from providers and process them in a standardized process, set provider compensation rates for member providers, and leave the actual health insurers with only a few key terms like copay amounts or deductibles being set by the actual health insurer which would bear the financial cost of claims processed for its insureds, but would not actually administer those claims. This could produce many market efficiencies even if the claim processing cooperative had no formal monopoly.

Of course, to some extent, this is the easy part of the equation. Once you have universal health insurance coverage, it is a relatively bloodless affair to reshuffle the expense from one pocket to another in the interests of more efficient administration and more sensible cost distribution that is consistent with ability to pay. The really hard part of the issue is figuring out which scenario is not going to be to reduce just administrative and marketing costs to a minimum, giving health care consumers the best value for their money. This is the low hanging fruit, which shouldn't be that hard to realize.

The truly hard part of the health care reform question, which still remains largely unanswered, is who is both willing and able to effectively negotiate lower compensation rates for providers that will translate into lower compensation for doctors, nurses, pharmacists, drug companies, medical equipment makers, hospital administrators, and so on. The deepest problem with the American health care system is that the people who are currently making these decisions, with other people's money, are leaving American providers much better compensated than those anywhere else in the world by a large margin, for the same or less or inferior work. And, very few people in the policy world are entirely clear on what precise flaws in the provider rate system is most to blame. Notably, the truly iconic seats of medical excellence in the United States, like Mayo and Bethesda, are not the ones with the most highly paid providers.

Even in a perfect world with high levels of transparency, the sick and the injured are simply not in a good position to bargain for lower provider costs at the time of treatment as one would with many goods and services. They need intermediaries to handle this for them. But, how do we get the intermediaries (who might be civil servants or insurance company bureaucrats that we have never met) the clout that they need visa-a-vis medical providers who we know and love and the incentive to do their job well?

READ MORE - Deconstructing the Concept of Health Care And Options For Dealing With It

Altitude Sickness Vulnerability Overwhelmingly Genetic

Robert Roach, who directs the Altitude Research Center at the University of Colorado, performed a similar test last year, taking 28 research subjects to a simulated altitude of 16,000 feet by putting them in a special chamber that mimics the effect of a low-oxygen environment. A blood test, screening for those six genetic elements, was able to predict with 96% accuracy which of the 28 would fall ill.

From here.

The military wants to know so that it can predict which soldiers will be most impaired when deployed rapidly to a high altitude situation, so it is funding the research, replicating the study described above with 140 subjects, and if it is successful, having a mass production "Acute Mountain Sickness Prediction Kit" for the military in place by 2014.

Military models indicate at least 25% of unacclimatized troops parachuting into a battlefield at 10,000 feet—and more than 80% of troops fighting at 13,200 feet—will get altitude sickness. One military study of a prolonged operation in the high mountains of Afghanistan found 14% of troops evacuated for medical treatment didn't have combat injuries—they had altitude sickness. Uncounted others, not sick enough to merit rescue by helicopter, were huddled in base camps while their units went out fighting, said Dr. Muza, the Army research physiologist. In most cases, acute mountain sickness dissipates within three days as the body adjusts to the elevation, though in severe cases, it can linger or lead to fatal complications. . . .

Projections for proportion of unacclimatized troops who will get sick at high altitudes.

10,000 feet – 25-35%
11,500 feet – 50-60%
13,200 feet – 80-90%
14,800 feet – 90-100%


Source: Stephen Muza, U.S. Army Research Institute of Environmental Medicine. . . .

While the military is funding the new research, a predictive blood test could also be marketed to the public, Dr. Roach said. That could benefit Colorado's ski industry, which says up to 40% of its visitors come down with mountain sickness. The Institute for Altitude Medicine in Telluride, Colo., estimates the illness damps spending at mountain resorts by $200 million a year, as afflicted tourists don't much feel like shopping, skiing or dining out.

The fact that this trait is so overwhelmingly predicted by genetics is itself surprising.

READ MORE - Altitude Sickness Vulnerability Overwhelmingly Genetic

Class, Culture, Toilets and Time

I heard two recent stories about toilets in Asia in the last twenty-four hours.

HADENYA, Japan — The colossal wave that swept away this tiny fishing hamlet also washed out nearby bridges, phone lines and cellphone service, leaving survivors shivering and dazed and completely cut off at a hilltop community center. . . . With no time to mourn for their missing loved ones, they were immediately thrust into the struggle to stay alive in the frigid winter cold, amid a hushed, apocalyptic landscape of wrecked homes, crushed vehicles and stranded boats. They had scant food and fuel and no news from the outside world — not even the scope of the devastation.

On Wednesday, after the Japanese military finally reached them for the first time since the tsunami struck 12 days ago, by erecting makeshift bridges and cutting roads through the debris, they told a remarkable tale of survival that drew uniquely on the tight bonds of their once-tidy village, having quickly reorganized themselves roughly along the lines of their original community: choosing leaders, assigning tasks and helping the young and the weak. . . .

Almost as soon as the waters receded, those rescued here said, they began dividing tasks along gender lines, with women boiling water and preparing food, while men went scavenging for firewood and gasoline. Within days, they said, they had re-established a complex community, with a hierarchy and division of labor, in which members were assigned daily tasks. . . .

Refugee centers like this one in Hadenya exhibit a proud cooperative spirit, and also a keen desire to maintain Japan’s tidy perfectionism. Along the hallways, boxes of supplies lie stacked in orderly rows. The toilets are immaculate, with cups and soap neatly lined up. At the entrance, sheets of paper list names and assigned tasks for the day, like chopping firewood, carrying supplies and cooking.

From here.

How can you not admire a society that is organized enough to keep its toilets immaculate and its people well organized, even in the most dire circumstances?

Yesterday, I heard a story on the radio about the state of rail infrastructure in India (probably NPR or the BBC although I can't find a link to the story), where construction surges ahead in places like Mumbai, while the existing infrastructure is aging and underfunded. Particularly striking was an account of a train called the "Super" which was anything but. It's toilets, typical of passenger rail in India, were noxious. As another recent story on the subject sums it up:

For most visitors, rail travel in India is an indispensable part of any holiday, although an ability to overlook the often filthy toilets and deal with basic comfort and crowded carriages is required.

India has no shortage of cheap labor. Indeed, it has a government program that guarantees every person in India who shows up wanting to work a minimum wage job a certain number of days per year, usually on infrastructure projects. It also has trains full of people who could volunteer to do the work if organized properly. But, it doesn't. It has nausea inducing cesspools used only by the most desperate instead that make life miserable for train passengers and present a poor image of the country to every traveler domestic and foreign.

Meanwhile, Japan manages to keep its toilets pristine, even an isolated village devastated by a 9.0 magnitude earthquake and a tsunami that hasn't had contact with the outside world for a week and a half.

It is hard to chalk this difference to religion. Both Hindu and Islamic religious precepts give considerable attention to ritual purity and cleanliness; at least as much as the Shinto, Buddhist and Confucian syncretism found in Japan. Nor can one look to differences in climate - if anything, toilet cleanliness is more important from a public health perspective in sultry India than it is in frigid Northern Japan. Nor, must toilets on conveyances necessarily be putrid. Amtrak and most commercial airlines manage to have at least marginally clean toilets most of the time. Back in the era when trains were a leading means of intercity transportation in the United States, toilets on trains were cleaner than they are on Amtrak today.

Instead, it is a product of culture, and perhaps, in a not unrelated way, of economic development. Japanese communities place a premium on having decently clean toilets and are willing and able to organize themselves to secure them. India's rail culture continually drifts on the edge of mayhem and chaos, and the communities that use and manage it lack the will to decide that nasty toilets on trains don't have to be tolerated.

It isn't that South Asians don't prefer clean toilets to dirty ones. An ability to provide indoor plumbing and running water are now central to a young man's hopes of securing a good marriage match in India these days, very much as they were in the Reconstruction Era American South. But, for whatever reason, today's India is having trouble organizing itself as a society to secure this desirable thing.

American culture is somewhere in between. There are places - upper floors of office buildings, university classroom buildings, McDonald's restaurants, airports, the Cherry Creek Mall in Denver, and country clubs, where toilets are routinely tidy. There are other places - small rural gas stations, the Burger King restaurant at Cherry Creek North in Denver, public parks, the first floor of inner city libraries, outhouses at construction sites, and bus stations, where nasty bathrooms are the norm.

In America, toilet cleanliness is a pretty reliable social class marker. The higher the social class of the people who usually use it, the cleaner they tend to be, although this is also strongly a function in the institutional culture of the toilet operator. Toilet cleanliness is also something that is typically greater in private settings than in public ones in the United States, although there isn't a firm general rule.

There are other fascinating things one can learn from toilet culture as well. Americans, despite their strong ideological commitment to market approaches to economics, very rarely charge directly for using a toilet, although many establishments try to limit them to customers only, especially in areas with large numbers of transients. The decidedly socialist leaning French, by comparison, routinely charge a small fee to use a toilet, or at least expect users to tip an attendant. French fee for service toilets tend to be quite clean.

Toilets are interesting as a cultural indicator because they are impossible not to observe if you spend any amount of time someplace, because it is a universal indicator since every society has to have some way of handling the issue, and because it is pretty much impossible to hide their condition.

To the extent that toilet conditions reflect some version of economic development and social class, how "civilized" a culture is to use an out of fashion term and way of thinking, and there seems to be reason to think that this is something of a general trend, one also has to ask how much this is an effect of affluence, and how much it is a result of some attitude about how communal affairs are managed that gives rise to affluence. Are clean toilets a result of a shared high value afforded to a tidy and well ordered public sphere? Of shared social norms? Of minimal civic obligation? And, these these same values translate into affluence in the economy?

People like Mustafa Kemal Atatürk, the founder of the modern Turkish State, were convinced that this kind of thing was crucial to economic development. His agenda for reform included not just changes to the legal system and political system, but such cultural level reforms as the adoption of a national, Western style dress code designed to root out social and religious markers of the Ottoman era, despite the lack of an obvious connection between wearing suits and ties and conducting the affairs of a modern society. After all, as a former employer of mine enjoyed observing, the British conquered the world in shorts. But, it also seems that there really is something cultural that has to transform in the course of economic development.

One of the fascinating examples comes from British history in the early Industrial Era, one of the first places in the world anywhere that was organized socially and technologically on an industrial basis (continental Europe followed later, often heavily driven by government action as opposed to private investment). At that time and place was a cultural upheaval that included a greatly increased attention to punctuality and uniform time measurements. Clock towers went up all over England to keep communities synchronized. Many farm workers in the first waves converting to the industrial regime had great difficulty getting used to ideas like showing up on time and getting paid by the hour. While not many economists study international toilet cleanliness levels, there is an entire subfield of studies on the link between punctuality and time consciousness and economic development (see e.g. here and here and here and here and here and here and here). Economists study how fast people walk, how fast people talk, how timely trains are, and more. The aphorism about the Italian fascists is that at least they managed to get the trains to run on time. Standardized time zones have their origins in the efforts of train operators to coordinate their time tables.

Certainly, suits and ties are any more necessary to economic development than kimonos. Likewise, toilet cleanliness is not a cause of the rise and fall of great empires. But, one doesn't have to believe such absurdities to conclude that economic development and cultural transformation are inextricably intertwined, and that the development of some set of social virtues is as a critical a technology as the railroad or the internal combustion engine to attaining the economic scale and social coordination that is necessary for an affluent society.

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Republicans Hate Hawaii

The Republican spending plan approved by House Republicans in Congress last month would have cut $126 million in cuts for the National Weather Service that houses the Pacific Tsunami Warniing Center in Hawaii. After all, who needs to know about the weather, it's just God's will.

READ MORE - Republicans Hate Hawaii

Possible Prion Disease Drug Identified

Using trial and error methodology that Thomas Edison could relate to, scientists have located a drug that may have the potential to treat prion diseases such as mad cow disease, scrapie and chronic wasting disease in animals, and diseases including Creutzfeldt-Jakob Disease, Fatal Familial Insomnia, and Kuru in humans, that "result from deposits of abnormal prion protein in brain tissue. Prion diseases are invariably fatal and no treatments are yet available." At this point testing is in mouse models and cell cultures.

Treatments exist for most other major classes of disease causing agents, such as bacterial infections, viruses, funguses, venoms, and parasites, but not for prions.

Prions are also worrisome because they are resistant to sterilization methods that destroy most other disease agents: "Prions are generally quite resistant to proteases, heat, radiation, and formalin treatments, although their infectivity can be reduced by such treatments." Strong acids in combination with higher than typically used heats are necessary to render them non-infectious.

READ MORE - Possible Prion Disease Drug Identified

Something Works For The Common Cold

Zinc supplements taken within one day after the onset of a cold have been shown to be effective at treating it by shortening the duration of symptoms and their severity in a meta-analysis of fifteen trials involving 1,360 people in all. So often, it seems, herbal or non-traditional remedies placed under the microscope of scientific examination of their effectiveness turn out to be mere placebos. But, this is an exception that applies to an exceptionally common condition. How common?

The common cold places a heavy burden on society, accounting for approximately 40% of time taken off work and millions of days of school missed by children each year.

READ MORE - Something Works For The Common Cold

Monday Miscellany

* Last week, Glendale's animal rights terrorist, thirty-four year old Walter Edmund Bond, got five years in prison for burning down the sheepskin factory (and a $1.2 million restitution judgment together with three years of supervised release) following a guilty plea, despite the fact that he was utterly unapologetic and taunted the victims as he spoke prior to receiving his sentence. No physical injuries to people were caused by this or her other fires, but the business, which was not insured, was destroyed.

"In a society that honors money over life, I am honored to be a prisoner of war," Bond said. As Bond raged in the heavily guarded courtroom — at one point saying he wanted Livaditis to "choke on everything you earned" — a member of Livaditis' family cried in the audience. . . . [He] told Judge Christine Arguello that he has no remorse for the fire, which he has said he lit under the banner of the radical Animal Liberation Front, or ALF. . . . [The judge said] he would face additional prison time if he didn't keep up with restitution payments. Bond told Arguello he would not willingly make the payments. . . . Bond also has prior arson convictions that had nothing to do with animal-rights issues. Holloway said Bond was convicted in Iowa in 1996 for lighting a pentagram on fire inside a church convicted again in 1997 in Iowa for setting fire to a building, an incident that killed a family's pet. . . .

Bond's speech today stood in contrast to statements his lawyer made on his behalf last month in a court filing seeking to get Bond a reduced sentence of less than four years. In that filing, attorney Edward Harris wrote that Bond had renounced "burning the businesses of those who offend his principles. . . . Mr. Bond ... now believes that the better course of action is to limit his advocacy to speech and writing," Harris wrote.

That sentiment was not evident during Bond's speech, as he called affiliating with the ALF, "the proudest and most powerful thing I have ever done." Bond, who has identified himself at times in online writings as "ALF Lone Wolf," addressed part of his speech to "my vegan sisters and brothers" and encouraged them to keep up their campaign.

About a dozen of Bond's supporters sat in the courtroom for the sentencing hearing. . . After the hearing, many of the activists, some of whom traveled from across the country to attend, said they supported Bond's statement.

The willingness of federal prosecutors to accept such a lenient plea bargain may have something to do with the fact that he faces two more counts in Utah that will add to the total time served before his release. This conviction will impact his criminal history for the next convictions under the U.S. Sentencing Guidelines. U.S. Attorneys in Utah will also, no doubt, consider his statements at this sentencing in considering what plea agreements they are willing to reach with him.

Still, it is hard to imagine someone who claimed that he did this in the name of Islam, instead of animal rights, receiving a similarly light sentence. When someone who is deeply repentant can be sentenced to 30 years in prison for sending $3,500 to an Islamic organization that engaged in both terrorist and non-terrorist activities funded by petty fraud under a law that had never before been enforced, it is hard to see why someone with a prior criminal arson record he burns down a shop and has no remorse for the act should receive a lighter sentence.

* There seems to be some evidence that fructose (one type of dietary sugar) encourages obesity more the glucose (another type of dietary sugar).

* Genetic evidence has led biologists to reclassify a few species of worms called Acoels and Xenoturbella, that had previously been seen as a missing link between invertebrates with radial symmetry (anemones, jellyfish and sponges, for example) that use the same body opening to ingest food and excrete waste, and animals with bilateral symmetry that have a separate mouth and anus (earthworms, snails, insects, sea urchins and vertebrates, for example), since these worms have bilateral symmetry but a single body opening to ingest food and excrete waste. The genetic evidence suggests that rather than being a missing link, the Acoels had an ancestor that has bilateral symmetry and both a mouth and anus, but lost the anus in later convergent evolution. They turn out to be more closely related to the vertebrates and sea urchins than to other bilateral animals by several different genetic measures.

* Old teeth found at an archeological site in Israel suggest that there may have been modern humans in the Levant much earlier than prior finds have indicated, perhaps even shortly after the evolution of modern humans in Africa:

Excavated at Qesem cave, a pre-historic site that was uncovered in 2000, the size and shape of the teeth are very similar to those of modern humans, Homo sapiens, which have been found at other sites is Israel, such as Oafzeh and Skhul -- but they're a lot older than any previously discovered remains.

"The Qesem teeth come from a time period between 200,000 -- 400,000 years ago when human remains from the Middle East are very scarce," Quam said. "We have numerous remains of Neandertals and Homo sapiens from more recent times, that is around 60,00 -- 150,000 years ago, but fossils from earlier time periods are rare. So these teeth are providing us with some new information about who the earlier occupants of this region were as well as their potential evolutionary relationships with the later fossils from this same region."

Teeth are the prime sources for ancient DNA because the enamel shields them from outside conditions, leaving open the possibility that it might be possible to analyze the DNA of hominins much older than any other ancient DNA ever recovered. Even results limited to mtDNA could shed light on whether the modern humans finds in the Levant are ancestral to modern Eurasian, or a "dead end" as their apparent absence from the Levant for tens of thousands of year suggests might be the case. But, the rare teeth have value whole, and the ancient DNA inside could easy be degraded and provide no useful information, so the decision on whether scientists should try to analyze them in destructive testing for ancient DNA is a difficult one.

* One feature that is surprising absent from library cataloging software (at least in Denver) and online book purchasing sites (like Amazon) is an easy way to bring up all of the books and other media that are part of the same series and arrange them in order. This is particularly annoying when several volumns of a series are written by different authors (common in non-fiction and sometimes seen in tribute works to deceased authors). Even more annoying, however, is the effort of publishers like Little, Brown and Company's paperback offerings, where I have seen it done, to deliberately obscure the fact that a book which is one of the middle books of a series has books that come before it in the series on the book cover. I understand the desire to sell more books, but in general have a low opinion of marketing approaches that seek to capitalize on consumer ignorance rather than by letting them know more about the product.

* Marginal Revolution is a blog that is increasingly attracting my attention as a source of interesting and timely tidbits. So is Truth on the Market (which is more academic).

* Most recently, the latter blog brings the sad news that Borders, I book store that I saw rise from its humble beginnings as a wonderful independent bookstore in Ann Arbor, Michigan while I was in law school, is going bankrupt. Borders was acquired by Detroit area based Kmart to revive its Walden Books chain, one that I liked to describe as a book store for people who don't really like books that based on shopping malls. The book stores were spun off from Kmart, which went bankrupt and was merged in the same group with Sears, another retail chain that had jumped the shark but had valuable real estate holdings. Borders was a delightful book store, but expanded too fast with non-bookstore exeecutives, failed to gain a strong foothold into the online world, and tried to hard to meld a chain oriented towards intellectuals and one oriented towards non-intellectuals that was ill fated. I personally think that the role of a lack of online initiatives at Borders which has been played as a "death of books" scenario distorts what really went wrong with Borders, which can just as easily be understood as a lesson in the limits of the economies of scale.

* The Democratic Leadership Council (and its deceptively named think tank, the Progressive Policy Institute), a conservative leaning organization within the Democratic Party, is dead. It has run out of money and is suspending its operations. While the DLC has been more Clintonian than outright Blue Dog conservative, it has earned a great deal of ire from the progressive elements in the Democratic party anyway. The 2012 election was a blow to its core constitutency, as right leaning Democrats favored Republicans over Democrats, although the Democratic party still has a much bigger tend than the Republicans politically at the moment. Also, the DLC has simply lacked much of a coherent vision.

* Arizona is talking about bringing counterclaims in the federal suit to invalidate its anti-immigration law on pre-emption grounds alleging that Arizona has incurred fiscal harms as a result of non-enforcement of federal law by federal officials. The claim is frivilous as a matter of law and a nearly identical suit was promptly defeated in the courts in Colorado when Attorney General Suthers was directed by the legislature in a special session to bring such a suit. But, the political grandstanding continues to outweigh the legal good judgment of the officials making the legal move.

READ MORE - Monday Miscellany

Self-Control Accounts For Much Of "W"

There is no real doubt that it is possible to measure a quantity, commonly called "IQ" whose platonic ideal in the psychological literature is called "g" that is closely linked to academic success and more generally linked to success in a whole host of other things in life.

But, it has also become increasingly clear, as I have previously noted, that people vary in persistent, systemic ways that arise early in life and that are uncorrelated with "g" which Steve Hsu likes to call "W."

In his oversimplified equation: "Grades = ability + work ethic = IQ + W"

Work ethic, however, is really a place filler for one or more unknown traits that influence performance after controlling for IQ in academics and a variety of other pursuits. One such W factor was found in dopamine gene variants. A study looking at lawyer practice performance after controlling for grades and LSAT scores has homed in on what seem to me to be several factors, with organization and self-discipline making up one large component, and effectiveness in interpersonal communication and practical judgment, which seem congruent to the idea of emotional intelligence, as another.

Some studies of childhood self-control v. impulsivity seem to buttress the dopamine gene and organization/self-discipline component of W findings.

Children with lower scores (poorer self-control) had poorer health at the age of 32. Their lungs didn’t perform as well. They were more likely to have gum disease, be overweight, or depend on drugs like tobacco, alcohol or cannabis. Among those with the highest levels of self-control, 11% had multiple health problems, compared to 27% of those with the lowest levels.

Those with poorer self-control were also more likely to run into financial or social problems. As teenagers, they were more likely to start smoking, leave school with no qualifications, or have unplanned pregnancies. As adults, they had more credit problems and troubles with money, and fewer tangible assets like a home, savings or a pension. They were more likely to have been convicted of a crime, and their own children were more likely to be raised in a single-parent household. And in fact, their childhood self-control was a better predictor of these financial worries than either their IQs or social backgrounds. . . . the more self-control people had as children, the better their futures, even for those at the high end of the scale. They also found that children who developed better self-control as they grew up fared better than those who stayed at the same level.

The differences observed in this study were pronounced by age three! But "7 percent of youngsters in the long-term study developed notably better self-control as they got older. Members of this group displayed better health, made more money and had fewer criminal run-ins as adults than would have been predicted by their self-control levels as young children."

The study largely replicates with a different testing methodolgy, the famous marshmallow test of Walter Mischel at Stanford University that demonstrated that a young child's ability to postpone eating a marshmallow in exchange for a reward later predicted a wide variety of lifetime success measures later in life.

W because it is less well defined and may have multiple components, is less well studied than IQ. But, it seems to be something "real" that can influence crime, poverty, health, social class and success in life at all levels. So, it deserves at least as much attention as IQ. For example, we know far less about how strongly W is hereditary than we do about how much IQ is hereditary.

My own sense is that there are probably multiple, independent components to "W" and that an impulsivity/self-control dimension is probably one of the most important components of it. Another big component may be "emotional intelligence" or "empathy" or "interpersonal skills" or something along that line. There are probably one or two other significant components as well - perhaps creativity, perhaps some other traits.

The impulsivity/self-control component of "W" seems to have some similarity to traits in the Five Factor Personality Model, particularly conscientiousness as:

A considerable amount of research indicates that conscientiousness is one of the best predictors of performance in the workplace, and indeed that after general mental ability is taken into account, the other four of the Big Five personality traits do not aid in predicting career success.

- per this study.

My sense is that the impulsivity/self-control dimension has a fairly strong hereditary element which may be possible to link to a fairly modest number of gene variations, although there is probably a significant gene x environment component to this as well. Efforts to teach self-control have shown measurable success. I have less intuition regarding the extent to which other components of "W" are hereditary or learned, although a guess of 50% hereditary, in line with the heritability of a great many psychological and personality traits, might be a good starting point for a guess on those.

There is, of course, a considerable literature, on ADHD (which has both a hyperactive-impulsive and an inattention component separately measured and used to determine subtypes of the condition), impulsivity (possibly with three or more distinct subcomponents), a variety of "impulse control disorders," the personality trait of novelty seeking, and a cluster of similar traits in the mental health and psychology literature. There is no doubt overlap between these concepts and the Big Five personality trait conscientiousness.

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A Cocaine Vaccine?

Suppose you could get some shots that dramatically reduce the potency of cocaine in your system through an immune system response to it? It is the sort of thing that might make it much easier for a cocaine addict to quit.

In mouse models, such a "cocaine vaccine" seems to be effective. Vaccinated mice have a far less pronounced response to comparable doses of cocaine than unvaccinated mice.

Methadone is a drug sometimes used to ween addicts off their drug addictions, but the need for fairly precise timing and dosing of a methadone therapy have been one of the important factors in a dramatic increase in accidental drug overdose deaths over the last decade or two. A vaccine treatment doesn't pose those kinds of risks.

Also, once someone received a cocaine vaccination, it would be unnecessary to monitor this part of the drug treatment program in an intensive way.

Research into similar treatments for heroin addicts and meth addicts is also underway.

Of course, there are all sorts of questions about how a mouse model translates into a human therapy. For example, the same vaccine that mutes cocaine response might actually be broader and also mute responses to medicinally useful painkillers or stimulants. Or, it might not be long lasting enough, or potent enough to deal with a heavy addiction. In the mouse model, the treatment effectively reduced drug doses by 60%. But, a human might simply increase the dose proportionately and continue the addiction.

Also, the mice were vaccinated before any exposure to cocaine, but this kind of treatment makes no sense for the general population even if the side effects and risks are pretty modest. It is hard to tell if the effect would be the same once the epigenetic changes that drug addiction causes were already in place.

Still, the prospect of a simple drug that once administered would cure people of drug addictions without long painful withdrawal and therapy, probably with relapses in most cases, at least temporarily, is a tempting possibility. And, given the negative health consequences and life consequences of being a drug addict to cocaine, heroin or meth, even significant negative side effects from the treatment would be an improvement if the vaccine is effective for people who have already become addicted. Indeed, it might even make since, pre-emptively, in people who have a strong family history of addiction and live in an environment that put them at high risk of becoming addicts themselves.

READ MORE - A Cocaine Vaccine?

Twenty Obvious International Trends

Lots of economic, environmental and political predictions are hardly better than horoscopes. Others are reliable enough to be thought of a "fundamentals." I'm more interested in the latter. Here are a few:

1. China's economic growth rate will be greater for medium term time periods (e.g. three years or more) than that of the United States for the foreseeable future, because it is engaged in "catch up growth," while the United States is not.

2. China will experience a notable economic crash in the next decade or so, because it hasn't had one for a long time and periods of even strong sustained growth are almost always interrupted periodically by economic crashes.

3. India's economic growth rate will be greater for medium term time periods than that of the United States for the foreseeable future, because it is engaged in "catch up growth," while the United States is not.

4. India's economic growth rate will exceed that of China sometime in the next ten to fifteen years, because China's per capita GDP is significantly greater than that of India, leaving India with more "catch up growth" potential than China.

5. Oil dependent nations in the Middle East will each experience serious economic contractions not long as oil production in the nation in question starts to fall due to exhaustion of the nation's oil supply. These nations are heavily reliant on oil revenues to sustain their standard of living with imported goods and temporary immigrant workers, both of which will be harder to come by when there are not new oil revenues available.

6. Countries in Africa that experience war and authoritarian governments will experience less economic growth than those with sustained periods of peace and democratic government.

7. In the developing world, it will be a long time before environmental and climate change concerns have enough political clout to cause air pollution to be reduced more rapidly than the increasing scope of economic activity increases air pollution. As a result, emissions will not be reduced rapidly enough to stop continued global warming.

8. Nuclear power will spread to more countries.

9. Oil more be more expensive in real terms in 2020 and more expensive again in real terms in 2030 than it is today. Rising oil prices will make technologies that are powered by energy sources other than oil more attractive. This trend will be a global one, because oil trades in a global marketplace.

10. Oil rich countries that are not close to exhausting their reserves will receive an economic boost from rising oil prices.

11. North Korea's political and economic system will collapse, probably within a couple of decades, if it fails to open itself up to the rest of the world. If it does collapse, it will probably be reabsorbed by South Korea.

12. Public health measures will improve in most of the developing and undeveloped world that are not war torn as patents on new effective drugs expire and make those drugs more affordable.

13. Global fertility rates will fall as more countries become more economically developed.

14. Developing countries will become less religious as they become more economically developed in fairly close synch with falling fertility rates.

15. The need to impose taxes as oil revenues decline will force Middle Eastern monarchs who have not already been deposed in revolutions and democratized of their own free will to make genuine democratic reforms.

16. The proportion of the world population engaged in farming will fall steadily for decades to come.

17. Some small island nations will be swallowed up by the sea and forced to relocate all or most of their populations as sea levels rise with global warming sometime in the next century.

18. A large share of the world's languages, probably half or more, will die in the next few decades.

19. A significant number of plant and animal species will go extinct in the next few decades.

20. The proportion of Africans who are Christians will increase significantly over the next decade.

READ MORE - Twenty Obvious International Trends

Do We Need A Better Early Warning System?

Meet Mr. Loughner

Jared Lee Loughner, the Tuscon assassin, was a troubled young man.

It was clear that he was a problem, possibly a violent one, in the community college he attended:

Pima Community College, in Tucson, issued a statement identifying Loughner as the suspect. It said he was a student from the summer of 2005 to fall of 2010, but he was suspended Sept. 29 for conduct violations. It said he agreed to withdrew from the college on Oct. 4.

The college said that from February to September of 2010, Loughner had five contacts with college police for disrupting classrooms and the library. It said he was prohibited from returning to the college.

A spokesman for the college said Loughner's videos troubled administrators and campus police, leading to his suspension. In one video, he "claims that the College is illegal according to the U.S. Constitution, and makes other claims," the college's statement said.

Loughner and his parents, Amy and Randy Loughner, met with administrators, who required him to be obtain a certification that "in the opinion of a mental health professional, his presence at the College does not present a danger to himself or others." . . .

Lynda Sorenson said she took a math class with Loughner last summer at Pima Community College's Northwest campus and told the Arizona Daily Star he was "obviously very disturbed."

"He disrupted class frequently with nonsensical outbursts," she said.

The community college alerted his parents that there was problem, something that they probably already knew. He apparently lived at home with them.

While he has in college, he was prosecuted for a minor drug related charge:

The Arizona Republic reported that the charge was for possession of drug paraphernalia. The charge was dismissed in 2008 by the city attorney after Loughner entered a pre-trial diversion program.

He left his high school after his junior year, despite not leaving the area, and around the time he started in at community college:

Tamara Crawley, director of the Marana Unified School District in Tucson, said Loughner attended Mountain View High School in Tucson for three years but withdrew after completing his junior year in 2006. . . . [A high school and college classmate] described him as having a lot of friends "until he got alcohol poisoning in '06" and dropped out of school.

He wrote odd and disburbing things on the Internet.

In November, less than two months after he was kicked out of college, Loughner had bought a Glock, purchased legally from a Sportsman's Warehouse in Tucson. Less than two months after that six people are dead and fourteen people are wounded, many of them seriously.

Spree Killings Are A Distinct Kind Of Crime

When one looks at the profile of people who commit these kinds of horrific one time explosions of violence, a good share share of them are people like Loughner. The warning signs in Loughner's case were similar to those involving Matthew J. Murray who went on a shooting spree in Arvada and Colorado Springs in 2007. They resemble those of Aaron Synder who tried to kill Governor Ritter in 2007. They have similarities to those shown by Seung-Hui Cho, who carried out the Virgina Tech massacre in 2007. They resemble Robert A. Hawkins who carried out the Westroads Mall shooting in 2007. They show resemblances to Eric Harris and Dylan Klebold who carried out the Columbine High School massacre in 1999.

These cases aren't that different from that of Malik Nidal Hasan, the Army medical officer who was responsible for the Fort Hood shooting in 2009, and Kyle Aaron Huff who carried out the Capitol Hill massacre in Seattle in 2006. They resemble Charles Joseph Whitman who in 1966 went on a shooting rampage at the University of Texas at Austin.

The Malaysians had a word for these kind of acts carried out by these kinds people long before we did that has entered the English language in the phase "running amok", although the force of the term has been diminished from overly casual use in English. The home made equivalent ideom, which has the Malayian meaning of "amok" is "going postal." The more clinical term used by the FBI for this kind of individual is "spree killer".

Spree killings aren't very common, but they do occur at a more or less steady pace all over the world and inevitably make headlines when they happen. The spree killers are almost always men. They almost always commit suicide, are killed by someone else in the course of their spree, or are caught and detained for life.

These men are very distinct psychologically from serial killers, from people who are part of criminal gangs or are "professional" criminals who kill in the course of their crimes, from paid hit men, from people who are normal when they aren't drunk or on drugs, and from people who carry out mass killings in connection with aggressive approaches to a position of authority like police, national guardsmen or soldiers.

While they often have grievances and concerns with a political slant and perhaps colored by the political and religious discussions of the day, and these men generally act alone or with a very small circle of troubled friends rather than as part of an organization, often have vague or irrational agendas. Generally, there is no "sane" person personally coaxing them to engage in violence.

Their crimes involve pre-meditation and planning, and the people who commit them are no doing so with any hope of bettering themselves. They expect to die or be incarcerated forever. These are acts more akin to suicide than to homicides carried out with a rational motive. They are terrorist suicide killings carried out by rebels without a cause that makes any sense. The lack of self-regard make them immune to the deterrence threat of punishment in the criminal justice system. Who cares about the death penalty when you expect that there is a good chance that you will die in the course of your crime anyway?

The Problem Of Definition

In an ideal world, we would have a well honed societal early warning system that would alert authorities to what family members, classmates, co-workers, school administators, bosses, and maybe even police already know, that a particular individual has a real problem and is at grave risk of causing massive harm to other despite having no strong history of violence causing injury, and would have a way of intervening to prevent this individual from causing harm to others.

American law permits involuntary mental health treatment and civil detention for someone who presents a danger to himself or others, aluded to by Pima College in the Loughner case, and we also have a civil restaining order system in place that receives quite heavy use in cases where the danger to others that is particularized to a small number of identifable others. Existing law, although ineffectively implemented, also prohibits those who have been involuntarily committed from buying guns, but bureaucratically, there is not good systemic integration of involuntary commitment records with instant background check systems, and substantively, this narrow definition of mental health problems is grossly underinclusive, particularly in an era in which over the last four decades or so, outpatient treatment of mental health issues have become the near universal approach to treating these issues with institutionalization limited to a very narrow subset of all people with serious mental health problems.

But, the existing system isn't very effective. It isn't clear who is responsible for intervening. It often isn't clear to those around the disturbed individual, especially in the case of an adult, who has the authority to intervene and what that authority entails. Most of all, it isn't clear when intervention is appropriate because often no one person has enough information to clearly establish a danger to others alone, even if many people have enough information to suspect it, and because the symptoms that establish that someone is a danger to others are not well defined.

This is particularly problematic in the American legal system, because our legal system and political culture is particularly suspicious of intrusions on autonomy and freedom for the greater good based on acts on might take, rather than acts one has taken.

On one hand, it is frequently obvious to those who interact with them that something is future spree killers are disturbed individuals. On the other hand, it is often not at all obvious where the line should be drawn. Perhaps one man in a thousand is as intuitively "off" as the people who end up committing spree killings, even though only a handful of spree killings take place in any given year in the entire United States, out of a population of tens of millions of men in the age range of people who commit these crimes.

Statistically, spree killings aren't a major cause of death. But, the immense psychological trauma they impose on the population makes them notable.

An ability to identify a group of fifty thousand people in the United States, from whom it is extremely likely that almost all of the several spree killings a year will be committed would be pretty impressive, compared in scale to the massive and not very effective probation and parole system we have in place. Since most spree killers obtain weapons legally, and many lack adequate mental health care, and a good share of no one who feels responsible for monitoring their well being.

If those individuals could be identified, disqualified from owning firearms via the database used to screen gun purchasers now, pro-actively offered and nudged into seeking mental health treatment, and subjected to light monitoring that would reveal major life changes or disruptions in mental health treatment and would be specifically designed to have a group of designated informants among school, work, family, treating medical professionals, and social contacts who would feel some slight obligation to alert a monitor if the person's situation seemed to be taking a turn for the worse, and that monitor had the authority and responsibility to intervene in those situations, a lot of these incidents could be prevented. The level of intervention required could be somewhat less intense than the kind of supervision that someone on probation or parole receives and still have a measurable effect. It might be that a large set of people so identified would have less intense supervision, simply being banned from purchasing firearms, offered free access to mental health treatment, and annually checking in close associates to let them know who to call if the circumstances changed or the situation appeared to escalate, while others who posed a higher risk would be monitored much more intensely. This would take a tiny share of the societal resources that we devote to the criminal justice system to implement, and it would also help to destigmatize mental illness and reduce the fear people have of the mentally ill who were not identified as high risk.

The payback of this kind of system would be considerably greater than simply reducing the incidence of spree killings for one out of a ten thousand supervised individuals. For every spree killer, there are no doubt tens or hundreds of people or more with a profile that puts them at high risk of becoming spree killers, who commit suicide, who would otherwise kill a particular loved one, who would neglect or abuse a child, who would lapse in taking psychiatric medicines and as a result see their careers and educational aspirations and personal relationships collapse, who would want mental health treatment if they knew it was available and could gain access to it, who cause serious damage to property, who kill someone's beloved pet, who injures others, who commits "suicide by cop," who ends up in prison, or who engages in reckless acts that endanger the public that are on the line between accidents and generalized malice.

Few people who fit a "spree killer" profile may actually commit a spree killing, but a very large share of people who fit that profile would benefit personally, and/or have people associated with them who would benefit, from intervention in their lives.

But, crafting an operational definition that is inclusive of almost all potential spree killers, while excluding people who are not at high risk for being either spree killers or otherwise being a danger to themselves or others, that can be vigorously applied without undue abuse and without unduly impairing the liberties of people who are merely "different" or have principled objections to the mainstream medical approach to treating mental health conditions is not an easy task.

Yet, this must be the kind of definition that becomes as distinct a part of popular culture as CPR instruction, "drop and roll" for people who are on fire, "direct pressure" as the cure all for bleeding, "don't drive drunk," "no means no" and other public health and safety messages, and to be effective, it has to win widespread societal acceptance from a significant share of people even in a lot of fairly anti-authoritarian subcultures. It needs to have the perceived authority of science behind it. It needs to be accepted as legitimate, if not by all people who fit this definition, at least, by a large share of all people who are friends and family and colleagues of people who fit this definition. The closest precedent would probably be the system that requires a large swath of people to report child abuse and neglect and provides a place for others to report it voluntarily.

Almost invariably, when serious consequences are attached to conduct or a condition that is described overinclusively, a large share of all people who suffer those consequences come under the overbroad part of that definition. For example, a surprisingly large share of first degree murder prosecutions involve women who kill their infants in the throes of childbirth or criminal accomplices who did not anticipate that a murder would be committed in the crime that they were involved in and had no personal participation in that murder. Similarly, a very large of racketeering cases involve relatively minor white collar crimes committed in an organized way, rather than anything closely resembling the kind of mafia activities that generated political support for RICO's tough sentences.

Slight overbroadness in defining a high risk category risks bringing far more people than necessary into the net, making the program much more expensive to manage, making the people who run the system less alert to the risk among those they are monitoring than they need to be, and making the intrusion into liberty interests involved much greater.

Another approach to deal with the limits of lay expertise in mental health diagnosis akin to the reasonable suspicion for a "Terry stop" v. probable cause for a "search or seizure" distinction in U.S. law under the 4th Amendment, would be to have a low threshold at which an individual could simply be compelled to receive a mental health evaluation and diagnosis, while limiting anything else to individuals who were diagnosed in a voluntary or involuntary mental health evaluation as suffering from a particular set of symptoms, or were found by some sort of public body (perhaps a tribunal or public office) to have that set of symptoms based on information received in cases where diagnosis is unavailable. Mental health evaluations might also be made a standard part of every criminal case more serious than a traffic stop, even if it is resolved with a diversion program or deferred prosecution.

A two tiered approach might also make members of the public less wary of intervening, as insisting that someone seek professional advice is less weighty making a complaint about someone that would lead directly to significant personal consequences for the person about whom authorities were alerted.

Including a voluntary diagnosis would disturb a bedrock foundation of confidentiality in the mental health care system, but the justification that privacy is necessary to cause people to seek help might be less compelling in a context where the government had the legal authority to compel someone to seek mental health evaluation and diagnosis on the basis of a reasonable suspicion (or probable cause to believe) merely that the individual was clinically mentally ill and could benefit from treatment. And, the individual alerting the system to the need might simply be told as feedback that "an inquiry was conducted based upon the information provided and that it was resolved in accordance with the law" rather than provided with detailed information on how it was handled. In all likelihood, in many cases, alerts would come for individuals who had already been evaluated and diagnosed and were in the system, and would simply lead to a brief memo to a designated mental health care provider.

I don't have great faith that psychiatrists can generally determine with much accuracy at all using existing methods whether or not someone poses a risk of future dangerousness. But, I do have greater comfort that psychiatrists can be reasonably accurate in diagnosing mental health conditions, and that it is possible to distinguish mental health conditions in which there is an elevated risk of someone fitting a "spree killer" profile from those where there is no elevated risk of that kind of activity, and the set of diagnoses where there is an elevated risk is, I suspect, a rather modest subset of all mental health conditions, and this designation is one case where a blanket gender distinction probably makes sense given the gross disproportion of men to women who commit these incidents. (The only American woman who might even remotely qualify is Caril Ann Fugate who claimed innocence but was convincted in a crime that her boyfriend admittedly was involved in committing in 1958 in Nebraska in a episode that is in any case a poor fit to the mental health driven spree killing model described above.)

In an ideal world, an in depth mental health inquiry and background check might be linked to eligibility to purchase guns, since spree killings are almost exclusively committed by people who have purchased firearms, allowing people who choose not to purchase guns and as a result pose far less of a threat to the public to escape supervision in most cases, and casting the mental health inquiry as rationally related and narrowly tailored to a right to do something in particular that poses an elevated risk, a bit like a driver's license, rather than as a punishment. After this inquiry was completed, it would be revocable if new information came to light, but might not have to be re-examined for each new purchase. This kind of inquiry also would have prevented at least some of the small number of shooting range shootings that take place, such as the attempted suicide pact of twins at the Family Shooting Center in Colorado in 2010, where at least one of the suicidal twins had a history of despondancy.

In the current political climate, that is probably not a possibility in the short run, given the strong association of the ascendant Tea Party faction of the Republican party with the Second Amendment and weak gun control laws. Although, even the NRA has supported improved record keeping to prevent those who have been civilly committed from being able to lawfully purchase guns, and many gun owners recognize that a large share of gun control efforts are driven by events like spree killings, and that gun control efforts might be far less intense if there were reasonable measures in place to reduce their incidence, even though spree killings a tiny share of all gun murders. The Heller ruling of the U.S. Supreme Court in 2008 that declared the right to bear arms for self-defense to be a constitutional right made clear in dicta that prohibitions under current laws on gun purchases by the mentally ill were permitted under the Second Amendment.

While the short run political climate may make this approach untenable, I think that one long run, bipartisan secular change in policy attitudes over the rest of my lifetime is going to be increasing intolerance of predictable and preventable tragedies. The more clear it becomes that there is a way to prevent tragedies, the more pressure there will be to take strong measures to prevent them.

Notably, along these lines, in Britain, Doctors agreed this summer to breach medical confidentiality if patients who own guns become seriously mentally ill.

READ MORE - Do We Need A Better Early Warning System?