Different River

”You can never step in the same river twice.” –Heraclitus

June 28, 2005

Stupid Drug Thieves

Filed under: — Different River @ 6:25 pm

Do drugs (I mean recreational, not therapeutic) make you stupid, or is it stupid people who want drugs? These two guys walked into an emergency room, pointed a gun at the staff, and asked for drugs to get them high. Read what happened.

Doctor for Starvation

Filed under: — Different River @ 4:54 pm

Earlier I posted the story of Marjorie Nighbert, who was starved and dehydrated by court order (like Terri Schiavo), but in Nighbert’s case she was conscious, ambulatory, and begging for food — and had to be restrained to her bed to enforce the court and prevent her from raiding other patients’ food trays.

Recently that post has started to attract comments — specifically, comments from a practicing neurologist who says he sees this sort of thing happen “on a regular basis.” And, he strongly implies that he sees this as right and appropriate.

If you think these are isolated, extreme cases, go read those comments.

(I’m disabling comment on this post. If you have something to add, please add it to the comments on the earlier post.)

Now, there’s an excuse!

Filed under: — Different River @ 2:46 pm

If you’re overweight and looking for an excuse not to go to the trouble of losing weight, you can’t do better than this: An article in the journal PLoS Medicine finds that overweight people who intentionally lose weight have a higher mortality rate than overweight people who just stay overweight. In fact, those who lose weight even have a higher mortality rate than those who gain weight! (Although those with stable weight have the lowest mortality rate.)

The study surveys Finnish twins in 1975, and asked overweight people if they “intended” to lose weight. Their weight was re-checked in 1981, and their mortality was followed until 1999. To summarize the results:

Mortality Hazard Ratios
Lost Weight Stable Weight Gained Weight
Intended to Lose Weight 1.87 0.84 0.93
Did not intend to Lose Weight 1.17 1.00 1.58

In other words, an overweight person who intends to lose weight, and succeeds in doing so, is 87% more likely to die than an overweight person who makes no effort to lose weight, and in fact maintains a stable weight. However, an overweight person who intends to lose weight and fails to do so is slightly less likely to die than someone who never intends to lose weight in the first place. Those who have no intention of losing weight but do so anyway are have a slightly higher risk of mortality, but not nearly as much as those who lost weight on purpose. Those who have no intention of losing weight and in fact gain weight have a substantially higher risk — but still less than those who lost weight on purpose. In short, if this study is right, the worst thing for an overweight person to do is to try to lose weight and succeed; the best thing to do is to try to lose weight and fail. Not trying at all is somewhere in between.

Not only is this the best possible result for those who like excuses (“Doctor, I’m trying to lose weight, but I’m not succeeding and that’s good!”), it also flies in the face of most previous work in the field, which of course shows that losing weight (or at least, not being overweight) is good. The article is by actual scientists and appears in a peer-reviewed journal, so it cannot be dismissed out of hand. However, given the weight of the evidence (sorry for the pun!) on the other side of the question, it can’t be accepted uncritically, either.

I can think of several possible reasons why the authors might have found the results they did that would still leave the conventional wisdom mostly intact:

  • Perhaps those who are losing weight on purpose are doing dangerous things to accomplish the loss. For example, not all diets are safe, even if they are successful. (Three doctors told me that if the only way I could lose weight was to use the Adkins diet, I was better off staying fat.) Also, some people may exercise beyond their body’s capabilities in an effort to lose weight.
  • The study counted as overweight anyone with a body mass index (BMI) greater than 25. This is a fairly loose standard; while many experts say 25 is the “ideal” BMI, few would label as “overweight” someone with a BMI of 25.1. Yet, this study appears to do so. Furthermore, there is some evidence that the longevity-maximizing BMI is actually more like 26.5, rather than 25. In this study, less than 10% had a BMI greater than 30 (i.e., were “obese”), and in fact those included had a median BMI of 26.7 — and “losing weight” was defined as reducing BMI by at least 1. So for about half the people in the sample, losing weight meant moving away from the longevity-maximizing BMI — so we would actually expect an increase in mortality. So perhaps it’s not that losing weight is bad for people who are actually overweight — rather, the people in the sample weren’t overweight enough to benefit from weight loss, and many of those who lost weighted actually dropped below their ideal weight.
  • The statistical model they used controlled for sex, age, current smoking in 1981, hypertension, physical activity, life satisfaction, work status, and income. Patients with previous heart attacks, diagnosed angina, or diabetes as of 1981 were excluded. However, the model did not control for family history of these conditions, nor did it exclude people with these conditions. It is quite possible that family history of heart attacks and diabetes — both of which are correlated with obesity — could both increase the probability of death by 1999, and cause people to want to lose weight. In other words, patients in the study know their family history, and if it contains heart attacks or diabetes, they know they are at higher risk of death. They also know — or at least, believe — that the risk of these diseases can be reduced by losing weight. So they report an “intention” to lose weight. Among those who report an intention to lose weight, those with a family history of obesity-related diseases are more motivated to succeed, and thus over-represented among those who both intend to lose weight and actually do so. However, weight is only one factor in those diseases; even after losing weight they still have a higher risk of those diseases — and thus early death — than people without that family history (even if their risk is less than what it was when they were overweight). The study then finds that people who intend to lose weight and succeed have a higher risk of mortality. But it’s not that the weight loss is causing the mortality, it’s precisely the opposite: The higher risk of mortality is known to the patients in advance, and thus causes the weight loss. (This is what econometricians call “reverse causation;” in fact, a brief Google search confirms that this has occurred previously in research on weight loss.) The weight loss may reduce the risk of mortality, but if so it does not reduce it enough to bring it down to the level of the general population.
  • Participants were asked once — in 1975 — whether they “intended” to lose weight (and if so, how). The determination as to whether they had done so was made in 1981, when they were not asked whether they had carried out their intentions. Lots of things can change in six years. As an extreme example, someone who got cancer in 1978 (say) may have lost a lot of weight from the disease by 1981, and be more likely to die by 1999. Perhaps such a person, knowing about cancer risk, reported an intention to lose weight in 1975, but failed to do so — until getting cancer three years later. This is of course a purely hypothetical example — and purely speculative. The point I’m trying to make is that the data may be insufficient to draw conclusions about the link between weight loss and mortality.
  • Another possibility is that they just got a weird draw from a random distribution. If you look at enough studies, this is bound to happen. Analogy: If you flip 10 coins, it’s very unlikely that you’ll get 10 heads, or even 9 — but it is certainly possible. If you flip 10 coins once, there’s only a 1.07% chance that you get 9 or more heads. But if 500 people flip 10 coins each, there’s a 99.54% change that somebody gets 9 or more heads. It’s like that with these studies, too. Assume that the conventional wisdom is right — that weight loss actually does reduce mortality. Even if that’s true, it’s still random in individual cases — even if weight loss reduces mortality on average, some people are going to lose weight and die early anyway, and some people are going to stay fat and live a long time anyway. Not as many, but some. Now, if you do a study on weight loss and mortality, it’s like flipping coins — it’s very likely you are going to find data consistent with the theory. But if 500 people do studies like that, somebody is going to find data inconsistent with the theory. But if it’s just one or a few studies, that doesn’t mean the theory is wrong — any more than one person flipping 9 out of 10 heads means that the “theory” of coin-flipping produces a 50% chance of heads.

The complete article is here. There is also a synopsis, a “patient summary,” and a note on “perspectives” which raises some other issues with the study, none of which I think are as serious as the issues raised above. Personally, I think the most likely culprit is reverse causation.

Is the Supreme Court Literate?

Filed under: — Different River @ 2:36 am

The Supreme Court issues two very strange rulings yesterday (Monday) on the public display of the Ten Commandments. Briefly, they ruled that it’s OK to display the Ten Commandments on public property (in this case, on the grounds of the Texas state capitol), but not OK in a state courtroom (in Kentucky). But it is OK in the Supreme Courtroom, which does in fact have such a display.

If that’s not confusing enough, wait until you read the actual decisions (McCreary County v. ACLU of Ky. and Van Orden v. Perry.)

Why do I ask if the the Supreme Court is literate? Because the five justices in the majority (and their clerks) had months to rule and write their opinions, but less than 16 hours after their decision was made public, Clayton Cramer had a documented, well-written article with complete citations showing that the facts cited by the majority for its decision were not exactly facts. In other words, the decision was based on legal and factual premises which are demonstrably false — not only that, but demonstrably false within hours by a computer programmer in Idaho, who presumably had a full workday to do all sorts of non-lawyer, non-judge, non-scholar things as well in that 16 hours — in which he also wrote three other blog-posts, including one documenting errors in a program on the History Channel, and another on ducks.

You should read the whole thing, but here’s a brief excerpt anyway:

The decision McCreary County v. American Civil Liberties Union oF Kentucky (2005) goes off the tracks immediately:

The touchstone for our analysis is the principle that the “First Amendment mandates governmental neutrality between religion and religion, and between religion and nonreligion.” Epperson v. Arkansas, 393 U. S. 97, 104 (1968); Everson v. Board of Ed. of Ewing, 330 U. S. 1, 15-16 (1947); Wallace v. Jaffree, supra, at 53.

They are following the precedents just fine; the problem is that the precedents are incorrect. The First Amendment was never intended by the First Congress to mandate “governmental neutrality… between religion and nonreligion.” At best, the First Congress intended to mandate that no religious establishment–that is, a particular denomination or organized body–would receive preferential treatment from the federal government.

I don’t dispute that the Fourteenth Amendment imposes the First Amendment against the states–but if you want to understand what incorporation imposes on the states, you need to first understand what the First Congress intended the First Amendment to impose on the federal government. …

[Here Clayton cites the state constitutions of Pennsylvania, North Carolina, Maryland, and Massachusetts to show that the states had religious requirements for public office back when the First Amendment was ratified. He then quotes something I read a long time ago in print, and searched in vain for months to find online -- Thanks, Clayton!]

The federal government–including the draftsman of the Bill of Rights, James Madison, and the most famous skeptic of the Framers, Thomas Jefferson–never seems to have understood the First Amendment as a restriction of the sort that the Supreme Court has now found. The Library of Congress’ exhibition on “Religion and the Founding of the American Republic” observes:

It is no exaggeration to say that on Sundays in Washington during the administrations of Thomas Jefferson (1801-1809) and of James Madison (1809-1817) the state became the church. Within a year of his inauguration, Jefferson began attending church services in the House of Representatives. Madison followed Jefferson’s example, although unlike Jefferson, who rode on horseback to church in the Capitol, Madison came in a coach and four. Worship services in the House–a practice that continued until after the Civil War–were acceptable to Jefferson because they were nondiscriminatory and voluntary. Preachers of every Protestant denomination appeared. (Catholic priests began officiating in 1826.) As early as January 1806 a female evangelist, Dorothy Ripley, delivered a camp meeting-style exhortation in the House to Jefferson, Vice President Aaron Burr, and a “crowded audience.” Throughout his administration Jefferson permitted church services in executive branch buildings. The Gospel was also preached in the Supreme Court chambers.

Jefferson’s actions may seem surprising because his attitude toward the relation between religion and government is usually thought to have been embodied in his recommendation that there exist “a wall of separation between church and state.” In that statement, Jefferson was apparently declaring his opposition, as Madison had done in introducing the Bill of Rights, to a “national” religion. In attending church services on public property, Jefferson and Madison consciously and deliberately were offering symbolic support to religion as a prop for republican government.

I know Clayton Cramer is a really smart guy, very well-read, knowledgeable, and intelligent. He seems to know more history than most history professors and more law than most lawyers. But you’d think that even with all that, you’d think the five justices who signed on to that opinion, who have been lawyers for decades and on the court for between 10 and 30 years, work full-time at law, and have several full-time clerks, and had literally months to write that decision — even if they wanted to make a decision against historical precedent, you’d think they could do better than write something that could be thoroughly debunked in a few hours by a non-lawyer with a day job.

The power of the Supreme Court obviously comes from something other credibility. I wonder how long this situation can last.


Filed under: — Different River @ 1:50 am

I normally don’t post “personal” things on this blog, but I make exceptions sometimes, when I think they might be of interest to the blog-reading public. This is one of them.

I recently had a birthday and turned 36, and this occasioned some reflections on the flow of time, age, and how time seems to be flowing fast, and I am starting to feel old — not in a vain sense, like oh-gosh-I-am-getting-wrinkles — but in the historical sense, in that I remember events that other people who are also considered adults count as history, and in that there are people around me, other than kids, who were born after both major milestones in my life, and major events that I remember.

The age of 36 is a good time for such reflection, particularly in the months of May and June. June is the month of high-school graduations. High school graduation is, for most Americans, the last turning point in life almost everyone shares. Depending on which statistics you believe (or rather, how you want to do the counting), somewhere between 67% and 85% of Americans graduate from high school. About 90% of those students are in public schools. Although there is some diversity in quality and student population, most public schools are mostly like each other in many important ways, providing — by intent, a leveling experience. Even a large percentage of private schools are similar, often differing only in the offering of some religious classes, or in the percentage of AP class, or some other details. Even for those who don’t graduate, much of the years up to age 18 are spent in school.

My point is not that all schools are the same, but rather that most Americans between the ages of 5 and 18 are doing things that are very similar to each other — certainly more similar than they will be doing later in life. The average future medical doctor and the average future construction worker are — at age 10 or 15, say — doing pretty much the same thing. Perhaps by age 15 their paths will have diverged a bit (they are taking different classes in 10th grade) — but only a bit.

At age 18, all this changes. Some people go to college, some don’t — and colleges are much more different from each other than high schools. Some get jobs, some get married, some join the military — and some do all three. These will put them on very different paths by, say, the age of 24 — by which age it is not surprising to find some people married, with children, and maybe buying a first house, and other still (mired? cocooned?) in graduate school, years from getting their first real (full-time, year-round) job. In short, at the age of 18, we lived lives very similar to those of others in our age cohort. After that, our paths diverge, sometimes very greatly. The corporate lawyer is living a very different life than the singer or doctor or secretary or at-home mom or teacher he stood next to — perhaps as friends, perhaps by alphabetical order — at graduation 18 years before. By age 36, we have spent just as much time diverging as staying on the same path.

In a very real sense, by age 36, we are in a different generations. There are people — lots of them — born on the same day I graduated from high school 18 years ago, who themselves graduated this month. To me, it doesn’t seem like that long ago — I remember who I took pictures with, the sharing of the what-college-are-you-going-to stories in the months before, what I did that summer, and how it felt to start college a few months later. I remember the fall of the Berlin Wall in 1989 as a shocking, earth-shattering event of unprecedented worldwide euphoria. The world I had known — with Europe and Asia divided by an ‘Iron Curtain” into separate “worlds” of Communism and Democracy, with the rest of the world lining up on one side or the other or professing to be “non-aligned” — changed forever in what seemed like an instant, without the massive war that usually accompanies sudden changed. I remember this as the pivotal (non-personal to me) event in my lifetime. Those graduating today were about two years old then. Most had probably learned to walk; some had probably not learned to talk yet. They could not possibly remember it. To them, the Iron Curtain is something they encounter in history books — if at all, given the state of history education these days. It’s precisely as remote to them as the fall of Saigon is to me. Likewise, Jimmy Carter’s presidency — the first one I remember — is as remote to today’s 18-year-olds as John F. Kennedy’s is to me and today’s other 36-year-olds.

For comparison, let’s go a generation in the other direction. Someone who was 36 when I was 18 is 54 now. Born in 1951, today’s 54-year-old was old enough to have served in the Vietnam War and remembers the presidency of John Kennedy and probably Dwight Eisenhower. And — this is the freaky part — could be be working in my office, on the same types of projects as I and the 22-year-old who was born well after his or her career started. Today’s 54-year-old was born six years after the end of World War II — and today’s 18-year old was born five years after the last real economic recession, which ended in 1982.

Today’s 18-year-olds also do not remember: gas lines, inflation, fear of nuclear war, Ronald Reagan, “Tear down this wall!,” or the release of the first three Star Wars movies. They do not remember a world without a world without music CDs, VCRs, or cell-phones. Unless especially precocious, they do not remember a Democratic-controlled Congress, MS-DOS, or rotary telephones. They certainly do not remember a time when computers filled rooms; by the time they were born, computers were common in homes. By the time they started kindergarten, computers were in a huge percentage of homes and most were running Windows. They were in the 8-12-year-old bracket when e-mail was becoming commonplace among the general public. That’s the age bracket when most people in my generation started getting permission to dial the phone and call our friends. For all practical purposes, today’s 18-year-olds don’t know a world without the internet. They also do not remember any of these events.

Likewise, I imagine today’s 54-year-old finds it similarly striking that those my age do not remember: Vietnam, the draft, John Kennedy, Elvis, hippies, Watergate, or the Moon landing — despite the special connection I’ve always felt to the first Moon landing given it’s proximity to my birth and the fact that my parents told me I was there “watching” it on TV as an infant.

The people graduating this month were born when I was the age they are now. They have
experienced more changes in themselves in the last 18 years than I have. Have I grown as much in the last 18 years as they have? I don’t think so. I certainly haven’t changed as much in the last 18 years as in the previous 18. (Think about this — it’s impossible.)

As we get older, time seems to go faster. I don’t know when I first noticed this, but the older I get, the more convinced I am that it’s true. My grandmother, who is now 94, confirms this — it seems to go faster and faster as you get older. Someone I knew in 10th grade said his father had this theory that any particular length of time “feels” long or short based on the percentage of your life it makes up until that point. Thus, a year or a day or an hour at age 36 feels have as long as the same length of time at age 18. I don’t know how we could ever prove it, but that sounds eerily right to me now.

I have been thinking about all this for the past month and a half or so. (I was going to type this in weeks ago, but got busy). Last week, I saw someone I know from high school (even middle school) who I don’t see all that often — in particular, we’ve seen each other twice, maybe three times since I graduated 18 years ago. I did the math and realized that we are more than twice as old as when we first met (an even which I must admit I don’t remember). If you are 18 and you’ve seen someone twice in the last 18 years, you’re strangers. If you’re 36 and you’ve seen someone twice in the last 18 years, you might count as old friends.

She was about to get married (and presumably did so over the weekend), and is hoping for babies very soon. Her children will not remember a world without e-mail, September 11, 2001, or getting on a plane without taking your shoes off. They might know what a VCR is, but they’ll probably never use one on a daily basis. (By the time they’re old enough, recordable DVDs — or the next similar thing — will be as common as VCRs were 10 years ago.) To them, perhaps, the term “Arab democracy” may not be an oxymoron or an innovation. They may never meet anyone who fought in World War II, at least not at an age when they will be old enough to remember it. They will not — unless the mood of the country changes drastically for the worse, which is possible but I think unlikely — remember a time when it was at best uncool and at worst an act of defiance to fly an American flag on one’s home. They may not even remember Fidel Castro. (I can hope, can’t I? ;-) )

The world changes, and it changes quickly. An individual’s life passes very quickly. Make the most of it!

Grand Rounds XL is up

Filed under: — Different River @ 12:00 am

Grand Rounds XL is up, hosted at the Health Business Blog — an interesting blog which I’ve just discovered, and will no doubt be reading regularly and quoting from.

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