Oh, and about those wait times for medical treatment. . .

When all their other arguments about the advantages of the current US health care system compared to universal, single-payer systems in France, Canada, England, Germany, etc. are shown to be false, apologists for the US health care system turn to their trump card: alleging that wait times to see a doctor in those countries is longer than it is in the US. This statement by the lobbying group America’s Health Insurance Plans is typical: “The American people do not support a government takeover of the entire health-care system because they know that means long waits for rationed care.”

The problem with this type of allegation is that the US does not systematically collect data on wait times, whereas the other countries do collect the data and make them public. The assumption seems to be that in the US, if there is no data, then the wait times must be zero. No data, no problem!

But using the scant data that is available, BusinessWeek points out that except in a few selected, non-emergency situations, even this charge is false: “In reality, both data and anecdotes show that the American people are already waiting as long or longer than patients living with universal health-care systems.”

As Paul Krugman points out in his New York Times July 16, 2007 column:

[B]y and large, opponents of universal health care paint a glowing portrait of the American system that bears as little resemblance to reality as the scare stories they tell about health care in France, Britain, and Canada.

The claim that the uninsured can get all the care they need in emergency rooms is just the beginning. Beyond that is the myth that Americans who are lucky enough to have insurance never face long waits for medical care.
. . .
[N]ot all medical delays are created equal. In Canada and Britain, delays are caused by doctors trying to devote limited medical resources to the most urgent cases. In the United States, they’re often caused by insurance companies trying to save money.

This can lead to ordeals like the one recently described by Mark Kleiman, a professor at U.C.L.A., who nearly died of cancer because his insurer kept delaying approval for a necessary biopsy. ”It was only later,” writes Mr. Kleiman on his blog, ”that I discovered why the insurance company was stalling; I had an option, which I didn’t know I had, to avoid all the approvals by going to ‘Tier II,’ which would have meant higher co-payments.”

He adds, ”I don’t know how many people my insurance company waited to death that year, but I’m certain the number wasn’t zero.”

(You can read about Kleiman’s plight here, which occurred despite having what he calls “fancy-dancy health insurance through my employer, which as it happens also owns one of the world’s dozen best medical centers”.)

And what about that favorite of US health care apologists, the waiting time for hip replacements? Krugman looked at that too:

On the other hand, it’s true that Americans get hip replacements faster than Canadians. But there’s a funny thing about that example, which is used constantly as an argument for the superiority of private health insurance over a government-run system: the large majority of hip replacements in the United States are paid for by, um, Medicare.

That’s right: the hip-replacement gap is actually a comparison of two government health insurance systems. American Medicare has shorter waits than Canadian Medicare (yes, that’s what they call their system) because it has more lavish funding — end of story. The alleged virtues of private insurance have nothing to do with it.

Krugman’s conclusion is right on target:

The bottom line is that the opponents of universal health care appear to have run out of honest arguments. All they have left are fantasies: horror fiction about health care in other countries, and fairy tales about health care here in America.


As usual, cartoonist Tom Tomorrow succinctly captures how the media is colluding with the administration in fanning the flames for war with Iran, exactly the way it did with Iraq.

Evolution-11: The rise of population genetics and the neo-Darwinian synthesis

(Please see here for previous posts in this series.)

The joining of Darwin’s theory of natural selection with the Mendelian theory of genetics is one of the great triumphs of biology, now called somewhat grandly the ‘neo-Darwinian synthesis’. It forms the basis of all modern biology, and was strengthened by the discovery of DNA as the structure of genetic information and which explained how Mendelian genetics worked on a microscopic scale. The modern ability to map out the entire genome of humans and other species has produced overwhelming evidence in support of Darwin’s theory of how organisms evolve and branch out into different forms. The rough tree of life that Darwin sketched out in his book based on the anatomy of biological species has now been made more precise and detailed by the mapping of the DNA of species, showing ever more clearly how species are related to one another and when they separated from a common ancestor.

Mendel showed that genes were discrete objects that retained their identity as they were handed down from generation to generation and that thus any changes in genes, however small, did not get blended away in a regression towards the mean. So you would have thought that the rediscovery and rapid popularization of Mendel’s ideas in 1900 would have signaled a resurgence of Darwin’s idea that natural selection worked on very small, almost continuous changes, and the defeat of those who argued that one needed discontinuous changes for evolution to occur.

Ironically, the exact opposite happened. Because Mendelian genetics was a discrete mechanism with the genetic information seeming to occur in small lumps that remained intact, it superficially seemed to support the discontinuous model of natural selection, and the proponents of discontinuous changes were able to co-opt Mendel’s theory to their cause. By around 1908 or so, it seemed like Darwin’s own favored model of small continuous changes leading to large changes was in almost total retreat, actually doomed by the arrival of Mendel. While there was a sprinkling of mathematicians like Udny Yule (what a wonderful name!) who argued that Mendel’s theory was compatible with Darwin’s model of continuous evolution, their voices were lost in the volume of controversy generated by the competing biological schools. (The Origins of Theoretical Population Genetics, William B. Provine, 2001, p. 85)

Part of the problem was that scientists were still struggling to understand the workings of both Darwin’s theory and Mendelian genetics and many misunderstanding of each were then prevalent. For example, one thing that was puzzling about genetics (and puzzled me for a long time too) was this whole business of dominant and recessive genes and how it affected population distributions.

It was Mendel’s work that argued for the existence of these two types of characteristics, the actual mechanism of which became better understood with the discovery on DNA and increased understanding of the way that chromosomal information was handed down from parent to child.

Simply put, each person has pairs of genes, one from each parent on the respective inherited chromosome. To be concrete, we can look at the gene for eye color. Each gene may be of a dominant type (denoted by A, for say brown eyes) or a recessive type (denoted by a, for say blue eyes). So a person would have one of the pairs AA, Aa, or aa on the pair of chromosomes that contain the genes for eye color. Since A is the dominant one, it always wins, and so those people with either AA or Aa will have the characteristic A (brown eyes) manifest itself in their features, and only the person who has aa will display the characteristic a (blue eyes). Each parent will also have AA, Aa, or aa, and will randomly pass on just one of the pair of genes it possesses to the child.

It seems intuitive that if a population starts out with some distribution of AA, Aa, and aa types, and there is random mating in the population, then the number of people displaying the dominant characteristic A will steadily increase in the population, while the manifestation of the recessive characteristic a will decrease and perhaps eventually even disappear altogether, since only someone possessing the relatively unlikely combination aa will manifest it. Since regressive characteristics did not seem to be disappearing in real life populations, and in fact seem quite stable in their numbers, early geneticists had some doubts about whether they were interpreting Mendel’s model correctly.

But starting around 1908, things started to change as better experiments were done and more mathematical versions of the two theories started being used. Mendelian and Darwinian theories started to get quantified and people began to realize that Darwin’s version of natural selection with continuous changes was in fact compatible with Mendel’s theory. By 1918, the reversal was complete and Darwin was ascendant and has remained so ever since. This was largely due to the rise of the field now known as population genetics, whose practitioners developed mathematical models that looked at the consequences of Mendelian genetics in natural selection.

What started the shift was the result now known as the Hardy-Weinberg law, which will be discussed in the next posting in this series.

POST SCRIPT: American beliefs about evolution

Gallup has done one of its periodic surveys about Americans views on evolution

These results show that:

  • 24% of Americans believe that both the theory of evolution and the theory of creationism are probably or definitely true.
  • 41% believe that creationism is true, and that evolution is false.
  • 28% believe that evolution is true, but that creationism is false.
  • 3% either believe that both are false or have no opinion about at least one of the theories.

That first group of 24% is definitely confused, since there is no way that evolution could have occurred in the 10,000 years or less allowed by creationism. The survey creators speculate that these were people who believed that god influenced evolution and somehow wanted to incorporate that view and responded in contradictory ways depending on which question was asked.


  • The reasons for rejecting evolution were mostly religious.
  • The more regularly you attended church, the less likely you were to believe in evolution.
  • Republicans were less likely to believe evolution (30%) than Democrats (57%).


It is apparent that many Americans simply do not like the idea that humans evolved from lower forms of life. This appears to be substantially based on a belief in the story of creation as outlined in the Bible — that God created humans in a process that, taking the Bible literally, occurred about 10,000 years ago.

Hidden costs of US health care

(For previous posts on the topic of health care, see here.)

In my previous posts following on the film Sicko (Haven’t seen the film yet? It is well worth it.) I have been focusing on the tangible costs and benefits of the US health care system compared to those of other developed countries, and showing why the US system comes out badly in comparison. The chief culprit is the insertion of profit-making private health insurance companies between the patient and health care providers, creating an immediate trade-off between profit and providing care that is detrimental to the latter.

But there are several intangibles that are also important. The main one is that having one’s health insurance tied to one’s place of employment highly distorts the basis on which people make important life decisions. Right now, many people make decisions of what job to take and where to live based on the health care provided by employers. People with families and young children are especially caught in a bind. Some people spend their entire lives in dead-end jobs that they hate, trapped because of the fact that they cannot afford to leave and lose the health benefits. This is especially so if they or a member of their family has a health problem that becomes a non-covered ‘pre-existing condition’ in their new workplace, and thus denied coverage, at least for a limited time.

What is the cost of this? For one thing, it discourages entrepreneurs and freelancers. A person who wants to quit his or her job to start their own business or implement an innovative idea is strongly discouraged from doing so, especially if they have families. Not only is the cost of purchasing private insurance for themselves prohibitive, so is the cost for providing it for their employees. In 2004, the average cost of health insurance for family coverage was $9,950, which means that it is likely to be around $12,000 in 2007. This is close to the amount earned annually by a full-time minimum wage worker. How many business ideas have never seen the light of day, how many jobs never created, because potential innovators just could not bring themselves to risk the health of their families by leaving their jobs?

Health insurance tied to businesses also discourages the creative arts. Painters, writers, sculptors, poets, actors, dancers, and musicians are people who add enormously to the quality of life of a community. A community that has a vibrant arts community is one that is lively and healthy. Most artists do not go into it for the money (although they have dreams of their work becoming widely recognized someday) but because they really love what they do and are willing to suffer some hardship for it. They are willing to forego luxuries and live fairly Spartan lives with respect to housing, food, clothing and the like, just to have the opportunity to create art. Many are willing to take part-time jobs to cover life’s essentials so that they have the time and freedom to devote to their passion. But the biggest single expense for such people is the cost of buying health insurance as private individuals. Many simply do not do so, gambling that they will not get very sick.

Then we have young people, straight out of high school or college who may want to experience a carefree life for at least a short time before settling down, and maybe travel around this vast country doing various jobs, seeing new things, meeting new people, and learning about the various communities they pass through. Maybe they want to work in underprivileged areas. Right now, the only way to safely do that is to do it through an organization that provides health insurance. If they go on their own, they have to buy expensive private health insurance or take the risk that they will not need health care. Even for the volunteer organizations that provide health insurance, providing it is a big headache and expense.

Then there is the problem of transitioning between jobs and between school and jobs. There are often gaps between the times when students leave college and start their first jobs. Because they have left school, they no longer are covered by their family or school health insurance policies. They have to shop around for some coverage for the transition period until they get their first job. People who have a gap when they move from one job to another can sometimes use COBRA coverage during the transition.

Even people who like their jobs and have health insurance plans to choose from (the so called ‘lucky ones’) face all kinds of irritations. The family may select an insurance plan and from it choose pediatricians for their children, an internist for the parents and a gynecologist for the mother, all within that one plan. The next year, they are likely to find that some of the physicians are now on different plans. So you have to repeat the process of comparing health care plans, weighing the costs and benefits, comparing physician lists, and trying to figure out who and what to keep and to jettison. This has to be done every year. And then you have to keep track of all the paperwork and receipts and co-payments. I think people have got so beaten down that they simply do not realize how much time goes into taking care of all these details. It is only when they get drawn into the bureaucratic nightmare that results when coverage is denied or some major illness strikes that they realize what a crazy system they are in.

Why have people in the US become so numb and accepting of this state of affairs? In surveying the responses to the film Sicko, James Clay Fuller makes a good point:

Not one mentions the comments by Tony Benn, a former member of Britain’s Parliament. Yet Benn’s statements probably are the most profound element of the film.

He notes, as other good people often do, that “if we have the money to kill (in war), we’ve got the money to help people.”

But, more importantly, Benn tells Moore, that all of Europe and many other places have good health care systems while the United States lacks such a basic service because in Europe and elsewhere, “the politicians are afraid of the people” when the people get angry and demand some action. In the United States, he observes, “the people are afraid of those in power” because they fear losing their jobs, fear being cut off from health care or other services if they speak up and make demands.

“How do you control people?” Benn asks, and he answers: “Through fear and debt.”

His point is that in the United States we have a great overabundance of both.

When are people going to get angry enough to say “We’re mad as hell and we’re not going to take it anymore”?

POST SCRIPT: The invertebrate Congress

On Bill Moyers’ show, Conservative Bruce Fein argues why Bush should be impeached and criticizes a spineless Congress for not doing so, and John Nichols (author of the book The Genius of Impeachment) agrees.

Here is a transcript.

Another conservative Paul Craig Roberts (Assistant Secretary of the Treasury in the Reagan administration and former Associate Editor of the Wall Street Journal editorial page and Contributing Editor of National Review) has also called for the immediate impeachment of both Bush and Cheney.

The idea of impeachment was inserted into the US constitution as a vital check against the president assuming dictatorial powers akin to those of a king. It was almost tailor-made to deal with situations like that which currently exists. But the Democratic Party leadership seems unwilling to do this.

Evolution-10: The debate over natural selection in Darwin’s own time

(Please see here for previous posts in this series.)

In Darwin’s own time, there was a three-way dispute concerning the theory of evolution. Strange as it may sound these days in the US where so many question whether evolution even occurs at all, the idea that evolution had occurred and new species were being created and old ones dying out was not such a major problem in the mid-to-late 19th century. Elite opinion of that time had been exposed to that idea and had accepted it even before Darwin because of all the fossil records that were being discovered all the time. Even Darwin’s own grandfather Erasmus Darwin, a freethinker, had around 1795 published a book Zoonomia that had floated the idea that species had evolved, but he used a Lamarckian model. What religious people mostly shied away from was the idea that human beings were also part of the evolutionary process and shared common ancestors with other species, a reluctance that still persists.

In Darwin’s time what the dispute mainly centered on was the mechanism of evolution and how it operated.

Apart from Biblical literalists and believers in special creation, there were those of a religious bent who argued that god had to intervene somehow at least occasionally to create new species (especially humans) and this view persists down to this day among people who seek a tangible role for religion. At the very least, believers in an immortal soul needed a god to insert it into humans at some point in that person’s development.

But the more interesting dispute was among those scientists who were not invoking religious ideas. Their dispute centered on the scale of the mutations necessary for natural selection to work.

Due to all the buffeting that Darwin’s theory had received from those who argued that the age of the Earth was too short for evolution to have occurred and that mutations would get blended away, in the later editions of his book, Darwin himself started qualifying some of the more ambitious claims that he had forthrightly stated in the 1859 edition. As a result, his later editions lost some of the directness and clarity of his first edition, and scholars now recommend reading the first edition as being the best. I personally found it a fascinating book, remarkably accessible to the layperson.

For example, his first edition contained a rough estimate by him, based on geological phenomena he observed in England, that the Earth was about 300 million years old, which was in his view sufficient time for evolution to have occurred. He arrived at this by assuming that the Weald, a valley in the south of England, had been created by erosion that had always occurred at the same rate it was occurring now. He removed this claim in later editions, presumably due to unease over physicist William Thomson’s calculations that the Earth was only 30 million years old. As it turns out, Darwin had no need to be worried since the current age of the Earth is calculated to be more than ten times his own estimate.

But while willing to give ground on some peripheral issues, Darwin steadfastly stuck until his death (in 1882) to one central idea, and that was that natural selection was able to act on even extremely small advantages in the fitness of some organisms, causing them to grow in the population, and that it was the cumulative effect of these minute changes that led to new species.

Contrasted with Darwin’s continuous model of change were those scientists (including even Darwin’s staunch defender and ally Thomas Huxley) who argued that natural selection could not really work with very tiny changes because they would get washed away because of blending inheritance. These people argued in favor of a discontinuous model which only valued those mutations that produced significant changes in the organism that represented a new and stable phenotype whose qualities were robust enough that they would not get blended away by breeding.

To better understand the difference, compare a sphere and (say) a twenty-sided die, which is almost a sphere, both resting on a table. The sphere can be shifted by any small amount and would stay in that new position. The die on the other hand, if tilted slightly and released, would revert to its original position unless the tilt were sufficient to topple it to rest on the adjacent flat face. Then it would be stable in the new position and would resist any further shift, even back to its original state. One faction led by Darwin was arguing that natural selection could act on the continuous changes represented by the sphere while others said that only the changes beyond a certain critical amount and represented by the die were stable enough for selection to work on.

It must be emphasized that both sides supported the mechanism of natural selection for driving evolution. They simply disagreed on its ability to act on very small changes. While we may think that this was a small issue to disagree on, in actual fact the debate was fierce and very acrimonious, with both sides trying to marshal evidence for their side and picking holes in the evidence of their opponents. William B. Provine in his book The Origins of Theoretical Population Genetics (2001) gives a fascinating account of this controversy, the personalities involved, and the heated nature of the exchanges, which grew increasingly bitter by the time 1900 rolled around.

The rediscovery of Mendel’s work on genetics (he was a monk who lived from 1822-1884 and published his major work in 1865, but it remained obscure until it was rediscovered in 1900) provided new fuel to the controversy. Scientists quickly recognized the significance and importance of Mendel’s work. While Mendel’s model was accepted as having finally produced the correct theory of how inheritance works, this did not immediately resolve the dispute because there was still disagreement about what Mendel’s theory actually implied and how it fitted into Darwin’s theory.

Next in this series: The synthesis of Mendelian genetics and natural selection.

POST SCRIPT: Why a secular public sphere works best

As I understand it, both US houses of Congress open with a ceremonial prayer which hardly any members bother to attend. Although each house has an official chaplain, it has become the practice to make this event more inclusive and ecumenical by having people of diverse faiths give the prayer.

For the first time last week, a Hindu was invited but his prayers were disrupted by hecklers from a Christian group, who saw this as an affront to their own god. See the video here.

Steve Benen provides some background on what happened.

Interestingly, some Christians see the saying of Hindu prayers in Congress as a sign that the end of the world is almost upon us, and their anger about this act of sacrilege is mixed with eager anticipation at seeing Jesus any day now.

One doesn’t know whether to laugh or cry. I think I’ll laugh.

Evolution-9: Early challenges to Darwin’s theory

(Please see here for previous posts in this series.)

In an earlier post in this series, I listed the three stages involved in natural selection, each of which seemed to have seemingly small probabilities. In the previous post, I showed how because of the large numbers of organisms and long time scales involved, the first item got converted into a very high probability event.

The next item in the list, the issue of how a mutation with a small advantage in the properties of an organism can end up with that property dominating the species, was both Darwin’s greatest challenge and his greatest triumph.

The triumph came from a crucial insight that Darwin had concerning the importance of varieties within species. Recall that Platonic ideas were dominant at that time, and that laid the emphasis on the idealized forms of things. So for example while a real triangle drawn on paper would contain imperfections, these were considered incidental, the drawing being a mere approximation to the idealized triangle that one could envision in some abstract space.

In Darwin’s time, the biological equivalent of this thinking was that while it was plain to see that (say) chickens were different from one another in small ways, these differences were not considered important. They were considered mere approximations to an idealized chicken that represented the essence of chickenhood (so to speak), and it was the latter that was important.

But Darwin realized that the variety that he saw in species, rather than distracting from an understanding of the ideal, was important in its own right. In fact, he recognized that the diversity within a species was so vast that it was often hard to say what was a variety within a species and what was a different species altogether. As he wrote, “[I]t will be seen that I look at the term species, as one arbitrarily given for the sake of convenience to a set of individuals closely resembling each other, and that it does not essentially differ from the term variety, which is given to less distinct and more fluctuating forms” (Charles Darwin, On the Origin of Species (1859) p. 52). It was this wide variety that allowed some animals to survive better than others and was the driver of natural selection. The existence of variety lay at the heart of his theory.

(The problem with all classification schemes is that it is often impossible to specify both necessary and sufficient conditions to make unerring judgments as to which category some organism belongs. The fact that there is often no sharp line that can be drawn between varieties within species and differences between species should put to rest the artificial distinction made by intelligent design creationists who say they have no trouble with what they call ‘microevolution’ (what they define as change within a species) but cannot accept ‘macroevolution’ (the creation of new species). This is a distinction without much merit.)

But Darwin faced a serious problem. Even though people might accept his idea that one variety of an species might be more suited to survive than another, the lack of a real understanding at that time of the mechanism of inheritance worked against him. It was believed that sexual reproduction resulted in features being mixed (called ‘blending inheritance‘), with the child of parents being intermediate in terms of properties such as height, skin color, etc. Hence even if an occasional particular mutation had better chances for survival, it was believed that its advantageous properties would soon get diluted and disappear by mating with those animals that did not have this same property. This is the well-known phenomenon of ‘regression towards the mean,’ first articulated by the polymath Francis Galton, a cousin of Darwin.

In artificial breeding one could avoid this blending outcome by simply restricting the breeding of animals to those organisms with the desired properties and thus preserve and enhance desired changes. But in the wild, organisms would mate more indiscriminately and this raised the question of how advantageous mutations could be preserved.

Around the same time that Darwin’s theory was already reeling from estimates of a short age of the Earth from William Thomson (aka Lord Kelvin), Fleeming Jenkins wrote a long article in 1867 criticizing Darwin’s theory on precisely the blending inheritance issue. In addition, the co-discoverer of natural selection Alfred Wallace (who had initially been seen as an even more zealous advocate of natural selection than Darwin) had become interested in spiritualism and in 1869 unexpectedly published a paper in which he asserted that natural selection, although it could explain everything else, couldn’t account for the human brain, and he even went so far as to espouse an early version of intelligent design creationism saying that while the living world is governed by laws, “an Overruling Intelligence has watched over the action of those laws, so directing variations and so determining their accumulation” in order to produce the wonderful thing that is the human brain (David Quammen, The Reluctant Mr. Darwin (2006), p. 215). (The idea that the workings of the human brain, and that the mind and consciousness lie outside the realm of natural selection and the laws of biology, is something that persists down to this day, a topic I will examine in the future when I look at what we are now learning about the nature of consciousness.)

There was nothing much that Darwin could do about Thomson’s criticism but hope that someone else would prove the physicist wrong, which did happen with the discovery of radioactivity in the first decade of the 1900s. There was also nothing that Darwin could do about Wallace going against one of the fundamental precepts of natural selection, although Darwin felt that the whole idea of natural selection was meaningless if an outside ‘intelligence’ could drive organisms towards a pre-ordained result. Darwin simply wrote “No!!!” in the margins of Wallace’s paper.

As for Jenkins’s criticisms, Darwin had not been unaware that this would be a problem for his theory and had tried to anticipate it by suggesting that successful mutations would take hold in only those cases where the mutations appeared concurrently in numerous individuals and that these would then breed with each other, allowing that variety to grow and take root in the population. (Quammen p. 212)

Darwin’s defense was not very persuasive but it was all he had. Although the real defense against Jenkins’s critique was already at hand in the form of Mendel’s theory of genetics (which showed that genes are discrete entities that remain intact on breeding and do not get blended away), Mendel’s work was not widely known at that time and Darwin’s theory had to wait until its rediscovery in 1900 to fully overcome objections of the type put forward by Jenkins.

Darwin the man and the scientist are fascinating character studies. He was painstakingly thorough in his work and conscientious about the need to amass evidence to buttress the main argument he was making. But once he felt convinced by the evidence that the theory of natural selection was sound, he was determined. While he was willing to give ground on the periphery of his theory, he was firm in his commitment to its core ideas, and one of these was that his theory would make no sense if you allowed an outside agency (an ‘intelligence’ or whatever name you gave to a god-like power) to intervene in the process at any time in any way. He was a methodological naturalist, a necessary condition for any good scientist.

But it is a very thin line that separates methodological naturalism from philosophical naturalism (or atheism) and this, at heart, which is why Darwin’s theory is so subversive to beliefs about god.

Next in this series: The debate over natural selection in Darwin’s own time

POST SCRIPT: Science? Evidence? Who cares?

In congressional testimony this week, outgoing US Surgeon-General Richard Carmona spoke of how in the Bush administration, ideology trumped science every time, with constant political interference muzzling him on scientific issues like embryonic stem cell research. He said, “Anything that doesn’t fit into the political appointees’ ideological, theological or political agenda is ignored, marginalized or simply buried.”

His testimony reminded me of this Tom Tomorrow cartoon from February 27, 2007.

Meanwhile, Secretary of Homeland Security Michael Chertoff’s extraordinary statement, also this week, that he felt ‘in his gut’ that a terrorist attack might occur in the US this summer reminded me of astronomer Carl Sagan’s reply when an interviewer pressed him for his ‘gut feeling’ as to whether there was life elsewhere in the universe. Sagan replied, “But I try not to think with my gut. Really, it’s okay to reserve judgment until the evidence is in.” (Richard Dawkins, The God Delusion, p. 47.)

Chertoff would be well-advised to follow Sagan’s advice.

How universal single-payer systems protect us against catastrophes

(For previous posts on the topic of health care, see here.)

I think almost everyone across the political spectrum would concede the fact that the fifty million Americans currently without health insurance would definitely benefit from the adoption of a universal, government-run, single-payer health care system. The reason that it has not been adopted is that many of the remaining 250 million have been frightened into thinking that their medical coverage would decline from what they have now.
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Evolution-8: The sufficiency of the mutation rate

(Please see here for previous posts in this series.)

One of the challenges faced by Darwin was whether the rate at which mutations creating new favorable varieties would occur was sufficiently rapid for his purposes. Since during his time the laws of inheritance were not known and neither was the mathematics involved, advocates of natural selection had to assume that things would work out eventually.

In his excellent book The Making of the Fittest (2006), Sean B. Carroll demystifies the various numbers and calculations involved in natural selection using our current knowledge.

Recall from the previous post in this series that DNA is made up of a string of bases A, C, T, and G. New genetic information is created when there is a change in the DNA and the most basic (but not the only) way that this can occur is by mutations acting at the level of a single base site in the DNA, changing one of the bases A, C, T, and G to a different one.

This long string of bases that constitute DNA is split into chromosomes. As one travels down the length of a chromosome, one encounters strings of bases that are called genes and these contain the code for manufacturing the vital proteins. Proteins are made up of strings of amino acids and the genes specify the arrangement of amino acids that are to be lined up, one after another, in each protein. The code for specifying which amino acid is to be added on is made up of three consecutive base sites, each triplet being either a code for one of the twenty amino acids or a code to stop the manufacturing process and release what has been created so far. Think of the whole process as a tape recorder with the DNA string being the tape being read and the tape recorder as a machine that produces the amino acids depending on what it reads in sequence on the tape.

There are 64 possible combinations of three sites made up of four distinct bases (64=4x4x4). But since there are only twenty amino acids, this allows for some redundancy to be built into the system. For example, the amino acid serine is coded for by any of the six triplets TCT, TCC, TCA, TCG, AGT, and AGC, while the amino acid cysteine is coded for by just two triplets TGT and TGC. The three triplets TAA, TAG, and TAA represent the ‘stop’ code that says that the process of adding on amino acids is to be halted and the completed molecule released into the body.

Because of this redundancy, some random single site mutations (say from TCT to TCG) will have no effect on the coding of the amino acid or the resulting protein. This is a good thing since it reduces the chances of the production of ‘good’ proteins being destroyed by a random mutation. Alternatively, a single base switch from TGT (cysteine) to TGA (stop) will result in the protein manufacture being prematurely halted and could be calamitous for the organism.

But if there is a random mutation at a single site that changes AGT to TGT, then we see that a cysteine amino acid will be added on instead of a serine in the creation of the protein. It turns out that which of these two codes for amino acids occupies the sites numbers 268-270 of the gene to produce an opsin protein determines whether the organism’s eye is sensitive to violet light or to ultraviolet (UV) light. Certain birds (ducks and ostriches) are sensitive to violet while others (zebra finch, herring gull, budgerigar) are sensitive to UV light. There are four different orders of birds that contain both violet or UV sensitive species, suggesting that this switch between base A and base T in location 268 of this opsin gene has occurred on at least four different occasions in evolutionary history. Given that there are over one billion base sites in the genome of birds, is this switch in one particular site likely to occur even once, let alone on four different occasions?

The instinctive conclusion is of course ‘very unlikely’, but Carroll (p. 156-158) says we need to get beyond that initial guess and actually crunch the numbers to see what is involved, taking into account the size of populations and the long time scales involved.

The per site rate of mutation averages between 1 per 500,000,000 bases in DNA in most animals – from fish to humans. This means that the exact A in position in position 268 in one copy of the bird SWS [short wavelength sensitive] opsin gene will be mutated, on average, about once every 500 million offspring. It has two copies of the gene, so this cuts the average to 1 in 250,000,000 chicks. However, there are three possible kinds of mutations at this site: A to T, A to C, and A to G. Based on the genetic code, only the A to T mutation will create a UV-shifting cysteine. If the probability of each mutation is similar (they aren’t but we can ignore the small difference), then one out of three mutations at this position will cause the switch. One A to T mutation will occur in roughly 750,000,000 birds (that’s 750 million).

Seems like a long shot?

Not really. It is important to factor in the number of offspring produced per year. According to long-term population surveys, many species consist of 1 million to more than 20 million individuals. With annual reproduction, a plentiful species like herring gull will produce at least 1 million offspring in a year (probably a very conservative number). Divide this into the rate of one mutation per 750 million birds; the result is that the serine-to-cysteine switch will arise once every 750 years. This may seem like a long time in human terms but we need to think on a much longer timescale. In 15,000 years, a short span, the mutation will have occurred 20 separate times in this species alone.

The four orders that these birds belong to are ancient – their ancestors have had tens of millions of years to evolve UV or violet vision. At the rate calculated in gulls, the A to T mutation will occur more than 1200 times in 1 million years in just this one species. Getting the idea?

Steve Jones (Almost Like a Whale, p. 149) estimates that among domestic cats there occur around 200,000 genetic changes each year in London alone. He adds, “Worldwide, any mutation is almost a certainty. If it is useful it will at once be picked up by natural selection.” He also discusses (p. 176) how a mutation in a single base site (similar to the serine to cysteine switch) enables the bar-headed goose better able to bind oxygen to haemoglobin and thus enables it to migrate at an altitude of over five miles (i.e., the height of Mount Everest), a height where humans would collapse and die within a few hours.

So small probability events cannot be considered in isolation. When factored in with large populations and long time scales, they not only become likely, they become almost inevitable.

But changes in single sites are not the only way that changes in DNA occur. They can also occur when entire chunks of the DNA molecule are changed during reproduction in the formation of the sex cells (meiosis) because of copying errors, duplication, recombination, insertional mutations, transposition, and translocation. (See here for fuller descriptions for some of these mutations.)

For example, humans have three kinds of opsin genes that code for three different proteins that are important for color vision. LWS [long wavelength sensitive] opsin enables us to see in the long-wave or red portion of the spectrum of light, MWS enables us to see in the medium-wave or green portion of the spectrum, and the already mentioned SWS type works for the short wave or blue region. It is the presence of all these three opsin proteins that gives us the full color spectrum vision humans enjoy. We share this ability with colobus monkeys, chimpanzees, and other primates such as all apes and all African and Asian monkeys.

But most other mammals have only dichromatic vision, having only two (SWS and MWS) opsin genes and consequently seeing only blue and yellow. They cannot distinguish between red and green. How humans and other primates achieved tricolor vision is by one of the dichromatic genes (the entire gene, which can consist of hundreds of thousands of bases) being erroneously duplicated during the copying process, resulting in three genes being created, and then one of the duplicate genes later undergoing changes in its bases similar to the way the violet-to-UV switching occurred, resulting in the creation of red-sensitivity in our eyes. (Carroll, p. 97)

But although this calculation shows that favorable mutations are by no means as rare as one might naively think, and are in fact quite likely when the large size of populations and long times are taken into account, how likely is it that a mutation that occurs in a single organism will succeed in ending up dominating the species? After all, even a few hundred mutations in a population of millions may not seem like a significant amount.

That question will be examined in the next posting in this series.

POST SCRIPT: Michael Moore blasts CNN and Wolf Blitzer

Michael Moore goes on CNN and blasts Wolf Blitzer and their resident medical apologist for the health industry Dr. Sanjay Gupta for effectively acting as shills for the medical industry, not to mention their abandonment of any real journalism prior to the invasion of Iraq. This is a must-see video.

Moore followed up with a detailed analysis of Gupta’s shallow reporting.

Time for ‘socialized’ medicine in the US?

(For previous posts on Sicko and the merits of a government-run, universal, single payer health care system, see here and here.)

Michael Moore’s excellent film Sicko has cinematically exposed the deep flaws of the US health system. His film scarcely touches on the awful plight of the 50 million people who have no insurance at all. That would have been bad enough but instead he sought to highlight the plight of those who do have health insurance and think they are secure, but discover to their horror that their insurance companies let them down in their moments of greatest need.

He emphasizes the fact that when you introduce profit-making entities in between the patient and the health care providers, you have guaranteed that attempts will be made to deny health care as much as possible. The insurance companies actually have employees whose task is to dig deep into your past to see if they can find anything, anything at all, that would enable them to invoke the fine print in their policies and deny coverage. Hence many people receive nasty shocks that they are not covered just as they are reeling from the discovery that they have a serious illness.

And this is why in the US you have a system in which the minority who are rich and powerful and influential have access to very good health care because they are in a position to create trouble for the insurance companies, while the vast majority are vulnerable to finding out that getting ill can mean ruin.

One of the curious things about the health care debate in the US is that the opponents of a government-run, single payer, universal health care system try to portray it as this mysterious, unknown, complicated, untried, massively bureaucratic, expensive system that one should not experiment with.

This is ridiculous. It is the system in the US that is mysterious, complicated, massively bureaucratic, and expensive. Government-run, universal, single payer systems are the norm in the developed world and in many countries of the third world. There are any number of working models that have been in existence for over half a century for which cost-benefit analyses exist and the operating structures are well known. It is the US, almost in isolation, that has a bizarre, labyrinthine, bureaucratic, and expensive system.

The basic concept of how single payer health care works is very easy to understand as this wonderful little animation illustrates. What is needed is to select the model that might adapt best to the US and modify it to meet our needs. The only difficulty to doing that would be to combat the vested interests of the health insurance and drug interests who will fight tooth and nail to keep making massive profits off the sickness of people.

Even magazines like BusinessWeek concede that the French system is superior to the US:

In fact, the French system is similar enough to the U.S. model that reforms based on France’s experience might work in America. The French can choose their doctors and see any specialist they want. Doctors in France, many of whom are self- employed, are free to prescribe any care they deem medically necessary. “The French approach suggests it is possible to solve the problem of financing universal coverage…[without] reorganizing the entire system,” says Victor G. Rodwin, professor of health policy and management at New York University.
. . .
France also demonstrates that you can deliver stellar results with this mix of public and private financing. In a recent World Health Organization health-care ranking, France came in first, while the U.S. scored 37th, slightly better than Cuba and one notch above Slovenia. France’s infant death rate is 3.9 per 1,000 live births, compared with 7 in the U.S., and average life expectancy is 79.4 years, two years more than in the U.S. The country has far more hospital beds and doctors per capita than America, and far lower rates of death from diabetes and heart disease. The difference in deaths from respiratory disease, an often preventable form of mortality, is particularly striking: 31.2 per 100,000 people in France, vs. 61.5 per 100,000 in the U.S.

There will still be some bureaucracy because it will be needed to do all the paperwork to run the health care system. But the point is that this bureaucracy is invisible to the patients. As far as the patient is concerned, you go to the doctor and you get treated. That’s it. You do not have to fill in any forms. The paperwork goes on behind the scenes between the government, the drug companies, hospitals, and the health professionals. Even for the doctors the paperwork is simplified because they are now dealing with just a single payer of their services and don’t have to keep track of multiple health insurance companies, each of which has different rules for what they can and cannot do. This is why the entire health system in Canada has fewer workers (scroll down) to serve its population of 27 million than Blue Cross requires to service less than one-tenth that population in New England alone.

But while the surface debate is about policy, the deeper debate is about a fundamental difference in philosophy

At one extreme, there are those who take the view that it is up to each one of us to look after our own interests and feel perfectly comfortable ignoring the needs of others. Such people take the point of view that each person is responsible for their health care. The ‘free market’ should operate and people should shop around for what works for them. If they do not have the means to do so, then that is their own fault or their own tough luck. They have failed to provide for themselves and cannot expect the rest of society to look after them, except for what private charities might provide.

At the other end (which is where I am) are those who feel that when it comes to basic issues like health care, it is the responsibility of every one to look after everyone else. Decent health care is not a commodity like toothpaste to be bought and sold on the market. It is a fundamental right that everyone (especially children and the elderly) is entitled to, irrespective of their ability to pay, and should be seen as a collective social obligation. Most such systems are based on spreading risk over a large number of people and because of that principle, while there are options for people to buy supplemental insurance on the private market, there cannot be an opt out provision, just as there is no opt out for police or fire systems or trash collection or libraries or parks or all the other similar collective systems that we currently have in place.

Those who oppose single payer health care systems try to frighten people with all kinds of bogeymen. The extent to which they are willing to go sometimes reaches levels of downright lunacy. In the wake of the release of Sicko, some have even said, if you can believe it, that adopting a single payer system could result in more terrorism! There are no depths of fear-mongering to which they will not sink.

But the tried and true standby to try and frighten people is the charge that single payer systems equate to ‘socialized medicine’, as if that is an automatic disqualifier.

It is a tribute to the success of the propaganda model that simply the word ‘socialism’ strikes such fear in so many people in the US. But the fact is that the word is ill-defined in this context. There are some health care systems where the hospitals are actually run by the government, and the health care professionals are government employees. This is perhaps closest to what might be meant by ‘socialized medicine’ and is close to what England has with its National Health Service. Then there is the French system where things are a mix of public and private, and the government mainly acts as the sole entity financing the system, collecting money in the form of taxes and using that to pay for services.

If the scaremongers want to invoke the word ‘socialized’ so broadly as to mean the spreading of the risk across the whole population, then that is no strange concept to the US because then socialism is already rampant in the US.

Sometimes US ‘socialism’ occurs a highly distorted form, where the risks are spread around to everyone but the benefits accrue to a wealthy few. Consider for example the FDIC insurance that banks carry. Every person is underwriting that insurance through our taxes, but it benefits the banks and those who have money to deposit. The past US government bailouts of the auto and airline industries when they were in trouble are examples where the costs and risks are borne by all of us, but the benefits accrued to a select few. The savings and loan debacle of the 1980s was again an instance of the risks and costs being ‘socialized’ (i.e., spread over the entire population), irrespective of whether people had money in the savings and loans institutions or not.

The better form of ‘socialized’ services is where everyone pays for services and everyone also benefits, such as is currently the case in the US with ‘socialized’ fire departments, ‘socialized’ police departments, ‘socialized’ parks, ‘socialized’ libraries, ‘socialized’ trash collection, ‘socialized’ hurricane and weather forecasting, ‘socialized’ air traffic control, ‘socialized’ roads, the list goes on endlessly. All these function on the assumption that there are certain things which are a collective good, and that we all should contribute to their maintenance so that we benefit as needed. ‘Socialized’ medicine should be seen as a natural addition to such existing ‘socialized’ public services, not some strange alien concept.

No health system is perfect. There will always be people who suffer and die because of the lack of equipment or drugs or incompetence. But no one should suffer and die because of the lack of ability to pay or because of bureaucratic hurdles erected in their path in order that some people can make a profit.

In the next post in this series on Thursday, I will look at the “But I’m ok, aren’t I?” attitude that opposes change in the health care system because the speaker thinks that he or she is secure now.

POST SCRIPT: Health care industry contributions to candidates

Michael Moore is helping us keep tabs on how the health care industry is contributing money to presidential candidates of both parties.

Of course, the industry is doing this purely out of a sense of public service and for the sake of supporting democracy, and not to bribe the candidates to make sure that a government run, single payer, health care system is never seriously considered, whoever happens to win.

Evolution-7: Genes, chromosomes, and DNA

(Please see here for previous posts in this series.)

In order to understand how inheritance works and the mathematics involved, it may be helpful to have a quick summary of some basic facts about genetics (a little simplified), using the human genome for concreteness.

All the genetic information in our bodies is found in the DNA, whose famous double helix structure was discovered in 1953. Thanks to the Human Genome Project, we now have a complete map of the DNA of humans, called the human genome, and know that it consists of a sequence of 3.1647 billion sites arranged in a row, each site containing one of four complex molecules (called bases) labeled A, C, T and G. It is this long arrangement of the four bases that define each of us genetically. Almost 99.9% of the arrangement of these bases is identical in all humans, and about 98% is identical between chimpanzees and us.
[Read more…]

Discussing health care seriously

In my discussions with people on serious and controversial topics, I have some simple rules of thumb to tell me tell whether the discussion is worth pursuing or whether the other person is not serious and talking further is a waste of time.

For example, when discussing evolution, as soon as someone says something along the lines of Mel Gibson’s “If we descended from monkeys, then how come there are still monkeys? How come apes aren’t people yet?” then you know that you are dealing with someone who is either being willfully dishonest or is so ignorant of the basic facts of the topic under discussion that it is not worth continuing unless one is willing to spend a lot of time to bring that person up to speed. The wrongful use of the second law of thermodynamics is another example of a warning sign.

A similar situation applies to global warming when, during a cold or snowy spell someone triumphantly suggests that this has conclusively proven that global warming is a myth.

In discussing politics, the signal is when one makes a criticism of some action of the US government (such as its decision to ignore habeas corpus, or to invade Iraq, or its numerous covert destabilization actions in other countries) and the other person replies “If you don’t like it, then why don’t you go to Russia/France/China/Cuba/Sweden/(fill in the blank for whatever other country the speaker does not like)?”

In all these cases, the signs are clear that there has been no attempt by the other person to really engage with the issue and he or she has resorted to what he or she thinks is a clever debating point but in actuality has little or no content behind it.

In the case of the debates over the merits of a universal, government run, single-payer health care system, the signal that someone is not serious is when he or she trots out the waiting times for hip replacements in Canada as an argument about how the Canadian system is so terrible in comparison to the US. In the wake of the release of Michael Moore’s film Sicko, we can expect to see this being trotted out repeatedly, as indeed it already has.

As Kevin Drum pointed out a few months ago, the hip replacement argument is a sign of egregious cherry picking of data.

When comparing huge and complex systems like the health care or education systems in different nations, making point-to-point comparisons of isolated cases is of little use. No system is going to be better at every single thing, so this kind of debate results in each side selecting just those pieces of data to suit its purposes. There are probably some elective procedures for which there are longer waiting times in other countries than for those with high quality insurance plans in the US. It would not surprise me in the least if access to tests using expensive equipment like MRI machines is easier in the US (for those who have the requisite insurance coverage, of course) than it is for people in other countries. Health care in the US is aimed at servicing the well-to-do, because it is they who are the decision and policy-makers and as long as they are kept content, they are unlikely to want to make changes that reduce the profits of the health care industry, let alone eliminate them entirely, even if the changes benefit the general public.

One needs to look at aggregate measures to better compare quality and cost across nations. For example, the World Health Organization in 2000 put out The world health report 2000 – Health systems: improving performance in which it used the following measures for the comparison for health systems, using measures of both goodness and fairness:

  1. overall good health (e.g., low infant mortality rates and high disability-adjusted life expectancy);
  2. a fair distribution of good health (e.g., low infant mortality and long life expectancy evenly distributed across population groups);
  3. a high level of overall responsiveness;
  4. a fair distribution of responsiveness across population groups; and
  5. a fair distribution of financing health care (whether the burden of health risks is fairly distributed based on ability to pay, so that everyone is equally protected from the financial risks of illness)

Based on these criteria, according to the WHO study (p. 152), the US comes in at #37 in rank internationally, compared to France (#1), England (#18), Canada (#30), and Cuba (#39).

Michael Moore’s Sicko (which you should really see) points out that on measures like life expectancy at birth and infant mortality rates (i.e., the number of infants who die before reaching the age of one year for each 1,000 births), the US lags behind its developed world counterparts, even though its spends far more on health care as a fraction of its GDP (13.6% in 1998) than its nearest competitor Germany (10.6%). Per capita spending is also highest is the US ($4,178) with the next highest being Switzerland ($2,794).

The reason the US gets so much less for the money it spends on health care is because of the vast amounts siphoned off to the insurance and drug companies, partly due to profits and partly due to a huge bureaucracy to handle the complex billing and processing process involved with private health insurance. Such costs account for between 19.3 and 24.1% of health care spending in the US compared with between 8.4 and 11.1% in (say) Canada.

 image001.pngThere is a strong (negative) correlation between infant mortality and life expectancy, as can be seen from this graph, where each dot represents the data for a country, along with a linear regression line. The implication is clear that the best way to improve life expectancy is to reduce infant mortality. The reason that many developing countries have high infant mortality rates and resulting low life expectancy is that lack of access to clean water results in diarrhea and this leads to dehydration, which is often fatal for infants. (As an aside, the international conglomerate Nestle deserves widespread condemnation for its policy of marketing infant formula in the developing countries, despite the lack of easy access to clean water to prevent infection. Breastfeeding is always preferred except in exceptional cases, but because of the Nestle marketing campaign became perceived as inferior to formula.)

But when comparing the US to the rest of the developed world, access to clean water is not the main issue, so widespread access to health care emerges as the prime suspect for its low ranking. For example, infant mortality rates for non-whites in US cities are two to three times as high as the national average.

What really irks many people in the US about Moore’s film is perhaps not so much the adverse comparison with Canada, England and France. People who for some reason are enamored of the system here will complacently trot out once again hip replacement waiting times to claim a spurious superiority. It is the fact that among the 221 countries listed, Cuba’s infant mortality rate (6.04, rank 40) and life expectancy rates (77, rank 56) are almost identical with the US infant mortality (6.37, rank 42) and life expectancy (78, rank 45) that really rankles.

The US government’s implacable animosity to Cuba, trying to strangle its economy with boycotts and embargos and repeated attempts at destabilization and even assassination of its leaders, has to be one of the cruelest policies ever implemented towards a country that is not a threat to its security. And yet despite that deliberate attempt at destroying the Cuban economy, Cuba has managed to create a public health system that is a model for third world countries, and produces results in key indices that are comparable with the US. Cuba is legendary among third world countries in its generosity, sharing its medical personnel and expertise around the world.

Kevin Drum wonders if Moore’s use of Cuba in his film was a clever public relations strategy, knowing that it would trigger the almost reflexive anti-Cuba venom that exists in certain quarters in the US and that they would make a huge fuss, thus giving him free publicity. “Moore’s brilliance at getting his mortal enemies to do all his publicity for him is unparalleled.”

Drum may be right. In the weird media world we live in, it is not enough for Moore to accurately portray the scandal that is the US health system compared to its peer countries. That information has been out there for a long time, and ignored by the power elites. He had to create a fuss and by going to Cuba, he did so.

POST SCRIPT: This Modern World

Cartoonist Tom Tomorrow sums up the predictable responses to Sicko by the apologists for the US health care industry.