Saturday, April 18, 2009
When the CIA began what it called an "increased pressure phase" with captured terrorism suspect Abu Zubaida in the summer of 2002, its first step was to limit the detainee's human contact to just two people. One was the CIA interrogator, the other a psychologist.
During the extraordinary weeks that followed, it was the psychologist who apparently played the more critical role. According to newly released Justice Department documents, the psychologist provided ideas, practical advice and even legal justification for interrogation methods that would break Abu Zubaida, physically and mentally. Extreme sleep deprivation, waterboarding, the use of insects to provoke fear -- all were deemed acceptable, in part because the psychologist said so.
"No severe mental pain or suffering would have been inflicted," a Justice Department lawyer said in a 2002 memo explaining why waterboarding, or simulated drowning, should not be considered torture.
The role of health professionals as described in the documents has prompted a renewed outcry from ethicists who say the conduct of psychologists and supervising physicians violated basic standards of their professions.
Friday, April 17, 2009
The era of personal genomic medicine may have to wait. The genetic analysis of common disease is turning out to be a lot more complex than expected.
Since the human genome was decoded in 2003, researchers have been developing a powerful method for comparing the genomes of patients and healthy people, with the hope of pinpointing the DNA changes responsible for common diseases.
This method, called a genomewide association study, has proved technically successful despite many skeptics' initial doubts. But it has been disappointing in that the kind of genetic variation it detects has turned out to explain surprisingly little of the genetic links to most diseases.
A set of commentaries in this week's issue of The New England Journal of Medicine appears to be the first public attempt by scientists to make sense of this puzzling result.
One issue of debate among researchers is whether, despite the prospect of diminishing returns, to continue with the genomewide studies, which cost many millions of dollars apiece, or switch to a new approach like decoding the entire genomes of individual patients.
The unexpected impasse also affects companies that offer personal genomic information and that had assumed they could inform customers of their genetic risk for common diseases, based on researchers' discoveries.
These companies are probably not performing any useful service at present, said David B. Goldstein, a Duke University geneticist who wrote one of the commentaries appearing in the journal.
"With only a few exceptions, what the genomics companies are doing right now is recreational genomics," Dr. Goldstein said in an interview. "The information has little or in many cases no clinical relevance."
Unlike the rare diseases caused by a change affecting only one gene, common diseases like cancer and diabetes are caused by a set of several genetic variations in each person. Since these common diseases generally strike later in life, after people have had children, the theory has been that natural selection is powerless to weed them out.
The problem addressed in the commentaries is that these diseases were expected to be promoted by genetic variations that are common in the population. More than 100 genomewide association studies, often involving thousands of patients in several countries, have now been completed for many diseases, and some common variants have been found. But in almost all cases they carry only a modest risk for the disease. Most of the genetic link to disease remains unexplained.
Dr. Goldstein argues that the genetic burden of common diseases must be mostly carried by large numbers of rare variants. In this theory, schizophrenia, say, would be caused by combinations of 1,000 rare genetic variants, not of 10 common genetic variants.
This would be bleak news for those who argue that the common variants detected so far, even if they explain only a small percentage of the risk, will nonetheless identify the biological pathways through which a disease emerges, and hence point to drugs that may correct the errant pathways. If hundreds of rare variants are involved in a disease, they may implicate too much of the body's biochemistry to be useful.
"In pointing at everything," Dr. Goldstein writes in the journal, "genetics would point at nothing."
Two other geneticists, Peter Kraft and David J. Hunter of the Harvard School of Public Health, also writing in the journal, largely agree with Dr. Goldstein in concluding that probably many genetic variants, rather than few, "are responsible for the majority of the inherited risk of each common disease."
But they disagree with his belief that there will be diminishing returns from more genomewide association studies.
"There will be more common variants to find," Dr. Hunter said. "It would be unfortunate if we gave up now."
Early this month, Carl Joseph Walker-Hoover, an 11-year-old boy from Springfield, Mass., hanged himself after months of incessantly being hounded by his classmates for being "gay." (He was not; but did, apparently, like to do well in school.)
In March, 2007, 17-year-old Eric Mohat shot himself in the head, after a long-term tormentor told him in class, "Why don't you go home and shoot yourself; no one will miss you." Eric liked theater, played the piano and wore bright clothing, a lawyer for his family told ABC news, and so had long been subject to taunts of "gay," "fag," "queer" and "homo."
Teachers and school administrators, the Mohats' lawsuit now asserts, did nothing.
We should do something to get this insanity under control.
I'm not just talking about combating bullying, which has been a national obsession ever since Columbine, and yet seems to continue unabated. I'm only partly talking about homophobia, which, though virulent, cruel and occasionally fatal among teenagers, is not the whole story behind the fact that words like "fag" and "gay" are now among the most potent and feared weapons in the school bully's arsenal.
Being called a "fag," you see, actually has almost nothing to do with being gay.
It's really about showing any perceived weakness or femininity – by being emotional, seeming incompetent, caring too much about clothing, liking to dance or even having an interest in literature. It's similar to what being viewed as a "nerd" is, Bennington College psychology professor David Anderegg notes in his 2007 book, "Nerds: Who They Are and Why We Need More of Them": "'queer' in the sense of being 'odd' or 'unusual,'" but also, for middle schoolers in particular, doing "anything that was too much like what a goody-goody would do."
It's what being called a "girl" used to be, a generation or two ago.
"To call someone gay or fag is like the lowest thing you can call someone. Because that's like saying that you're nothing," is how one teenage boy put it to C.J. Pascoe, a sociologist at Colorado College, in an interview for her 2007 book, "Dude, You're a Fag: Masculinity and Sexuality in High School."
The message to the most vulnerable, to the victims of today's poisonous boy culture, is being heard loud and clear: to be something other than the narrowest, stupidest sort of guy's guy, is to be unworthy of even being alive.
Total drug spending in Canada is estimated to have reached $29.8 billion, or $897 per Canadian, in 2008, according to figures released today by the Canadian Institute for Health Information (CIHI). This represents an estimated annual growth rate of 8.3%, an increase that exceeds other major health-spending categories, such as hospitals and physicians. In 2008, spending on drugs accounted for 17.4% of total health spending—nearly doubling since 1985 (9.5%). Spending on prescribed drugs continues to grow faster (9.0%) than spending on non-prescribed drugs (4.6%). Prescribed drugs are estimated to have accounted for 84% of total drug spending in 2008.
"Over the last 20 years, drugs have consistently remained one of the major cost drivers in health care," says Michael Hunt, Manager of Pharmaceutical Programs at CIHI. "Spending on pharmaceuticals has more than doubled over the past 10 years, outpacing growth in health spending by hospitals, physicians and other health professionals."
Here's something that has gotten lost in the drive to institute universal health insurance: Health insurance doesn't automatically lead to health care. And with more and more doctors dropping out of one insurance plan or another, especially government plans, there is no guarantee that you will be able to see a physician no matter what coverage you have.
Consider that the Medicare Payment Advisory Commission reported in 2008 that 28% of Medicare beneficiaries looking for a primary care physician had trouble finding one, up from 24% the year before. The reasons are clear: A 2008 survey by the Texas Medical Association, for example, found that only 38% of primary-care doctors in Texas took new Medicare patients. The statistics are similar in New York state, where I practice medicine.
More and more of my fellow doctors are turning away Medicare patients because of the diminished reimbursements and the growing delay in payments. I've had several new Medicare patients come to my office in the last few months with multiple diseases and long lists of medications simply because their longtime provider -- who they liked -- abruptly stopped taking Medicare. One of the top mammographers in New York City works in my office building, but she no longer accepts Medicare and charges patients more than $300 cash for each procedure. I continue to send my elderly women patients downstairs for the test because she is so good, but no one is happy about paying.
The number of teenagers and young adults developing cancer is on the rise, and they face tough challenges getting proper diagnosis and treatment, according to a new report.
There are often delays in diagnosis - largely because doctors rarely consider that young adults could have cancer, the report says. Young people often don't feel comfortable in support groups designed for older adults, and often deal with devastating side effects of treatment such as infertility and substantially higher odds of cancer later in life.
"Young people need support from diagnosis to cure and beyond," said Ronald Barr, a professor of pediatrics at McMaster University in Hamilton, and chair of the adolescents and young adults committee at the Canadian Cancer Society.
The society's report - Cancer Statistics 2009 - says about 2,075 young people aged 15 to 29 will be diagnosed with cancer this year. About 325 cancer deaths are expected in this age group, which represents 1.5 per cent of total cancer deaths.
But the relatively small number of deaths doesn't reflect the huge impact the disease has on the young patients, their families and society, said Loraine Marrett, a senior scientist at Cancer Care Ontario and chair of the statistics steering committee at the cancer society. There is a "lack of appreciation" for the patterns of cancer in young people, she said, "and for the challenges they face fighting a deadly disease at a time when they should be studying, building careers and starting families."