Relevant and even prescient commentary on news, politics and the economy.

Malingering or science? Part 1

About 1.4 million troops have served in Iraq and Afghanistan. Pentagon research indicates that:

Up to 28% of combat troops may have been exposed to bomb blasts and suffered at least mild traumatic brain injury.

30% of Iraq and Afghanistan casualties treated at Walter Reed Army Medical Center have been diagnosed with mild, moderate or severe traumatic brain injury.

USA Today carries a link to a memo the Armed Forces Epidemilogical Board sent to William Winkenwerder Jr., Assistant Secretary for Health Affairs at the Department of Defense, as regards diagnosis of levels of TBI and reasons for concern in combat and returning home. There is a list of what to look for in terms of symptoms and performance as well as behavior.

Title 38 USC 1110 Basic Entitlement

For disability resulting from person injury suffered or disease
contracted in line of duty, or for aggravation of a preexisting
injury suffered or disease contracted in line of duty, in the
active military, naval, or air service, during a period of war, the United States will pay to any veteran thus disabled and who was
discharged or released under conditions other than dishonorable
from the period of service in which said injury or disease was
incurred, or preexisting injury or disease was aggravated,compensation as provided in this subchapter, but no compensation shall be paid if the disability is a result of the veteran’s own willful misconduct or abuse of alcohol or drugs.

The tangles of policy and money allocation, and entrenched viewpoints on the expectation of the diagnosis of malingering, need your thoughtfullness and input to the powers that be.

More will be posted as basic information. The military is trying to develop a blood test for in the field diagnosis based on released proteins from brain damage, and has about 200 stations that have basic scanning devices that feed into a central computer for diagnosis.

Unfortunately the best treatment in support systems (family and buddies) is only just begun.

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Just a business expense and opprtunity cost

Salon reports:

In April 2007, William Winkenwerder Jr. retired from his position as assistant secretary for health affairs at the Department of Defense, where he had been in charge of all military healthcare. On June 1, he went to work for a Wisconsin-based private contractor named Logistics Health Inc., which hired him to serve on its board of directors and “advise and counsel LHI on business development,” according to a company press release. It was a hire that seems to have paid quick dividends.
On June 13, 2007, the Department of Defense began accepting bids for a contract to give soldiers medical and dental exams before they head off to war. Logistics Health was among the companies bidding on the contract, which was worth hundreds of millions of dollars over four years. Before he left the DOD, in addition to running military healthcare, Winkenwerder had also been in charge of the office that wrote the contract.

The revolving door becomes direct access. Opportunity costs become part of procurement procedures and contract writing. I hope the company is efficient and does a good job at a reasonable cost.

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New NIE report

WSJ reports on the news conference and new National Intelligence Estimate.

The new assessment concludes that Iran actually suspended its covert nuclear weapon program in the fall of 2003. That tends to undercut Bush’s recent warnings about the danger of “World War III” if Iran’s nuclear ambitions are realized.

At least the first half-dozen questions were related to the issue, with several reporters bluntly questioning whether Bush has exaggerated the danger from Tehran, especially in recent months. Several also sought to link the flip-flop on Iran intelligence to earlier U.S. intelligence miscues over Iraq. “Can’t you be accused of hyping this threat?” asked NBC’s David Gregory. “And don’t you worry that that undermines U.S. credibility?”

In response, Bush pointed out repeatedly that the new intelligence shows that U.S. diplomatic pressure actually has been working. He added that Iran remains a danger because of its demonstrated desire for a nuclear arsenal, as well as its continuing uranium-enrichment program, which could provide material for constructing a weapon. He also said he’d only been informed about the re-evaluation within the past week. Intelligence officials had told him earlier that there was a new development. But they weren’t being specific until they’d checked it out, Bush said.

The president also took the time to push for the trade bill with Peru as a way to fight terrorism, which is up for a vote today or tomorrow, calling it free trade again, instead of the WTO GATS modeled capital flow and nothing else trade bill. While the presidential candidates are mostly for it, they probably will be absent on the vote.

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PTSD and TBI at home

PBS has a very short description of the effects of PTSD and TBI by several authors that might help in sorting out why the diagnosis is important both for policy, treatment, and moral judgements we as Americans are prone to use to avoid costs of war.

As you stand with other parents watching the kids play soccer, discussing sports or the weather, and your body screams danger. Or a light touch makes you mentally jump a foot into the air as you return the caress. It is a hard tightrope to walk even when you know what is going on. Lack of sleep makes it impossible for some.

Update:

Assessments of the many ways in which transitioning from high-stress combat war zones to a peaceful home community environment can be the hardest part of military service. Explaining the difficulties and what can be done to help are psychiatrist and author Jonathan Shay; VA psychiatrist Andrew Pomerantz; retired Navy psychologist Dennis Reeves; Col. Thomas Burke, director for mental health policy for the Dept. of Defense; Vietnam vet and VA counselor Jim Dooley; and Fred Gusman, a director of the VA National Center on PTSD. These excerpts are drawn from their extended FRONTLINE interviews.

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Al Odah and US

Tomorrow, December 5, the Center for Constitutional Rights will return to the Supreme Court for the most important case of this decade. This historic case – Al Odah v. United States – will in all likelihood determine once and for all whether the men detained at Guantánamo have the right to a fair trial before a real court.

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Meds and blogs


Brain chemistry analysis is being born as I write.

Scientists have understood something of the chemical imbalances underlying mental health problems, but making meaningful chemical measurements in the brain has not always been easy because of the small size of synapses and the inaccessibility of the brain.
Recent breakthroughs are now advancing knowledge. In 2006, University of Michigan scientists developed a sensor that will monitor levels of neurotransmitters in a patient’s brain. The device has enabled them to study chemical changes associated with behaviour and disease.
Last year, researchers at the University of Cambridge identified specific biomarkers for schizophrenia. The team looked for psychosis-associated changes in the fluid which circulates around the brain and spinal cord. Their results showed that levels of some proteins and peptides were elevated in schizophrenic patients. They also saw characteristic changes in samples taken from patients with depression.
The identification of specific biomarkers could redefine the diagnosis of psychotic disorders, which is currently very subjective. Biomarkers may also help to distinguish between different mental health conditions which is not always possible to do at present.
The future potential of the discovery of biomarkers for mental illnesses is immense. Improved treatments and preventative medicines might all develop from such early research.

The author of the article is being a little hyperbolic about actual interpretations of diagnostic abilities at the moment. Like the research on ADHD, interpretation is still primitive and not predictive, much less confirming, but is a significant step.

Claims to treat depression for instance describe serotonin uptake this and dopamine that are not based on brain chemistry or levels, but blood levels and outward behavior and reporting. Great strides yes, and invaluable for many, but hardly accurate and measured as regards brain chemistry.

The pushing of meds as a cure for what ails you has become a standard we all use, and is something I have written also in comments. What often is missed in conversation about the economic part of big pharma profits schemes and payments and doctor ‘collusion’ or ‘acceptance’ is the ethical standard of prescribing medications on such a huge scale, often for non-researched age groups, off label uses, and as a first line treatment without good lengthy histories, informed consent, family supports and such that are necessary as well.

Patients come and request certain meds as well, which requires the same evaluation if the doc has time.

It reminds me of throwing round dice sometimes as we claim knowledge we do not have.

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Following THIS POST using census data, Tim Worstall suggested the data include more than income. He cited the Tax Foundation study as an example of a study that attempted to address what the authors saw as a more accurate picture when describing “living in poverty” (by including transfer payments and benefits of spending in ‘standard of living’).

pg 24-25
In general, federal government spending is more sharply tilted toward lower-incomehouseholds, due to the large amount of federal transfer payments to lower-incomehouseholds through Social Security, Medicare and Medicaid. State and local spending isgenerally more flatly distributed across income groups with the largest dollar amountstargeted at the highest income quintile. This is largely due to high state and localgovernment spending on programs that are disproportionately used by middle- and upperincomehouseholds. These include public education that is heavily utilized by upperincomegroups with the largest total numbers of children enrolled in public elementaryand secondary schools, highways that are disproportionately used by upper-incomehouseholds with the most vehicles, and interest payments on government debt thatdisproportionately fall on upper-income households who hold government bonds.25Note that the government spending amounts in Figure 4 include government spending onpublic goods such as environmental protection, public health, and national defense, aswell as spending on private goods and transfer payments. Because of the nonrivalrousand nonexcludable nature of public goods, in the current study spending on public goods…..As can be seen from the table, the exclusion of public goods does not change the overalldistribution of government spending, but reduces the amount of government spendingreceived per household in every quintile by an equal amount. In 2004, total governmentspending on public goods was roughly $8,150 per household—$6,059 in federal spendingand $2,090 in state and local spending.Figure 5 presents the share of government spending received by each income quintile.Households in the two lowest income quintiles receive the largest shares of totalgovernment spending, together accounting for 51.4 percent of total spending. This resultis largely driven by spending on government transfer payments to elderly households—many of whom reside in the lower income quintiles—and other government aid to lowincomehouseholds. Households in the fourth quintile receive the smallest share of total government spending, at 14.8 percent.

Utility and value are excluded from the the purview of this paper but acknowleged. I think the quote nails down the gist of the distribution, and found it interesting. Obviously the paper leaves out a lot of detail. If it does, I need help in looking at the explanations. At first glance the inclusion of Social Secuity bothers me. I found they did not exclude SS to compare across quintiles (unless I missed it.)

What would be the advantages of tracking the money, and disadvantages? Currently the big black box takes care of flow.

I did not follow some of the details of the evaluation, but I think I found the central component. If not, correct me.

Update: Change the “Tim Worstall cited” to a more accurate “mentioned as first study to address the issue when searching”.

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Oil and water do not mix to our benefit

The Albuquerque Tribune editorializes:

In oil drilling, the question is always who suffers and who benefits – not in the abstract but in the details of daily lives.

Sure, the American economy needs more American oil. But mining and property laws are often ruinous to ranchers, farmers and homeowners who are beset by drillers, their wastes and their high-handed assumption that their right to profit is greater than the property rights of those they traumatize.

Gas drilling in the San Juan Basin has brought huge profits to drillers – and destroyed the livelihoods of many ranchers, killing their cattle with drilling waste.

And the ranchers have absolutely no recourse. It amounts to the privatization of eminent domain, in which a company with mineral rights can use someone else’s surface rights, despoil their land, their peace of mind and their property value, all to make money just for themselves.

The chief problem with drilling in the Galisteo Basin is soil and water pollution. Tecton, the Texas company drilling in the basin, claims to have new, cleaner technologies. But oil and gas drilling around water cannot be accomplished without damaging the water. It’s a physical impossibility.

Here’s a partial list of potential wastes that come from exploratory and production drilling: huge quantities of brine, or “produced water,” associated with oil and gas deposits; water runoff from cleaning rigs and vehicles; engine coolants and water- and oil-separating antifreeze; benzene; drilling fluid, sometimes called “mud,” with its clays and chemical additives that cools and lubricates the drill heads; drill cuttings; the various lubricants that keep the drill tubes going; hydrogen sulfide from bacteria on field equipment, killed only by dangerous biocides; oil debris in filters; dirty diesel; and halons and other ozone-depleting chemicals used as fire and explosion suppressants.

The issue here is simple. Pollution is no longer a cost-saving irresponsibility. It has to be cleaned up, and that costs lots of money and takes a long time. And the water might never be drinkable again.

In a rush to mine coal and oil, two huge behemouths collide in the Soutwest. Surface dwellers be careful. Do you actually know what your water rights are? Or what dwells beneath?

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Kidneys and community

Kidney dialysis is a terribly expensive way to survive that is offered to those whose kidneys have failed.

Here is what’s happening: two companies-DaVita and Fresenius-provide most of the kidney dialysis services in the U.S. They want Congress to force kidney patients to stay on private insurance for a longer period of time before they can qualify for Medicare.
Usually, patients need to be 65 years old before they qualify for Medicare. But in 1972, because the high cost of dialysis put care out of reach for all but the wealthiest patients, Congress made the historic decision to extend Medicare coverage to dialysis patients of all ages. But patients who need dialysis have to stay on private insurance for 30 months before they are eligible for Medicare. DaVita and Fresenius want to make patients wait longer-another year-before they can get access to the program.
It’s not hard to figure out why DaVita and Fresenius want to keep kidney patients out of Medicare. These companies can typically charge private insurers-and ultimately employers and workers-nearly three times more than they can charge Medicare for the same services.
It’s staggering how much money is at stake with this “small” change. It’s estimated that dialysis providers like DaVita and Fresenius would cash in a $2 billion…over five years”

This note would have escaped my attention unless kidney dialysis was not personal. Mrs. rdan’s brother had an infection in a knee from minor surgery that somehow spread. In three months either the infection or the massive antibiotics to treat the infection caused scarring in both kidneys to the point of shutdown. His job involved quotas which he found he could not maintain when on dialysis due to impaired stamina, which also takes 3-4 hours times three a week to live, so he lost his job, and access over time to insurance.

He had worked at this company for ten years and was a good worker.

What, if any, help does a community offer for the random events of the universe?

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Anbar and Pakistan

John Robb offers a viewpoint on progress in Iraq and lessons to be learned.

When the Askariya shrine was bombed in February 2006, it fractured Iraqi social systems along religious lines. In the fighting that followed, Sunni guerrilla groups underwent a transformation from small and loosely connected to large and bureaucratic. This change was driven by three factors:
Shiite militias, operating without much government interference, were able to field large military formations in their attacks on Sunni targets.
Sunni neighborhoods needed a permanent militia to defend them against attacks.
US forces were relatively ineffective against Sunni guerrillas up until that point and offered no meaningful counter. The guerrillas were flush with cash and confident the US posed little threat. The combination of organic group growth and formal cross group affiliation led to the formation of the bureaucratic structures necessary to maintain groups larger than 150 people (read: “The Optimal Size of a Terrorist Network” for more). Here’s an example from Amit Paley’s WP interview with a recently captured “al Qaeda” insurgent in Mosul:
The 28-year-old said he was responsible for running the bureaucracy and arranging payments to the 500 or so fighters for the group in the city, who he said try to carry out as many as 30 attacks a day. This expansion in group size led to a radical increase in violence against almost every potential target. It also changed the underlying dynamic of the insurgency. The process of increasing group size and a movement towards local protection forced the following:
As groups formally affiliated to form larger organizations, a schism developed between homegrown guerrillas and those operating under “al Qaeda’s” banner.
Tighter ties to local communities for protection against Shiite militias led to jihadi control over neighborhoods. This in turn led to jihadi overreach and a local counter-reaction.
The increase in group size finally made al Qaeda accessible to US counter-pressure. It now had a center of gravity to attack. This is yet another level of complication that should muddy the “lesson” of “the Anbar tribal revolt.” The US should military think long and hard before it squanders tens of millions (soon hundreds of millions) of dollars on Pakistan’s Frontier Corps.

This sort of discussion goes on other blogs familiar with the topic. Levels of complication as we talk about success or failure is a useful approach, while political memes of ‘less violence’ is not.

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