Denialism Blog

Author: MarkH

  • Pollan and Bittman, the Morano and Milloy of GMO anti-science

    Why do food writers think they are competent to evaluate the scientific literature? I know of at least two who, based on their tweets, clearly are not. One is Mark Bittman, who we have previously chastised, and now also Michael Pollan who has been a bit more coy about promoting anti-science related to GMO. Now they’ve both been broadcasting the flimsy results of this paper – A long-term toxicology study on pigs fed a combined genetically modified (GM) soy and GM maize diet – published in the “Journal of Organic Systems”. Why do I feel like I’m reading headlines from Climate Depot or Milloy’s Junkscience? Because it’s the exact same behavior.

    For all you budding science journalists out there, here is your first red flag, novel groundbreaking research is rarely reported in a such journals. Not to demean the smaller journals, good science is done there, but the quality of the publications must be one of the first factors taken into account when evaluating the significance of results published in the lay press. Note Reuters and Huffpo both published fluffy repetitions of “press release” evaluations of the study. Neither appears to show any skepticism or depth into the significance of the results, other results within the paper, or whether the fundamental conclusions of the authors are even supported by the data. Let’s do this now.

    First, let’s describe the study. It’s a long-term (22.7 week) feeding study in pigs, with two groups of 84 pigs randomly selected to either receive GMO feed or non-GMO feed. During the trial all conditions are controlled, the feeds are found to be nutritionally identical (interesting given how GMOs has no nutrients!11!!!), and were obtained according to standard practices of pig farmers from similar local sources. The pigs were raised to the standard age they are when they go to slaughter, and were then killed and their bodies autopsied. While living the animals were evaluated by weights weekly, level of activity of pigs, level of contentment, skin problems, respiratory problems, eye problems, stool quality, blood biochemical analyses right before slaughter, and mortality. At autopsy organs were weighed and evaluated by veterinarians for evidence of tissue pathology.

    Second, the findings. A good science journalist determines these by looking at the data, not by repeating whatever the authors tell them. Looking at the data there were no differences in any of the major variables evaluated by the study, such as weights, veterinary costs, illnesses, or mortality. No significant differences in blood biochemistry were found. At autopsy most organ weights were similar between groups. There was a statistically significant (but likely clinically-meaningless) increase (0.1kg vs 0.12kg) in uterus weights in the GM group. At pathology there were nonsignificant decreases in cardiac and liver abnormalities in the GM group (half as many), in stomach pathology there was one significant finding of more “severe inflammation” (on a 4-point scale from no inflammation to severe) in the GM group. This is the finding that has been amplified as variably “damning” or “concerning” depending on which source is reporting these dramatic new findings.

    But since we’re skeptics here (real skeptics not like global warming “skeptics” in scare quotes) we ask, is it really?

    Lets take a closer look at the data in table 3. Here are the relevant numbers:
    Carmentable3data

    While it is clear that along the severe inflammation row there is a difference, look at the moderate inflammation row immediately above it, and see if it changes your mind. What if we were to combine this table into a binary, no to mild inflammation vs moderate to severe? The numbers become GMO 41, non GM 38. Why would I look at it this way? Because pathologic scales of things like inflammation are subjective. (***Update It has been pointed out that the authors also didn’t actually do tissue pathology, instead they just graded how red the stomachs were on gross pathology, which also makes this assay totally meaningless. See full update below***) One should be very cautious about results presented on such a scale representing true differences especially given the next nearest population on the scale is reversed and eliminates your effect when the two groups are combined. Trying to make this objective data to suggest an association is very much trying to cram a square peg through a round hole, and would not fly on most reviewers’ reads of this data, and if I had been a reviewer I would have squashed this on this point alone. The fixation on one single data point in this table to the exclusion of the others and building the conclusions around it is unscientific. One needs to be a lot more cautious given the design of this study. Let me explain.

    This is not hypothesis-driven work. They authors did not at the outset say, “we propose stomach inflammation will be greater in GM fed pigs because of x”. No. What they did was feed pigs two different diets and then go fishing for abnormal values. This is not necessarily wrong behavior, scientists go on fishing trips all the time looking to find significant effects. What is wrong is then publishing the results of your fishing trip! This is unscientific.

    If you were to study some 20 variables in your study (these authors studied far more variables and I would actually expect more abnormal results then we have), and have a cutoff for significance at the standard arbitrary value of p = 0.05, one would expect, just by chance, that 1 of those variables will be significant. A good scientist then says, “well that’s interesting, let’s see if it’s real”, and then follows this study with a hypothesis-driven study specifically designed to study the apparent effect. When the single effect is then studied in isolation, with appropriate power, one should see if the result you found, perhaps by chance, is a real effect or not.

    So what we have in this study is the first half of a valid study (the fishing trip) but no real hypothesis driven research to confirm if this 1 in 20 result is real. There is no molecular data to suggest a mechanism. They don’t further determine if it was the soy component or corn component on the diet. There are no follow up evaluations examining this effect alone, or trying to link ingestion of cry proteins on stomach inflammation. So far, one can only conclude that it’s just as likely that this result occurred by chance as it is to be an actual effect of feeding the pigs GM corn and soy. Now, is that “damning” or “concerning”? Concerning is even a stretch.

    Third, it’s important for the good science journalist to interpret these new findings in the context of the literature, and perhaps consult an expert in the field to determine the significance of these results in context of the total knowledge in the field.

    One should mention the extensive literature on the safety of GM foods. Other writers including Mark Lynas have evaluated this paper as well with similar conclusions as mine. Additionally, Mark points out the paper’s favorable interpretation of Seralini’s work – a bad sign. The authors appear to have ties to anti-GMO advocacy groups, and even thank Jeffrey Smith (the hysterical anti-GMO fake expert with no scientific or medical training). Andrew Kniss points out that he can’t replicate their result with the appropriate statistical test. I admit, I am confused about exactly how they calculated the p value, as in their methods they describe using t tests, Mann-Whitney and Chi Squared variably based on the distribution or categorical nature of the variables, so half the time reading I was trying to figure out which test they were using at any given moment. I’m still unsure exactly why they chose to do which test in each instance – in table 5 they appeared to switch between a Wilcox and a t-test at random. Although in table 3 they appear to have used a Uncorrected Chi squared based on the footnote, I’m not exactly sure, based on how one could be constructed with different expected values, if this was appropriate. No statistical expert am I, but again this smells a bit like statistical fishing to me. Even so, it doesn’t change the relevance of the results. Even if it does technically pass statistical muster, it’s still just the first step in a real scientific investigation. Another GMO expert suggests given the levels of mold they measured on their GM corn, it could have been a result of their source selling them moldy feed (at levels much higher than are usually found on GM crops).

    So, to summarize, in this paper the authors performed a large non-specific screen for potential evidence of harm from GM crops. Of the many analyses performed, one showed statistical significance for severe stomach inflammation on a pathology scale in the GM group, but this effect rapidly-disappears if one groups inflammation based on broader categories. The clinical significance of this finding can only be determined by subsequent hypothesis driven research into this potential effect, but it is equally likely this is a result of random chance.

    Or you can skip all the words above and read the XKCD one of Mark Lynas’ commenters suggests

    XKCD knows stats

    A final note, I’m not interested in comments saying I work for Monsanto, that I’m a corporate shill, blah blah blah. I haven’t worked for, or accepted money from, a corporation in my adult life (excluding Nat Geo sending me beer money for this blog, and working as a valet for Toyota dealership when I was 16). Address the data, the paper, relevant biological arguments etc, or get lost.

    **Update**
    In reading an additional response to the Carman et. al study, I now change my opinion on this paper from “competently performed but meaningless” to “totally meaningless”.

    At issue is a criticism by Robert Friendship in the link above, that the author’s assay for inflammation is basically meaningless. In my initial read of the paper I didn’t notice this sentence “Typical examples of each of the four categories of inflammation are shown in Figure 1. For a severe level of inflammation, almost the whole fundus had to
    be swollen and cherry-red in colour.”

    I incorrectly assumed the authors had taken sections, performed histology, then assessed inflammation based on a legitimate pathological scale. This was apparently too generous. No, they just looked at the color of the stomach by gross pathology. As Dr. Friendship points out, this is meaningless.

  • An apology, from America, for Alex Jones

    Dear British friends,

    I am deeply ashamed, and mortified, on behalf of my entire country for the embarrassing phenomenon that is Alex Jones. I see you have learned now for yourselves, this disturbed, bizarre person, is quite possibly the worst guest you could have ever invited to be on a television show. I have enclosed the relevant clip below.

    I feel the need to apologize, as Jones appears to represent the worst stereotypes of Americans; that we are loud, bullying, and rude, that we prefer to shout to win debates, that we have no manners compared to our cousins across the pond. Please understand, we find him just as awful as you do. He is just as uncivilized, rude, loud and obnoxious within our borders as he is without. If we could have avoided having him inflict his company on you, we would have, but sadly that is beyond our power.

    I know you will say that you too have nutters that you have inflicted upon the world (David Icke comes to mind), but I would remind you that your nutters have always been unfailingly polite when they have visited us. I appreciate the enormous restraint Andrew Neil showed in only calling Jones an idiot while making the universal “crazy person” sign. I promise the next time I am in England I will try to offset some of this harm by buying rounds, speaking softly, and by no means mentioning the existence of Simon Cowell. I can see how you already have that problem in hand.

    (start at minute 1:45)

    Sincerely,
    MarkH (on behalf of America)

  • What is at the root of denial? A Must Read from Chris Mooney in Mother Jones

    Chris Mooney has been exploring the basic underpinnings of denialism lately, with this latest article a good summary of the basic problems:

    In a recent study of climate blog readers, Lewandowksy and his colleagues found that the strongest predictor of being a climate change denier is having a libertarian, free market world view. Or as Lewandowsky put it in our interview, “the overwhelming factor that determined whether or not people rejected climate science is their worldview or their ideology.” This naturally lends support to the “motivated reasoning” theory—a conservative view about the efficiency of markets impels rejection of climate science because if climate science were true, markets would very clearly have failed in an very important instance.

    But separately, the same study also found a second factor that was a weaker, but still real, predictor of climate change denial—and also of the denial of other scientific findings such as the proven link between HIV and AIDS. And that factor was conspiracy theorizing. Thus, people who think, say, that the Moon landings were staged by Hollywood, or that Lee Harvey Oswald had help, are also more likely to be climate deniers and HIV-AIDS deniers.

    This is similar to what we’ve been saying for years. Ideology is at the heart of antiscience, (yes even liberal ideology) and when in conflict with science will render the ideologue incapable of rational evaluation of facts. The more extreme the ideology, the more likely and more severe the divergence from science. Then there is the separate issue of cranks who have a generalized defect in their reasoning abilities, are generally incompetent at recognizing bad ideas, often believing conflicting theories simultaneously, and are given to support any other crank who they feel is showing science is somehow fundamentally wrong. This is the “paranoid style”, it’s well-described, and likely, irreversible. However, more run-of-the-mill denialism should be preventable.

    We’ve discussed this extensively in regards to research by Dan Kahan, although I have disagreed with this jargon of motivated reasoning. Chris, however, knows what they’re referring to with their fancified science-speak, ideology is at the root of denial.

    Recognizing that the problem of anti-science is not one of a lack of information, or of education, or of framing is of paramount concern. This is a problem with humans. This is the way we think by default. People tend to arrive at their beliefs based on things like their upbringing, their religion, their politics, and other unreliable sources. When opinions are formed based on these deeply-held beliefs or heuristics, all information subsequently encountered is either used to reinforce this belief, or is ignored. This is why studies showing education doesn’t work, the more educated the partisan is on a topic, the more entrenched they become. You can’t inform or argue your way out of this problem, you have to fundamentally change the way people reason before they form these fixed beliefs.

    Scientific reasoning and pragmatism is fundamentally unnatural and extremely difficult. Even scientists, when engaged in a particular nasty internal ideological conflict, have been known to deny the science. This is because when one’s ideology is challenged by the facts you are in essence creating an existential crisis. The facts become an assault on the person themselves, their deepest beliefs, and how they perceive and understand the world. What is done in this situation? Does the typical individual suck it up, and change, fundamentally, who they are as a person? Of course not! They invent a conspiracy theory as to why the facts have to be wrong. They cherry pick the evidence that supports them, believe any fake expert that espouses the same nonsense and will always demand more and more evidence, never being satisfied that their core beliefs might be wrong. This is where “motivated reasoning” comes from. It’s a defense of self from the onslaught of uncomfortable facts. Think of the creationist confronted with a fossil record, molecular biology, geology, physics, and half a dozen other scientific fields, are they ever convinced? No, because it’s all an atheist conspiracy to make them lose their religion.

    How do we solve this problem?

    First we have to recognize it for what it is, as Mooney and others have done here. The problem is one of human nature. Engaging in denialism doesn’t have to mean you’re a bad person, or even being purposefully deceptive (although there are those that have that trait), the comparison to holocaust denial, always a favorite straw man of the denialist, is not apt. Denialism in most people is a defense mechanism that protects their core values from being undermined by reality. And no matter what your ideology, at some point, you will have a conflict with the facts because no ideology perfectly describes or models all of reality. You are going to come into conflict with the facts at some point in your life no matter where you are on the ideological spectrum. The question is, what will you do when that conflict arises? Will you entrench behind a barrier of rhetoric, or will you accept that all of us are flawed, and our beliefs at best can only provide an approximation of reality – a handy guide but never an infallible one?

    Second, we have to develop strategies towards preventing ideological reaction to science and recognize when people are reacting in an irrational fashion to an ideological conflict with science. One of my commenters pointed me to this paper, which describes an effective method to inoculate people against conspiratorial thinking. Basically, if you warn people ahead of time about conspiratorial craziness, they will be more likely to evaluate the claims of conspiracists with higher skepticism. We should encourage skeptical thinking from an early age, and specifically educate against conspiratorial thinking, which is a defective mode of thinking designed to convince others to act irrationally (and often hatefully). When we do see conspiracy, we shouldn’t dismiss it as harmless, the claims need to be debunked, and the purveyors of conspiracy theories opposed and mocked. Before anyone ever reads a line of Alex Jones, or Mike Adams, a training in skepticism could provide protection, and with time, the paranoid style will hold less and less sway. People primed to expect conspiratorial arguments will be resistant, and more skeptical in general. The Joneses, Moranos, and the Adamses of the world don’t have the answers, they know nothing, and their mode of thought isn’t just wrong, but actively poisonous against rational thought. As skeptical writers we should educate people in a way that protects them from their inevitable encounter with such crankery. This is why writers like Carl Sagan are so important with his (albeit incomplete) Baloney Detection Kit. He knew that you have to prepare people for their encounters with those with an ideological agenda, that others will bend the truth and deny the science for selfish reasons.

    This is what is at the heart of true skepticism. First, understanding that you can be wrong, in fact you will often be wrong, and all you can do is follow the best evidence that you have. It’s not about rejecting all evidence, or inaction from the constantly-moved goalposts of the fake skeptics. It’s about pragmatism, thoughtfulness, and above all humility towards the fact that none of us has all the answers. Second, it’s understanding not all evidence is created equal. Judging evidence and arguments requires training and preparation as recognizing high-quality evidence and rational argument is not easy. In fact, most people are woefully under-prepared by their education to do things like read and evaluate scientific papers or even to just judge scientific claims from media sources.

    Thus I propose a new tactic. Let’s get Carl Sagan’s Baloney detection kit in every child’s hands by the time they’re ten. Hell, it should be part of the elementary school curriculum. Lets hand out books on skepticism like the Gideons hand out Bibles. Let’s inoculate people against the bullshit they’ll invariably contract by the time they’re adults. We can even do tests to see what type of skeptical inoculation works best at protecting people from anti-science. It’s a way forward to make some progress against the paranoid style, and the nonsense beliefs purveyed by all ideological extremes. There is no simple cure, but we can inoculate the young, and maybe control the spread of the existing disease.

  • Psychics like Sylvia Brown are immoral frauds

    In the wake of the dramatic events surrounding the discovery of three women including Amanda Berry, being held captive for a decade by a monster, it’s important not to forget another sociopath played a role in this drama. That sociopath is the psychic who told Amanda Berry’s mother that her daughter was dead:

    Her mother, Louwana Miller, never gave up hope that the girl known as Mandy was still alive, according to the Cleveland Plain Dealer. The case attracted national attention when Miller went on Montel Williams’s nationally syndicated television show in 2004 and consulted a psychic.

    “She’s not alive, honey,” the psychic said. “Your daughter’s not the kind who wouldn’t call.”

    After Berry’s mother died in 2006, there were occasional clues in the search for Berry, and police have conducted a number of searches over the years. All proved fruitless — until Monday night, when Berry, Gina DeJesus and Michelle Knight were rescued from the house in Cleveland.

    As Ben Goldacre reminds us, that psychic was Sylvia Brown, speaking out of her ass, surely “just for entertainment purposes” when she told Louwana Miller her daughter was dead. As the Wiki shows, her predictions aren’t reliable, and not surprisingly, she has a history of criminal behavior, including indictments and convictions for fraud and grand theft.

    Psychics are by definition frauds. They don’t have magic powers. No human has the ability to read minds or see into the future. If you then take money under such known false pretenses that is the definition of fraud. If they truly do think they have magic powers, they should submit themselves to James Randi’s 1 million dollar paranormal challenge to determine if they can perform in a blinded, controlled test (which none of these frauds has ever come close to passing). Not surprisingly, Sylvia Brown has refused, many times, to take this challenge. This is because psychics know they’re frauds. Worse, Brown has even been previously convicted of fraud but sadly not for giving psychic readings. As a criminal, I guess she smartened up since 1992, the question is, why don’t we treat all psychics as criminals all the time? The burden of proof should be on them to prove they have this exceptional ability under controlled circumstances. Until then, we should simply arrest people that take money from others on the basis of such lies.

  • Obama Makes Hospital Charge Masters Public

    And the best article on the implications of this, surprisingly, comes from Huffington post authors Young and Kirkham:

    The database released on Wednesday by the federal Centers for Medicare and Medicaid Services lays out for the first time and in voluminous detail how much the vast majority of American hospitals charge for the 100 most common inpatient procedures billed to Medicare. The database — which covers claims filed within fiscal year 2011 — spans 163,065 individual charges recorded at 3,337 hospitals located in 306 metropolitan areas.
    …
    Within the nation’s largest metropolitan area, the New York City area, a joint replacement runs anywhere between $15,000 and $155,000. At two hospitals in the Los Angeles area, the cost of the same treatment for pneumonia varies by $100,000, according to the database.

    We discussed this issue before when it was brought to the public’s attention by Brill’s “Bitter Pill” piece in Time. Hospitals have a wildly-irrational billing scheme that represents a war they are in with payers. However, Brill was wrong to attribute excess costs of US healthcare to the charge master problem, while the HuffPo piece gets this issue right. It’s not a problem for insurance companies, or government, since they don’t pay these bills. It only screws payers without negotiating power or knowledge of how to navigate these bills – the uninsured:

    “The charge masters are totally irrational,” Robert Laszewski, a former health insurance company executive who consults for health care companies as president of Alexandria, Va.-based Health Policy and Strategy Associates, wrote in an email to The Huffington Post.

    Hospitals used to base prices on health care costs and on the need for profit that would, among other things, enable them to make investments in their facilities, Laszewski explained. “They became the baseline from which the hospitals started,” he wrote. But over time, hospitals raised charges in anticipation of negotiating discounts with private health insurance companies while maintaining their revenue streams, he said.

    Prices have continued growing over decades to the point where there is no plausible justification for them, according to Laszewski: “Over the years, the charge masters have become more and more disconnected from reality.”

    And since they haven’t been public or shared before now, I suspect each hospital probably has some set of services that appear to be priced excessively compared to their near neighbor. The costs haven’t grown so much from a response to the treatments they provide, so much as the perceived ability to force insurers to pay a larger portion. Each hospital has probably independently evolved a strategy to do this, hence the wide variability in pricing.

    The charges are the prices hospitals establish themselves for the services they provide. Although Medicare and Medicaid don’t base their payment rates on these figures, private health insurance companies typically do, which means they usually pay more for the same health care than the government does. That translates into higher premiums for people with insurance. And uninsured people are expected to pay the full list price or a discount from that number, which tends to mean they pay more than anyone else.

    When a hospital doesn’t get paid as much as it wants from one source, it tries to make up the difference in other ways, such as billing so-called self-pay patients — almost always the uninsured — for the full list price of a service, said Robert Huckman, a health care expert at Harvard Business School. Even when hospitals agree to huge discounts for patients who can’t pay the bill, those discounts are taken from inflated prices much higher than those the government or private insurance companies pay, he said.

    “The charge master is complete nonsense that really doesn’t matter — unless you are an uninsured person and you’re getting these huge bills driving you toward bankruptcy,” Laszewski wrote. “The biggest irony of the U.S. health care system is that only the uninsured — often people who don’t have a lot of money — are the only ones the hospital expects to pay these incredibly inflated list prices!”

    Hospitals also inflate charges to raise money for things that aren’t related to treatments, said former Sen. David Durenberger (R-Minn.), who is senior health policy fellow at the University of St. Thomas in Minneapolis.

    “The biggest factor by far, in my experience, is what are you trying to cross-subsidize,” he said. Hospitals will increase charges to finance things like technology upgrades and education and research and to compensate for their operational efficiencies, Durenberger said.

    We’ve discussed extensively the sources of excess costs in US healthcare. It’s not the chargemaster. It’s excessive administrative costs of private health insurance, excessive drug costs (everything from direct-to-consumer advertising, the fact US citizens are charged more and GWB made it so medicare can’t negotiate for lower drug prices), inefficient delivery (primary care in the ER), redundant delivery, lack of a government-implemented or regulated standardized electronic medical record (EMRs from private companies actually increase costs), defensive medicine, excessive end-of-life care, and excessive reimbursements of procedures and diagnostic testing.

    What will this data release mean for health care costs? Probably not much as the hospitals will now just normalize excessive bills to each other, rather than just having their own individually-irrational billing scheme. The charge master is unjust, but it’s not why we pay more for healthcare overall.

    There is a solution to the charge master problem though, and it was found in New Jersey. Force hospitals to charge the uninsured what they charge Medicare. It’s that simple. It’s that easy.

  • Why we should be concerned Tamerlan Tsaernev read Infowars

    I’ve recently written about the relationship between conspiracy theories and hate speech. Too often, conspiracy theories are used to justify irrational hate for one group or another, and to direct anger over lack of control of one’s life onto a group the conspiracist ideologically opposes. Historical examples include the Protocols of the Elders of Zion or blood libel and more modern examples include everything from the racist birther allegations that our president isn’t American, the homosexual agenda, and the rabid anti-government conspiracy theories advanced by lunatics like Alex Jones, and Glenn Beck. Beck, astonishingly, made the assertion that it must be a foreign terrorist behind the Boston bombings because American terrorists only attack the government, they don’t attack streets full of people.

    Think about that for a minute. Ignore, for the moment, the obvious factual inaccuracy of the statement given the homegrown terrorists that have bombed abortion clinics, churches, planes, the Olympics, or schools. Think about what Glenn Beck is saying. He’s saying that previous terrorists who have targeted the government, like for instance Timothy McVeigh, weren’t targeting people in their attacks. They were targeting government. Never mind that at OKC Timothy McVeigh killed 168 people, including 19 children under 6, and injured 680. Those weren’t people. They were “the government”. This man is sick.

    Enter Alex Jones, who has never had a conspiracy theory he didn’t like, from moon-landing conspiracies to constant (and hilariously false) predictions of impending government collapse, government assassinations, terror attacks, monetary collapse, or whatever seems to spring into his mind from moment to moment. A compendium of his hilariously-false predictions is a fascinating watch:


    (thanks to Ed Brayton

    By their fruits you shall know them.

    Why should we be at all surprised that someone as full of hate as Tamerlan Tsaernev was a believer in a host of conspiracy theories:

    It’s not particularly surprising that Tsarnaev would be drawn to a wide range of conspiracy theories, as research shows that people prone to believing one conspiracy theory will likely believe many — even if they’re completely contradictory. And he fits a profile of a type of person likely to be drawn to conspiratorial thinking, considering he was allegedly alienated from and disgruntled with society.

    On top of Jones and anti-Semitic conspiracy theories, we have to add the one that seems to be the most important of all: The kind of anti-American conspiracy theories pushed by Islamists. For instance, the Washington Post reports that the brothers were apparently motivated by the wars in Iraq and Afghanistan and atrocities committed by U.S. soldiers there. As with many conspiracy theories, there is a grain of truth here — American soldiers really have done some horrible things in those countries. But Tsarnaev went beyond the evidence by telling people that “in Afghanistan, most casualties are innocent bystanders killed by American soldiers.” In fact, according to the U.N., the Taliban is responsible for the vast majority of civilian deaths — 81 percent in 2012.

    Anti-American and anti-Semitic conspiracy theories are foundational to al-Qaida and other radical groups’ ideologies, according to Matthew Gray, a professor at Australian National University who wrote in his book “Conspiracy Theories in the Arab World,” that ”the speeches of Osama Bin Laden are peppered with conspiracist language and the assumptions that underline conspiracism.”

    Indeed, conspiracy theories are hardly unique to the United States and often run rampant in the Muslim world, as Eric Trager of the Washington Institute for Near East Policy wrote in the New Republic, and seem to be especially strong among Islamists. A 2011 Pew poll of residents of Lebanon, Jordan, Egypt, Turkey, Pakistan, the Palestinian territories and Indonesia found that the vast majority refused to believe that Arabs executed the terrorist attack on 9/11. “There is no Muslim public in which even 30 percent accept that Arabs conducted the attack,” the study found.

    From the Protocols of the Elders of Zion to 9/11 truth, to Alex Jones Infowars, Tamerlan was a promiscuous-believer in conspiracy theories, and his younger brother, from his Twitter account, appears to also be a CT proponent of 9/11 truth.

    While the right would like to blame the behavior of these individuals on radical Islam, I’d like to propose a different source of radical, and hateful behavior. I would suggest we consider that conspiratorial thinking might be behind this type of group violence. As the Salon article mentions, one of the major propaganda elements of groups like Al Qaeda are conspiracies about the US, about Jews, about Israel, about anyone who they believe is their enemy. Conspiracy theories are often a reflection of a feeling of powerlessness, and those who are more likely to believe them are reacting a world which is often disordered, and out-of-control. The conspiracy theory is a simplistic explanation for one’s troubles, and usually incorporate one’s irrational, tribal, or bigoted beliefs about the world.

    But while conspiracy theories might make people feel better about an out-of-control world, as it gives them the false perception that they (and no one else) really knows what’s going on, at the same time they feed back on themselves and reinforce that very sense of powerlessness. If democratic government is just a sham, the US is imminently about to round us up and put us in FEMA camps, or kill us with a billion DHS bullets, your supposed grasp of the problem does nothing to solve it. It only further shows how helpless you are to do anything. What are the solutions the conspiracists fall back on? Arming yourself, doomsday prepping, and detachment from society, especially all those stupid sheeple (it’s amazing how often Jones calls his audience stupid!), is the solution. Civil society, voting, community, charity, and collective action aren’t the solution. It’s guns, and isolation.

    Should we then be surprised when individuals influenced by these conspiracy theories resort to violence? Should we be surprised that when people are told the political process is a sham, the government is killing us at will, and everyone else who doesn’t believe this is stupid, that they then go out and target government, and other citizens, and cops, indiscriminately? Isn’t this just conspiracy theorists, like Jones, and Al Qaeda for that matter, just reaping what they sow?

    In the aftermath of this tragedy, the usual actors came out of the woodwork to ghoulishly use human suffering to advance their agenda, whether it was attacking government, or blaming abortion, people who knew nothing and cared nothing for their fellow citizens sought to use the tragedy to their advantage. The conspiracists, of course, settled on the usual suspects (Beck has his Saudi agent/government conspiracy, Jones and Mike Adams the FBI/government). Not that they had any information that we didn’t. They were pronouncing this nonsense within minutes of the attack. Now that we have some information we know that the two alleged suspects have some pretty damning evidence against them if the timeline is correct. They were both witnessed at the scene with, and then without backpacks. One was filmed dropping a backpack at the scene of the second bomb. Both were filmed coolly-observing the aftermath. They shot one MIT police officer to death, apparently in cold blood. They carjacked an individual who said they identified themselves to him as the Boston Marathon bombers. They had pressure cooker bombs in their apartment. They exploded such a bomb while eluding police, critically injuring another police officer.

    This is, to put it mildly, a damning case.

    However, the conspiracy theorists have not changed their tune. Beck continues to blame some Saudi national who’s major crime appears to be he happened to be in Boston that day. Jones and infowars continues to blame the FBI, the CIA, anyone, including Sunil Tripathi, the missing student who has been found dead. Likely this will not stop them, they’ll just say that the FBI killed him to keep him quiet, and keep victimizing his poor family, who have suffered enough from the loss of their son. If the analysis reveals he died over a month ago, that won’t stop them either, because who did the analysis? The government! It’s sad, and pathetic, and horrible. They blame the innocent, and further create the impression that in our society there is no justice, the government is the real criminal (and is not composed of living, breathing, human people), anyone who believes otherwise is stupid.

    My question is, for those who believe this nonsense, how long until we see another one plant a bomb? For those for who believe they have no political or civil power, isn’t violence the outcome encouraged by this belief?

    I think we have to stop just blaming the religious extremism, and start considering the role of conspiratorial extremism in acts of political violence and terror around the world. When you make people feel powerless, and stupid, and excluded from society and participatory democracy, one should not be surprised when they turn to violence and political terrorism. The Tsaernev family insists their children didn’t learn this from them, or in their life abroad, they learned to think this way in America. Maybe they’re right.

    Jones’ response that Tamerlan was a fan was typical, another conspiracy as will the responses to whatever I write here I’m sure. I’ll be accused of being paid off, working for the FBI, a shill, whatever. It’s boring, and part of the known self sealing aspect of conspiratorial thinking. Whenever anything conflicts with the predetermined truth, it must be then incorporated into a new, grander conspiracy. One of my commenters joked about this phenomenon:

    A group of elderly JFK conspiracy theorists were comparing notes when one of them suddenly had a heart attack. After going through the whole tunnel light scenario he finds himself facing God. He asks “Oh Lord, who really killed JFK?” And God replied “It was Oswald acting alone.” At that point the EMTs were able to jolt him back to life. Later in the hospital with his co-theorists he said in a low voice “The conspiracy is bigger than we thought.”

    So on that lighter note, I ask to think about how dismissive we should be of conspiracy theorists. We often treat them as just ridiculous and foolish. But given the historical and modern examples of hatemongering through conspiracy theories, and the conspiratorial beliefs of terrorists from Timothy McVeigh, to Al Qaeda, to the Tsaernevs, maybe we should be looking at the darker side of this behavior. Maybe it’s time to recognize that those who call us stupid, and powerless, and helpless, are the ones encouraging violence as a solution.

  • Conspiracy Theorists are Just Like the Westboro Baptists

    And Alex Jones and Mike Adams are their Fred Phelps. It’s a wonder that Anonymous doesn’t retaliate against these ghouls as well as against Westboro who are planning to picket the Boston Marathon funerals.

    Why are the the same thing? Because they’re all ghouls, and they all use any tragic event to bolster their warped, abhorrent world view no matter what the facts are, and no matter how offensive to the victims.

    Within minutes, with no one knowing any facts, Jones claims this is a false flag attack. The only appropriate response to an event like this, within the first minutes and hours, is to hope the first responders and emergency personnel can get to and rescue as many as possible. But to the ghoul, every event such as this is another chance to push their agenda of hate. For the Westboro Baptists, similarly not knowing anything, they think this is further evidence that God hates America because we tolerate homosexuality. For the conspiracy theorist, all traumatic events instantly become incorporated into their evidence that the government/FBI/CIA whatever is faking them/planning them to increase their control over us. No matter what the evidence is, or will be, it will just be further sealed into this fixed, false belief. Avicenna at FtB has a good post (warning for graphic images) of examples of how despicable this behavior can be. I think one of the most grotesque acts yet was one of the CTs asking the governor of Massachusetts if this was a false flag. How stupid and awful a person do you have to be to ask that question in the wake of such a tragedy? Here is the governor, trying to address a crisis, and some scumbag is basically asking (1) is the US government randomly murdering innocent US citizens (2) is he in on it? To the governor’s immense credit, he didn’t immediately jump into the crowd and start strangling the questioner. CTs were so awful as to accuse the victims of just being actors, of the whole thing being staged, or the whole thing actually being performed by government (read your fellow US citizens), including Mike Adams’ immediate blaming of the event on government agencies. What is their evidence? They have no evidence. They just hate without reason.

    These conspiracy theorists are just another type of hatemonger. This event is just the latest proof. No matter what the reality is, what the facts are, every event just becomes further proof of their warped and hateful world view. Never mind that it casts civil servants and law enforcement as the murderers, the victims as liars, and the rest of us as fools, that’s what they believe. We shouldn’t continue to tolerate this as just fringe wackiness. This is hate mongering, and the worst kind. It’s hate mongering in the immediate aftermath of a tragedy, designed to make us hate and fear our fellow citizens, those trying to help us, and those who were hurt the most. It’s hate and divisiveness when we should be pulling together rather than apart. It’s no different from what the Westboro Baptists church does. And Alex Jones and Mike Adams are just like Fred Phelps.

  • Antibiotics in Meat Do Lead to MRSA in Humans

    I was extremely disturbed to see in the NYT’s letters a veterinarian’s defense of the practice of overuse of antibiotics in animals that suggested transmission of resistant organisms does not occur. Nonsense! It is abundantly clear that antibiotic use in animals results in resistant strains that then colonize humans. They are being recognized as the newest reservoir for strains of MRSA.

    Unlike the GMO nonsense, this is a clear public health issue with a plausible (and demonstrated) mechanism of transmitted risk to humans. The author of the letter, Charles Hofacre, says two, wildly misleading things. For one, he suggests the antibiotics they are using are somehow substantively different from those in humans by saying, “About a third of livestock antibiotics used today are not used at all in human medicine.” Well, that means 2/3rds are the same and just because we don’t use the exact same antibiotics doesn’t mean they don’t share the exact same mechanism. If he’s trying to suggest resistance in livestock antibiotics isn’t relevant to human pathogens, he is just wrong, wrong, wrong. Second he says, “There is no proven link to antibiotic treatment failure in humans because of antibiotic use in animals for consumption — a critical point that is often missed. ” This is such a misleading statement I can’t believe an academic would say such a thing, as it assumes we’re just idiots. This suggests that there is not a transmission issue, or at least none of clinical relevance. But this is also wrong. There is extensive documentation of Methicillin-resistant Staph Aureus (MRSA) becoming more common in livestock, being transmitted to humans, and appearing in hospitals. There hasn’t been a “treatment failure”, because we still have antibiotics that work against MRSA, and MRSA is usually not pathogenic on its own without some failure of the host immune system, broken skin/non-sterile injection, surgery, chemo, etc. That doesn’t mean we should go around spreading MRSA! We have to start taking out the big guns to deal with MRSA infections when they do occur (we don’t treat colonization), and the more we expose these bacteria towards the better antibiotics, the more we’ll train them for resistance to those drugs. But it should be made clear, the transmission of resistant bacteria from farm animals to humans has been documented, just because the patients didn’t die doesn’t mean that there’s no problem here. This is just shameful.

    Antibiotic resistance has existed since before we even used antibiotics and will only get worse the more we train the organisms to grow in the presence of antibiotics. These genes for resistance aren’t “new”, but not all bacteria carry them because there is an energy cost associated with production of proteins, and if it doesn’t benefit their survival, those bacterial strains wasting energy will become less common. If we constantly create a selective pressure on bacteria to maintain resistance genes, we are going to increase the proportion of bacteria that carry resistance, and thus the resistant organisms we are exposed to. Then, as we have to use more and more powerful antibiotics to address resistance, we create additional selective pressure on the organisms to carry more and better resistance genes (not all beta-lactamases are created equal), and as they mutate to become more effective, those effective resistance strains will eventually mutate into bacteria for which we have no therapeutic option. These are already starting to emerge as those who followed reports of the MDR-klebs outbreak at NIH know.

    In my GMO thread I used the analogy that the beta-lactamase used for genetic modification of organisms by molecular biologists is like a “sharpened stick” it can use against weaker penicillins. This is why those resistance genes aren’t a danger for humans. They’ve been around forever anyway, all the bacteria that are going to carry them already do so we don’t even bother using weaker penicillins on those types of infections, and they can’t beat our stronger beta-lactam drugs like the anti-staph and extended-spectrum beta lactams. The multiple-resistance and pan-resistance bugs that we are finding in our ICUs are the “multiple nuclear warhead” bugs because they beat multiple classes of drugs as well as our extended-spectrum drugs. We’ve created these bugs by the steady application of selective pressure with exposure of the organisms to progressively more powerful antibiotics. The continued injudicious use of antibiotics in animals will invariably lead to the same phenomenon, just all over the place in communities and the workplace rather than just in the ICU. We are going to see a higher prevalence of resistant bacteria, those bacteria will mutate their resistance genes to become more and more effective, they’re already crossing over to humans and hospitals, and we’re going to have to use our big guns more which will speed up the loss of our antibacterials’ efficacy.

    Some caveats. One, this represents more of a threat for farm workers than consumers, as MRSA is not carried in the meat itself, although it will likely contaminate the meat at higher frequency (this has indeed been shown) as the prevalence increases from slaughterhouse contamination. MRSA usually colonizes the outside of the animal, the nares, etc., not the inside of the animal. Two, standard practices of food handling will also decrease, but not eliminate our risk. Cooking meat and washing hands with soap after meat handling (which should be your standard practice) kills MRSA. Don’t prepare hamburger then pick your nose people. Clean surfaces on which meat has been prepared etc. However, the packaging, your cutting board, your trash can, all are likely to get contaminated if the meat was surface contaminated. Three, realize MRSA is not pathogenic in normal healthy people. But, something as simple as a cut can introduce staph and create a serious infection. Staph is everywhere, and the human body generally has no problem handling it. But when those defenses are down, MRSA reduces our therapeutic options. You don’t want that. Fourth, this is just one bug we may be exposed to, we’re also training the animals e. coli and enterobacter to become resistant too, and with poor food prep and exposure, you can get colonized with these bugs as well.

    From a public-health standpoint it’s important that we reduce the prevalence of resistant bacteria we’re exposed to, so fewer of our infections will require the big-gun antibiotics. There is good news though, and we shouldn’t just develop a fatalistic attitude towards this problem. As we stop the overuse of antibiotics, selective pressure on the bacteria will cause some of them to shed the resistance genes, and there won’t be a reason for the bacteria to maintain and improve their antibiotic resistance genes. Without consistent exposure to antibiotics, they have far less selective pressure to produce proteins and maintain plasmids that provide them no advantage. While the resistance genes will still be out there (always have, always will), we can still benefit from common-sense measures that decrease their prevalence, and thus our individual risk of exposure to resistant organisms. And, the less we have to take out the big guns to treat infections, the fewer multiply-resistant organisms we’ll see.

  • Conspiracy belief prevalence, according to Public Policy Polling is as high as 51%

    And it may even be more when one considers that there is likely non-overlap between many of these conspiracies. It really is unfortunate that their isn’t more social pushback against those that express conspiratorial views. Given both the historical and modern tendency of some conspiracy theories being used direct hate towards one group or another (scratch a 9/11 truther and guess what’s underneath), and that they’re basically an admission of one’s own defective reasoning, why is it socially acceptable to espouse conspiracy theories? They add nothing to discussion, and instead hijack legitimate debate because one contributor has abandoned all pretense of using actual evidence. Conspiracy theories are used to explain a belief in the absence of real evidence. Worse, they are so often just a vehicle to direct vitriol and hate. We need less hate and partisanship. We should be able to disagree with a president without saying that he’s part of an agenda21/commoncore/obamacare/nazi/fascist/communist/North Korean conspiracy to make American citizens 3rd world slaves (not an exaggeration). We should be able to disagree with a corporation’s policies without asserting their objective is mass-murder. What is the benefit of this rhetoric? It’s just designed to poison our discourse, and inspire greater partisanship, divisiveness and incivility. Conspiracy theories are often used as a more subtle way to mask vile invective towards whichever group you hate. As you look underneath these theories you see it’s really just irrational hatred for somebody- liberals, conservatives, homosexuals, different races or religions, governments, or even certain professions. This is because at the root of the need for conspiratorial thinking is some irrational, overvalued idea, and often the open expression of the belief would result in social scorn.

    I’ve found in my experience, almost everyone carries one really cranky belief that they can’t seem to shake, no matter how evidence-based their other positions are (probably because we are all capable of carrying some overvalued ideas). But it’s worth peering through PPP’s full results to see the nature of some of these associations.

    For one, some of these associations I think are spurious, poorly questioned, or just reflect misinformation, rather than conspiracy. For instance:

    44% of voters believe the Bush administration intentionally misled the public about weapons of mass destruction to promote the Iraq War, while 45% disagree. 72% of Democrats believed the statement while 73% of Republicans did not. 22% of Democrats, 33% of Republicans and 28% of independents believe Saddam Hussein was involved in the 9/11 terrorist attacks.

    Many have questioned the inclusion of this question because, in reality, there were no weapons of mass destruction found in Iraq. So the question of whether we were “misled” or “intentionally-misled” puts us in the murky position at having to guess at the motivations of individuals like Bush and Cheney. Mind-reading is a dubious activity, and I tend to ascribe to the Napoleonic belief that you shouldn’t ascribe to malice, that which can be explained by incompetence (also known as Hanlon’s razor). Is it conspiratorial to think maybe they were more malicious than incompetent? While I think that administration really were “true believers”, of course I don’t really know for sure, and I don’t think it’s fair to describe such as conspiratorial reasoning. Instead it’s just the dubious but common practice of guessing at the intentions of others. The generally-similar numbers on the Saddam Hussein/9/11 connection, I believe, just suggests ignorance, rather than necessitating active belief in a conspiratorial framework (keeping in mind the margin of error is about 3% these aren’t huge partisan differences like over WMD).

    One of the most disappointing numbers was on belief in a conspiracy behind JFK’s assassination:

    51% of Americans believe there was a larger conspiracy at work in the JFK assassination, while 25% think Lee Harvey Oswald
    acted alone.

    That’s 51% conspiratorial belief, 24% probably showing ignorance of one of the most important events of the last century, and 25% actually informed. This is pretty sad. The movements of Oswald were so thoroughly-investigated and known, the hard evidence for his planning and involvement are so clear, the conspirators so unlikely (the mob/CIA/LBJ/KGB hiring crackpot loser communists for assassinations?), and the fabrications of the conspiracists so plain (asserting the shots couldn’t be made despite it being easily replicated by everyone from the Warren Commission to the Discovery Channel and even improved on, the disparaging of his marksmanship when LHO was a marine sharpshooter, altering the positions of the occupants of the car to make the bullet path from JFK to Connelly appear unlikely, etc.) it’s sad that so many have bought into this nonsense. The historically-bogus picture JFK, by Oliver Stone, may also play a large part in this, and is an example why Oliver Stone is really a terrible person. People that misrepresent history are the worst. If anyone wants to read a good book about the actual evidence that of what happened that day, as well as destroys the conspiracy position, Reclaiming History by Vincent Bugliosi is my favorite, as well as the most thorough.

    But there is one redeeming feature of conspiracy about the JFK assassination. For the most part, conspiratorial ideas on the subject aren’t due to some dark part in people’s souls, as for many other conspiracies, but rather the very human need to ascribe more to such earth-shattering events as the assassination of a president than just the madness of a pitiable loser. The imbalance between the magnitude of the event, and the banal crank that accomplished it, is simply too much. There’s no way that a 24-year-old, violent, wife-beating, Marxist roustabout could be responsible for the death of a man like JFK right? Sadly no. The evidence shows even a man that pathetic can destroy the life of a much greater man with a cheap rifle and a simple plan.

    The conspiracy theories embedded within this poll that really disturb me because I think they demonstrate the effect of irrational hate are ones such as for whether President Obama is the antichrist (although is that even really a conspiracy?). 13% of respondents believed this, 5% of those that voted for him still answered this question in the affirmative (really? you voted for the antichrist) as opposed to 22% of those that voted for Romney. Do we really need to elevate political disagreement to the level of labeling people the antichrist? Around 9% thought government adds fluoride for “sinister” reasons, and 11% believe in the LIHOP 9/11 conspiracy theory. They clearly think very little of their fellow Americans, and believe some really demonic things about our government. Our government is neither competent enough, or evil enough, to engage in then successfully cover up either of these things. Our top spy couldn’t even hide a tawdry affair.

    Other conspiracy theories seem to indicate their is a baseline number of people, at about 15%, who will believe in just about anything from the moon landing being hoaxed to bigfoot. I would have actually pegged this number higher, given my pessimism about rational thought, but that seems to be what we can read from this. However, without being able to see whether or not it was the same people answering yes to each individual absurd conspiracy from reptilians to “government adds secret mind-controlling technology to television broadcast signals”, it’s possible this number is actually much larger. I would be curious to see the data on the overlap between these questions, as the phenomenon of crank magnetism is well known.

    Ultimately, I read this data as saying that Americans have a big problem with conspiracy theories entering our political discourse. We should be embarrassed that as many as 37% of us believe that global warming is a “hoax”. That requires a belief is a grand conspiracy of scientists, policy-makers, journals, editors, etc., all acting together to somehow fabricate data for a single objective – often described as world-government control conspiracy to cede our sovereignty to the UN. Somehow, every single national scientific body, all those national academies, all those journals, and all those scientists, all those governments, all working in perfect secrecy according to some master plan (which I’m often accused of being a part of but I’m sure I’m missing the memo), and this is plausible how? The answer is, it’s not, unless you remain steadfastly ignorant of how science actually works and progresses.

    Everyone, of any political persuasion, should be embarrassed by the conspiracy-theorists in their ranks. This isn’t healthy thinking, it isn’t rational discourse, and it only serves to divide us and make us hate. Enough of this already.

  • There Are Legitimate Criticisms of Obamacare – Hospitals Should not be Penalized for Readmissions

    Crazy ranting about impending socialism/fascism aside, there are legitimate critiques to be made of Obamacare. One policy in particular that raises my ire is penalizing hospitals over performance metrics and penalizing readmissions in particular. The way it works is, patients are admitted to the hospital, treated, and eventually discharged, but a indicator of failure of adequate care is if that patient then bounces back, and is readmitted shortly after their hospitalization:

    Under the new federal regulations, hospitals face hefty penalties for readmitting patients they have already treated, on the theory that many readmissions result from poor follow-up care.

    It makes for cheaper and better care in the long run, the thinking goes, to help patients stay healthy than to be forced to readmit them for another costly hospital stay.

    So hospitals call patients within 48 hours of discharge to find out how they are feeling. They arrange patients’ follow-up appointments with doctors even before a patient leaves. And they have redoubled their efforts to make sure patients understand what medicines to take at home.

    Seems reasonable, right? These are things that are part of good medical care; good follow up, clarity with prescriptions, etc. It should be the responsibility of hospitals to get patients plugged into the safety net, assign social workers, and make sure patients won’t fail because they lack resources at home. However, the problem arises when the ideal of punishing readmissions as “failures” crashes into the reality of the general failure of our social safety net:

    But hospitals have also taken on responsibilities far outside the medical realm: they are helping patients arrange transportation for follow-up doctor visits, get safe housing or even find a hot meal, all in an effort to keep them healthy.

    “There’s a huge opportunity to reduce the cost of medical care by addressing these other things, the social aspects,” said Dr. Samuel Skootsky, chief medical officer of the U.C.L.A. Faculty Practice Group and Medical Group.

    Medicare, which monitors hospitals’ compliance with the new rules, says nearly two-thirds of hospitals receiving traditional Medicare payments are expected to pay penalties totaling about $300 million in 2013 because too many of their patients were readmitted within 30 days of discharge. Last month, the agency reported that readmissions had dropped to 17.8 percent by late last year from about 19 percent in 2011.

    But increasingly, health policy experts and hospital executives say the penalties, which went into effect in October, unfairly target hospitals that treat the sickest patients or the patients facing the greatest socioeconomic challenges. They say a hospital’s readmission rate is not a clear measure of the quality of care it provides, noting that hospitals with higher mortality rates may also have fewer returning patients.

    “Dead patients can’t be readmitted,” Dr. Henderson said.

    This is a problem with the careless application of rewards and penalties tied to medical outcomes. While I think it’s a healthy response that hospitals are taking on more of the social work that formerly would have been the arena of government programs, there is another defense mechanism used when government creates perverse incentives in health care. When you create payment incentives for good outcomes, you run the risk of patient selection, discrimination, and fraud. My favorite paper on this topic comes from the British NHS, and their attempt to reward physicians based on better clinical outcomes. My advice with this paper (and with most papers frankly) is to ignore what the authors say about their data (and the amazing success of their program!) and just look at the data for yourself. What they found with rewarding physicians based on health metrics was that doctors that treated the young, healthy, and rich did well, those with more patients, poorer patients, and older patients did more poorly. Finally, physicians that filed lots of “exception reports” to eliminate all their poorly-performing patients did great (yay, fraud!).

    Metrics are good for identifying problems, but the mistake is the assumption that poor performance at a metric has everything to do with the physicians or the hospitals, or that slapping a penalty on poor performance will fix the problem. Sometimes, you’re studying society, not medical care. Incentive structures that put the burden on hospitals to take care of the most basic needs of their patients are going to penalize those hospitals that take care of the neediest, sickest, oldest patients, and reward those who treat insured, wealthy, younger, and fewer patients. Worse, if you penalize hospitals for taking care of difficult patient populations, I can predict the outcome. More bogus (and occasionally dangerous) transfers, more patients dumped on public and university hospitals, and all the other tricks of patient selection private hospitals can engage in to avoid getting stuck with the economic losses. That is, patients who are really sick, really poor, really old, and most in need of care will get transferred, obstructed, and dumped. Hospitals that are referral centers, major university and public hospitals that can’t refuse or transfer problem patients, will end up with the disproportionate amount of the penalties because they are often the healthcare providers of last resort. Not surprisingly, the early data already shows this is happening:

    The second important development was the release of data on who will be penalized: two thirds of eligible U.S. hospitals were found to have readmission rates higher than the CMS models predicted, and each of these hospitals will receive a penalty. The number of hospitals penalized is much higher than most observers would have anticipated on the basis of CMS’s previous public reports, which identified less than 5% of hospitals as outliers. In addition, there is now convincing evidence that safety-net institutions (see graphsProportion of Hospitals Facing No Readmissions Penalty (Panel A) and Median Amount of Penalty (Panel B), According to the Proportion of Hospital’s Patients Who Receive Supplemental Security Income.), as well large teaching hospitals, which provide a substantial proportion of the care for patients with complex medical problems, are far more likely to be penalized under the HRRP.3 Left unchecked, the HRRP has the potential to exacerbate disparities in care and create disincentives to providing care for patients who are particularly ill or who have complex health needs, particularly if the penalties are larger than hospitals’ margins for caring for these patients.

    It would be unfortunate if in the course of creating incentives for better care, we fall into the same old trap of punishing those who take care of the neediest. What we need instead is to acknowledge one major source of bad outcomes is a broken social-safety net. We can’t just keep creating these unfunded mandates that put all the onus of taking care of the uninsured, the poor and elderly on hospitals, and punish the centers that already carry the largest social burdens with responsibility for the failure of our nation to take care of its own. Unfortunately, our answer to problems like these is always to create one more shell game that hides the real, unavoidable costs of taking care of people by shifting it around. This will just result in higher bills on the insured, more crazy chargemaster fees, overburdened public and university hospitals, and ultimately, a system of regressive taxation.