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The US health care debate

Writing about the political dance in Washington, DC is not a pleasant task. I intend to skirt around the edges of it. It is marginally about health care and largely about the relative power of the two major US political parties.US_capitol

Nonetheless, since it has brought the Obama health care plan back to the top of the national political agenda, it is worth recalling some basics.

First, the principle of insurance is that a catastrophic risk is spread across as many people as possible making advanced contributions so that funds are pooled and available to any individual suffering that risk. For example, individuals buying life insurance at a young age receive a favorable premium rate and are likely to contribute for a long time, much longer than the time it would take to accumulate the death benefit, but for those individuals not so fortunate, the monies are there in a pooled risk fund to be distributed to the family of someone who dies prematurely. The risk of an expensive illness with accompanying medical costs is similar.

Second, millions of Americans have not had health insurance. Some of those are young, feel invulnerable and do not want health insurance. Others have pre-existing health impairments and have been refused health insurance. Still others do not receive insurance through their employers and cannot afford it on their own.

Third, there are negative consequences to our society for these uninsured:

  1. Those without insurance still must be treated when they get ill or have a motor vehicle accident.
  2. The young, less likely to be net expenses to a pooled risk fund, need to be part of the contributors under the principle of insurance
  3. Those denied insurance because of pre-existing conditions need to be saved from bankruptcy, and the hospitals need to be protected from having to serve them at no cost.
  4. Those who do not have insurance through their employers, who could not afford individual insurance policies, require a means to participate.

Fourth, the Patient Protection and Affordable Care Act (PPACA), commonly known as “Obamacare,” is an honest attempt to address those concerns, as well as reining in the ever-rising costs of medical care.

Fifth, the term “socialized medicine” is easily bandied by politicians, but there are two distinct areas of government involvement in health delivery that can more accurately be called “socialized medicine,” and “socialized insurance.” The US has both. Socialized medicine occurs when the government provides access to healthcare either directly through government clinics or through social insurance used in government health facilities. In that case, the health care providers are government employees. Foreign examples are the National Health Service of the United Kingdom. NHS-logoIn the US the system of hospitals under the Department of Veterans Affairs (VA). Socialized insurance is when the government supplies health insurance but the healthcare practitioners are not government employees. Medicare is socialized insurance, as are the national health systems of Canada, France, Italy, and Germany. There are advocates for socialized insurance in the United States, under the banners “Medicare for All” and “Single-Payer.” There is no recognizable group that favors socialized medicine in the US–NONE.

Sixth, Obamacare is neither socialized medicine nor socialized insurance, because all of the providers are private, and all of the insurers are private. An early proposal to include a “public option” form of insurance was dropped. It is not surprising that Obamacare is completely privatized–it is a proposal in concept by that most conservative think tank, the Heritage Foundation. (More recently, it has taken a further turn to the Right by engaging former SC Senator Jim DeMint as President; however, it has always been quite conservative.) Its proposal was adopted, supported, and implemented by the Republican governor of Massachusetts Mitt Romney. The theory was that the accelerating costs of healthcare could be addressed by a market system, and the government assumed the role of creating the market or even playing field for the insurance companies to compete for business.

Seventh, the individual mandate, which draws a lot of the political fire, was part of the original Heritage plan by Stuart Butler in a 1989 paper, and of the Romney plan. It is essential to the effectiveness of the system in two major ways:

  1. It makes the younger, healthier citizens participants, with the benefit of their consuming less than they contribute but not being a burden when struck by accidents or rare illness.
  2. More importantly, it makes possible the elimination of pre-existing conditions. If pre-existing conditions could not prevent obtaining insurance, no one would buy insurance until contracting an illness, and would then be assured of acceptance. Because the insurance would have to cover the illness, with no reserve built up, with no spreading of risk across the entire population per the insurance principle, the insurance would be nearly unaffordable with the premiums set at the level of the average illness since it would have to cover the risk. Pregnancy benefits are often rated that way in insurance policies since the benefits being paid are nearly assured.

Eighth, there is the issue of affordability. Enterprises with over 50 employees are required to provide insurance. Most already do, but these employers are a very small segment of the workforce, perhaps 10 percent. The rest of us are self-employed or employed by smaller enterprises. If they already provide health insurance that is fine, but under the individual mandate, if they do not, then anyone working there including the executives will have to fulfill the mandate by finding insurance on the exchanges, and by shopping for the level of coverage at a premium they can afford. Both affordability and insuring the young are addressed in part by requiring adults to be eligible until age 26 for insurance under their parents’ plan.

For those at the bottom of the pay scale, those who do not qualify for Medicaid, which can have very stringent asset limitations (in California, for example, having funds over $2,000 disqualifies one from Medi-Cal), those often called “the working poor” may be eligible for government subsidies. In addition, the federal government is offering states financial incentives to expand the Medicaid program to cover more of the working poor.

Finally, there is the issue of what is health insurance coverage? If we want to require people to buy it, we need to be able to say what is and what is not acceptable coverage, to avoid individuals and businesses buying something so minimal that it complies with the law but does not address the problem of access to health care. An individual buying a policy hat pays $100 daily for hospital care has not really bought insurance. So, the government through implementing regulations has stipulated what a minimum policy contains. This has raised issues of conscience for those who do not believe in one or more aspects of medical science as applied to health care.

The religious reservations are well-known in the United States. Among them are a preference for Christian Science practitioners among Christian Scientists, an avoidance of blood transfusions among Jehovah’s Witnesses, rejection of birth control measures among Catholics, as well as rejection of pharmaceutical and surgical interventions to prevent or abort a pregnancy among numerous denominations. The law has allowed a religious exemption for churches. The point of contention has been for practitioners who participate in commerce and do not wish to compromise their religious beliefs by providing the means for something they consider murder. From a public policy view, the problem is multiple:

  1. Recognizing that right by owners of businesses and organizations may deny access to some of their employees who feel equally strongly that obtaining those treatments is their right.
  2. Recognizing those rights by one group implies, under equal protection, recognizing such objections by all groups and individuals. That places the government in the powerful and unwelcome position of determining which religious beliefs are legitimate and entitled to protection, an intrusion into religion that most Americans would find offensive.
  3. Recognizing that right with respect to abortion, would open the possibility of recognizing objections to all forms of insurance. A business owner might claim religious exemption to providing any insurance, undermining the public purpose of the law.

In order to address these concerns, the law limits religious exemptions to religious institutions, such as places of worship. There are pending court cases that may change the way this challenge is addressed in order to comply with First Amendment considerations.

One theory of American government is that the states act as laboratories for the society and the nation, trying approaches, which, if successful, can be generalized. That has occurred here, with Massachusetts providing the laboratory. As the national experiment is just beginning, it is too early to tell whether the proponents or opponents of Obamacare have correctly analyzed its impact and future. Five years from now, it will be much clearer. I look forward to seeing that day and looking around to see what worked and what did not, what needs changing, what has been correctly changed, and what has not. I have often thought that politics is America’s most engaging indoor sport, and, at this moment, Obamacare is at center court.

What we almost know

The impact of intestinal flora on health conditions is known, thus fecal transplants for numerous conditions. Last week I wrote about an experiment with mice verifying the impact on obesity.

As a consequence, there are numerous products being marketed as “probiotic.” We have no idea whether those products are helpful, harmful, or simply benign.Bacterial flora are an instance where we know some bacteria are essential, and we know some can be added beneficially, but we do not know which ones to add. There are promising studies with lactobacillus acidophilus shown: lactobacillus We almost know about GI flora, but not quite enough yet.

There are other topics where we are at a similar place. We know a lot about what mental illness is and isn’t. We know that increasing serotonin in the interstitial spaces of the brain helps with depression and that too much serotonin is associated with schizophrenia. As of this point, however, we don’t have imaging or blood tests or biopsies that will tell us who is mentally ill–we use written testing and observation not laboratory tests to diagnosis it. When physicians attempt to treat it, it is largely a matter of trial and error. We do not know beforehand whether a particular selective serotonin re-uptake inhibitor (SSRI), such as fluoxetine or venlafaxine will work with an individual, or if any SSRI will work. Some people will do better with buproprion, which uses a different mechanism. Others will do better with a serotonin–norepinephrine reuptake inhibitor (SNRI) such as duloxetine. Others will experience no clinical effect at all. We almost know about mental illness, but not quite enough yet.

These examples lead to a more general question about what we know and do not know. It is usually phrased as “nature vs. nurture,” but it is really genetics vs. environment. I am not sure if the the “versus” between them is appropriate–something else I do not know–as it is the relative interaction of the two rather than a false choice between them that is a more likely source of the truth about who we really are.

Researchers often conduct identical twin studies, controlling for genetic variation by comparing the environmental impact of twins with nearly identical DNA. Molecular computer graphic of DNA double helix However, the studies are limited: it is intriguing if they both smoke the same brand of cigarettes or like the same foods despite very different upbringings, but it does not neatly tell us which behaviors are genetic and which are environmental.

Similarly, we know that 3/4 of children of two bi-polar parents are likely to have bi-polar disorder, which seems to indicate a Mendelian genetic inheritance, but we only almost know about the inheritability of mental illness, not quite enough.

Even where we know that a trait is inherited, we often do not know what genes or constellation of genes are associated with a given, visible trait. We almost know about the human genome, but not quite enough yet.

As scientists or those of a scientific bent, we are obligated to say what we know and what we don’t know, being able to distinguish the difference. It is not always an easy distinction to make, but is central to our effort to know more, and eventually know enough.

Learning about fat people

When I was growing up, I had a first cousin who was morbidly obese, long before the efforts of the rest of the country to catch up with her. Her failure, and it was considered a failure, to lose weight was seen as evidence of a moral failing, a lack of willpower, only slightly less pejorative than the sin of gluttony in earlier times. There was some vague talk that she might have some hormonal imbalance, but it was clear that all around her considered her problem to be predominantly one of willpower.

Both alternative and scientific medicine have taken a recent interest in gastro-intestinal (GI) flora, or “gut bacteria.” The alternative medicine folks have favored “probiotic” supplements and yogurts fortified with bacteria. The probiotic movement began with Nobel laureate Elie Metchnikoff, known as the “father of probiotics,” who believed that longevity of rural Bulgarians and Georgians could be attributed to their consumption of fermented milk products.
Metchnikoff

Consideration of the impact of GI flora on diarrhea is not really new–a half century ago I can recall being given lacto-bacillus pills to counter the gastric distress resulting from penicillin. It is the potential impact of bacteria on obesity that is notable in the current focus. Recently National Public Radio (NPR) interviewed Jeffrey Gordon, a microbiologist and director of the Center of Genome Science and Systems Biology at the Washington University School of Medicine in St. Louis. Audio Player

While I hope you will either listen to the embedded audio clip (about 12 minutes) or read the interview transcript, the short version is that there the research shows a recursive feedback loop between how the bacteria impact our appetite and how what we eat impacts the bacteria that are in our intestines. By eating the right or “lean” foods, we encourage the bacteria that help us maintain our weights at a healthy level. Now, there has been some experimentation with fecal transplants, having a similar aim, but that does not seem to be for everyone–particularly those of us who would be grossed out by the very idea. Eventually, we will probably have probiotics, which, combined with proper diet (they need to be fed or cultivated in our gut), can be delivered to our intestines in pill form, or at least a suppository rather than a fecal transplant.

Over time my cousin became estranged from nearly everyone in the family and died a few years ago, not having been seen by any family members in decades. Waxing philosophically, I cannot help but wonder how different my cousin’s life might have been had she been born a half-century or better a century later. And, I wonder how different my father’s life might have been had he survived his first heart attack and lived to see statin drugs.

It seems that much of our survival depends upon living just long enough for technology to address a mortal weakness in our genome. Nonetheless, it is encouraging to note that promising approaches to obesity may make it seem like nothing more interesting than a historical healthcare statistical blip rather than the crisis it appears to be as we live with it and address it.

Herd Immunity — How vaccines avoid thinning the herd

Part of the difficulty in making a case for universal vaccination against dangerous disease is a lack of understanding of probability. Since there are few certainties in life, except its eventual end for individuals, we are constantly calculating probabilities. What is the probability that I will get to the other side of the street before that oncoming car arrives? What is the probability that the wheel stop on my number or that I will draw the card needed to complete my hand? What is the probability that the game I am going to attend will occur or get rained out? And, of course, what is the probability that the suggested intervention will cure my disease rather than kill me or leave me permanently debilitated?

Some probabilities are more difficult to calculate than others: what are the odds that I will die from prostate cancer, and what are the odds that the operation will leave me impotent? how do I calculate the best course when my choices are an operation with an 80 percent success rate that leaves another 15 percent paraplegic and 5 percent dead? How about the same operation with 93 percent success, 5 percent paraplegic, and 2 percent dead?

The more complex the alternatives, particularly when they are being balanced against complex outcomes from non-intervention, the more difficult it is for us to make a rational decision.

That leads to a discussion of vaccination. Let’s consider a disease such as smallpox, which has killed 100s of millions of people. Not everyone got smallpox. Not everyone who got smallpox died from it–estimates are that about 30 percent, or 3 out of every 10 died. Now, consider that not everyone who gets a vaccination gets 100 percent immunity. Some people get partial immunity. Some very small percentage may not produce antibodies in reaction to the vaccine. Some people actually die of the side effects of the vaccination.

As an individual, you might think, well, it’s not great but 70 percent odds of surviving are better than none, and maybe it will miss me altogether, so why should I vaccinate? Of course, smallpox has been eradicated, and we don’t have to make that kind of determination any more since the dangers of side effects from the vaccination exceed the danger of contracting smallpox, particularly in the United States where the last documented case appeared in 1949.

If you were a free individual, not part of a society, not part of the possible transmission stream of a disease, then no one is likely to care too much what you decide? However, if you are reading this, you are part of a society providing this message to you via a societal mechanism. As part of that society, you have obligations to others in the society, including children, yours and others, who once were considered private property but are now considered individuals with rights, albeit limited compared to adult rights.

The concept of “herd immunity” goes directly to the questions posed and to your obligations within the society.

Herd Immunity Concept

Those who are vaccinated provide a barrier to illness for those who are not:

Consider:

Assume you have 5 friends who do not know one another, and that everyone has 5 such friends.

Assume that vaccinations give almost 100% immunity and that the corresponding disease gives almost 100% probability of infection if you come in contact with a person who has it.

Now, if 80 percent of people are immunized against the disease, it is quite possible that one of your friends is not immunized. However, if 80 percent of that person’s friends are immunized, there is now only 1/5 times 1/5 or 1/25 = 4 percent chance of the disease vector reaching you. It may be that you friend’s friend has friends with 100 percent immunity, all five of them immunized, and the further you are socially from the source of infection, the lower your odds of becoming infected–even if you are not immunized. You are protected by herd immunity.

However, consider if only 60 percent of people are immunized, then 2/5 times 2/5 is 4/25 or 16 percent chance of becoming infected. That is 4 times your chance of infection from a secondary friend, as in the first example. The degree of herd immunity is a complicated calculation depending upon the percent immunized and the way the disease is transmitted. Your chance of infection depends on those factors as well as your social distance from the source of the infection.

For an animated look at the concept, click on “Play Animation” in the three scenarios of The History of Vaccines: Herd Immunity.

Here are the thresholds for different diseases as estimated by the Centers for Disease Control (CDC):

Herd Immunity Thresholds CDC

Think about flu shots for a moment:

  1. The vaccine is based upon recent mutations of the virus, so you might catch a virus that is not part of the vaccine.
  2. Not everyone gets 100 percent protection from a vaccine–it may be sufficient to protect against some strains and give partial protection against others
  3. In part, because of herd immunity, not everyone exposed to influenza is infected

So, we have friends and relatives drawing the wrong conclusions (e.g. the vaccine caused me to get influenza), based on an association of factors that are coincidental or subject to an alternative explanation, such as a new strain or partial immunity. For most young people, the flu is an occasional inconvenience rather than life-threatening; however, their failure to vaccinate exposes others whom they could be protecting by a simple annual injection. Let’s spread the word–it might not save those young individuals–just an older person, or an asthmatic standing close to them.

Vaccination–Now and Then

Smallpox was long one of the scourges of humanity, killing millions throughout history. Early attempts were made to combat it through “variolation,”inoculation with the scabs of the disease. Such efforts began at least a thousand years ago in China. ChineseVaccination

Without images to guide us, it is easy to think of smallpox as chickenpox that kills. Not exactly. Besides the fact that smallpox does not concentrate on the torso, the number of pustules seems much more severe to my eye. Here is a child in Bangladesh in 1973 with smallpox. This is what we no longer fear because of vaccination:

Child_with_Smallpox_Bangladesh

Vaccination is relatively new in human history–the United States of America is older. Just before and after 1800 Edward Jenner, noticing the apparent immunity to smallpox of milk maids, experimented with inoculation using the relatively benign disease cowpox to which they had been exposed. It was not until 1840 that the British government routinely provided the means for inoculation, as the medical establishment had been slow to accept Jenner’s findings.

Nonetheless, the disease that killed an estimated 400,000 Europeans annually at the time of Jenner’s discovery, was still able to kill several hundred million in the 20th century.

The last documented case of smallpox occurred in Somalia in 1977. By 1980 the World Health Organisation (WHO) was able to declare smallpox eradicated. Consequently, routine smallpox vaccination was discontinued in the 1980’s as the statistical danger from the vaccination (14 to 52 per million per the CDC) exceeded the danger of the disease.

I would prefer to be able to present a time series of smallpox cases, but have been unable to locate one this week. Failing that, here is the impact of vaccination in the US on numerous diseases during the 20th Century, worth considering when someone questions the value of vaccination.
Vaccination_US_thru1998

Celebrity and science: the vaccination controversy

Bill Maher is witty and funny–particularly if you are not politically or religiously conservative.

However, the closest he will get to being a virologist is when a video clip of him goes viral.

In 2009 he provoked a controversy by tweeting that anyone who got a flu shot was an idiot. In a blog post on November 15, 2009 he backed off a bit, but defended himself by:

  1. I’m a comedian
  2. I tweeted it, didn’t say it on my show.
  3. Saying there are questionable things about vaccines.
  4. Endorsing a group opposing vaccinations.

It was a non-apology worthy of a Washington official. The truth is that while Bill Maher is neither an authority nor an expert on vaccines, he has influence based upon his celebrity. And, as a result, he can influence many people who should get vaccinated but are undecided, as can any other celebrity. After all, who likes hypodermic needles except for the rare needle freak? We all want some cover for deciding to avoid needles.

We may all be grateful that celebrities are not the go-to experts on health care for most parents; however, a 2011 University of Michigan study found that 1 out of 50 parents rely on celebrities a lot for information, and that 1 out of 4 rely on celebrities some.

MichiganVaccineSurvey2011

One of the sources that Maher cited was the National Vaccine Information Center (NVIC). It is reasonable that individuals who have suffered side effects from vaccines or any other medication might band together to ask that there be full disclosure on the risks as well as every effort to promote safety. Unfortunately, NVIC goes a step forward, suggesting that vaccination is a matter of preference rather than necessity. It is a bit like receiving a full glass of water and obsessing about the emptiness between the top of the water and the lip of the glass.

A key paragraph in their statement of purpose:

This traditional paternalistic medical model is increasingly being rejected by today’s more educated health care consumers and, along with this challenge, is also an historic challenge to the supremacy of the allopathic medical model as the only means of maintaining health and preventing disease. The movement toward a more diversified, multi-dimensional model health care system is a phenomenon occurring not only in the United States but in many technologically advanced countries.

In short, it is a rejection of science in favor of some other belief system for medical care. The United States makes ample allowance for alternative belief systems; however, alternative behaviors are circumscribed. If you wish religion taught in the schools, you must attend a parochial school, not a public one. Similarly, if you want to attend a public school, then a vaccination prerequisite is reasonable, particularly when you have private alternatives, including home schooling available. Even that stretches the limits, because unvaccinated people lower the safety of everyone. Since vaccines are not 100 percent perfect (and what is in this world?) we depend on an adequate percentage of vaccinated people to prevent an epidemic among those who are only partially protected by vaccines against communicable diseases such as polio, diphtheria, and influenza.

This is “herd immunity,” or:

Indirect protection against disease that results from a sufficient number of individuals in a community having immunity to that disease. With enough immune individuals, the transmission of a disease can be reduced, thus limiting the potential for any one individual to be exposed to it. Herd immunity does not apply to diseases, such as tetanus, that are not spread via person-to-person contact.


One of the best and simplest ways to lower healthcare costs and to improve public health is to increase our rates of vaccination. Consider this: do businesses pay for flu vaccinations because they are loving and generous, or because it will lower absenteeism and paid time off?

All That Jab – one more reason to vaccinate

Those who look toward the scientific for explanations know that only UFOs and and political assassinations attract more conspiracy theories than vaccines do.

The challenge of conspiracy theorists is similar to the challenge of mental illness–no amount of evidence contrary to a deeply held view is sufficient or dissuasive. Astute observations are followed by non-sequitur conclusions, or either-or alternatives with no room for gray in between the black and white alternatives.

Nonetheless there is heartening new evidence that influenza vaccines are benign for pregnant women–or as Reuters put it:

Pregnant women who get flu shots are at no greater risk for complications like high blood pressure, urinary tract infection or gestational diabetes, according to a new U.S. study.

The study of Inactivated Influenza Vaccine During Pregnancy and Risks for Adverse Obstetric Events, which will appear in the September issue of Obstetrics & Gynecology found In this large cohort, influenza vaccination during pregnancy was not associated with increased risks for medically attended adverse obstetric events.

Often such studies are handicapped by small sample bias, not enough people studied to draw a strong conclusion, even if statistically significant. Not the case here, as the authors report that their study group was 74,292 vaccinated females matched on age, site, and pregnancy start date with 144,597 unvaccinated females.

One might ask, “Why bother? So, I get the flu while pregnant–one more nuisance.” The same article in Reuters Health addressed that question:

For a pregnant woman, contracting the flu is “really dangerous,” according to Dr. Laura E. Riley, medical director of labor and delivery at Massachusetts General Hospital in Boston.
Pregnant women with the flu are at greater risk of death, respiratory disease requiring hospitalization and premature labor and delivery, Riley told Reuters Health.
The risk-benefit ratio was already clear, she said, but collecting new safety data is always good.

On the positive side, the benefits of vaccination accrue not only to the mother but to the baby:

“Flu shots protect pregnant women, their unborn babies, and even protect the baby after birth,” Kharbanda said.[lead author Dr. Elyse Kharbanda of Health Partners Institute for Education and Research in Minneapolis, Minnesota]
Babies don’t receive vaccines until six months of age, so they are vulnerable to catching the flu in the first six months of life, he said. But previous studies have found that some of the protection passes across the placenta to the baby and can help shield them from flu after birth.
“What mother doesn’t want to do that?” Schaffner said [ Dr. William Schaffner, chair of the department of preventive medicine at Vanderbilt University Medical School in Nashville, Tennessee]. “There should be no hesitation for women getting the vaccine.”

There is no reason for a pregnant woman not to get vaccinated against the flu; there is every reason to avoid possible consequences of not getting vaccinated; and, if not for you, then for the benefit of your baby, who does not need the flu while getting used to living outside the womb.

Patriotism and Healthcare

The furthest left button on my car radio is tuned to C-SPAN radio. It could easily be tuned to National Public Radio if I lived elsewhere.

As I have long been curious about public policy issues, it is a matter of course for me to see what is playing when I start my car engine.

On Wednesday July 24, I heard an interview with Jim McDermott on the implementation of the Patient Protection and Affordable Care Act (PPACA) or Obamacare.

Jim McDermott is a partisan Democrat, who has represented the Seventh District of Washington since 1989. He mixes it up with the Republicans on numerous occasions, actively participating in the partisan back and forth that is national politics in the US. Part of his presentation that day were partisan talking points that we are accustomed to hearing from public office holders of both major parties.

Something else caught my attention. McDermott pointed to a change in our view of the obligations of citizens to the Republic and to our society. Since the end of the military draft, wars have been fought with minimal inconvenience to the civilian population, engendering an atomistic individualism, all of us isolated and alone sharing a space and looking out for ourselves.

Here is how he put it at the 8:48 minute mark of C-Span’s National Journal on July 24,2013:

It’s a much larger problem than just healthcare. When we ended the draft in 1975, we said to all young people in this country you have no responsibility for your country. You are an individual. You can live in any way you want. You don’t owe anything to your country. So we raised a whole generation, actually two generations of people who do not see themselves as responsible for their neighbor. We have young people who figure if I get hurt, if I am on my motorcycle and get into an accident, they will take me down to the emergency room, they’ll patch me up. I will not have money to pay for it, but somebody will pay for it and everybody in society who has health insurance is paying an extra $1000 a year for these kids who refuse to anticipate that something might happen to them. Young people get cancer, young people have skiing accidents, young people have all kinds of problems and they just act as though somebody else will take care of it. That’s not right. Part of the bill says you have the responsibility to pay for the possibility that you may be . . . “We require them with automobiles. We do not let people drive without auto insurance. It’s not your problem because someone else will pay for it. We say you have to have auto insurance.

Were it not for the partisan wrangling on Capitol Hill, are these not conservative values of individual responsibility and citizenship that all but the most ideological acolyte of Ayn Rand could agree to?

Plato addressed similar questions in his dialogue: Crito. Socrates had been condemned to death. His friend Crito attempted to convince him to flee into exile rather than accept that penalty. As part of a lengthy discourse about law and society, Socrates responded by imagining an argument with laws of the society:

Then the laws will say: ‘Consider, Socrates, if we are speaking truly that in your present attempt you are going to do us an injury. For, having brought you into the world, and nurtured and educated you, and given you and every other citizen a share in every good which we had to give, we further proclaim to any Athenian by the liberty which we allow him, that if he does not like us when he has become of age and has seen the ways of the city, and made our acquaintance, he may go where he pleases and take his goods with him. None of us laws will forbid him or interfere with him. Any one who does not like us and the city, and who wants to emigrate to a colony or to any other city, may go where he likes, retaining his property. But he who has experience of the manner in which we order justice and administer the state, and still remains, has entered into an implied contract that he will do as we command him. And he who disobeys us is, as we maintain, thrice wrong: first, because in disobeying us he is disobeying his parents; secondly, because we are the authors of his education; thirdly, because he has made an agreement with us that he will duly obey our commands; and he neither obeys them nor convinces us that our commands are unjust; and we do not rudely impose them, but give him the alternative of obeying or convincing us;–that is what we offer, and he does neither.

In order to uphold his agreement with his society, Socrates chose to accept its death sentence rather than flee. We are not faced with such stark choices in 21st Century America. We have on occasion leaders and laws preferred by others, but we agree in our democratic contract to accept them, so long as we retain the right to speak out against them and to elect different representatives on a regular basis. Such is our obligation to respect Obamacare, which is the law of the land.

We do not have to go out on a battlefield shouldering a weapon to be patriotic. We do not even need a war or an enemy or an adversary to be patriotic. It can be sufficiently patriotic to respect the laws, particularly those that assign us social responsibility, for like Socrates, we have accepted all the bounty of this society, and it would demean us not to accept the accompanying responsibilities.

Disease and National Defense

In Biblical times, where historical accounts and historical myth sometimes mingle, there are accounts of great armies being destroyed by disease. Conflicting accounts of the siege of Jerusalem circa 701 BCE by the Assyrian king Sennacherib are of that nature.

Fast forward two thousand years. Evans, Kleinman, and Pagano write:

In 1334 an epidemic struck the northeastern Chinese province of Hopei. This “Black Death” claimed up to 90% of the population, nearly five million people. The epidemic eventually reached and decimated Tartar forces that had been attacking Kaffa, a Genoese colony on the Crimean Peninsula. In 1347, the departing Tartars catapulted plagueinfested bodies into Kaffa. The Genoese quickly dumped these bodies into the sea, however it was too late. Four ships escaped back to Italy carrying the plague that in just two years killed one-third of the European population.

The relationship between disease and national defense is not a new one in the US. Just a simple web search revealed this 72-year-old article from the American Journal of Public Health on the dangers of venereal disease to military preparedness. Another article in the Journal of the American Medical Association (JAMA) of the same year reports that venereal disease has been a concern of the US Army and Navy since 1778.

There is continued concern about the impact of infectious disease on national defense, for example, the emergence of antibiotic-resistant pathogens and the threat from tick-borne diseases, and from influenza.

Indeed, with anthrax and ricin scares, preventing and managing bio-terrorism is a major part of contemporary national preparedness.

In addition, the Department of Defense is participating in prevention initiatives. As Dr. Jonathan Woodson, Assistant Secretary of Defense for Health Affairs in the Department of Defense, put it:

At the Department of Defense, we’ve moved from a concept of health care to health, meaning that we understand health really is a much more involved concept other than just freedom from disease. It relates to healthy communities and healthy and active lifestyles and also addresses mental wellness and spiritual wellness as well. For us to create a fit and ready force, we need to make sure that we’re paying attention to all these dimensions of health and wellness.

All of these efforts center upon a single premise: national defense depends upon maintaining the health of the civilian and military populations.

That raises an important question: does it matter whether the threat to our health is a foreign enemy, a small band of domestic terrorists, or what we do to ourselves?

As we eat too much, as we eat too much of the wrong foods, as those foods provide biological encouragement to continue those habits, as we exercise too little, and as we create our own national health epidemic, is that not more than what any adversary could do to us?

Or as Walt Kelly’s cartoon Pogo once famously stated: We is met the enemy, and he is us.

Leptin and Ghrelin and Fat, oh my!

I am so embarrassed.

I have been confusing ghrelin and leptin, as we all do from time to time.

Still, I am very embarrassed.

I know that they are appetite-related hormones, and there was recent news about them. And, it seems I am not alone in the confusion.

But, first let’s go to the news desk.

An international team with principal investigator in the United Kingdom has published A link between FTO, ghrelin, and impaired brain food-cue responsivity in the Journal of Clinical Investigation.

In lay terms, as that is my language, what the study found was that individuals with the genetic indicator FTO, known for a tendency to obesity, are less satisfied after eating because of higher levels of ghrelin, a hormone that increases appetite.

Ghrelin has been known about since 1999, and there has been considerable debate about the possibilities of a ghrelin-antagonist to address obesity in a pharmaceutical. The alternative would be a leptin-stimulant as it is leptin that gives us the feeling of satiety after eating.

One of the two approaches, or both, is likely to lead to a very effective pharmaceutical approach to obesity.

But, back to my confusion for a moment. A 2010 Spanish study found that after weight-loss dieting, lower levels of ghrelin and higher levels of leptin were associated with gaining back the lost weight. Furthermore, the ghrelin was significant for men while leptin was statistically significant for women.

Oh, my. I am very confused.