Mark Pine

Senate Commerce Committee member Amy Klobuchar concocted that slogan, on the spur of the moment, during a hearing on distracted driving. The idea came to her during a discussion of a proposed public educational program to discourage practices like texting on cell phones while driving. The catch phrase would get used like the “Click It or Ticket,” motto that’s been successful in seat belt campaigns.

Witnesses at the hearing, Ray LaHood, Secretary of Transportation, and Julius Genachowski, Chairman of the FCC, testified that 6,000 fatal auto crashes each year are attributed to distracted driving. Half a million people are injured in car accidents for that reason.

Distracted driving fits into three broad categories: Distractions of the hands (e.g. holding a car cup), distractions of the eyes (e.g., looking at the scenery), and distractions of the mind (e.g., having a conversation). Texting on cell phones involves all three forms. It’s the most dangerous form of distracted driving, more dangerous than driving drunk. Texting increases by 400% the amount of time drivers look away from the road, and an average texting act takes up the length of a football field.

Talking on cell phones is dangerous, too. Drivers talking on cell phones are four times more likely to crash as other drivers—as likely as drunk drivers. But despite the known risks of texting and talking on cell phones, LaHood told the committee, 800,000 Americans use cell phones while driving every day. 40% of those users are under age 30, the group most prone to use a “cell” and drive at the same time. Consequently a disproportionately large number of the killed and injured are young.

To deal with the problem, yesterday Committee Chairman Sen. Jay Rockeller and committee member Sen. Frank Lautenberg introduced S. 1938. The bill would provide grants to states that enact laws regulating use of cell phones while driving: Banning texting, requiring a hands-free device for talking on phones, and prohibiting drivers under age 18 from using a cell phone while driving.

Sen. Charles Schumer also testified at the hearing. In July, he introduced a bill prohibiting train conductors and bus drivers from texting on the job. The legislation followed major accidents in Massachusetts and California caused by cell phone use by operators.

Coincidentally, the hearing took place only a few days after a Delta Airlines flight flew past its destination airport in Minnesota because the pilots were using their laptop computers.

When Vice President Joe Biden’s position on the Afghanistan war got publicity several weeks ago, I thought it sounded like a good idea. Limit the military involvement that country, leaving enough forces for security in Kabul and major population centers. Concentrate on rooting out Al Qaeda in Pakistan and supporting that nation, which is under sustained attack by Islamic radicals and is actually more important to our national security.

But I wavered when advocates for a much larger Afghan effort made strong arguments, too. Unless America and NATO boosted forces significantly, they said, the Taliban would quickly overrun the country. Al Qaeda would return. We would lose the war.

If the president wasn’t dithering I was. I didn’t know what we should do.

And while the debate has been going on, the troops have been getting killed in larger and larger numbers. At the same time, the legitimacy of the Karzai government has come under a dark cloud, due to questions about the recent election and official corruption that includes the Afghan president’s brother.

In the past week, though, it has become clearer what may be the best (least worst) strategy. On Monday, John Kerry—just home from Afghanistan—said Gen. McChrystal wants to do too much in too little time, and he called for a narrower, focused strategy more like the vice president’s position than the general’s nation-building approach. Then, State Department official Matthew Hoh resigned because of doubts about our reason and purpose for fighting in Afghanistan. And Tom Friedman, not usually a dove, wrote this morning that America should reduce its presence and goals there.

It’s clearer now than ever before that Americans will not continue to support a large Afghan effort that is killing many troops and won’t establish a stable state for many years.

President Obama seems to be resolving to limit the Afghan build up and focus forces on protecting population centers. It’s a good strategy, in my opinion. It is the only one that the American people will sustain, and therefore it’s the only one that can possibly succeed.

Last August I gave up on the public option in health care reform. “R.I.P.,” I wrote, saying cynically, that the White House had sold out on the government run health insurance plan in order to keep the support of the nation’s hospitals. That’s what I had concluded from a story in the NY Times the previous day.

Imagine my astonishment and delight when the reports came out yesterday that Senate Majority Leader Harry Reid announced he would send a bill to the floor with a public option that states could opt out of. Today, however, the newspaper reported that Reid’s aides said the senator lacked firm commitments to the legislation from all Democratic senators. Since all the Republicans, including Sen. Olympia Snowe of Maine, oppose any health care legislation with a public option, the assent of the entire Democratic caucus—all 58 Democrats and 2 independents—would be needed to move the legislation forward.

Nevertheless, as discussed last evening by MSNBC-TV commentators Ed Schultz and Jonathan Alter, all Democratic caucus members might agree to vote for cloture and allow the bill to pass with 51 votes. That would permit a few Democrats to vote against the legislation without sending it down to defeat.

Dana Milbank, writing in his “Washington Sketch” column for the Washington Post, described Reid’s news conference yesterday. When the Senator was asked if he had the votes to pass health reform with an opt-out public option, “he put his palms together as if in prayer,” Milbank said. The columnist implied that Reid had been under intense pressure from liberal groups in his home state, Nevada, and that the decision to include the public option might have more to do with Reid’s bid for reelection than with his assessment of support for the bill in the Senate.

Perhaps Reid is gambling. Perhaps he’s throwing a Hail Mary pass to the end zone…. Or perhaps—as Einstein is reputed to have said—“God is subtle but he is not malicious.” Once the bill hits the floor, conservative Democrats may not be willing to vote with Republicans to filibuster it. They would risk the wrath of the rest of their caucus and their president. And they would know that sending health care reform to defeat would be politically disastrous for all Democrats, including them.

Perhaps Reid was praying in thanks. He has said consistently that he favors the public option. Perhaps under Providence he has been allowed to see how to move the pieces on the chessboard, so that he satisfies liberals in Nevada and at the same time enforces how the health care endgame plays out.

Since screening with mammograms and PSA tests became widespread in the 1980s, the number of Americans undergoing treatment for cancer of the breast and prostate has increased substantially, but the incidence of lethal cancers of these organs hasn’t dropped much. This disappointing conclusion comes from an article last week in JAMA, the journal of the American Medical Association.

As an example of the inutility of breast cancer screening, the authors of the report from the University of California, San Francisco, say that 836 women must get screened for 6 years to save one life from breast cancer. Similarly with prostate cancer screening, a European series showed that 1410 men tested for PSA for 9 years resulted in one life saved from the disease. The dilemma is intensified because treatment for these cancers isn’t simple or harmless. Even if one judges that saving even one life justifies the testing of so many for so long, that view fails to take into account that many of those testing positive have slow-growing, non-lethal cancers but nevertheless undergo chemotherapy or surgery and suffer anxiety and depression.

The failure of these screening practices to reduce lethality results from the inescapable circumstances of screening as much as the medical facts of the diseases. Because screening is performed periodically, one or more years usually passing between tests, the programs discover mainly slow-growing, less dangerous new cancers that haven’t yet spread. On the other hand, aggressive, dangerous cancers are more likely to have spread by the time the next screening test is done.

The most successful screening programs are those that include measures to remove incipient tumors before they become malignant—e.g., colonoscopies that remove polyps and pap smears followed by surgical excision.

Moreover, screening programs of any kind are subject to the mathematics of large and small numbers. Many people who don’t have a disease must be screened in order to find the small percentage who do. Because no test is perfect, many false positive tests will occur. Thus, screening a million people even with a highly accurate test that has only a 0.1% rate of false positives will nevertheless yield 1000 patients who will have to undergo further evaluation or treatment but who are not sick.

What’s to be done? Right now probably nothing. The medical establishment is unlikely to terminate these screening programs for various reasons. But the future holds hope for resolving the problems. The key will be developing tests that can differentiate potential cancers that will be aggressive in the early stages. One avenue of research with great promise is the development of nucleic acid microarray tests. Such chips contain thousands of strands of RNA, and they may be used to identify patients whose cells are producing strands of matching RNA associated with dangerous tumors.

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Follow-up to my post of October 21 on the H1N1 pandemic: This morning the FDA announced the availability of Permavir IV, an experimental intravenous antiviral drug, which may be used in certain cases of severe flu, under an Emergency Use Authorization requested by the CDC.

For weeks health care reform has dominated the news, but this week the government turned up the heat under the financial reform pot.

Barney Frank’s Financial Services Committee in the House voted 39-29 to move forward a bill establishing a new consumer protection agency that would regulate consumer credit products, including mortgages and credit cards. The White House wants to pass such legislation this year.

Ben Bernake, chairman of the Federal Reserve said his agency would increase supervison of banks and begin to reign in bank pay arrangements that could promote excessive risk-taking by executives.

And the Obama Administration’s pay czar, Kenneth Feinberg, announced he intends to cut the pay of top executives at seven giant banks that got bailout loans from the government last fall and winter.

But one thing we haven’t heard about recently is the notion of a macro-financial regulator. The concept was widely discussed last winter and spring. A “systemic” regulatory agency would be established that could intervene when levels of financial risk rose to the point of threatening the economic stability of the nation. Such an agency could deal with non-bank financial firms that are too big to fail but get into dire straits (like AIG), require that firms dealing in financial derivatives retain a financial stake in their products, limit the debt and leverage of large companies, and also deal with pay structures that encourage excessive risk taking by executives.

In fact, Frank was a leading proponent of the systemic regulator idea in March, and said then that legislation to create it would be his first priority. Now he is focusing on consumer protection. Why did he make the shift?

So financial reform news is boiling now that health has moved out of the committees and legislative year is approaching the end. After dose after dose of health care news, it’s a welcome change. But the proposals and programs discussed this week take on only bits and pieces of the problem. I remain concerned about the systemic risk issue, and I wonder why the idea of a system regulator hasn’t come up now, along with the other issues.

Three years after the Massachusetts legislature enacted health care reforms to establish universal coverage in the state, more than two-thirds of Massachusetts medical doctors support the law that changed the system. This datum comes from a poll done by the New England Journal of Medicine (a publication of the Massachusetts Medical Society), and it was reported online yesterday in the journal.

In 2006, Massachusetts created the nation’s first health care system designed to insure everyone in the state. At present, 97% of all residents are covered by health plans meeting at least “minimum credible” standards. Every resident of the state is required to purchase health coverage or pay a penalty. Low-income residents may receive subsidies from the state.

The journal polled physicians because they “can provide critical insight into how the law is actually functioning and how it has affected access to high-quality health care” according to the article reporting the results. On the whole, the doctors’ verdict is highly favorable. 70% support the law, while only 13% oppose. 75% favor the legislation continuing in effect, while only 7% want to repeal it. About 2 to 3 times as many doctors are inclined to increase the scope of the legislation’s coverage as wish to reduce it.

The following tables show conditions pertaining to the effects of the law or to the health care system of the state as it operates at present under the law. Massachusetts doctors rated these either positively (favorably) or negatively (unfavorably). The table shows those conditions about which more than 10% of the doctors had an opinion and the proportion holding one opinion was at least twice as great that holding the opposing opinion.

In commenting on the poll, the authors of the report wrote:

Examination of physicians’ views on care for their patients provides little evidence to support criticisms that the law is negatively affecting the quality of care that most physicians deliver. With regard to their own practices, a sizable minority of physicians indicate that the legislation has increased their administrative burden. Physicians’ views concerning the effect of the law on the state’s health care environment are more mixed. Most believe it is helping the formerly uninsured, but that positive view is coupled with a majority belief that the program is driving up the cost of health care in the state.

In a second article published online in the journal yesterday, the state Secretary of Health and Human Services and a policy advisor in her office wrote that the reform has not been a “budget buster.” Less than 1% of the state’s budget is devoted to new spending due to the new system.

My son had personal experience with obtaining health insurance in Massachusetts following reform. At the time he completed a master’s degree program in the state, he had grown too old for coverage under my insurance. That was shortly after reform passed. Fortunately, he worked and continued to remain a resident of Massachusetts after graduation. Because of a pre-existing condition, he would have had difficulty obtaining insurance anywhere else in the nation.

Together, my son and I went online and obtained insurance for him using the Commonweath Connector, the insurance exchange open to all residents under the new system. We were able to choose among a number of different offerings by insurance companies and providers. We easily found good coverage for him at a reasonable price. I was impressed by the system and greatly relieved that he was able to obtain coverage. And I was extremely thankful that he happened to choose that state in which to go to school and remain to work.

H1N1 (swine) flu is widespread in 41 states and 86 children have died, HHS Secretary Kathleen Sibelius told the Senate Homeland Security Committee this morning. Ninety percent of fatalities from this type of influenza have occurred among persons less than 65 years old. The committee hearing on the H1N1 pandemic was broadcast on C-SPAN Radio.

In contrast to H1N1 flu, with seasonal influenza, which has not spread widely so far, the majority of deaths usually occur among the elderly. The reason that serious cases of H1N1 flu are occurring mostly among younger persons probably is due to the fact that people who were alive at the time of swine flu epidemic in the 1950s have some residual immunity.

Vaccination is the most effective means to avoid getting the flu. The secretary said that the number of vaccination doses available at this time is below expectations because of problems producing antigen, the viral protein component of a vaccine that stimulates the immune response. But these problems have been resolved, and she expects many more doses will become available in the first weeks of November. In the coming months, anyone who wants to be vaccinated should be able to do so, she said. There are about 150,000 sites for vaccination around the nation, and they can be located online at www.flu.gov. Many schools have begun clinics for vaccinating their students.

Meanwhile, statisticians at Purdue University predicted the number of cases of H1N1 will peak this week, too early for the vaccine to prevent the pandemic, according to a report yesterday in the Washington Times. They forecast that 63% of the population would get the flu by the end of this year. If they are correct, Americans should NOW be taking special precautions: washing hands frequently, avoiding touching hands to the face, staying out of crowds, distancing from sick persons, coughing and sneezing into elbows and sleeves, and staying home if they get sick. And getting vaccinated as soon as possible.

At present and for several weeks at least, the best available treatment for persons with severe cases of the flu will be antiviral drugs. Young people especially should not hesitate to seek medical attention if they suffer flu symptoms—including fever, coughing, sore throat, runny or stuffy nose, headaches, body aches, chills and fatigue. In H1N1 flu infection, vomiting and diarrhea may also occur. Check www.flu.gov for information about symptoms.

The most serious flu cases may require intravenous treatment with antiviral drugs. Such drugs are new and still being tested and developed. But the manufacturers are ramping up production of IV antivirals in anticipation of need, and the FDA is rapidly reviewing their safety and effectiveness. The FDA has a “compassionate use” program so that the CDC can distribute IV antivirals for administration at this time in the most serious cases.

Several new antiviral drugs are in rapid development, the secretary said, and the FDA is reviewing the safety and effectiveness information on these new drugs now. She expects the agency to announce within “a matter of days” the approval of one or more new drugs. The FDA is also acting on the availability of antiviral drugs in suspension for use in infants and children who cannot take pills. At present there is a shortage of antivirals in suspension from drug manufacturers. But the agency has released guidelines on making these formulations, so that local pharmacists can prepare suspensions from pills for young children in their communities.

Schools, colleges, and universities are being affected by the pandemic. Secretary of Education Arnie Duncan, also testifying at the hearing, said schools should not close unless too many faculty members get sick. He said many children depend on schools of meals, and many would be home alone unsupervised in the event of school closures.

Among school systems providing vaccinations to their students, the education secretary mentioned those in Rhode Island, where every school has a vaccination clinic.

Sen. Susan Collins of Maine, a committee member, spoke at the hearing of jump in flu cases at Bates College in her state. She said that the number of students infected rose from 6 to 254 in the last week. New England health crisis intervention agencies have gone to the college to deal with the rapid spread of the disease.

This morning C-SPAN Radio broadcast a recorded telephone news conference given by Senate Finance Committee Chairman Max Baucus. The event was sponsored by Families USA and took place yesterday. Baucus is the principal author of the health care bill approved by the committee last week.

In response to questions from two reporters, the chairman said his bill would reform the health care delivery system by moving away from fee-for-service reimbursements for providers to a system of “value-based” payments. The concept is to change the system from paying for services to paying for valuable health outcomes.

Baucus made the point twice, and he emphasized it. That was a surprise—to me, anyway. Although the idea is vital for successful health care reform, I’m not aware that he even mentioned that part of his bill in the past, no less called attention to it.

For example, last Tuesday, the day it approved the bill, the committee issued a news release, “Eight Things to Know about the America’s Healthy Future Act (PDF).” It stated: (1) Americans can keep their present coverage if they choose, (2) coverage can’t be denied for pre-existing conditions, (3) insurance companies can’t charge more based on gender or health status, (4) companies that pay executives huge salaries will lose tax deductions, (5) members of Congress will have to buy their health insurance through the same system, (6) yearly and lifetime limits on coverage will be prohibitied, (7) there will be no Medicare benefit cuts for individuals, and (8) low and middle-income Medicare recipients will have 50% drug coverage in the “doughnut hole.”

But there was nothing about health care delivery reform. Apparently Baucus didn’t feel it important enough to put that point in the eight things to know about the bill.

So what does the Baucus bill do about it?

Last Tuesday, the committee also issued a more comprehensive press release: “Finance Committee Approves Baucus’ America’s Healthy Future Act (PDF).” It’s a 22-page summary of the bill, and it includes five paragraphs under the heading “Reforming the Health Care Delivery System.” On page 10, it’s not prominent, and it’s smaller than the sections on “quality coverage” (page 3, 15 paragraphs) and affordability of coverage (page 6, 17 paragraphs).

In the health care delivery section, the document fails to make a credible case that reform will happen, because it lacks strong provisions and enforcements.

It states that beginning in 2012, “a percentage of hospital payment would be tied to hospital performance on quality measures related to common and high-cost conditions, such as cardiac, surgical and pneumonia care.” No percentage is specified, nor is anything said about what would happen for failing to comply. It says also merely that “quality measures will be developed.”

It goes on to say that for home health agencies and nursing homes, the secretary of HHS would develop a plan for “value-based purchasing” by 2011. Physicians would be required to participate in a quality reporting program, as would long-term care hospitals, rehabilitation facilities, cancer hospitals, and hospices. But nothing is said about how these providers would get paid.

Baucus’ plan is too little, takes too long, lacks enforcement, and moves too gingerly. It is a problem that needs robust measures to foster change. The bill doesn’t have them.

So Baucus touted the delivery system elements of his bill yesterday. I say, “Ho hum. It won’t change how providers are paid.”

The Curious Case of Benjamin Buttons, has been out about a year, but I first got a chance to see it this weekend. (Netflix is great for catching up on movies I missed.)

It’s a film worth thinking about. Although it wasn’t entirely successful, what it attempted and what it succeeded in illuminate issues central to human life.

Benjamin, played by Brad Pitt, was born on the day World War I ended. Narrating his own story through the vehicle of his diary, Benjamin tells us that at birth he had the physical appearance and physiology of an octogenarian, and unlike all other babies, he lived his life growing younger. In contrast, his dearest friend for life, Daisy Williams (played by Cate Blanchette) grows old the usual way. They meet when they are chronological children, but since any liaison between them is obviously difficult, they succeed most fully only when both are in their 40s.

A lot of not-too-surprising but nonetheless unusual situations are encountered by a young man who is physically old at the beginning of his life but old and physically young at the end. Yet the story is more than a sci-fi fantasy.

Through the perspective of Benjamin aging retrograde, we see commonplace events of life in fresh light. We appreciate meaning and consequence in much we take for granted. When Daisy and Benjamin consider marriage, the circumstance that he will grow young while his wife and children age sharpens our understanding of marriage, what it requires, and how it is best lived. The film reveals life by backlighting it, presenting the negative image of it.

The movie spotlights the roles of coincidence and fate. When two people grow old together in the usual way, they have their lives for happenstance between them. But when one is growing younger, they are like trains passing, with only moments for chance occurrence.

At one point Daisy is badly injured. Benjamin the narrator recounts the day’s preceding events, showing how if any one had happened differently, the accident wouldn’t have occurred. It’s the clearest statement of the moral of the story.

Throughout the film, because Benjamin grows younger, we see how much of the way his life turns out depends on the precise but fortuitous synchronicities, which, if timed slightly otherwise, would have altered his course. It points to a law of coincidence operating in the universe.

But though the film inspires deep philosophy, it falls short as a film. Only Benjamin and Daisy have much depth of character; all the others are stereotypes. Even the leads behave rather predictably. The movie moves too slowly and lasts too long, seemingly trying to demonstrate in pace and length the critical role of time in the plot. Although the story line is often clichéd, it has its moments of poignancy and brilliance. Before seeing this film, I would not have suspected how stark the resemblance between the dementia of old-age and the helplessness and ignorance of infancy.

My favorite dinner water is Gerolsteiner. The brand isn’t as popular or available in the U.S. as some of the Italian or French fizzies, but I find it has more tang, probably due to its particular combination of minerals in solution. But all sparkling waters have one taste in common, a trace of sourness.

Yesterday, a news release from the National Institute of Dental and Craniofacial Research (NIDCR), part of the NIH, announced that researchers have discovered an enzyme on the sour taste buds responsible for perception of the sparkling-water flavor. The research was reported in Science magazine

It turns out the enzyme is well known—a type of carbonic anhydrase. It catalyzes the combination of CO2 and H2O to carbonic acid, and then splits the molecule into a proton and bicarbonate. The effect is to buffer the pH of tissues.

The researchers at Columbia University discovered that the taste of fizzy water depends on the activity of a carbonic anhydrase receptor located on sour taste buds. They monitored the neural activity of the main nerve from the sour taste buds on the tongues of mice, according to a review of the research in the same issue of Science. When the activity of the enzyme was inhibited, so was the activity of the nerve in response to carbonated water.

But the result leads to a puzzle. In the words, of Nicholas Ryba, one of the authors of the Science report, “Of course, this raises the question of why carbonation doesn’t just taste sour.” Carbonated water also tingles the tongue. But Ryba adds:

When people drink soft drinks, they think that they are detecting the bubbles bursting on their tongue,” he said. “But if you drink a carbonated drink in a pressure chamber, which prevents the bubbles from bursting, it turns out the sensation is actually the same.

Ryba’s explanation is that carbonation also stimulates the mouth’s somatosensory neurons, and that what we perceive as sparkling-water taste is a combination of sensations from the sour taste buds and the somatosensory neurons.

Perhaps so, but I still wonder. If the bubbles are suppressed when you drink a carbonated beverage a pressure chamber, then why should the somatosensory system react?

And Ryba’s explanation also seems to conflict with a finding reported in the review of the article. In 1988, a physician used the drug acetazolamide to prevent altitude sickness while climbing a mountain. On reaching the summit, he drank a beer to celebrate, but the beer tasted flat, “like dishwater.” Since acetazolamide inhibits the activity of the carbonic anhydrase on sour taste buds, it seems that the sour-tingly taste of carbonation depends on the carbonic anhydrase on the taste buds.

I would like to suggest an alternative, rather radical, explanation of the taste of fizzy water: The perception comes from the activity of carbonic anhydrase itself. The enzyme carbonic anhydrase on the taste buds is the receptor for fizziness. Although the same taste buds are also responsible for our perception of sour flavor, the enzyme receptor for sourness is a different one. The activity of the anhydrase is perceived as fizziness, the activity of the other enzyme as sourness.

My suggestion comes not so much from this one article, as from my understanding of the nature of consciousness, which I’ve developed over many years. I believe consciousness is a fundamental property of the universe, and that everything that exists possesses consciousness to some (often tiny) degree. Consciousness arises, expands and unifies when its components are in communication (as, in this case, the components of taste are in communication with structures of the brain).

Indeed, I want to make clear that I’m not trying to build a theory of consciousness based on this one single article. Rather, I think the article just provides a good illustration of how I think about it, a concept that I’m putting out in a long series of blog postings on this website.

Sourness and sparkling-water flavor appear to involve different receptors on sour taste buds. The usual theories of consciousness would locate the different perceptions in some structure of the brain. But in the findings of this research, we seem to have a case of the same cells responsible for the two differing perceptions.

Rather than locate the difference solely in the brain, I wish to propose that the perceptual difference is located in part in consciousness associated with the activity of the different enzyme receptors.

The activities of the different receptors give rise to the difference between my taste for Gerolsteiner water and my distaste for lemon juice.