I watched his interview on Fareed Zakaria's GPS dated November 1, and read his letter of resignation, and am now very troubled by this insider's perspective on the effectiveness of American operations, and by extension Canadian military operations, in Afghanistan.
On Afghanistan's Pashtun:
"To put simply: I fail to see the value or the worth in continued US casualties or expenditures of resources in support of the Afghan government in what is, truly, a 35-year old civil war. [...] a tragedy that not only pits tribes, valleys, clans, villages and families against one another, but, from at least the end of King Zahir Shah's reign, has violently and savagely pitted the urban, secular, educated and modern of Afghanistan against the rural, religious, illiterate and traditional. It is this latter group that supports the Pashtun insurgency [...] fed by what is perceived by the Pashtun people as a continued and sustained assault, going back centuries, on Pashtun land, culture, traditions and religion by internal and external enemies. The US and NATO presence and operations in Pashtun valleys and villages [...] provide an occupation force against which the insurgency is justified."
--from the letter
On the mission:
"I do not believe any military force has ever been tasked with such a complex, opaque and Sisyphean mission as the US military has received in Afghanistan. [...] We are mortgaging our Nation's economy on a war, which, even with increased commitment, will remain a draw for years to come. Success and victory, whatever they may be, will be realized not in years, after billions more spent, but in decades and generations. The United States does not enjoy a national treasury for such success and victory."
--from the letter
On containing Al Qaeda:
"This is an organization that is quite ephemeral. It doesn't really exist. Occupying a country is not going to defeat them. It's the proverbial fly versus a sledgehammer. [...] In a population of twenty to thirty million, how are we going to keep a hundred people from being disaffected and joining some fringe group? It's impossible. Furthermore, occupying a location only provides justification and only lends credence to the goals of that organization. It only inspires young Moslem men to want to defend their culture against an occupying army, which is what we are."
--from the interview
On increasing the American troop commitment:
"Increasing troops is only going to fuel insurgency. We need to stop our combat operations in areas where we are fighting people only because they are fighting us. Otherwise, it's going to be 2013, we're going to look back four years, and we're going to say, 'What did we accomplish? What did we get? What was this worth? What did we get out of this?' We might be able to stabilize the Afghan government for five to ten years, with a lot of resources. I believe we could militarily defeat the [Qadashura? unclear] in two to three years with a lot of resources and a lot of debt. However, is it worth it? What do we get out of it? What's the benefit of us doing it? It doesn't politically defeat the insurgency in the south, and more importantly, it doesn't defeat Al Qaeda."
--from the interview
Go here to view CBC's roll call of Canadian Forces soldiers killed serving in the Afghanistan mission.
Matthew Hoh Resignation Letter -
Frank: "When you ask me that question, I am going to revert to my ethnic heritage, and answer your question with a question: On what planet do you spend most of your time? Ma'am, trying to have a conversation with you would be like trying to argue with a dining room table. I have no interest in doing it."
Stewart: Aww, damn!...You better hope Blue Cross don't consider ugly a pre-existing condition!...Aww, damn!...Your mama's so dumb, she thinks the Public Option is a porta-potty!...Aww, damn!...Your mama's so old, we're gonna get together a panel and euthanize her.
Many liberals pride themselves on their sensitivity, openness, and receptiveness. A hallmark of this is an unconscionable patience for the disgusting vitriol some vent, or the despairingly profound ignorance some belie. It was the willingness of sensitive liberals to listen to Borat's sexism and racism, to patiently offer an alternative perspective rather than a stern reprimand or a punch in the face, that discomfited me the most when I watched Borat. I saw shades of me.
When Frank shut down his questioner, he restored the balance. A balanced conversation is not one in which opposing viewpoints have equal weight, but one in which rational viewpoints have equal opportunity. Creationism is not a valid alternative to natural selection to explain speciation. Ethnic cleansing is not a morally equivalent approach to multiethnicity versus a plural and liberal society.
Dick Morris: I don't know if he'll ever win anything if he fails to get this passed.
Jon Stewart: Yeah, he'll probably end up some two-bit partisan troll, a shell of his former self, his outward physical appearance slowly reflecting the putrefaction of his soul, a Harvey Fierstein-esque conservative minstrel, rolling from town-to-town in a rented conversion van, each day a carbon copy of the last, with only the changing of his three gravy-stained red speech ties to mark the progression of time, every sunrise an incandescent fuck you from a God that long ago abandoned him.
Henry Louis Gates Jr. Redacted Police Report -
I loved reading the officer's report on the conduct of Henry Louis Gates. So, this officer responds to a call of a possible break-in. His priority is securing the property of Henry Louis Gates. Gates responds by villifying the officer, refusing to cooperate, threatening the officer, and by uttering a dated 'yo mama' epithet.
He shut his sanctimonious trap after he was cuffed. Coincidence? I think not.
Gates needs to eat some humble pie, and the President was premature in his commentary.
By the way, I love docstoc.
In fairness, a couple of these cases arose under the previous Liberal government, and the fault is not all the Conservative Party's.
According to Travers, Ignatieff has made key "rookie mistakes" that now have his party "down in the dumps." That's an interesting interpretation of the most recent polling data from EKOS, July 9, 2009.
For Ignatieff's catastrophic blunders of "taking a position that can't be abandoned without severe damage or high risk," and threatening to bring the neoConservatives down without being prepared to follow-through on an election, Ignatieff has been punished by...continuing to enjoy a narrow lead.
The latest polling shows the Conservatives and Liberals in essentially a dead heat (31.8 to 32%, respectively) with the other parties trailing far behind. Thanks to those millions spent on the attack ads, Canadians now feel Harper is almost as fit to lead the country as Ignatieff.
You will remember Zelaya was overthrown two weeks ago today by the Honduran military. Since then, support for him has been rolling in. The Organization of American States has suspended Honduras’ membership. President Obama came out on Tuesday in favor of the democratically elected president of Honduras.
Let me register a modest dissent. While Zelaya is indeed the democratically elected leader of the nation, what he was trying to do was decidedly undemocratic. You see, the timing of the coup wasn’t random. It was to stop a referendum Zelaya had called for the next day, an illiegal referendum that would have trashed one of the eight unalterable pillars of the Honduran Constitution.
Zelaya was trying to abolish term limits to allow himself to stay in office indefinitely. The nation’s Supreme Court and Attorney General had already declared Zelaya’s plan unconstitutional, and Congress had begun impeachment proceedings. Still intent on going forward with the referendum, Zelaya was arrested on orders of the Honduran Supreme Court.
Zelaya is a radical who declared himself a socialist in 2007, and has been destroying his country’s prospects for growth. Hugo Chavez is one of his closest political allies and his role model. Indeed, Zelaya probably got the idea for his referendum from Chavez, who did the same thing in his country, as did fellow leftist Rafael Correa of Ecuador and Evo Morales of Bolivia. The difference is all of them succeeded.
So while we should support democracy, and we should be against political change by military coup, we should also be opposed to unconstitutional power grabs by radical demagogues.
The United States, Mr. Biden said in an interview broadcast on ABC’s “This Week,” “cannot dictate to another sovereign nation what they can and cannot do.”Biden overstates Israel's sovereignty here. It is a country created by diplomatic fiat that relies heavily on the protection and aid of the US. The weapons, and the money to buy them and pay the soldiers firing them, in any strike on Iran will come in large part from the US. See Must There Be Foreign Aid To Israel? from 2004.
"Israel can determine for itself — it’s a sovereign nation — what’s in their interest and what they decide to do relative to Iran and anyone else," he said, in an interview taped in Baghdad at the end of a visit there.
Biden also neglects Iran's status as a sovereign nation, and its right to self-determination. I'm not saying Iran is right, I am merely pointing out the contradiction of the Administration's attitudes toward Israel and Iran.
Biden and the President need to take responsibility for enabling Israel's military power and choosing not to restrain Israel should it elect to take action against Iran.
To be fair, Biden has also said, addressing the AIPAC, that "Israel has to work toward a two-state solution. You're not going to like my saying this but not build more settlements, dismantle existing outposts and allow Palestinians freedom of movement."
By the way, Biden's sentiment is not new, and perhaps is not news. He made similar remarks during last year's campaign, reported at the Jerusalem Post on September 3, 2008:
Democratic Vice Presidential candidate Joe Biden said Wednesday that Israel should be able to take whatever action it feels necessary to defend itself from Iran [...]
"Israel has an absolute right to defend itself. It doesn't have to ask us."
"During these turbulent economic times, our economy can ill afford higher taxes, higher costs and more uncertainty under an inexperienced NDP government. The Opposition’s reckless and irresponsible policies and promises will kill confidence and will put our province in an even weaker position than it was in the 1990’s."
The Government intended to raise its carbon tax as part of a multi-year plan to do so at its inception in 2008. Interestingly, you know the only time the carbon tax was mentioned in the Liberal Party Platform? In a quote attributed to Vancouver Mayor, and former NDP MLA, Gregor Robertson. Certainly no accident there. Minimally lower income and corporate tax, and tout the fact in inch-high letters, then attribute praise for a modest tax increase to the enemy camp.
Maybe the answer to the question posed in this post's title can be found in the response of Paul Krugman to Fareed Zakaria in a recent episode of Global Public Square (at 6:28):
FZ: What's wrong with the argument that, if what you're trying to do is produce a rapid increase in purchasing power, that a tax cut--a permanent tax cut--would actually deliver it faster?
PK: Uh, gee, so we do a permanent tax cut every time the economy is weakening, and now what do we do when the economy is strengthening? Have a permanent tax increase? But, then, in that case, it's not...--There's a logical problem here. You can't have a ratchet where you always cut taxes and never raise them. Eventually we end up with no government at all, which is, I guess, some people's goal, but you can't do that.
It certainly appears to be the objective of the Stephen Harper's neoConservative Party to slash the government along with taxes and revenues. Now Harper wants to have his cake and eat it too. He will cut taxes, cut revenues, cut the government's levers for inluencing the economy, for the sake of his ideology. He will spend on a stimulus package, spend on an auto bailout, spend to expand his Cabinet, spend Canada into the largest deficit of its history, all the while blaming the Liberals for making him spend, and collecting accolades from those he spent the money on.
A footnote: Which party was in power when Canada's last record deficit was posted? The Progressive Conservative Party in 1992/93, with a deficit of $39b. Flaherty, Harper, and his neoCons shatter the previous record with a deficit now projected for $50b.
I was thinking about this the other day, kind of a What Would Barack Do? gedanken experiment. I imagined fielding the obvious question, "Are you pleased that Sarah Palin is considering a run for the Presidency in 2012?"
At first, I imagined Obama quipping, "I would love nothing more than to compete against Palin in 2012." Then I understood the answer to WWBD? He would say, "I am only six months into a four-year mandate. I am focused on meeting America's complex and challenging objectives at home and abroad. I will not worry about the intentions of Governor Palin in 2012. But I will say this, the American people deserve the best candidates for the Presidency in 2012, and in every election. If the Republican Party nominates Governor Palin for that role, it will be up to the American people to decide whether she is the superior candidate."
This is all the more surprising considering that the expression was already out there. I only discovered its risque meaning after Stephen Colbert ordered his Nation to type the search terms into google.
Like his guests--authors, politicians, musicians--I, too, enjoyed a Colbert Bump, a momentary surge in popularity by association. The evidence:
Says the pastor: "I don’t see any contradiction in this. Not every Christian denomination is pacifist," and "God and guns were part of the foundation of this country."
I can hardly think of a more sacrilegious act than the shooting and murder of a man inside a Kansas church, unless it was the clergyman himself who was shot. A temple is meant to be a sanctuary, where people commune with each other and with God, and learn the lessons of scripture. It is used as a political instrument in every faith, to be sure. The Times claims that the New Bethel Church promotion is part of a larger anti-Obama backlash. That may be true, but that hardly justifies the juxtaposition of the Church and a deadly instrument of violence.
I studied to obtain a firearms safety license two years ago. I wanted to be comfortable in the handling of a firearm and possibly go out and hunt. I've fired weapons, and even enjoyed it. But I am too concerned about safety to allow guns in my house. I don't want one of my four sons misusing a gun with tragic ends.
That bears restating: I am too concerned about safety to allow guns in my house. This inverts the misguided belief most gun-toting Americans have about ensuring the safety of their loved ones.
According to the BBC, the early Christian church (pre-Constantine) was strongly pacifist. Some snippets from the Bible selected by Jim Foxvog in his online article, "Christian Pacifism is the Scriptural Position," affirm this stance:
“Love your enemy and pray for those who persecute you.” ( Mt 5.44 , Lu 6.27 , Lu 6.3 ) “Do not use force against an evil man.” ( Mt 5.39 ) “Do not resist evil with evil.” “Forgive and you will be forgiven.” (Lu 6.37 ) “Do not be anxious about your life.”( Lu 12.22 ) “He who lives by the sword will perish by the sword.” ( Mat 26.52 )
Says Colbert: "Yes! The Fist of the Statue of Liberty! Who can forget her siren call of freedom: Give me your tired, your poor, your huddled masses yearning to breathe free...or I will f**k you up."
"The United States is not, and will never be, at war with Islam. (Applause.) In fact, our partnership with the Muslim world is critical not just in rolling back the violent ideologies that people of all faiths reject, but also to strengthen opportunity for all its people."Such a sentiment unites the US and the Muslim world in resisting the perniciousness of extremism. This unity of purpose, not a threat of recrimination, is what is needed for nations harboring terrorism to feel invested in its eradication.
"I also want to be clear that America's relationship with the Muslim community, the Muslim world, cannot, and will not, just be based upon opposition to terrorism. We seek broader engagement based on mutual interest and mutual respect. We will listen carefully, we will bridge misunderstandings, and we will seek common ground. We will be respectful, even when we do not agree."Obama's pledge to undertake a multilateral approach is perhaps a little less noble than it sounds. In Robert Kagan's book, Of Paradise and Power, the author contends that Europe's inclination toward multilaterality is a consequence not of moral superiority but of weakness. If individual European nations were capable of projecting power unilaterally, they would. Bush II should have realized that the age of unchallenged US interventionism has passed. Its adversaries are strengthening and it now stands precariously at the brink of fiscal collapse.
Obama's approach is certainly more sanguine than Bush II's. While it is difficult to know its true source, this much is true: the era when the primacy of the US's interests in dictating international relations is no longer. The multipolar landscape that replaces it is riskier and less certain to the US and its allies, but even its allies may benefit from this more cooperative approach.
"We will convey our deep appreciation for the Islamic faith, which has done so much over the centuries to shape the world -- including in my own country. The United States has been enriched by Muslim Americans. Many other Americans have Muslims in their families or have lived in a Muslim-majority country -- I know, because I am one of them."This personal identification with Muslims is politically courageous of Obama, and sure to be appreciated in the Muslim world. It reminds me of something Andrew Sullivan wrote in the Atlantic in December 2007:
[Imagine that] "Barack Hussein Obama -- is the new face of America. In one simple image, America's soft power has been ratcheted up not a notch, but a logarithm. A brown-skinned man whose father was an African, who grew up in Indonesia and Hawaii, who attended a majority-Muslim school as a boy, is now the alleged enemy. If you want the crudest but most effective weapon against the demonization of America that fuels Islamist ideology, Obama's face gets close. It proves them wrong about what America is in ways no words can.Lastly, Obama carefully avoided passing judgment on Turkey's genocide against Armenians during World War I, and again exposed the vulnerability of the US's past posturing, noting that the US "still struggles with the legacy of our past treatment of Native Americans." Obama's frank disclosure of America's vulnerability communicates volumes about Obama's personal strength, pragmatism, and constructiveness.
"To be black and white, to have belonged to a non-religious home and a Christian church, to have attended a majority-Muslim school in Indonesia and a black church in Chicago, to be more than one thing and sometimes not fully anything -- this is an increasingly common experience for Americans, including many racial minorities. Obama expresses such a conflicted but resilient identity before he even utters a word. And this complexity, with its internal tensions, contradictions, and moods may increasingly be the main thing that Americans have in common."
Dr Aaron Sodickson and his colleagues at Harvard published their study in the April 2009 issue of the journal Radiology. The study concludes that patients undergoing CT scans have an increase in the risk of cancer as a consequence. It also concludes that the more scans you undergo, the greater your risk. Lastly, it concludes that the lifetime attributable risk, the risk of the CT inducing a cancer, is up to 12%.
My concerns about the way this study is being presented relate to its methodology. The investigators never actually study how many cancers occur in a population undergoing repeated CT versus a population not undergoing CT. They did analyze a cohort of patients: those undergoing CT scan at their hospital over the course of one year, 2007. Their analysis was limited to determining how many lifetime CT scans these patients underwent and for what reason.
Sodickson et al did not determine the risk of developing cancer from actual cancer cases in this cohort. Instead they modeled how many cancers they would expect based on a mathematical model called the Biological Effects of Ionizing Radiation VII methodology to estimate these risks. I decided to read much of that document too, to get a look at their methodology.
A report was prepared by the Board on Radiation Effects Research of the US National Research Council titled Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2. The Council extrapolated data from Hiroshima and Nagasaki atomic bomb survivors, from studies of cancer patients receiving therapeutic doses of targeted radiation, and from studies of occupational and environmental exposures. The consortium also analyzes the effect of diagnostic radiation, tests that use x-rays, the only class of radiation exposure that applies to Sodickson's CT study as far as I'm concerned. For example:
"A cohort study of 64,172 tuberculosis patients was carried out in Canada to assess the risk of cancer associated with multiple fluoroscopies (Miller and others 1989). In this cohort, 25,007 patients were exposed to highly fractionated radiation from repeated fluoroscopic examinations used to monitor lung collapse from pneumothorax treatment. Howe (1995) studied the risk of lung cancer in this cohort...The average lung dose per fluoroscopy session was estimated to be 11 mGy. The mean total dose to the lung was 1.02 Gy (range 0–24.2 Gy), and the mean number of fractions was 92. During the study period (1950–1987), 1178 lung cancer deaths occurred. There was no evidence of an association between risk of lung cancer and dose: the ERR [excess relative risk] at 1 Gy was 0.00 (95% CI −0.06, 0.07)."That's right, the excess relative risk was 0.00. Only a handful of additional studies are described, using chest x-ray not CT scan, and citing excess attributable risks on the order of about 10 per 10,000 person years per Gy (a unit of radiation dose). In other words, out of 100 people undergoing a CT scan, and receiving a dose of less than one Gy, on average it would take more than 10 years for one of them to develop a cancer caused by the 100 CT scans, assuming you could legitimately extrapolate the CXR data.
In the Sodickson study, only 1 patient of the 31,462 patients studied had a predicted lifetime attributable risk of cancer that was 12%. They also estimate that 99% of the patients scanned had a lifetime risk of dying from cancer that was less than 1.6%.
CTs aren't done for nothing. They are done to detail injuries, detect strokes or lung clots, monitor for cancer relapse, etc. In such circumstances, the longshot of suffering a CT induced cancer is not foremost in one's mind. Dropping dead of a pulmonary embolus or a ruptured spleen is.
The problem, the risk we need to be worried about, is when CT scans are done in healthy subjects to detect disease states early, like lung or colon cancer. In populations that would be screened for lung cancer, the annual risk of developing a lung cancer is on the order of 0.5% per year. That dwarfs the 0.1% risk in ten years posed by CT scanning.
I am still waiting for the National Lung Screening Trial to mature, comparing CXR to CT scan screening of lung cancer. Initial data may be reported in 2010.
Until then, accept the findings of Sodickson et al for what they are, conjecture and food for thought supported by mathematical models, not direct observation. Even taken at face value, the risks are simply not that high. Their findings should not be regarded as a legitimate warning against CT scanning.
The study analyzed a cohort born during the period 1959 to 1965 with cognitive measures collected at 8m, 4y, and 8y. The use of a cohort of that era reduces the influence of confounding factors like assisted reproductive technology, divorce, and complex stepfamily structure.
In contrast to the adverse effect of advanced paternal age is the superior performance on cognitive tests conferred to children of older mothers. Both of these age-related effects were reduced but not eliminated after controlling for socioeconomic factors like race, income, and education, or for parental mental health.
"In his speech to a joint session of Congress on Tuesday, Obama referred to his economic recovery plan and said, "It will launch a new effort to conquer a disease that has touched the life of nearly every American, including me, by seeking a cure for cancer in our time." Both his mother and grandmother died of cancer.
The economic stimulus measure signed by Obama on Feb. 17 included a huge, two-year infusion of about $10 billion for the National Institutes of Health, which funds research, of which about $1.26 billion is expected to go for cancer research."
During the press conference today, Harper explained his heel-dragging on environmental policy: "Canada has had great difficulty developing an effective regulatory regime alone in the context of an integrated continental economy. It's very hard to have a tough regulatory system here when we are competing with an unregulated economy south of the border."
That was honest and revealing. It shows that Harper was at least unable and probably unwilling to use the levers at his disposal to advance environmental policy. Canada is America's largest oil supplier. Most think it's Venezuela, or Saudi Arabia. In fact, Canada supplies about 1 million barrels of oil per day more than each of Mexico, Venezuela and Saudi Arabia. We are its most visible and respectable ally in Afghanistan, the Right War. We are the top uranium and potash producer in the world, and in the top three for natural gas, nickel, zinc, and asbestos. All of this gives us incredible leverage when negotiating with the world's most voracious economy (maybe being edged out by China now).
We can find other markets. Naturally, we preferred our likeminded and deep-pocketed neighbours. It is in the US's interest to find suppliers that are politically and economically stable. Preferably lickspittle sycophants who parrot your policy du jour.
So now Harper is going to get tough on the environment because he has finally found some coattails attached to someone headed in that direction. Well good for him. But pardon me if I don't find Harper's Change something I can Believe in.
Their main thesis: the initial impressive double-digit survival gains of past decades can no longer be achieved. Instead we are left to produce 'advances' with diminishing returns, at staggering expense, and of dubious benefit. We may even be discarding solutions of true benefit because our research systems are too blunt or cumbersome to detect an advantage in small groups of patients.
Low thresholds for judging effectiveness "benefit many stakeholders. Investigator careers are built on "positive" studies, statisticians become indispensable when advances are so small that only they can detect them, National Cancer Institute programs demonstrate that they help identify "active" new drugs, the US Food and Drug Administration demonstrates that it fosters safe access to "useful" new therapies, companies can market new agents, and providers can bill for new therapeutic options delivered. Drug sales yield advertising dollars to fuel publications and campaign dollars to fuel elections. Insurers simply pass on the higher costs by raising premiums. Almost everyone benefits. Unfortunately, the gain for patients is often exceptionally modest and at exorbitant cost."
"Large armies of dedicated people are fighting very hard in this war on cancer, but maladjusted research goals, governance, economics, politics, legalities, accepted clinical research practices, and dogma unintentionally impede progress."
"a drug that leads to dramatic responses, but only in 5% to 10% of patients, might be predicted to fail in randomized trials involving unselected patients." [...] "It is time to stop investigating efficacy of drugs against tumors defined solely by histopathologic type and to instead investigate efficacy against tumors defined by a combination of histopathology and molecular and genetic profiles." [Note: This has been done to some degree, e.g. for her2/neu-positive breast cancer and trastuzumab/Herceptin, for c-kit-positive gastrointestinal stromal tumours and imatinib/Gleevec, and others]
"Like amassed troops targeting only a nearby trench, large randomized trials aiming to increase survival by a few weeks are a huge expense likely to achieve only modest gains, because modest gains are precisely what they are aiming for. We instead need a plethora of highly mobile smaller trials each with the goal of achieving much more ambitious outcomes."
"The current regulatory burden in the conduct of clinical trials is to the war on cancer what World War I mud was to trench warfare. The thigh-deep, sticky Flanders mud jammed rifles, entrapped vehicles, weighed down massively caked clothing, pulled like glue at legs and boots, and swallowed and drowned those who stumbled and fell. This regulatory burden is onerous, misguided, and expensive, with little value added. For example, one author's (D.J.S.) department receives around 600 external serious adverse event (SAE) reports per month for agents that it is studying clinically. A single event may generate a dozen or more SAE reports (one for the original event, one for each follow-up, and a separate copy of each of these for each protocol using the agent). In addition to the SAE reports being highly repetitive, the overwhelming majority report events that are more likely related to tumor progression or comorbidity, are well-known toxicities of the agent, or are irrelevant for other reasons. Despite this, purportedly to raise the safety bar, each copy of each form received required a separate document be prep ared, submitted, reviewed, corrected (to properly conform to the shifting regulatory interpretation du jour) and resubmitted to the institutional review board (IRB). This does not improve patient safety but does magnify research costs and investigator frustration. Similarly, Humphreys et al documented that 16.8% of the total costs of an eight-site observational trial were devoted to IRB interactions, desp ite no visible effect on human subject protection, and the essential procedures of their study never changed substantially despite exchanges of more than 15,000 pages of material."
I recently submitted a clinical trial application for review by my IRB. They reviewed the consent document, a document meant to assist a patient in understanding a trial before making a decision to participate. The trial tests high doses of radiation therapy together with chemotherapy and a new targeted agent in this setting. The patients enrolled to the study have stage III lung cancer, a disease with a five-year survival of about 15%.
The treatments are potentially life-threatening in a variety of ways that I enunciated ad nauseum in the consent document I submitted. Nevertheless, the IRB objected to the omission of a statement that patients may find items on a questionnaire about their quality of life "upsetting." When someone's treatment or disease has a substantial risk of killing them, a likelihood of making them seriously ill, and a certainty of making them feel like hell for about four months, the possible eyebrow-raising discomfiture provoked by a questionnaire item is not a make-or-break feature of the trial.
The document runs 13 pages and contains redundant assurances about protection of privacy, superfluous statements about expenses such as specifying that parking costs will not be covered, and the like. It is a Frankensteinian concatenation of every paternal impulse ponderous regulatory institutions can muster, ostensibly for patient protection, more likely to limit liability.
I applaud the courage of Stewart and Kurzrock for making a case that is long overdue. Their piece is an electrifying manifesto, and should be required reading for every researcher and regulator. I have no doubt that they are incredibly frustrated and inhibited by the regulatory and granting environment they find themselves in. Who knows what great advances we have overlooked, what novel ideas have been turned away, how many eager researchers have been stonewalled by a process that is "perfectly designed to get exactly the results it gets."
The Decision Memo is preliminary, and Medicare canvassed for comments:
"We are requesting public comments on this proposed determination pursuant to Section 1862(l) of the Social Security Act. After considering the public comments, we will make a final determination and issue a final decision memorandum. As with all national coverage analyses, the public may submit comments or additional evidence that cause us to reassess our evidentiary review and arrive at different conclusions. If that should occur during finalization of this decision memorandum and we determine that CT colonography is clinically effective, then we would need to determine, using current or additional cost information, if CT colonography is cost effective. We are asking for public comment on the cost effectiveness of screening CT colonography for the Medicare population if we were to alter our clinical decision."
It's not clear to me if that means Medicare has already determined that CTC is clinically effective but are awaiting evidence of cost-effectiveness or what.
A discussion of the test's accuracy can be found at the New England Journal of Medicine, where a recent report was published on the ACRIN study 6664, "Computed Tomographic Colonography in Screening Healthy Participants for Colorectal Cancer." The study found that CTC could detect 90%of abnormalities greater than 10 mm (about 3/8") in size compared to a gold standard of colonoscopy.
Dr Robert Fletcher commented on the study findings in the NEJM citing several reasons why he was underwhelmed. He notes that 17% of the subjects were thought to have polyps larger than 10 mm, but only 1 in 4 actually did on confirmation colonoscopy. In 16% of subjects, there were incidental findings outside the colon, and these usually don't amount to anything substantial (aside from life-threatening abdominal aortic aneurysms). On this point he cites his previous editorial in support! He also mentions the inconvenience and discomfort of scheduling a colonoscopy to evaluate abnormal colonic findings on CTC, though more than 80% of patients are spared such an examination by undergoing CT first. He warns of the threat posed by radiation risk, though he concedes that the dose from one such scan "may be acceptable" and the "radiation risk is uncertain." It is perhaps worth noting that Dr Fletcher disclosed his past role as a consultant to Exact Sciences, a company exploring competing technology for colorectal cancer screening, stool-based DNA screening.
If you wish to influence Medicare's decision, you can submit your comments here, I believe. They do take public commentary seriously. In fact, they provide a detailed review of public comments in their Decision Memo. The comments included feedback in support of CTC from the American Cancer Society, American College of Radiology, American Gastroenterological Association, and--perhaps less impressively--from the Medical Device Manufacturers Association and Medical Imaging Technology Alliance. Thirty-four lay public also commented, and the content of their comments are noted in the memo.
To be honest, I'm impressed with the transparency, frankness, comprehensiveness, and quality of the Decision Memo, and agree that the evidence for supporting CTC in the Medicare population, with an average age of 75 years, is weak. Probably worthwhile applying this technology to younger subjects, however. This decision should not be taken to suggest otherwise.
This week could have marked a turning-point in the an ever-deepening global slump, as Barack Obama produced the two main parts of his rescue plan: a $789 billion stimulus plan and his outline for a (probably even more expensive) bank bail-out. This double offensive could have broken the spiral of uncertainty and gloom that is gripping investors, producers and consumers across the globe. Alas, that opportunity was squandered. Mr Obama ceded control of the stimulus to the fractious congressional Democrats, so the fiscal boost is less efficient than it should have been. The financial-rescue blueprint, touted as a bold departure from the incrementalism and uncertainty that had plagued the Bush administration's Wall Street fixes, is depressingly more of the same: timid, incomplete and short on detail.
Editor in Chief
Evaluating various energy storage media in terms of megajoules per kilogram, author Kurt Zenz House describes the attraction of hydrocarbons for energy storage: they store large amounts of energy in a material that is stable at room temperature and easy to transport, store, and convert. One kilogram of crude oil contains 50 megajoules per kilogram. Natural gas and coal are in this ballpark at around 55 and 20-35 MJ/kg respectively.
Batteries pack virtually no energy wallop by comparison. Lead-acid batteries store about 0.1 MJ/kg, about the same amount of energy stored in half a teaspoon of crude (2 ml). Lithium-ion batteries can store about o.5 MJ/kg, with a theoretical limit of 2 MJ/kg that has been elusive to achieve.
Capacitors and superconductors have still yet to exceed a density of 1 MJ/kg and the theoretical limits of these strategies are shy of 10% of hydrocarbon's phenomenal capacity. House describes other fanciful strategies including toroid carbon nanotubes, zinc-air batteries, elemental aluminum, without suggesting any real hope these strategies could reach their theoretical limits or feasibly be implemented.
Hydrogen combustion releases triple the energy per kilogram as crude oil. The only problem: hydrogen is a gas at standard temperature and pressure, and pressurizing hydrogen to 700 bars yields only 6 MJ/l compared to 34 MJ/l for gasoline at 1 bar. Pressurizing hydrogen requires the baggage of a heavy cylinder for vehicle transport, and heavy pipelines for line transport.
House concludes that hydrocarbons will be with us for a long time until these limitations can be superseded. House's comments mislead in several ways.
While batteries have low energy density, they require very little overhead for the conversion of their potential energy to kinetic energy. Small motors driving wheels are far lighter than heavy engines, transmissions, and exhausts required in combustion systems. When the bulk of the energy released in the internal combustion engine is dissipated as heat or consumed in moving the weight of the vehicle itself rather than the occupants, we see that hydrocarbons have limitations, too.
Moreover, biodiesel offers a way to fix carbon dioxide from the atmosphere and reintroduce it into the hydrocarbon/combustion energy infrastructure. You can regard biodiesel fuel generation as a form of solar power, fixing solar energy, CO2 and water into organic compounds that can be burned. For biodiesel, hydrocarbons remain the energy storage medium, but fossil fuels aren't used.
The biggest problem with biodiesel is that current paradigms require freshwater and arable land, commodities that will become increasingly scarce before fossil fuels do. New paradigms of biodiesel employ saltwater based algae, no land or freshwater required.
Algae: some food for thought. Before Soylent Green was people, it was algae. Is there nothing Charlton Heston can't teach us?