Virtuous Circle

Tinker Tailor Soldier Fascist

This LINK made me think about my long infatuation with the work of John LeCarre.
I used to love his work. The sophisticated closed world: the sometimes-incomprehensible jargon (you were his postman, yes but you were his vicar), the thrilling tradecraft, and Smiley’s world-weary depression. I loved it all. I owned all of his books in hardcover, even” The Naïve and Sentimental Lover”. They occupied a central, eye level place of honor on my bookshelves. I even thought of putting a portrait of LeCarre on my wall as he has a more than superficial resemblance to my father and could easily pass as family.

Over the years though I became increasingly uncomfortable with his work. The moral relativism, present from the beginning and always a theme and at first easy to overlook, became increasingly onerous as my own worldview shifted. The stultifying romanticizing of character defects, in“The Russia House” morphed gradually into the glorification of marginal thugs such as the Chechens by “Our Game” .I didn’t even buy his last few books and was not seriously tempted to even borrow or steal them.

By 2003 this all crystallized in his public pronoucements. Here. Apparently his newest book Absolute Friends contains more of the same attitude. Why am I surprised? It was all there from the beginning. Unfortunately last year I threw away my entire collection and can’t look this up directly but I remember clearly an exchange from “Tinker Tailor Soldier Spy” between Smiley and Bill Haydon after Haydon was unmasked as a Soviet mole. Smiley asked him if he had done it for the money. Haydon replied haughtily (and here my recollection must be from the TV miniseries on the BBC)”of course not”. This alleged disdain for money and the almost insulted sneer when asked about it was memorable. Haydon’s excuse was that since after WWII Britain was washed up as a world power the only alternatives were the US and the Soviet Union. To Haydon the US was unacceptable as a matter of taste. This was representative of a British upper class mentality that felt Britain could play"Greece" to the Soviet Unions Rome. Nowhere are principles mentioned. This moral equivalence, now that the cold war is over has turned in on itself and finds as its target the US and Israel. Here
Here and Here.

Because he was charming and sophisticated Le Carre seems to have gotten a free pass. Perhaps it has expired.

Guns Pediatricians Polio and Tipping

Pediatricians Should Know Better-Lead With the Head Not the Heart

Mrs. C and I disagree on the subject of firearms in the home. Understandably she emphasizes the maternal concerns of child safety and opposes firearms in our home while I believe crime prevention and firearm education are overriding. We never seem to get anywhere in these discussions. I might add that we live in a community where doors are rarely locked and people keep their keys in their cars. I believe this is related to the high concentration of firearms in the community while she is agnostic on this point.

It was very distressing to me that the American Academy of Pediatrics has not only affirmed a policy that advocates the removal of handguns from the home but more alarmingly reaffirmed its policy of advocating the banning of handguns and semi-automatic weapons entirely. This reminded me of my neighbor who has the very sensible attitude that “while I don’t want firearms in my home I’m glad my neighbors have them”
Convicted felons say that they are more deterred by armed victims than by the police. In the United States, where roughly 50 percent of households are armed, only 13 percent of burglaries occur with residents at home. In contrast, in Britain, where homeowners are disarmed, 50 percent of home burglaries take place with the residents present. Here
That firearms in the hands of private citizenry prevent crime is a staple of conservative thinking but seems never to have occurred to the American Academy of Pediatrics. Perhaps the medical profession, traditionally conservative, now reacts in a reflexively liberal way i.e. as an elite rather than being ideologically neutral and empirical in formulating policy.

Directly from the AAP statement is this quote.
· "The AAP advocates that a coordinated, comprehensive national surveillance data system be maintained by the Centers for Disease Control and Prevention, as well as the National Center for Health Statistics. "

Perhaps if we took an epidemiological approach we could find some common ground or at least determine if we agree or disagree on fact or on principle. All this leads me to the concept of “Tipping”. Long appreciated by epidemiologists, this principle can be summarized as” the point at which an ordinary and stable phenomenon-a low-level flu outbreak- can turn into a public-health crisis. “ From Malcolm Gladwell's original New Yorker article Here which served as a prelude to his book . Gladwell looks at a decrease in crime at some point being non-linear with respect to various policing inputs-getting just one more criminal off the street could have a large effect on decreasing crime. At some point a virtuous circle occurs in which decreased crime results in, for example, more ordinary citizens on the street-more eyes and ears available which results in less crime which results in more eyes and ears etc. Or fewer criminals means a better chance of young people being influenced by positive role models which means less crime which results in more positive environment which means the development of more positive role models which means less crime.

Similarly for firearms in a community: Think of each home or individual with a firearm as being successfully immunized against crime. Now the theme of herd immunity comes in. For certain immunizations e.g. the common childhood ones of diphtheria, tetanus etc-only the individual receiving the inoculation is protected. For others notably oral polio vaccine-each successfully immunized individual also protects unimmunized individual by decreasing the reservoir available for the given pathogen. A critical mass of firearms will protect the entire community not just those actually armed. Moreover this will occur in a non-linear way which epidemiologists could quantify and encourage. When a criminal perceives that there is a high likelihood of being confronted with a firearm he will seek other venues. My neighbor’s firearms protect me whether I have them or not.
What is the positive tipping point in a community? How much crime is actually prevented.? Here and here Why is there an inverse correlation between violent crime and firearm possession? How wide is the circumference of protection? Will this apply equally to urban, suburban and rural areas? What are the long-term effects of victimhood? What are the positive psychological effects of empowerment? Shouldn’t the CDC with all of its resources and statistical sophistication be looking at this? Shouldn’t the American Academy of Pediatrics take these concerns into account? Ideology should not apply here. I believe the empiric evidence will support the second amendment. For historical perspective read this.

The Physiognomy of Hate

Crazed Michael Jackson Fan

Idiotarian of the Year Rachel Corrie
Their Spiritual Cousin

A psychologist named Paul Ekman has been studying the relationship between human facial expression and emotion for more than 30 years. He has developed quite subtle and exhaustive catalogues of facial muscle movement and positioning. He has advised law enforcement agencies and at least one very forward thinking plastic surgeon of my acquaintance is familiar with his work. sumarized here
He is also one of the participants in the symposium with the Dalai Lama which I wrote about yesterday.
I wonder what he would think about this expression.
Somehow I can't imagine Ronald Reagan ever looking this way, or Franklin Roosevelt or even John Kennedy. Maybe GWB when he was still drinking but not now. The only generally upbeat president I can imagine looking like this is Teddy Roosevelt but I suspect that Ekman can make the distinction between Roosevelts impatience and the hate emanating from these 3 eerily similar countenances.

Folk Medicine-Atkins Jarvis Mom and Me

My mother had a subscription to Prevention magazine and believed deeply that orthodox medicine was remiss in not emphasing the area of Nutrition. In the nineteen seventies when I first became aware of the magazine it's format and feel seemed to be a throwback to an earlier vision of redemption through diet.It was a gentle,low-rent, non-paranoid sort of Reader’s Digest for the wheat germ and honey/Linus Pauling set. Prevention faded from center stage after it’s founder and publisher a Mr. Rodale had the nutritionally incorrect misfortune to keel over with a fatal heart attack on a national late night talk show. I also have an uncle who is a devotee of “Folk Medicine” a book still in print by a late Dr. Jarvis of Vermont who advocated the ingestion of large amounts of apple cider vinegar and honey to ward off all of life’s ills. Dr. Jarvis until recently was probably the most well known medical practitoner from the Granite state and a lot more positive, cheerful and innocuous (except for the smell of the apple cider vinegar) than the physician/governor/democrat contender who has supplanted him. My uncle, alive and quite well in his eighties, alas had what we used to call “issues” and was ridiculed for his beliefs. So when I became a quite traditional medical practitioner my own family became my intellectual provocateurs.

I don’t know how or by what route Prevention ever made a transition to a slick and upscale variant of Self but it did. here

All this is a lead in to my thesis that in medicine as in much of society much of what was fringe and counter cultural in the sixties and seventies has gone mainstream. In the case of folk medicine it looks like some of its precepts are even gaining scientific credence.

Dr. Atkins of the low carbohydrate diet that bears his name died just as serious investigators were confirming his theories. Not only did his diet, high in fats though it might be result in weight loss but it also had sanguinary effects on cholesterol and the notoriously recalcitrant tri-glycerides. here Further evidence supporting the use of dietary modification continues to emerge. In this week’s archives of neurology here close to 5000 elderly Utah residents were surveyed prospectively for the use of vitamin supplements and monitored for the subsequent development of Alzheimer’s disease.

Results Analyses of prevalent and incident AD yielded similar results. Use of vitamin E and C (ascorbic acid) supplements in combination was associated with reduced AD prevalence (adjusted odds ratio, 0.22; 95% confidence interval, 0.05-0.60) and incidence (adjusted hazard ratio, 0.36; 95% confidence interval, 0.09-0.99). A trend toward lower AD risk was also evident in users of vitamin E and multivitamins containing vitamin C, but we saw no evidence of a protective effect with use of vitamin E or vitamin C supplements alone, with multivitamins alone, or with vitamin B–complex supplements. Conclusions Use of vitamin E and vitamin C supplements in combination is associated with reduced prevalence and incidence of AD. Antioxidant supplements merit further study as agents for the primary prevention of AD.

While hedged in the usual cautious language and without access at present to the full text article I don’t want to impute too much but it does look intriguing. Like many advances in the general health level such as: decreased smoking and alcohol intake, increased exercise, better diet, less exposure to UV radiation, the public is way ahead of the medical profession. It wouldn’t be surprising to see a decrease in Alzheimer’s' incidence in 15 years from antioxidant and anti inflammatory drugshttp://www.alzheimersupport.com/library/showarticle.cfm/ID/1586/e/1/T/Alzheimers/analogous to the contemporary decline in mortality from cardiovascular disease resulting from lifestyle changes of 15-20 years ago.

Other emergent dietary treatments include the use of omega 3 fatty acids to prevent cardiovascular disease and more recently as a mood stabilizer in bipolar disorder . here The use of the popular dietary supplement chromium piccolinate has been advocated for a variety of neuropsychiatric disorders and weight loss. However there is always a potential downside with unproven remedies and chromium piccolinate has lost some of its luster as chromosomal damage concerns have come to the fore here While generally the counter cultures distrust of all traditional authority has led to disastrous effects open mindedness coupled with rigorous scientific discipline has a curious way of advancing knowledge and should be lauded. This has been a very slow transition for me and on any given issue my instincts still scream out fraud. My prediction on the next big big thing in this arena-- The emergence of Buddhist style meditation into the medical mainstream. : Destructive Emotions: A Scientific Dialogue with the Dalai Lama This book which is the summary of a series of discussions between the Dalai Lama and first rate neuro scientists and clinicians is a must read and will be discussed in more detail in subsequent posts.

Velcade Approval- Pragmatists and Purists

I noticed that Velcade got a positive response from the European Medicines Evaluation Agency’s Committee on Proprietary Medicinal products here. This virtually guarantees European approval of this product. The history of the acquisition and subsequent development and approval of this product has investment implications that in my opinion will be felt for many years,

First the history of the acquisition briefly summarized here Proscript was in essence willing to give the product away. If I remember correctly the final price for the whole company was on the order of two million dollars. At that time I was engaged to advise a potential purchaser of Proscript and to review the entire package on a scientific and clinical and marketing basis. The client had a deep and talented scientific crew who were not at all smitten with the “Not Invented Here” bug and kept an open mind throughout the entire due diligence process. Nonetheless we all felt that a) the product was too non-specific-after all the target is not called Ubiquitin for no reason and b) the side effects predicted for humans on the basis of the pre-clinical models were daunting-mainly neuropathy. The client passed on the opportunity, which was then picked up by Leuko-Site and then folded into Millennium. Not one of my greater predictions.

The approval of the product from the time of initiation of the phase I trials to the granting of the NDA was also much shorter and less stringent than many observers expected about 4.5 years here. While many believe the FDA under the new commissioner is more responsive the broader implications on investment and political bases have been less extensively examined. For as long as I can remember there has been a battle between pragmatists and the purists regarding the optimum amount of data required for approval to market a drug. In most instances there is a tradeoff between safety and efficacy that is fairly obvious and therefore the more severe the disease the less efficacy required/unit of safety. So far so good-cancer patients are now clearly the biggest beneficiaries of the ascendancy of the pragmatists. However the basis of this newfound readiness in rooted in strictly utilitarian terms and does not seem to have broader libertarian implications.

While pragmatists are ascendant in the cancer arena-the purists are holding sway absolutely in the arena of gene therapy and probably in the cardiovascular arena as well. Mandatory drug testing in children for any drug, which might ever be used in one, is also not a sign of the demise of the purists. Moreover FDA advisory panels, (made up of a group of outside experts who are quite influential in the drug approval process) vary greatly in their respective outlooks. I would like to examine the committee members in each of the therapeutic areas and see if their composition and pre-existing pronouncements have some predictive value in their recommendations. I have felt for many years that the presence of a biostatistician or too many PhD’s on any advisory panel increased the odds of a negative outcome (purist win.)

While the FDA is in my opinion still extremely productive, countervailing pressures are also necessary. Patient advocacy groups are one, and a more libertarian political atmosphere as reflected in the appointment of a commissioner is another. However to infer a more sanguine outlook to the drug approval process in general on the basis of anti-cancer agents is probably premature.

These swings are probably more cyclical than our short-term memories allow for, and the further we are from the thalidomide tragedy the more likely we are to have forgotten its lessons.

This Can't Be Good For the Country

But instead of helping clinicians manage their information needs, the fragmentation of our health care system poses barriers to communication between hospitals and practices, and between practices and research facilities. With the push of a button, a doctor should be able to receive the latest scientific articles along with his patient's chart, or prescribe a medicine and send it to the pharmacy. But often, the systems are not in place for them to do so. These barriers to communication don't serve physicians, and they don't serve patient
Hillary Rodham Clinton-

By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care
George W. Bush

Both of these statements are from this week. The presidents right from the SOTUA. The cameras showed Hillary smiling during right after that line.
Perhaps the fragmentation (The boldface is mine)-is the only thing that allows us choices. A unified and national medical record system would not only be a major blow to the small remaining privacy in the patient/doctor relationship but would overcome a major logistic impediment to initiation of a single payer system. Fortunately unified medical records are not simple but that won’t stop HRC. Having GWB sign on is not a good sign. The issue is out in the open the subterfuge is not that subtle and the battle lines are being drawn for 2008.Unfortunately the GOP is heading down the same path.

“When you control the mail you control IN FOR MAAAY SHUN”
Newman

Why I Am Creating A Weblog

In starting this blog I am reminded of the advice of two of my former teachers. Dr. Robert A. Good of the Memorial Sloan Kettering Cancer center told us to write every day. He said that the discipline would be good and it would hone our thought processes as well as serve to prepare us for publishing on a more or less continuous basis. I didn’t choose to continue in an academic medical setting because my interests were more in the clinic and less in the academic arena. In retrospect part of my reluctance was related to my distaste for putting pen to paper.

Years later I found myself on Wall Street as a security analyst and had to overcome my reluctance to write both in real time as well as longer more thought out reports. The ability to write well is a great asset and I regretted not following Dr. Good’s advice. Over the years I came to enjoy writing particularly one to two page essays where precision was paramount and excess poison. An excellent set of editors taught me at the age of 40 what I probably should have assimilated at 14.

Several friends suggested Blogging to me as a way to resume thinking about business and political issues in a more rigorous fashion and to bring these considerations into the information age. In the 7 years or so since I last wrote regularly for a brokerage house, the nature of information distribution has changed seismically. The economic implications are just beginning to be sorted out. This sounds like a good time to take Dr. Good’s advice.

I am also reminded of my calculus professor Ralph Palmer Agnew. He would take a student step by step through his mistake in a kind but firm manner. At the end he would mischievously ask if the student enjoyed conducting his education in public. I hated that as a young student but hope I’ve become thick skinned enough to enjoy it now.

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