Albuterol and Political Correctness

Nobody get all prescriptive versus descriptive linguistics on me, but I'm noting a bizarre thing lately. It may not be new, but there's this odd tendency for people to call decisions or acts that they disagree with that they think are clearly done to please somebody not them "politically correct."

There's a fair deal of politics in this post, but I swear it's about a pharmacy-related issue.

Political correctness, PC-ness or PC-ism is a term mostly associated with liberals and liberal thinking. The basic gist of PC-ness is the idea that you shouldn't offend people, but it extends beyond that; you shouldn't do things that might offend people. Furthermore, everything you do is potentially offensive to someone, no matter how mundane it seems to you. Taken to its extreme, PC-ness is "left-wing censorship." It is frequently assumed within the context of PC that white males are not really offended by anything, but that women, racial minorities, and religious minority groups are "sensitive" to "careless speech." Women in particular are used as an example, partly because some feminist groups really do go way too far, insisting that the word "human" is offensive because it contains the word "man" and that alternative terminology needs to be developed.

The idea of what is and is not offensive is highly affected by cultural and subcultural norms, so I'm not even going to go into that. You could write a book on the subject. I'm sure someone has.

What I'm going to take issue with is the use of the phrase PC being grossly misapplied and my understanding of why it happens. The most recent example of this that I've seen was when I, out of morbid curiosity, clicked a link to "saveCFCinhalers.org" (I'm not going to link them because I don't want to boost their google ranking).

Summary: CFCs, or chlorofluorocarbons, are compounds that have been used as aerosol propellants and refrigerants for roughly the past century. CFCs react with ozone in the upper atmosphere and catalyze its destruction. Because CFCs are a catalyst, they are not used up in the reaction, so a single CFC molecule may destroy a number of ozone molecules, converting them to oxygen. Ozone blocks ultraviolet radiation, specifically UVB rays. It is well-established that CFCs deplete ozone and that this will increase the amount of UVB rays that reach the earth's surface. CFCs were phased out of aerosol paints and other products during the last decade. 2008 was the last year that CFCs could be included in metered-dose inhalers (MDIs, or "puffers").

MDIs containing a different, non-CFC propellant (HFA inhalers) have been on the market since 1996. As of December 31st, 2008, CFC inhalers may no longer be sold and supplies have basically been exhausted anyway since nobody has been making them for a while. The most commonly used MDIs are albuterol "rescue inhalers" that expand the passageways in the lungs. This is a big deal drug--if you want to know what it's like to have an asthma attack, go get a straw. Put it in your mouth. Breathe only through the straw without opening your mouth wider or using your nose.

Anyway, the old inhalers have been replaced with environmentally-friendly versions. Same drug, same dose, same efficacy. Some people are throwing a fit about this.

There are a few big complaints.

1. The HFA inhalers cost a little more. The old albuterol generic was about $25, less if insurance picked up part of the tab. The new inhalers are about $35-40 and insurance pays less since they're generally "brand name" products now. The whole insurance payment thing might change soon if enough people complain about it.

2. The HFA inhalers don't "feel" the same when sprayed--they're a bit less "forceful," which leads people to think that they don't work.

3. The propellant contains a very tiny amount of ethanol, which might leave a bad taste in the user's mouth. It is not enough to get you drunk by any stretch of the imagination.

The websites railing against HFA inhalers are full of comments that basically tell the same story. My inhaler doesn't work anymore. My daughter changed to an HFA inhaler and she died of an asthma attack a few months later. I changed to an HFA inhaler and now I have a huge long list of health problems I didn't have before. The government and the FDA are ripping us off and lying about the safety and efficacy of HFA inhalers. Here's a list of doctors that don't believe the HFA inhalers work as well. The American Lung Association is full of shit. Etc. I actually got into an "argument" of sorts with a coworker over this one day--not someone that works in the pharmacy. He was convinced that albuterol had been taken off the market completely and that you simply couldn't get it anymore, and when I informed him otherwise he seemed incredulous--but I didn't get an opportunity to talk to him about it further.

The comment that piqued my interest (and inspired this entry) was the complaint that CFCs had been removed from inhalers to "be politically correct."

I don't know exactly what train of thought the commentor used to get to that point, but here's how I see it. Before anyone accuses me of straw-manning anybody, I'm quoting statements made by my incensed coworker. While his thoughts may not be echoed by everyone who opposes this particular bit of regulation, this is the only dialogue I've had with someone who had a problem with the banning of CFCs on principle rather than because of some specific complaint (such as the new inhalers costing more).

1. Some people ("environmentalists") think that CFCs damage the ozone layer.
2. People who want to be "environmentally-friendly" by using CFC-free products should have the right to buy them; let the market decide.
3. I'm not convinced that CFCs damage the ozone layer.
4. Not letting me choose which product to buy is an unfair limitation of my personal freedom.
5. Therefore, a CFC ban limits my personal freedom.

This train of thought hinges on one particular premise, which, again, lest you think I'm constructing a straw man, was basically the crux of my coworker's entire argument: I'm not convinced that CFCs damage the ozone layer.

Let's go with the "free market" approach. In order to make an informed decision about which product is best, you have to understand several things. First, you have to know what the ozone layer is. Second, you have to know that CFCs damage the ozone layer. Third, you have to know the consequences of damaging the ozone layer. Once you have all of that information, you can make a choice: Do I care whether or not the ozone layer is damaged by the products that I use?

Here's the problem. This isn't a personal choice that's (primarily) going to affect only you, like what color to paint your shutters or whether or not to snort cocaine. Your decision is going to affect everyone living on the Earth for at least the next 50 years, which is how long an individual CFC molecule can remain in the atmosphere destroying ozone molecules. You are contributing to an increase in UVB radiation reaching the planet's surface during your lifetime, much of your children's lifetime, and at least part of their children's lifetime. You are increasing the risk of skin cancer for everyone alive now and everyone who will be born over the next several decades.

Frankly, I don't think you should be allowed to make that decision any more than you should be allowed to shoot me and take my wallet or dump sewage on my property, and the fact that you're too short-sighted to see the consequences of your actions shouldn't affect my personal health. I have rights too, you know.

(Incidentally, to preempt the slippery slope, I don't favor smoking bans because if second-hand smoke bothers you, don't go where people are smoking. If the owner of a particular piece of property opts to ban smoking for the comfort of their non-smoking patrons, that's their call, but nobody should be able to tell you you can't smoke outside or in your own car--though exposing your kids to second-hand smoke is certainly irresponsible and I have mixed feelings about it.)

What does any of this have to do with PC-ness?

Well, PC-ness is about not offending people. One of the things that I've heard said several times, more by conservatives than by liberals, is that "you don't have a right to never be offended," and I agree. Sometimes, people are going to do or say offensive things, and unless they're hurting you or there's a specific rule against whatever they're doing (sexual harassment at work, for example), you just have to get over it and move on. That doesn't mean you have to like it, and you can certainly say you don't like it, because criticism is not the same thing as censorship. Plus, some things are just socially unacceptable within a specific culture because enough people have decided that they don't like thing X that doing or saying thing X will get you publically ostracized (being openly racist in many circles in the US is a good example).

At this point, environmentalists become a minority group identified by a set of opinions or beliefs. If you don't accept the whole CFC-ozone layer thing, you might call it an "environmentalist belief," which puts it on par with any other faith-based assumption that you don't share. At that point, the government banning CFCs does seem like a "PC thing." They're doing it to appease some minority's feelings.

Which means that you're treating the CFC-ozone "belief" kind of like the beliefs of religious groups that are not your own. It's like if the government banned pork products because Muslims consider them unclean. You don't care what Muslims believe if you aren't one. Why should the "belief" of a minority group infringe upon the rights of the majority? Stupid political correctness!

This is why calling something PC in this context is just an empty smear--we're not talking about offending people here. We're talking about reducing the risk of skin cancer for human beings all over the world. There is a concrete reason for banning CFCs that has nothing to do with anyone's feelings. The EPA, NASA, National Weather Service and National Oceanic and Atmospheric Administration all concur. So do independent researchers at Manchester Metropolitan University in the UK and scientists from Germany, Belgium, Denmark, Norway, Spain, Switzerland, Finland, Canada, and Greece. Some very compelling evidence would be necessary to invalidate current theories.

Here's the part of all this that I don't entirely comprehend. Conservatives are generally very black-and-white--things are true, or they aren't. They pride themselves on being practical thinkers and denounce liberals as naïve idealists. The reason I think that this is funny is because calling evidence-based environmentally-friendly legislature "PC" is essentially invoking a kind of relativism. "You and I believe different things. Neither one of us can produce proof that will convince the other, so let's just agree to disagree." Except that you can't do that, because whether or not CFCs affect the ozone layer (for example) isn't a matter of opinion. It's either true or it isn't. And if we're talking about laws, something is either a law or it isn't; we have to decide. To "agree to disagree" in that context is to suggest shutting down dialogue on the subject--therefore, nothing is changed and the conservative viewpoint "wins" by default.

Inappropriate use of relativism regarding what is valid knowledge--which I see on both the far left and far right--is actually an interesting enough topic to warrant its own post, and I might have to make one later.

So. Here's the tl;dr summary: You can't criticize someone for being "PC" when what they're doing is not about avoiding offending people but about responding to objective, measurable conditions. This is true even if you think that the thing being done is intended to appeal to a "minority group" because you don't care about the issue at hand. Using the phrase PC doesn't make a damned bit of sense--but as with all language, you're free to use the phrase to mean whatever you want. You just shouldn't expect your listener to interpret what you're saying properly.

But Think of the CHILDREN!

You ought to recognize that line as a classic refrain of those in a state of "moral panic."

According to a recently released study, 3% of all children and adolescents in the United States go without health insurance at some point in a given year:

That translates into almost 3 million U.S. children with no medical care at all and no access to prescription drugs over a full year. Slightly more than half of that number qualify for public coverage but aren't enrolled.

Overall, more than 9 million U.S. children are uninsured; some 18 million have a coverage gap at one time or another, according to the study.

But, surprisingly, this includes kids whose parents have coverage:

The authors of the first study looked at data from 2002 to 2005 on children and adolescents under the age of 19 living with at least one parent. The study included more than 39,000 participants.

Their analysis found that 3.3 percent of children and adolescents were uninsured, even though they had at least one insured parent. (emphasis mine)

What about demographic information?

Uninsured children and adolescents were 58 percent more likely to be Hispanic than white non-Hispanic; had double the odds of being from a low-income versus a high-income family; were 48 percent more likely to be from a middle-income rather than high-income family; and twice as likely to come from a single-parent home than a home with two married parents.

...children whose parents had less than a high school education were 44 percent more likely to be uninsured; they were also 64 percent less likely to be insured if their parents had public coverage rather than being privately insured.

None of this should be a surprise. Poor kids don't have adequate health care coverage. Middle-class kids are less likely to be insured than kids from richer families; kids whose parents make between $38k and $72k a year are just as likely to be uninsured as their poorer counterparts. Kids with parents who have limited education are less likely to be insured, probably because the parents are less likely to have jobs that offer comprehensive family healthcare plans.

Why haven't we passed legislature to provide all children with health care coverage? Remember, the people who typically vote against candidates daring to propose universal health care are also the people who are most opposed to family planning.

"But N.B.," say some members of the audience, "the article says that over half the kids involved qualify for public assistance but aren't signed up. That's the fault of parents, not the government."

You're right. But not providing health care for children is sheer negligence, and we punish people for child neglect already. The definition of child neglect is "any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation." It is considered neglect to fail to provide for a child's basic needs, and medical care is included among them.

About half of U.S. children without health insurance had to go without medical care or prescription medications while they were uninsured, said researchers from the University of Rochester Medical Center. Even more children went without preventive care, including receiving necessary vaccinations.

If you don't see why this is a problem, you're part of it. And if you don't see why there need to be laws mandating health coverage for children (and adequate government assistance for those who need it), you're still part of the problem. Until there are laws mandating health care coverage for all children, we're losing a battle. There are kids out there who don't get treatment for the most basic illnesses because they lack health care coverage. Maybe one of them is yours.

"Children are like flowers," they say. "You can never have too many."

If you aren't watering your garden and your flowers are dying, maybe you should rethink that assertion.

So...please! Think of the children!

Five "Myths" about Socialized Health Care

A friend of mine and I were having a discussion about "socialized medicine" the other night. After a lot of verbal parrying and thrusting we concluded at about 3:30 AM. When I woke up, I found that he had left me a message--a link to an article called "five myths about socialized health care." Here's the article. It's written by a "John Goodman."

Here's what I think about each of Goodman's "myths" and his ultimate conclusion.

Myth: "Socialized medicine gives you a right to health care."

Goodman argues that socialized medicine does not REALLY give you a right to care. In Canada, he claims, you don't have a right to heart surgery. You don't even have a right to a place in line.

In a sense, Goodman is correct. Just because the government provides single-payor insurance doese not mean that all people have the right to care automatically. That's why single-payor insurance/health care coverage is necessary but not sufficient. We need both single-payor health care AND a government declaration or law stating that citizens have a right to health care.

This argument is fallacious because it has inverted cause and effect. People aren't saying they want socialized medicine because it gives them a right to care. People are simply asserting that they have a right to care. People don't have a right to care under the current "free market" system, either.

Goodman claims that the market provides a means for people who need care more to get it--by paying more for it. He asserts that patients "waiting for care" in socialized systems are suffering. This is completely ridiculous. Hospitals in single-payor systems rank patients based on priority. The patients who are in most urgent need of care get it first. Care costs money; what Goodman is saying is that someone who really, really needs to get to "the front of the line" will magically produce as much money as it takes to get there. Where does this model account for people who really, really need to get to the front of the line but have no money for care?

Furthermore, many people are already sitting around and suffering because they can't afford medical care. Right now we are rationing care based on people's ability to pay rather than the severity of their illness. From a medical perspective, this makes absolutely no sense. You should treat the sickest patients first, not the wealthiest patients.

Myth: "Socialized medicine gives people higher-quality care."

Goodman claims that patients in Canada and the UK get worse care based on the number of patients in chronic renal failure who get dialysis or the number of patients who get coronary artery bypass surgeries. He also asserts that British doctors spend less time with their patients than American doctors.

In one study done in America (Ohio to be precise) physicians spent an average of 17.5 minutes with each patient. And it's true that physicians in Britain spent, on average, just under 10 minutes. But Goodman is exaggerating when he says that the physician barely has time to take the patient's temperature. Routine examination tasks like checking temperature and blood pressure are now relegated to nurses; doctors almost never do these things themselves.

If a patient is complaining of "coughing up yellow gunk" and "sinus congestion" and similar symptoms it generally takes about five minutes for the physician to listen to the patient's lungs and diagnose the problem appropriately because he's seen the same presentation of symptoms ten thousand times. The mean visitation time is likely skewed downward by the fact that some illnesses honestly don't take that much time to diagnose. Medical professionals report a prevalence of 62 million cases per year for the common cold; you can't really expect them to spend 20 minutes explaining proper treatment for that sort of thing.

Dialysis and coronary bypasses are strange endpoints. Dialysis is only actually medically necessary when kidney function declines to about 10%. 485,000 patients in America are estimated to have end-stage kidney disease requring dialysis or transplant; in 2005, 341,000 patients recieved dialysis, or 70% of patients with ESRD. 17,429 kidney transplants were performed, so 3.5% of patients recieved a new kidney instead (which is better).

In 2005 there were 32,375 Canadians requiring renal replacement therapy. Of these, 19,721 recieved dialysis, or 61%. It's true; this number is lower. But 12,654 patients recieved a functioning kidney transplant. So 33% of Canadians who needed a new kidney got one. That's TEN TIMES more people who recieved a new kidney, which is infinitely better than dialysis as far as patient quality of life and outcomes.

Also, we shouldn't brag about how many coronary artery bypass surgeries we're doing. The fact that people need bypasses means that preventative measures have failed. Ideally we'd do fewer bypasses because fewer people would need them because we provided better preventative care.

Myth: "Socialized medicine gives people more per dollar in terms of care."

Goodman claims that Americans don't get more care despite spending more money. He asserts that life expectancy is the primary measure used to judge "health care quality."

The WHO created a scale to assess health care quality in different countries based on five criteria:

-Overall level of population health
-Health inequalities (or disparities) within the population
-Overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts)
-Distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system)
-Distribution of the health system's financial burden within the population (who pays the costs)

So no, no one is claiming that life expectancy is the primary criterion for evaluating health care quality.

Goodman also claims that more people who get breast cancer or prostate cancer in the US survive than those who develop these conditions in other countries.

See page 4 of this document.

It is true that the US outranks Canada and England in terms of breast cancer survival rates (in fact, it is 14% higher). But the survival rates for colorectal cancer are better in the UK and Canada. Childhood leukemia survival rates are better in Canada than the US. So are kidney transplant rates, as I already pointed out. So are liver transplant rates (about 20% higher, in fact).

Cherry-picking breast and prostate cancer is dishonest. Disease survival rates, incidences, and other statistics vary from country to country. Choosing two examples where the US outperforms other countries does not prove anything in the grand scheme of things.

Myth: "Socialized medicine gives people equal access to health care."

Goodman claims that care in countries with socialized medical programs does not really offer equal access because minorities still get less care. That's a terrible thing, but it doesn't really help his point. It isn't damning that socialized medicine isn't perfect.

Goodman then cites a survey of the elderly. According to the results, the elderly think that it is easier to get care in America, that they have shorter wait times, and that services are better.

This survey doesn't prove jack the way he's citing it. It's terribly misleading because as the author is presenting it he's basically saying "more elderly people think health care is good in America, so it is!"

I found the actual study cited--"The Elderly's Experiences with Health care in Five Nations" by Cathy Schoen et al., published May 2000. Let's see what it says.

12% of polled US elderly said it was "very difficult" to get care. 15% said the same in the UK; not a huge difference, and potentially attributable to randomness. 13% of Canadians said it was very difficult to get care--again, not terribly significant. Only 6% of Australians and 9% of New Zealanders thought it was very difficult to get care.

7% of those polled in the US said they had to wait five weeks or more for nonemergency surgery compared to 51% in the UK. So? That's the point--it's "nonemergency surgery." There's less rush to get it done. Having to wait to get an appointment to remove a mole or get a vasectomy is not a serious problem.

32% of those polled in the US rated their health care as "excellent." It is true that only 25% of those in the UK did the same, but New Zealanders had the highest rate at 39%. And again, 40% of US respondants reported "excellent care from their doctors," whereas 51% of New Zealanders did.

27% of respondants in the US described their most recent hospital stay as "excellent" compared to 39% in New Zealand.

9% of US respondants complained that their hospital stay was "too short." What in the world is this about? I think a team of medical professionals is in a better position to judge when you're well enough to go home than you are, especially since the longer you have to stay in the hospital the more it costs (both you and them).

I'm not going to go into the part of the study about prescription drugs because this study was released before Medicare Part D, and I'm sure that things have changed significantly.

As far as "younger patients preferentially getting care," which makes more sense--a liver transplant for a 30-year-old or a liver transplant for an 80-year-old? Who will ultimately benefit more?

In short, the US is somewhere in the middle of the pack. We do better than the UK and Canada on some issues but are vastly outperformed in most categories by New Zealand and Australia (and they have socialized medicine there, too). All this means is that if we institute universal health coverage we should learn from the flaws of the UK and Canadian system and emulate the good parts of systems from countries like New Zealand.

Myth: "National health insurance is an efficient way to deliver care."

Goodman says that the US health system is more efficient than other systems. He first asserts that this is true because the US has shorter hospital stays than anyone else. But he just cited a study where respondants complained that their hospital stays were "too short!"

What he says is true, to a point:

A 2006 survey says that in England the average length of stay was 6.3 days whereas in America it was 4.8 days (average of all diagnoses). One day's difference, really. That's not terribly significant in the long run. And hospital length of stay is not really an appropriate sole measure of the efficiency of health care systems.

Goodman continually uses the UK as an example of a poorly-run socialized health care system. What he fails to take into account is that the UK is not the only country with socialized medicine, and it does not have the best system by any stretch of the imagination. Saying that Britain's health care system is socialized but not as good as ours in terms of efficiency does not prove socialized health care is bad, it proves that Britain's health care system is less efficient. We would have to compare America to more than one country. Furthermore, if the British model is bad, we can choose to do things differently than they do, taking examples from what works in other countries and throwing out whatever doesn't.

Goodman also asserts that when you incorporate the cost to hospitals and doctors that Medicare and Medicaid are inefficient, but he doesn't provide numbers to back his assertion.

Cato: "Capitalism will fix the problem."

No it won't.

The free market won't fix health care because as far as the "free market" is concerned there is no problem. People who can't pay for goods and services in a free market economy don't get them. Ability to pay is the primary rationing mechanism. This means that it's okay if people don't get medical care if they can't pay for it because you only deserve things you can pay for.

What medical insurance does is not provide you with health care--it protects you against the astronomical cost of health care. Insurance works by spreading out the risk of illness over many people. This is why it's cheaper to insure a whole company, where the risk is distributed over a larger group, than it is to buy private insurance. Health care is not going to get cheaper. As we develop more advanced technology it requires more specialized knowledge to be a doctor or nurse. This means doctors and nurses require more expertise and education. This translates into increased costs.

To quote someone else's words on the subject:

For most Americans, providing health care ought to be different from selling soap; they won't tolerate doctors acting like commissioned salesmen and investment bankers. And if that means having less market competition and more regulation in the health care system, it seems to be a trade-off they're willing to make.

The free market is fantastic for regulating the price of most goods. Grecian urns? They're worth whatever someone is willing to pay. Luxury cars? Caviar? Designer clothing? Pepsi versus Coke? Price is a good rationing factor for all of these things. If people won't buy Pepsi because it costs more than Coke, Pepsi can lower their prices and see if people change their minds.

If you have a heart attack you don't have time to comparison shop. There is no incentive for hospitals to charge less. If you need a drug and there are no other drugs on the market that are just as good because the only drug that treats your illness is too expensive for you to afford, why should drug companies lower their prices to accomodate you? Medicine isn't a luxury, it's a basic human need. It cannot be subjected to the whims of the market. It cannot be treated like "just another service." There is no other industry where "buy" or "don't buy" is literally a decision between life or death.

Seriously. Every choice you make regarding health care directly impacts your chance of survival. We as a society, if we value the lives of our members, cannot afford to permit people to make the wrong choices. This doesn't mean people should be treated against their will. It means that people who want care should be provided with the best care available.

Patients often have no idea how to choose which care is best--that's why they go to doctors. If you develop an infection, do you know which antibiotic to use to treat it? In a true "free market" scenario drug companies would advertise their antibiotics directly to consumers and let them choose which one to use. This would be an absolute disaster; patients would wind up choosing antibiotics based on who connected with them through advertising rather than which antibiotic would actually treat the infection. If you have trouble believing this, consider the fact that 75% of consumers purchase brand-name drugs when buying over-the-counter medications despite the fact that on average generics cost about 2/3 as much and are equivalent products. They choose the more expensive product even though it is no better than the cheaper product. They do this because of brand recognition, faith in companies that produce brand name drugs, misconceptions about generic drugs, and many other reasons.

I have a hard time with the idea that patients who won't buy generic acetaminophen because they like Tylenol better will choose the right therapy for complicated illnesses. Which insulin should a diabetic use? Which ACE inhibitors have the best data to prevent strokes and heart attacks? What chemotherapy regimen is best? Giving patients full control over these choices is a mistake because they typically do not have the information necessary to make them--and most people overestimate their ability to make the right choice. If I had a dollar for every time a patient told me they should be able to get antibiotics whenever they wanted (and pick the ones they should get) because "I know when I'm sick" I would be a millionaire.

And that's what I think.

Abortion Issue Major Deciding Factor for Catholic Voters

I realize that this is probably kind of like saying "water issue major deciding factor for fish voters," but:

Many "small-town Catholics" are opting to support McCain on the abortion issue alone. Or so they say. That can't be the whole picture:

One parishioner ruled out voting for Mr. Obama explicitly because he is black. “Are they going to make it the Black House?” Ray McCormick asked, to embarrassed hushing from a half dozen others gathered around the rectory kitchen. (Five of the six, all lifelong Democrats who supported Mrs. Clinton in the primary, said they now lean toward Mr. McCain.)

Man, you can still say things like that in public without being ostracized for being a terrible human being? We sure have made progress in America these past 50 years or so.

Many parishes distributed a voter guide, produced by an outside conservative Catholic group called Catholic Answers, which identified five “nonnegotiable” issues for faithful voters: abortion, embryonic stem-cell research, human cloning, euthanasia and same-sex marriage.

I think that's pretty stellar. It's totally acceptable to re-elect a member of a political party whose flawed policies have sent our economy down the tubes. We should definitely consider with seriousness a candidate whose health care plan is no health care plan at all. We should get behind a man who doesn't seem to realize that "clean coal" technology doesn't fix the fossil fuel reliance problem.

We should do all of these things because we care more about blastocysts than ambulatory human beings and the idea of gays having proper civil rights is just terrifying.

America the beautiful.

(H/t Mike the Mad Biologist).

Doing One's Duty

Most people have heard of the Hippocratic oath. Physicians traditionally took the oath upon graduation. Some parts of the oath are less applicable today; I think a lot of people would object to swearing in the name of a bunch of Greek gods. And while some doctors may not want to perform abortions, I think that it's unlikely that anyone is going to prescribe insertion of a silicone ring as a method of doing so. You get the idea.

But did you know that there's a pharmacist's oath? And a written code of ethics?

The oath is pretty brief. But that's good. It's concise. Here's what it comes down to: You, as a pharmacist, have obligated yourself to serve people. You're going to do this by knowing lots of stuff about drugs.

Likewise, the code of ethics is pretty to the point. You're going to serve patients, and you're going to do your best to be fair about it. You're going to respect and utilize the knowledge of other professionals. And you're going to respect your patients' autonomy.

So why do so many pharmacists think that it's somehow acceptable to refuse to dispense contraceptives?

Now, what I think this guy (Koelzer) is doing is stupid. But in one sense, he's doing this the right way. He's started his own pharmacy. He is not asking businesses that he does not own to make a special exception for his religious beliefs. If people want to patronize a pharmacy that refuses to stock contraceptives, it deserves to stay open as much as a pizza parlor that won't stock non-Kosher toppings. It would be an unfair imposition to tell Koelzer that he has to shut down his pharmacy, because he has the right to run whatever kind of business he wants. It would be wrong.

Koelzer might be a good business owner. But is Koelzer a good pharmacist?

I don't think so, because he's violating the pharmacist's code of ethics. He's violating his oath. He swore to make patient care his first priority--and he isn't. Guaranteeing women control over their own reproduction is patient care. It's not some kind of luxury. Koelzer might say that if women want to control their reproduction that they should refuse sex. But that's not respecting his patient's autonomy, either. His patients in search of contraceptives have clearly decided that they would like to have sex. A lot of people who use contraceptives are married, so this isn't just about sinful, blasphemous fornicators.

So if you want contraceptives, you won't go to his pharmacy. He owns his own business. It's his right not to offer them, and it's your right to shop somewhere else.

But he's still a bad pharmacist.

"Pray for McCain's Death"?

You know, when I started this blog I specifically told myself I didn't want to get into talking about politics except when necessary. I wanted to talk about pharmacotherapy and pharmacoeconomics and maybe the politics of medicine, but I really can't resist passing this along. Hat tip to Ed Brayton (and also compliments to PZ Myers, who also mentioned this story):

Palin is a Christian, so she ought to get elected president. Here's the "plan":

1. Vote Constitution Party. (I vote my conscience and cannot support McCain even with Palin.)

2. Hope and pray for McCain/Palin to win. (I am an idealist, but also a realist!)

3. Pray for John McCain's salvation and pray specific imprecatory prayers if he fails to pro-actively defend the sanctity of human life. (Google The Forerunner's articles on Impecatory Prayer if you don't understand this.)

You can't make this stuff up, folks. Some people are totally batshit crazy. Even if you believe in the existence of a god or gods, explain to me how it's even remotely moral to pray for someone's death so that you can get the president you want? Aren't these the same people who are always saying that the ends don't justify the means (which is why abortion is terrible, even if it's to save a woman's life)?

I just don't get it.

FYI, for anyone who's going to come along and say, "no one is praying for McCain's death!" I did as the writer suggests and looked up "impecatory prayer," which is actually spelled "imprecatory prayer," but you will get a billion google results for the former because everyone is reposting this story.

Anyway, imprecatory prayer is when you pray for God to help you hurt somebody else or defeat some enemy (because supposedly you are praying for a "righteous" reason, otherwise God won't help you and you're a dirty, dirty sinner. What is "righteous" is presumably up to the individual to decide by reedin' his Biiiiible).

Doing the Minimum

So I managed to get myself into a dispute with someone in another arena about the minimum wage. He seemed to think that the free market would sort everything out equitably if we eliminated it. (He also provided no data to support this assertion. I have to charitably assume that he thinks this will be the case because he just has that much faith in humanity to "do the right thing.")

I'm not even going to touch that, but someone came along and attempted to defend Mr. Free-market's viewpoint. At the end of his post, he posed a philosophical question of sorts. What is the intent of the minimum wage?

I think that the "intent" of the minimum wage is to make sure that employers aren't paying employees less than they are able to live on. I decided to dig up some information on the subject.

The Economic Policy Institute has an interesting calculator that lets you put in typical family structures and locations to calculate a "basic family budget." The budget only covers the cost of food, shelter, and clothing. It includes "no savings, no restaurant meals, no emergency funds--not even renter's insurance."

I decided to calculate the cost of living based on two parents and one child for Indianapolis, Indiana. I myself live in Indianapolis, so I can tell you exactly how much I pay to live here for comparison. I live with three other roommates and we all pay equal shares, but we also all earn wages and are employed at least part-time (I work about 10-12 hours a week). I am also lucky to have parents that pay some portion of my expenses (I am a full-time student). Unless stated otherwise, I am only listing my share. To estimate the "actual" cost, multiply by four.

• My monthly rent is $1000, of which I owe 1/4 (I have roommates) for a total of $250/month.
  
• I spend about $125/month on groceries.
  
• My basic utilities cost me about $150 a month.
  
• I also have phone and internet access that costs me $12/month.
  
• I don't pay my own car insurance, but I decided to estimate it by getting a quote from my insurance company. Basic coverage would cost me $100/month.
  
• Gas to operate that car currently costs me about $45/month.
  

Total: I spend $632/month for my barest necessities, not factoring in entertainment or savings, which amounts to $8,184 per year. It also doesn't include health insurance, which I have through my family. I suppose I could tack an extra $75/month on for a health care plan that basically doesn't cover anything--that's what my girlfriend has (and a $2500 deductible, to boot). If I had to pay everything myself it would cost $32,736 per year. None of this accounts for my $30,000/year education, which I can only pay for because the government is subsidizing some loans and I have a small scholarship.

The budget calculator suggests the following monthly expenses for a family of two with one child living in my city:

• Housing: $726
  
• Food:: $514
  
• Child care: $542
  
• Transportation:: $447
  
• Health care: $286
  
• Other necessities: $298 (I assume they mean toiletries, clothing, etc)
  
• Monthly taxes paid: $377
  

The monthly total is $3,189 and the annual total is $38,273. I have zero problems believing that this calculator is accurate at estimating the cost of a family of three living in Indianapolis.

Indiana's minimum wage is $6.55/hour as of July 24th, 2008.

$6.55/hour x 40 hours/week x 52 weeks/year means that if you take no unpaid vacation, get no overtime, and work every day you possibly can you make $13,624 per year in Indiana. If you are married or in a domestic partnership and your spouse has the same earning potential you will therefore make $27,248 per year, before taxes.

You are about $10,000 short.

As far as state taxes go, Indiana has the third lowestindividual income tax rate of any state as of 2007. Federal income tax for this family will be filed jointly (let's assume they're married). For reference, here is a tax bracket calculator. They make between $16,050 and $65,100, so they pay 15%, or $4,087. But hey, they get it all back, right?

In short, anyone arguing that the minimum wage is actually sufficient to live on clearly hasn't done any math lately. How is the average American family supposed to live with a $10,000 budget deficit? And that's without any recreational expenses. No movies, no restaurant dinners, no mommy-and-daddy dates, no alcohol or tobacco purchases. The answer is that they borrow it, and that's where we get into trouble.

Here's the thing. You have to be a dreadfully callous human being to say that people who work minimum wage jobs (mostly those who didn't or can't get a college education) don't deserve a living wage. Should people with more education make more money? Of course. But should people with only a high school diploma be paid less than they can afford to live on?

Repetition =/= Truth

Apparently Tim Pawlenty, governor of Minnesota, was recently questioned about his position on teaching creationism/intelligent design--mostly because it's something that's come up with VP Sarah Palin, who favors "teaching the controversy."

GOV. PAWLENTY: I saw her comments on it yesterday, and I thought they were appropriate, which is, you know, let's -- if there are competing theories, and they are credible, her view of it was, according to the comments in the newspaper, allow them all to be presented or allow them both to be presented so students could be exposed to both or more and have a chance to be exposed to the various theories and make up their own minds.

Emphasis mine.

That's it. Full-stop. If they are credible. They aren't.

Evolution is a scientific theory. So is natural selection. They are supported by data, research, and observation. They don't just explain something, they invite further questions. How do things evolve? What pressures favor which adaptations? What conditions affect the visible "rate" of evolution? Thousands of issues are being explored by biologists using what we know about evolution as a starting point because it's been thoroughly demonstrated that it happens.

Creationism doesn't invite any serious questions that can actually be answered ("so, who is this designer, anyway?"). It doesn't present any hypothesis other than "stuff was designed," and that hypothesis isn't scientifically valid because it isn't testable. It is not a competing theory because it is not science.

It's disgusting that people are offended that their children are learning science in science classes because science apparently offends their theological sensibilities. And the politicians that are using this talking point--"it's a local issue"--are doing the smart thing, politically, and dodging the issue altogether. They're not saying they don't have an opinion. They're saying that they won't voice their opinion because they're afraid of alienating some portion of their constituency. No political candidate who wants to keep his career is going to stand up in front of America's 75% Christian population and tell them that their faith and beliefs are irrelevant when it comes to determining what is and isn't verifiably true.

Even if local school boards don't want their kids exposed to scary ideas like evolution, it's a waste of taxpayer dollars to teach them bullshit instead just so that they can be sheltered from theologically unpalatable truths.

A (Sterile) Needle in a Haystack

As much as I hate to flagellate a deceased equine, I really don't think my last entry drove home the point about why we need to provide clean syringes and needles to injectable drug abusers.

There are numerous arguments made by those opposed to selling (or even giving) syringes and needles to drug users. It "doesn't work; addicts will use dirty needles anyway." It "sends the wrong moral message about drug use," which we all know is of primary concern to good, patriotic citizens. And, my personal favorite, it encourages drug abuse by making it "safer."

The first argument can be refuted with science. The second can't be strictly refuted because it relies entirely on subjective opinion; despite what some people seem to think, morals are cultural values, and they vary from person to person instead of being absolute or inherent.

The last argument annoys me more than the others because it blatantly ignores reality. IV drug users may be concerned with their safety, but what constitutes "acceptable risk" for abusers of illegal drugs is not the same as it is for you and I. In clinical practice, we never have patients self-administer IV injections, partly because it is considerably more difficult than giving a subcutaneous or intramuscular injection. Not only is the technique more complicated, but the risks are considerably greater. Forget about dirty needles for a moment; let's look at all the other "safety" issues being bypassed.

1: No way to verify purity of product. You don't know how much heroin you actually have and how much of that product is fillers--many of which do not belong in your veins. Even seemingly innocuous fillers such as talc or cellulose can cause tissue death.

2: Product concentration considerations. Injectable products have to be carefully balanced so that their osmolarity does not disrupt existing tissues. A solute (drug + additives) concentration that is too high will cause cells to shrink as water is sucked out of them to equalize the concentration gradient. A concentration that is too low will result in water rushing into cells and bursting their membranes.

3: Product and injection prep environment sterility. Even if you're using a clean needle, I doubt most IV drug users prepare their doses in a laminar flow hood. When pharmacists or technicians prepare injectable drug products they must meet many standards. You can potentially contaminate your product by touching any one of various critical needle/syringe areas, failing to wipe injection ports with alcohol, cleaning the hood improperly before use, taking your hands out of the sterile environment, leaning too far into the hood...the list goes on.

A "clean" needle is just the first step to sterility. You don't buy heroin in multidose glass vials that meet USP standards for purity and stability, buffered to appropriate pH and preserved with appropriate IV-safe additives. You buy heroin from a shady drug dealer in a back alley somewhere. You have no idea where he got it. There's no one you can complain to about manufacturing standards or product flaws. The fact is that drug users are willing to introduce a substance they bought in a back alley directly into their veins, bypassing all the body's barriers against infection and introducing contaminants or particles that can directly damage blood vessels.

It is so risky to abuse IV drugs that denying addicts access to clean needles is not going to be the straw that breaks the camel's back and turns them away from their dangerous habits forever. It is going to be added to the laundry list of hazards that addicts have already classified as "acceptable risks." And it isn't just addicts; new users aren't really concerned about their safety, either, and if they tell you that they are, they're lying, whether they realize it or not. There's a serious contradiction between "I prioritize being safe" and "I'm willing to inject substances of indeterminate origin and quality directly into my veins."

So we can ignore the reality that hard-core addicts are going to shoot up whether we give them clean needles or not and live in a political fantasyland where people don't do dangerous things. Or we can face the facts.

The fact is that IV drug users don't tend to pay their medical bills when they OD or contract hepatitis. They wind up in the ER, where they cannot be legally denied care, and everyone else absorbs the shock through increased healthcare costs. When addicts end up on Medicaid, you are paying for their AZT. You are paying for their hospital stays when they're suffering from liver failure. Your healthcare costs more when you deny clean syringes to drug users and more of them become seriously ill. I'm not saying you have to approve of their habits. I'm saying that you have to consider the economic ramifications of disease control. More sick people who can't pay their hospital bills means higher hospital fees for everyone so that hospitals can recoup their losses.

The fact is that the moral paternalists who oppose needle programs--and Narcan--don't care about the lives of drug addicts. They cloak their lack of empathy with layers of political doubletalk. But even if you can't bring yourself to have basic human empathy--or honesty--look at the situation from a pragmatic perspective. You are increasing costs for the entire healthcare system every time you deny that syringe sale because Johnny the addict doesn't have an insulin prescription.

Narcan, or: Why You Deserve to OD and Die

Pharmacy colleague (and I hope he doesn't mind my calling him that) and fellow blogger Abel Pharmboy provides a most excellent summary of the current buzz in the blogosphere about statements made by Dr. Bertha Madras. Dr. Madras, in the event that you were unaware, is a head member of the White House Office on National Drug Control Policy. And Dr. Madras would rather see opioid abusers die than distribute rescue kits that "encourage" opioid use.

I'm sorry, I thought we lived in a country that gave a damn about whether or not its citizens lived or died. Apparently, moral paternalism trumps compassion, which should be no surprise considering the government's track record with the "war on drugs."

This provides me with a handy segue into a topic that bothers me immensely: Pharmacists who refuse to dispense needles and syringes without a prescription, even in states that have laws that protect them from liability. Dispensing syringes without a prescription is clearly legal in 26 states, and most states that permit dispensing without a prescription absolve pharmacists (and technicians) of all responsibility.

The risk of contracting AIDS, hepatitis, or other blood-borne illnesses is not an effective deterrent for IV drug-users. Thinking otherwise is just flat-out delusional. If you believe that denying clean needles to drug users is going to make the give up their habit, you are way off. Drug use, especially injectable drug abuse, is a risky behavior, and it is an all-consuming urge. The fear of withdrawal symptoms is often considerably more powerful than the fear of contracting an illness. Many AIDS or hepatitis patients have no symptoms; they don't even know they carry the disease. They can and will pass that disease to others. It isn't that they don't know that sharing needles is dangerous. Using heroin is dangerous, too. The issue is that the risk is acceptable, given the information that they have. And if you don't know you're a carrier for a disease, you don't have all the information, which means that you're going to incorrectly evaluate the odds.

What denying needles (and Narcan) to addicts does do is send a powerful message. It says "society doesn't care about you, and we're secretly hoping you die so that we don't have to deal with the problem anymore." These are the same people who think you deserve to be punished for unintentionally getting pregnant. They don't care about outcomes. They don't care any more about addicts than they care about single mothers. They can all die, and decrease the surplus population.

They just want you to shut up and pay your taxes.