April 6, 2006

Pedophilia Makes You Stupid

Homeland Security Official Charged in Online Seduction

The system has failed.

Plot synopsis: DHS press secretary is caught in online sting, as he has sexual online chats to what he thinks is a 14yo girl but is really a cop.

Seriously, what's wrong with these people? Do you need a 14yo so badly, at any cost, you're willing to tell them you actually work for Homeland? Is that supposed to turn on 14 year old girls?

You would think the deputy press secretary of Homeland Security would know that he could be easily caught on the internet trying to solicit sex from a minor, or at least that the Department would know what he is doing on their computers. But he doesn't, for two reasons: a) he's stupid; b) in fact, the Department doesn't know what he is doing, because the Department is stupid.

I'll do you one better: no one traffics kiddie porn on IRC if they have half a brain in their head. You want to traffic kiddie porn? Make your connections over online games like WoW, Everquest, or Halo. In the case of the former two, the chat conversation works as well as irc, and in the case of the latter, it's voice traffic. In no case is the transcript or anything else logged. I bet there's more weird crap happening in online games than you'd want to know.

Add to that freenet, which is basicaly encrypted decentralized bittorrent with invite-only peers, and you've got a pretty robust digital underground.


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April 3, 2006

Nature Weighs in On What Is True

and turn out to be wrong.

There's been something of a controversy raging over the best place to get accurate information.

Specifically, there's a free, user-written encyclopedia called wikipedia at http://www.wikipedia.org that competes with the
Encyclopedia Britannica. The idea is that anyone who uses wikipedia can edit any story. So if you happen to be reading an article that has an error in it (for example, if it says the Constitution was ratified in 1798) you can correct it with a few clicks (e.g. you change it to 1789). Aside from controversial topics (where articles are edited constantly to favor one
opinion or the other), the "hard facts" articles on science, culture or history are fairly decent. Or so they seem at first glance.

The controversy is this: Britannica's editor in chief went on record (in a newspaper article I can't find) stating that Britannica is a better, more reliable source of "knowledge" because it's a closed controlled editing environment, where articles are researched, edited, and reviewed internally by academics who are experts in their respective fields.

Wikipedia responded saying it doesn't need all that editorial oversight because any error in an article is corrected relatively quickly by an expert in the field.

The essence of the argument is "top-down" (Britannica) vs. grass-roots/bottom-up (wikipedia), or,  to put it more succintly, does the existence of a gatekeeper for knowledge improve the quality, accuracy, and veracity of knowledge?

The debate matters for two reasons: (1) at some point people have to agree on the basic facts of whatever they are talking about, and (2) there needs to be a place where you can find the core true facts about any subject.

So anyway, the medical journal Nature decided to compare the two sources of knowledge:


Now you may ask what the hell business is it of Nature's (a quasi-medical journal) to do this (review the accuracy of encyclopedias), but that's my point and I'll get to that in a second.

Anyway, surprise surprise, Nature says that in the case of science articles, wikipedia is better. This was not unexpected - wikipedia claimed all along that it amounted to enabling peer-review of its articles by readers, and Nature, of course, is all about peer-review.

Britannica responded, finding errors in Nature's methodology (warning: pdf ahead, but it's worth reading if you think for a second Nature should be trusted to do anything):


concluding that the study was bogus, and that Britannica had far fewer errors and omissions than Nature claimed.


What interests me here is not the accuracy of Wikipedia vs. Britannica, but why Nature feels it is in any position to examine this.

Here is Nature's response to Britannica's criticisms:


Here's the line to focus on:

"Britannica complains that we did not check the errors that our reviewers identified...but there is a more important point to make. Our reviewers may have made some mistakes — we have been open about our methodology and never claimed otherwise — but the entries they reviewed were blinded: they did not know which entry came from Wikipedia and which from Britannica."

For the record, Nature says this is how the test was

"Each pair of entries was sent to a relevant expert
for peer review. The reviewers, who were not told
which article came from which encyclopaedia, were
asked to look for three types of inaccuracy: factual
errors, critical omissions and misleading statements. 42 useable reviews were returned."

And this, my scientician friends, is why medicine isn't a science. Nature is saying that its methodology is sound because the entries they reviewed were blinded - BUT WHO ARE THE PEER REVIEWING EXPERTS, WHO SELECTED THE ENTRIES, AND ACCORDING TO WHAT CRITERIA?


You cannot excerpt an article describing something and then test the excerpt for omissions. Furthermore, the excerpting is not blinded, and the person excerpting things may have a different opinion of what can be safely left out than the person doing the review.

Nature's mistake is assuming that the expert is always right. If the expert disagrees with Britannica, then Britannica is wrong.  You should be able to test the accuracy of an entire encyclopedia article *by giving it to multiple experts*. Not the other way around, multiple articles to one expert. The hypothesis is "do experts think the article is correct", and you test it by find the percentage of experts that think it is/isn't. 

What is truly ironic is that while Nature likes to hold itself out as an open source for medical knowledge (and thus more like Wikipedia), it is in fact a gatekeeper of knowledge like Britannica. When Nature publishes an article, the belief of the scientific community is that the article is correct *because it's in Nature*. But Nature is the journal of statistical regression sciences - medicine, global warming, etc., i.e. disciplines where there is no right answer or it's impossible to know the right answer because you are observing only a small percentage of all the variables being affected.  It tests associations, not causality. 

Keep this in mind when a journal like Nature also makes policy proclamations ("global warming needs to be stopped") or creates artificial hierarchies by its coverage (substantially more articles on HIV than malaria, so HIV becomes more "important" than malaria, etc.)


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December 11, 2005

So Ends The Ochlocracy of Medicine: How To Fix Medicaid, Part 1

Preferred Drug Lists are the bane of the practicing clinician. Instead of, for example, a psychiatrist being allowed to prescribe any antipsychotic they think appropriate, Medicaid requires them to pick from a list of only three, "on formulary" agents.

Unfortunately for doctors, the logic is sound. Unless one can show that, for example, two antipsychotics do not have the same general efficacy or tolerability across a population, than an insurance company cannot be reasonably obligated to provide both, especially if one is cheaper.

Psychiatrists complain that some patients respond better to one drug than another, but while this may be true, there is no way to predict this; try the formulary ones first. But this is just a red herring. What angers doctors is that these restrictions are an intrusion on their practice. Doctors are better able to decide risks and benefits of a medication; which drugs to prescribe, and when.

This would be a great argument if it were true. It isn’t.

The truth is that doctors are woefully ignorant of the available scientific data. As with literature and philosophy, most doctors read about the science, not the actual science itself. In general, doctors prescribe medicines not based on careful review of data, but impulse, habit, and the recommendations of “thought leaders.” (Seriously. They’re actually called that.) Prescribing medicines based on partial information or clinical soundbites may feel like "the art of medicine" but it is, in fact, a random process. It is certainly no better than having an insurance company that did review the data tell you what not to prescribe.

They also tend to practice in a vacuum. A patient’s psychiatrist and cardiologist have no link. Are the treatments synergistic? Antagonistic? Neither fully know that the other is doing.

And so, because doctors are not rigorous about their practice, someone else has to be. One of the most outrageous way psychiatrists, and possibly other physicians, waste money is to use multiple medications for a situation that could well have been handled by one. “Polypharmacy” is so common that it is actually codified in treatment guidelines, despite—and this is where insurance companies go insane—there being practically no evidence that this is ever appropriate. Why combine two antipsychotics when maybe more of one will do? It may seem plausible that two are better than one, but they aren’t. It may be true that a patient needs two drugs; but you can’t assume that. The default practice cannot be augmentation. That has to be the maneuver of last resort.

Loose practice has caused the paradigm shift. It used to be that everyone deferred to the judgment of the wise physician. No more. Now, it’s incumbent upon us to show why we need to use a treatment, not for the insurance company to trust that we know best, that we made a careful analysis of the risks and benefits—because we didn’t. We complain that medicine is being assaulted in a million different ways—insurance companies, lawyers, alternative practitioners—but the reality is it is the exact same assault: we are no longer trusted to know best.

So what to do? There is a solution. But you’re not going to like it.

Link each Medicaid patient with a pharmacy budget per specialty—money controlled by the psychiatrist. A psychiatrist can use any drug, any dose, no restrictions, but only up to, say, $10 a day. Go.

There are numerous advantages.

First, there is cost control.

Second, Pharma will inevitably cut prices in order to compete.

Third, it gives doctors their autonomy.

Fourth: it will force doctors to pay very close attention to what is, actually, best practice. They will have to be more attentive to outcome studies. They will have to predict side effects: if you’ll need to add a second drug to counteract the side effects of the first, it may be better to use a completely different drug.

Fifth: They will use fewer medicines. Two is not always better than one; but it certainly is twice as expensive with twice as many side effects.

Sixth: Pharma no longer has incentive to create “me too” drugs. They are incentivized to come up with novel, even niche, treatments.

If you really want to tax the imagination of doctors, and force a level of rigor in medicine that has not been seen since, well, since never, create a global pharmacy budget per patient across all subspecialties. This way, if a psychiatrist wants to prescribe Zyprexa, he’s going to have to discuss with the cardiologist whether that is more cost effective than the Lipitor. Wow.

The unexpected benefit is that the two doctors have to communicate. Maybe a switch from Zyprexa could preclude the need for Lipitor? Maybe? Hello? Let this communication be billable to Medicaid. $100 per “consultation” is more than offset by the pharmacy savings. There are going to be some patients who actually do require more money, more medications. In that case, the doctor can petition for increased benefits. Doctors hate doing this. Too bad. The problem was created by doctors, not by pharmacists.

Finally, to bring Pharma into the game: the first 30 days of a prescription must be piad for by the Pharma company making the drug, i.e. samples or vouchers.  This way, only the drug that actually works gets paid for by Medicaid.  That's gold. 

It’s worth stating, for the record, that I am opposed to government interference in my practice. I don’t particularly like lawyers, either. But the sad truth is that the state of psychiatry is the fault of psychiatrists, who have failed to take full responsibility for their own education and practice. To blame anyone else at this stage is totally disingenuous.

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October 21, 2005

If France Gets Its Way, 38 Million People Will Die

"All of healthcare is in crisis." Well, Chirac is not helping matters.Healthcare policy has two concurrent and dangerous trends developing. In the first trend, as detailed recently by Dr. Marcia Angell in the New York Review of Books ("The Truth [sic] About Drug Companies") is the pervasive notion that pharmaceuticals are a need and a right, and cannot be left to the drug companies to disburse with an eye to profits. Leading us to the second trend, as evidenced by France's recent swipe at the U.S. for not allowing poor countries to bypass patents and create cheap generic HIV drugs, which specifies that when medical need arises, government should be allowed to commandeer treatments and prices for the good of the people who need the drugs. Looks like the old argument: social justice vs. personal responsibility.  Except the argument isn't grounded in reality. Saying something vague like "people need these drugs," misses the immediate point: which drugs? On what grounds is it even possible to say that people "need something" that didn't exist until a company created it? Under what circumstances can we say people now need a drug that won't be invented for another 10 years?

The problem, in part, in this debate arises from scientists confusing discovery or research with invention. Looked at in terms of the production of novel material, certain distinctions can be made. Discovery and research are not creative acts. While they require creative thinking, they do not add anything materially new to the world. Alternatively, invention is the act of creating something that did not exist. There was no Prozac or Tylenol until someone invented it. You may think the rainforests have all the cures, but they don't.  As of right now (things could change) the law appreciates this, and only allows for the grant of the patent right when the invention in question is new, useful, and not obvious. However unfair this may seem, that is the system. Ordinarily, no one debates what is new or useful. Obvious, by contrast, is the source of much debate. Can something be not obvious if it was the logical next step? Or if someone else would have done it sooner or later? Many do not understand this debate, lamenting the unfairness of assigning property rights in science "when discoveries that depend on generations of prior science are patented by the person who made the last step."

This is the classic mistake. The last step is not obvious before it is taken. Perhaps there exists an example of a patent in which the inventive step was obvious to everyone before the inventor himself took that step? It seems obvious now for surgeons to wash their hands before operating, but tell me, why wasn't it obvious to the doctors who performed surgery in the hundreds of years before the practice was conceived? It is common in many fields to look at patents and say "oh, I could have thought of that." This is impermissible hindsight, because the determination of obviousness can't be made after the fact.

I suspect, however, that the current debate among politicos over drug patents has little to do with the assignment of property rights (which is best left to lawyers and judges skilled in the practice of assigning rights generally). Rather it is a land grab to curry favor with voters at the expense of the health of future voters. This is what is so damaging about the controversy over HIV drugs. The drugs exist, and they are needed now. But how to hand them out?

Note that the debate is not about changing patent law with respect to future drug patents. Rather, the debate is over changing the laws on existing patents for successful and safe drugs that were developed under the assumption that the patent to them would last 20 years.

This is "patently" unfair, because it amounts to changing the rules after the game has already been won. Drug companies invest hundreds of billions to create (not discover - create) these drugs. Scientists like to dismiss this part of the argument, because they feel that crass commercialism sullies the purity of science. This is as childish as it is preposterous. Scientific research is massively expensive. The investment is made by investors who don't care about science, but do care about returns, based on the understanding that anything they invent they will be able to sell exclusively, at least for a while. To threaten abrogating the patent right for successful drugs, or artificially manipulate their prices will cause investors to pull out of drug companies now and into more predictable and less regulated industries. This will reduce the investment in future drugs. You don't appreciate the strategic problem here, because the future drugs that will never get invented don't exist, so it does not seem like you are losing anything.

But you are.

If you do not think that this is true, consider the fact that many of the newest drugs are cosmetic or lifestyle drugs, like Viagra et al, or are "me-too drugs" (other versions of the same kind of drug, i.e. 5 different Prozac like drugs.) Drugs which treat conditions that are not life-threatening and which are therefore not prone to federal or HMO price control. Compare this to the fact that drug companies invest comparatively little in new antibiotic research to combat the well-known problem of drug resistant bacterial strains. Public and social policy has distorted the market and predictability of patent rights, so drug companies stay away from research that is likely to become a political issue. Why bother investing to invent an antibiotic (or HIV drugs) when it could be commandeered by the government because it is "needed?" And the public suffers. It is convenient for France to demand the commandeering of the patent to HIV drugs to allow for cheaper generics. But current HIV drugs are not curative. Who, exactly, does France expect to invent the actual cure--- that will then likewise be commandeered? In a flashback from the Fountainhead, France wants to take credit for charity that someone else will pay for.

Would you rather have Viagra or a new HIV vaccine? Both are a question of money, but if you are going to place a value judgment on one over the other, then you have to incentivize the drug companies to do what you want. At the very least, you shouldn't disincentivize them.

Good drugs cost a lot, and we are going to have to pay it. Period. Because the alternatives are completely unfathomable: that good drugs are never invented; or, that they are invented but kept secret. Maybe they are used only to cure members of one's family, or race, or class, or religion. That is perfectly legal, by the way. France should think about this before they sentence millions to death.

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