Monthly Archives: February 2015

What a healthy child. And so full of organs!

Recently I decided to apply my unlikely super power “finding all sources of protein gross” to eating organ meats, on the theory that if I’m pushing myself to eat something it might as well be cheap and nutritious.  Organ meats have way more vitamins than muscle (compare chicken muscle with chicken liver).  Polar bear liver has so much vitamin A you can die from it.

death_by_polar_bear

But you can’t die from chicken liver, or at least I can’t, because I eat a few snips at a time.  Plus I had some chicken organs in my freezer from the time I went to a backyard farm and killed a chicken, which I expected to get a really great blog post out of but in the end my take away was “I am okay with this system but hope we develop a better one soon.”, which is not a great blog post.

I’m going to spare you my recipe because I really hope there are not that many people with my combination of digestive and chewing issues, but what I will tell you is that liver taste like crickets.   Maybe that is just what nutrition tastes like? Mostly this was an excuse to post my favorite Invader Zim clips.

Review: How to Be Sick (Toni Bernhard)

Everything this book says is absolutely true.  Mindfullness is awesome.  Spending energy being angry at reality for not living up to your expectations is not useful.  A calm acceptance of where you are now without attachment to the future is useful in almost any situation.  But my primary feeling reading the book was “This is fine for you, but I’m going to get better, so I’m just going to go wait for that.”  I told that to someone in the waiting room at the IV place who was probably suffering from something pretty serious*, thinking I was making a funny joke about how I had failed at zen, and she said “good for you, keep fighting.”

This captures a lot of the tension around health problems that are prolonged or chronic or ambiguous as to where they fall between the two.  If you “accept your limitations” too hard you end up putting yourself in smaller and smaller boxes until there’s nothing left.  If you don’t accept your limitations enough you push too hard and make yourself worse.  How to Be Sick isn’t falling into those traps.  It’s describing a third way, of zen acceptance that doesn’t overly narrow or widen your vision for the future because it’s not about the future.  The problem is that this is hard to teach.  The author had been practicing Buddhism for 10+ years when she fell ill, and most of the book feels more like describing the benefits or appearance of a mindfulness practice rather than how to achieve it.   I did get one really useful technique out of the book, enough to justify all of the time I spent reading it, and I suspect that will be true for a lot of people so I do recommend it.  It’s just not magic.

Although maybe it kind of is.  I ordered the book from the library when my doctor looked at me and said “maybe being pain free isn’t a realistic goal for you and you need to redirect your energy to learning to cope with it.”  But then I saw a specialist who told me that the damage was healing, would probably be finished in about a year, and in the meantime enjoy this pain medication that leaves you almost pain free.  So I can’t rule out that this book actually is magic, and if you are at the point where you’re considering books with subtitles like “A Buddhist-Inspired Guide for the Chronically Ill and Their Caregivers”, you probably are going to try weirder things in your attempt to heal yourself.  So give it a shot and please report back.

*I’m there to mainline protein because my teeth and stomach aren’t up to the task of eating enough to heal me, but a lot of people are there for debilitating but poorly understood collections of symptoms like fibromyalgia, or better understood but more terminal diagnoses like cancer.  Nothing makes me you feel grateful for your health after having dead bone scraped out of your jaw like seeing an eight year old get cancer treatment.

McDentistry

Sarrell Dental is a chain of dental clinics that serve children on public assistance almost exclusively.  Sarrell is a non-profit in that no one is an official owner collecting profits, but it is financed entirely be fees for its service; there are no donations.  Sarrell not only provides dental care to poor children for screamingly low reimbursement rates, but does outreach and education for free.

I have a few feelings on this.  First, the care could just be low quality, but that is not interesting, and providing care that is a pareto improvement over nothing (meaning it is doing some good and no harm) is not actually that hard.  Doing harm is not impossible, and humans are ingenious, but it is difficult.  So let’s assume for the sake of argument that they are maintaining an acceptable quality of care.  If that is true they are doing an amazing service: dental health is incredibly important for overall health.  Bad teeth are a class marker than often keeps adults who grew up poor down, regardless of their merits.  Getting poor children teeth cleanings is incredibly important and I am glad someone is finding a way to do it.

Second, I bristle at the comment that “This means that patients don’t always see the same dentist, and that can be a good thing on both sides of the drill. Dentists get a close look at their colleagues’ work and at the treatment plans they’ve suggested for their patients.”  If seeing a different dentist every time was so awesome, middle class people would do it.  They don’t because continuity of care is considered more valuable than a second pair of eyes.  But is that correct?  It seems entirely plausible to me that the ideal of continuity of care- a medic who knows you, who knows your history, who can spot subtle trends and probe for additional information- is absent for most people even if they are technically saying the same person repeatedly.  I saw the same orthopedist twice when I hurt my knee and had to remind him the problem wasn’t nor had ever been buckling under load five times in those 15 minute two visits.  I’m not sure seeing a different orthopedist for the second visit, or swapping in a different orthopedist halfway through a visit, would have reduced the quality of care noticeably.   The same could easily be true of dentists.

Moreover, I’ll bet Sarrell writes its records with an eye towards having each visit with a different dentist.  I find it plausible if not proven that this is better than the 10 minute rushed visit people get with a dentist who doesn’t write anything down because he’ll totally remember it.  This gels with my experience at those acute care clinics, which were much less personal but had systems in place to make sure everything ran smoothly.

Third, it seems great that more kids are getting dental care and education.  But I worry that this will run into the same problem we have with the pharmaceutical and adoption industries: we privatize the cost of a thing we consider a moral good and then are surprised when the system begins aligning with the interests of the people funding it.  This is true even if Sarrell’s current MO is a pareto improvement over nothing, and if no one does anything malicious or even intentional.  I don’t think it’s likely Sarrell will secretly encourage children to chug pixie sticks hourly, but could they maybe reinforce the requirement that cleanings be overseen by a dentist rather than a mid-level dental practitioner?  Seems plausible.

Which doesn’t mean I want to fight Sarrell, or McDentistry in general.  The fact that it’s not the platonic ideal doesn’t mean it’s not the best compromise we can get, and those kids need cleanings now.  But it’s important to remember that nothing is free.

Bug or Feature? SAT edition

A few weeks ago there was a Less Wrong thread about truly brilliant people, especially mathematicians, who often got good but not perfect SAT scores.  The consensus was that the SATs were a better test of how long you can go without making a mistake than of genius.  At the time I read this I (who got good but not perfect SAT scores) was all “yeah, the SATs are bad at measuring brilliance.  And I did better in more advanced classes than I did in the intro ones, because the intro ones were about how close you came to matching their expectations, and the advanced ones were about original thought.  In fact the smartest people will do worse, because this is so trivial to them it is boring.  I sure hope the SATs feel bad for failing to recognize my their brilliance.”

I was about 10% of the way through Safe Patients, Smart Hospitals when I realized that if I am recovering from dangerous surgery and need a central line*, it is more important that my doctor can follow the safety checklist without getting bored than that he be capable of original thought.  Like, way, way more important.  We need doctors capable of original thought somewhere, so they can invent new procedures and drugs and things, but outside of their magesteria they do more harm than good.

dr_house_brain
Gregory House would be terrible at inserting central lines. That’s why he has Taub.

So maybe the SATs are doing a valuable service by injecting a little bit of what it takes to succeed in the real world into their otherwise-pretty-much-an-IQ-test.  And maybe we should start selecting doctors for what they actually do most of the time.  Alternately, maybe we should move central-line-type work to techs and computer algorithms and use doctors for research and cases weird enough to be on TV.  But what we should definitely not do is select people for brilliance and make lives depend on their ability to work methodically.

*Central lines deliver fluids better than IVs but are more vulnerable to infections, which can be fatal, especially in people recently weakened by trauma or illness, which is everyone who is getting a central line.  You can greatly reduce the chance of an infection by following a fairly simple list of steps like “use gloves” and “sterilize skin”, but these are often skipped.

Review: Immune Defense Video Game

Medical-inspired video games have a long history of disappointing me.  For example, real pathogens don’t ride rocket ships around your organs (Trauma Center)

nor does every single member of the species worldwide suddenly develop a new trait all at once (Plague, Inc)

And Surgeon Simulator does not follow Atul Gawande’s best practice surgical checklists at all

Plus Trauma Centers’s difficulty curve is insane, and they found a way to make repeating unskippable cutscenes worse. But one of the nice things about game development getting cheaper is they can make games for me and the four other people who will appreciate a cross between an immunology textbook and Majesty, which is the best way to describe Immune Defense.  In Immune Defense you play as the immune system, releasing various immune cells (each with different skills, and customized to different pathogens), which you do not directly control (it isn’t pac-man) but can lure over to the bacteria with antibodies if the %^&*ing macrophages will stop eating them.  In place of the usual Hit Points it has an inflammation count, which is actually pretty reasonable.  It has some biological inaccuracies (I’m reasonably certain real neutrophils don’t change receptor types instantaneously), but it’s still overall educational. Note the lack of rocket ships in this trailer.

That said, it’s obviously still in beta, and if the phrase “immunology x majesty” doesn’t grab you, you’re probably better off waiting.  The tutorial is really lacking and they need to smooth out some of the controls.  But I had a ton of fun until tendinitis forced me to stop playing, and if “immunology x majesty” does inspire joy in your heart you will probably enjoy it a lot, so check out the IndieGoGo and demo.

Oral Probiotics for Dental Health

Bias disclosure: I started taking oral probiotics because my doctor told me to and I have vaguely positive feelings about probiotics.  I kept taking them because simple inspection with my tongue showed I was developing fewer dental plaques.  But the friend I recommended them to wanted actual data, so I did some digging.  The results were overwhelmingly positive.  They reduced not only cavities, but in the study that checked, total antibiotic usage.  In your face, friend who asked for data.

But only one of those tested a probiotic lozenge, the rest were milk products supplemented with Lactobacillus rhamnosus.  Not all Lactobacillus species scored so well, so I went to check what my supplement had.  Turns out it has no Lactobacillus at all.   So I went back to google scholar and checked the bacteria I was actually taking (Bacillus coagulans and Streptococcus salivarius).  Luckily the news was still good: in head to head trialsBacillus coagulans was found to be as effective as a mix of Lactobacillus rhamnosus and Bifidobacterium species, and Streptococcus salivarius also performed well.

Then I found the motherload: someone did a comparative survey.  This was less helpful to my cause.  Oral probiotics were almost universally found to be helpful to children, but results in adults were mixed.   My first argument is “well, yeah, adults develop fewer cavities per unit time than children, so you’d need a bigger sample over a longer time period to detect a difference.”  But the studies looked at intermediate results like “bad” bacteria presence, and even the 15 month trial in older and elderly people didn’t see a difference.

My conclusion is that oral probiotics are definitely good for children, and in light of the additional data for my personally, good for me, but possibly not for all adults.  I still feel confident recommending other people try them, but not that they stick with them if they don’t see results.

Activism Field Trip

One of my ongoing concerns about Effective Altruism is that it doesn’t handle activism or political change well, because the marginal value of any given activity is essentially zero.  You can do some relative effectiveness- Martin Luther King Jr apparently scouted out towns most likely to react violently to his nonviolent protests, in order to get more sympathetic publicity- but it’s no where near the certainty of Against Malaria Foundation’s cost per life saved (which itself has a huge confidence interval).  And yet, political activism is essential as a tool for improving the human condition.

Recently I participated in a FreePress.net-organized visit to one of my senators, to convince them to more vocally support net neutrality, and specifically Title II classifying cable utilities as common carriers.  This is a thing that seems important as long as cable has a stranglehold on broadband in the US, and my impression was that all I had to be helpful was live in the senator’s state (check) and show up.  That is within my power, and now was a relatively easy time to do it (still on leave for dental surgery but at a relative high in my ability to talk).  I think on some level I expected it to be a more fleshy version of phone calls for the EFF, where they do all the dialing and give you a script to read, and your job is just to demonstrate to powerful people how many unpowerful people are willing to spend their time annoying them over a specific issue.

The plusses: I was shocked by how diverse the delegation was.  I was expecting a bunch of 20-35 year old tech nerds, but the age range was probably 30-75, with me as the only programmer, and a wide range of political orientations.  Several of the people were longtime activists.  At the end of the visit the senator had agreed to do what we wanted.

The minuses:  the visit could have been much better organized.  There was a real disconnect between what FreePress said our senator’s position was, and what the senator’s aid said their position was.  We didn’t so much convince the senator to change positions as ask for something they were already doing.  Maybe FreePress didn’t bother to investigate, maybe the senator’s aid was weaselwording.  There was no one who knew and no one had the authority to shift our collective gears.

This was the first time in a while I’d experienced the gap between talking with EAs and talking with politically and socially active non-EAs.  The groups have different skills.  None of the people who took point could have persuaded anyone I know out to pour water out of a boot if the instructions were written on the bottom*, but they did organize rallies of 1000+ people, which I have never done and have never heard of being done in the history of effective altruism.  We’re more a blogging type of people.  And the dailykos reporter is better than me at that, in the sense of “many more people read him”.  This is bothersome when he is complaining about rising rents and construction in the same paragraph, but useful when shining light on police misconduct.

So EA is still my home, and probably will be for a while, even if I’m drawn to areas that don’t have any officially blessed EA charities, like mental health and first world education.  I would like us to have more thought diversity than we do, but really enjoy not having to explain why you can’t complain about rent and construction at the same time, or at a bare minimum knowing that if I do have to explain it I’ll have social support.

*”But what if there is a faster or less energy-intensive way to empty the boot?”

Review: Selling Sickness ( Ray Moynihan, Alan Cassels)

(Previously)

Selling Sickness‘s goal was to convince the reader that pharmaceutical companies manipulate perception to create an impression of disease where none exists.  I was going to say it failed, but no, it didn’t.  It actually has some pretty good examples of how pharma manipulates perceptions.  I just find it’s own view problematic as well.  E.g. Pharma is trying to make the diagnosis of Female Sexual Dysfunction equivalent to male impotence, when it clearly isn’t, and that’s bad.  But Selling Sickness’s  implication that the components of FSD (low libido, anorgasmia, pain during intercourse) should not be taken seriously by medics is ridiculous.  Sexual pleasure is important to many people in its own right, and any of those issues could be a symptom of a serious underlying problem.  Testosterone is a bad treatment for low libido because it’s a major hormone with far reaching effects, but it is an excellent treatment for low testosterone, a serious health problem for which low libido may be the most obvious symptom.

Selling Sickness talks about how pharma companies manipulate disease definitions (by sponsoring educational conferences and key decision makers), but it doesn’t explain anything else about how those decisions are made, or what would happen in the absence of pharma money.  Without that information it’s hard to draw conclusions.  Which I guess is how I feel about the book as a whole: its advocating a very specific point of view rather than informing you on the topic as a whole.  There’s nothing wrong with that, except that it (rightly) condemns pharmaceutical companies for doing the same thing.

*Obviously there’s a lot of variation and some doctors respond to those symptoms properly.  My sense from the literature and anecdata from my friends is that they’re going against the grain when they do so.

ETA: Slate Star Codex provides an example of pharma criticism done right, because he talks about the cracks in the system capitalism is filling.

Selling Sickness: Depression and Anxiety

Previous: Aceso Under Glass Valentine’s Day Special

Like many people, the authors of Selling Sickness believe that drugs for depression and anxiety are over-prescribed, that they are used to escape everyday emotions, and that this is terrible.  Again, I wish they’d defined their terms better.

For example, it sounds ridiculous to give someone Prozac because they’re sad their mom died.  That sadness is categorized as natural and healthy, in fact barring very unusual circumstances it would be viewed as sick not to feel sad at that point.  But you only get anti-depressants for “being sad” if it lasts more than two years.  Until then, anti-depressants are given only when negative emotions* start destroying a person’s ability to run their own life, and thus become self-reinforcing.  It’s completely natural and healthy to still be morning your mom’s death two months later, but if you’re unable to shower or eat for that length of time it doesn’t matter that the depression has an obvious external cause, it’s hurting you and there shouldn’t be any shame in accepting medical treatment for that.

A common fear I hear around anti-depressants is that they make people tolerate situations which should be depressing, and thus impede their exit.  That’s a real concern, and I think we should watch for it.  On the other hand, there are lots of people who want to leave but are unable to do so because they’re so depressed, and anti-depressants give them the activation energy and hope in the future that lets them leave.  And the same drug can have both effects in different people, or even the same drug at different times, because humans are weird and we don’t understand what we’re doing.

“We don’t understand what we’re doing” is not a great endorsement for something that’s screwing with the chemicals inside your brain.  I do think we need to use caution, that the risks are poorly understood, especially by GPs, and that nutrition and exercise are underutilized as treatments.  I also think that even when anti-depressants are the best individual decision, mass use of them can indicate a problem (I’ve heard 50% among PhD students, which cannot be okay).  And there will always be room for debate- should you be expected to work productively a month into grieving?  To work in a really difficult, dehumanizing office environment?  Would you need anti-depressants to take care of your kids if you had better community support?

But big pharma is not the one creating those societal conditions, and destigmatizing mental illness because it benefits them financially seems like a success story to me.  If we’re going to counter over prescribing let’s look closer to the problem (doctors) or further away (societal structure), not question the people receiving needed help.

*Not necessarily sadness.  In fact in men depression often manifests as anger, which leads to under-diagnosis.

Gender-based variation in grading and teacher attitudes.

Jezebel (via NYT): “Girls Outscore Boys on Math Tests, Unless Teachers See Their Names”
New York Times:  “How Elementary School Teachers’ Biases Can Discourage Girls From Math and Science”
Study Abstract:  “We’re going to skip explaining how we proved gender bias and just talk about its effects”
Actual Study (no public link): “Young Israeli girls outscore boys on anonymously graded national math exams but receive lower classroom grades, but eventually begin to underscore them in national exams as well.  The size of the discrepancy in scores is positively correlated with discrepancy in teacher attitude reported by boys and girls.  This pattern does not hold for English or Hebrew.”

I went in to reading this study pretty guns blazing, but it actually looks quite well done and robust.  You could argue that the teachers and tests are evaluating different things and the teachers’ goals are not necessarily worse, but

  1. Stereotypically, girls are better at pleasing teachers than boys.  And that is in fact the pattern we see in Hebrew and English.
  2. Low-biased teacher grades was correlated with a decrease in performance among girls in later grades (beyond that that would be predicted by low grades alone). The best case scenario is that the teachers are spotting some hidden weakness in the girls that the lower grade tests didn’t cover.  Except…
  3. Grade bias was positively correlated with negative student reports of the teachers attitude, and specifically discrepancies in the attitude reported by girls and boys.

So the actual study is pretty impressive, and astonishingly so for being in the field of education.    Touche, Lavy and Sand.  I also found it interesting that bias against girls was strongly correlated with the socioeconomic status of girls in the class as a whole, but not with any individual girl’s SES.  E.g. having a poor girl from a large family with uneducated parents lowered the grades of other girls in the same class, regardless of their own status, which suggests all kinds of unpleasant things.

The popular reporting on this paper is less impressive.  Jezebel flat out lies, implying that the same test was graded blindly and with the name (but no other data) available, which led to 100 comments asking how math grades could even vary that much, and 100 other comments saying “partial credit for showing work”.  The New York Times isn’t quite so egregious but does describe the input as “The students were given two exams, one graded by outsiders who did not know their identities and another by teachers who knew their names.”  That’s technically true, but implies that the two exams were much more similar than they actually were.   I expect this kind of crap from Jezebel, but the New York Times shouldn’t have to sensationalize results that are already this interseting.