Posted 8:21 AM by Paul

Genomics and Health Insurance
I wanted to get back to science on this one, in particular the intersection of scientific and medical advancement in genomics with our current and potential future medical insurance system. At the outset, let me say this; I don't particularly want nationalized health care(single payer), although I am not completely opposed to the idea. HMO's, which were instituted to save an ailing, bulging health care system, have fundamentally undermined it instead, by putting profits ahead of health. I am not sure if I have discussed this before, but it is a somewhat off topic anyway. Anyone who cares to argue this point, please note I am not referring to for-profit medical device or pharma, which needs to have the profit motive to spur innovation (although, it should be noted that hundreds of thousands of University Professors, research M.D.'s, grad students and post-docs do a great deal of innovative medical research with a much reduced, but not eliminated, profit motive). For profit insurance companies do not have the patient's health as their primary responsibility (to do so would be a breach of fiduciary responsibility). In particular, publicly traded for-profit insurance companies must focus on the bottom line, to the utter exclusion of all else. As a patient population, we cannot allow this to go on forever. Undoubtedly, HMO's served to lighten the burden on state-controlled health plans, and introduced competition into the marketplace, but eventually, this runs (has run?) its course. In any event, this is not what I want to discuss in this post.

The interesting thing to think about, at the juncture of genomics and insurance, is how genomic technology (and proteomics, but in a different way), changes the game. In order to think about this, think about how health insurance is apportioned, and how a profit is made by an insurance company. Now, in auto, home, and life insurance, the rate you pay is tied intimately to personal factors (driving record, age, marital status, education for auto; location, value of home; health, age, risk factors such as alcohol and tobacco for life). For many (most? I haven't looked at the stats), however, health insurance is provided as a part of a benefits package at work, with no regard to risk related to a given employee (you probably have to pass a physical under some circumstances, although I and my family never have). The risk is distributed, over a very large potential patient population. Based on actuarial tables (essentially the aggregated risks based on population statistics), the company predicts how much it will have to pay, and then charges a bit more than that (what the market will bear, of course!). Fundamentally, this is based on poor information. With a little gaze into our crystal ball, we can predict what will happen to this system. (WARNING: Unwarranted, baseless guesswork and speculation ahead! Proceed with caution...)

So we come back to the fundamental question, What can genomics tell us? Well, in a limited sense, it can tell us exactly what the genetic makeup of any given individual is, down to the specific base pair in question (not right now, but within 3-5 yrs). Knowing that, it is much more likely that we can make good, accurate predictions about chronic disease manifestations, in particular the biggest killers in the developed world (the developing world can't get past malaria and TB), Cancer and Heart Disease. Some time in the future I will come back to Paul Ewald's remarkable, intriguing, but as yet unproved hypothesis that microbes are responsible for the lion's share of chronic disease as well as conventional infectious disease (it is known that some cancers, such as Burkitt's lymphoma, can be caused by viral infections, in this case Epstein-Barr virus). In any event, a number of genes are already known to be tied to high cancer risk (c-myc, p53, and rb are a good start, for the cell biologists out there), and others to higher heart disease risk (hypercholesterolemia leaps to my mind, but there are, I am sure, others), so these are perhaps a good model. Within a few years, epidemiological and lab model system experiments will allow for identification of most, if not all, of the risk factors. Guessing a bit, I would suspect that there is a normal distribution of risk in the population (a Bell Curve, if you will). Because we will be able to specifically and conclusively identify these risk factors, we, that is to say the insurance companies, will be able to assign a pretty good relative risk value to each client/patient.

So, you might ask, why is this a problem? Well, I may be wrong, but I think this puts the patients (and, to be fair, the doctor's) in a bit of a tricky spot. After all, when all I have to go on is some loose guidelines, it is hard to be too concerned about whether healthy Jane, who is a Vegan and runs 5 miles a day, is paying too much for health care, while fat slob Pete, who eats 3 steaks a day and jogs from the bed to the couch, is paying too little. When I know for a fact that Jane has a 10-fold greater cancer risk because of genetic factors, and Pete has perfect genes that mean he'll live to be 100 no matter what he eats, that changes the calculus. It no longer is an economically viable model to charge everyone the same rate over a large (say, company/industry/statewide) population, when you have solid knowledge about who is a high risk. Of course, it could be that drug companies will invent a cheap pill for every condition, but even then, wouldn't you rather insure only the people who didn't have to take it?

I suspect (no, I know) I am not the first person to think about this, and there may be very good answers to my concerns. If there are, I would love to hear them. If they are of the "Insurance companies would never do that, they are good public citizens!" variety, leave 'em somewhere else, 'cuz they aren't wanted here. Constructive ideas/criticism/speculation is always welcome, however!

Posted 7:31 AM by Paul

Lileks has an interesting "Bleat" about the connection between an Islamic investment fund, a relief organization for Palestinians (no identified link to militancy or terror), and a coffee company near and dear to my heart, Caribou Coffee. I worked there for about a year when I was a grad student at the U. of Minnesota, so I have some personal experience with the company. I also first became utterly, completely addicted to caffeine as an employee there. Now, Lileks doesn't seem to like their coffee so much; I disagree with him on that, but it is, of course, a matter of personal preference. The Islamic investment group in question seems to own a very large percentage of the company (~88%), which is interesting, because the company was built on the notion of a young couple traveling in Alaska, coming up with the idea, "Hey, what if we started a store that sold really great coffee?" Of course, the story seems like so much BS, but this little aside into the world of private investment banking and funding could spell trouble for them. The rest of the column is about Lileks' interest in the vagaries of Islamic law, and how different it is from the Minnesota cult of choice, Lutheranism (that's a joke, Bowen!). I think there is a pretty simple explanation for why this investment company might want to get involved in coffee. First, it is a pretty good investment, as anyone who has paid 4 bucks for a double almond mocha will tell you. Second, a lot of coffee comes from Muslim countries in North Africa(Kenya and Ethiopia were major sources for Caribou, as I recall) and Southeast Asia (Indonesia is a major coffee producer), so this is a good way of trying to economically encourage growth in Muslim countries (or at least, that could be a justification). Finally, Caribou is a small, fast growing, privately held business, that would be easy for a privately held group that maybe doesn't want a lot of publicity for its investments to get involved in. Anyway, I thought it was interesting, because of my personal connection to the place. When I worked there, it was a lot of fun, and they never tried to enforce Islamic law on the employees!(I don't actually know if this investment group was involved in the company when I worked there, but the point is, as Lileks says, there is no real chance of such a thing happening)

Posted 2:20 PM by Paul

One more thing about the "dirty bomber", before I get back to the boring science crap. I hope this Hispanic ex-con marks the absolute last word we ever hear about how hard it is to infiltrate Al Qaeda. Here we have a lifetime petty criminal, Hispanic, converting to Islam in prison, and then joining the merry gang of murderous thugs to blow stuff up. As if that wasn't enough, we also have a 17 year old Marin County layabout who managed to infiltrate and become "thick as thieves" with them too. I am pretty sure our vaunted intelligence services can do at least as well as an ex-con and a seventeen year old, what do you think. Next time Ashcroft, Mueller or Tenet, or any of their defenders, starts talking about the difficulty of getting "Humint" on these guys, we should just point to the seventeen year old and the Hispanic ex-con who managed to do it, without all that fancy-pants training.

Posted 9:32 AM by Paul

I am glad to see this article that says the "dirty bomber" (I like that) won't be tried by a military tribunal. Perhaps civil liberties still have a place in our society. I would like to note an aspect of this. I heard very little in the blogosphere about this question (well, to be fair, I heard lots in the left/liberal blogosphere, much less in the right/libertarian blogosphere), but I did hear reporters asking questions about Mr. Mujahir's Constitutional rights immediately after the announcement, at the deputy AG's press conference. Perhaps all that liberal media bias is protecting us all, just a little bit?

Posted 5:32 PM by Paul

As usual, Will Saletan is pouring some ice-cold reason on this story, noting the biggest problem with a "dirty" bomb is the fear and panic it will sow. Here is an excerpt (this is a blog, after all);

This morning, Attorney General John Ashcroft announced the detention of an alleged al-Qaida agent in the United States on suspicion of plotting to detonate a radiological ("dirty") bomb in Washington, D.C. If you're freaking out over this or refusing to take it seriously, you aren't alone. Both reactions are natural in the face of a scenario that seems too awful to contemplate. But both reactions have to be overcome. You have to get used to the idea that a radiation-bearing bomb will go off in this country sometime soon and that despite it, life will go on. Otherwise, you risk becoming part of the fallout.

That is the introductory graf. The story is about a simulation of a "dirty" bomb exploded in D.C. Read it.

Posted 5:02 PM by Paul

Psychosomatic Radiation Sickness

A bit of personal experience that is relevant to the fear of radiation exposure. I work in a biology lab, and I have used radioactivity as a "tracer" in several different types of experiments. I have used [32]P and tritium (3H). Now tritium is pretty harmless, as long as you don't ingest it (it is very dangerous if you do). From my reading of Tom Clancy (Sum of All Fears), I know that watches with glow in the dark hands often contain tritium. [32]P is pretty dangerous from an environmental exposure perspective, an needs to be handled behind a thick plexiglass shield or in a lead container at all times. I was always super extra careful about this, and I always had a visceral fear/distaste for handling these materials. Even when I was being very safe, however, I noticed that I would suddenly start feeling pains and aches in various parts of my body both as I was working with the nuclear materials, and for a day or so afterwards. There is, for me at least, a constant voice in the back of my head saying "Did you put that cap on carefully? Are you getting exposed to deadly radiation right now?" Of course, I was never exposed to biologically significant levels of radiation (here is a chart that illustrates the important levels), and was in considerably more danger from the biological toxins and chemicals that I used daily, but such are the vagaries of psychology. My suspicion is that it is the sensory deprivation that enhances the fear factor. You can smell noxious chemical fumes, and see (and smell) bacterial culture spills, but radiation is odorless, and colorless, and penetrates normal protective gear (labcoat, goggles), making it extra scary. I was listening to NPR Talk of the Nation, and they were discussing a radioactive material accident in Brazil in 1987. An interesting note in the discussion was that apparently one of the big problems they had in dealing with this accident was the high rates of psychosomatic radiation sickness clogging emergency rooms in the area, making it much more difficult to care for people who really needed it (many of whom, of course, had problems unrelated to the spill). Some thing to think about.

Posted 4:49 PM by Paul

Thoughts on Terrorism, "Dirty" Bombs, and the efficacy of "Homeland Security"

I have been touring the blogosphere today (not a complete tour, obviously, but a reasonable one), and I noticed the commentary on today's announcement about the "Dirty" Bomb arrest of Juan Padilla, aka Abdullah Al Mujahir has been a bit thin, so I thought I would weigh in. Plus, this blog has gotten way too science oriented, and a good dose of reality can't hurt.

My first thought was, naturally, "Oh, shit, some idiot is really trying to do this. Well, I'm glad they caught him." Of course, when I heard the reports and found out that they had him since May 8, I wondered about the timing, but I will give Dubya and Ashcroft the benefit of the doubt, and assume that they kept it under wraps so they could catch more bad guys.

When I heard he was going to be tried in a military tribunal, but he is an American system, I was caught a bit off-guard. I think this is deeply troubling and wrong in many ways. There are really two possibilities here, one that is marginally ok, and the other that is very problematic. Either the case against him involves highly secret evidence, that needs to be protected for reasons of national security (which I am sure will be the given explanation), or the case against him is so weak that only under the more lenient evidentiary and "burden of proof" standards of a military tribunal do they have a chance of getting a conviction. I sincerely hope that the former is the real reason, but I am leaning toward thinking that the latter is more realistic.

A quick aside on that last thought; I don't like Ashcroft or Dubya, but I was willing to give them the benefit of the doubt after 9/11, for a while. The secrecy, dissembling, and cover-up mentality that I have seen and heard over the past few weeks, and the slow drip, drip of information that suggests bigger problems than anyone might have thought to exist, make me less trusting of their methods and motivations. A brief diatribe on Ashcroft; if there was ever damning evidence of the danger of Christian fundamentalism, it's this guy. He, in his early acts as attorney general, reduced the funding for counterterrorism, and focused on drugs. After 9/11, he used his power and resources to go after Assisted Suicide in Oregon and Medical Marijuana in California. This administration has shown itself to be secretive and manipulative, and with little or no regard for the public's right and/or desire to know what is going on. In fact, the best example is the high volume, low specificity "terror warnings" that we predictably get whenever there is a question rising in the press about the job the administration is doing fighting terror. Not only are we having to deal with the predictable money, power, and religion scandals that will come with a GOP administration (to refresh your memory, that would be Enron, Energy Policy, and "National Prayer Day"), but we not even getting the benefits of having hawkish warmongers running the show!! Don't get me wrong, I have no problem with taking the fight to our opponents, and bombing them right out of their mudhuts and tents, and destroying any threat to the USA, but they aren't even doing that right! Instead, we are gearing up to attack a nation (Iraq), that is not clearly involved at all, while patting the backs of two nations (Pakistan, Saudi Arabia) that have been clearly and deeply involved in Al Qaeda terror. The hawks are starting to look a lot like chickenhawks to me.

Back to the events of today. Here is what really worries me. It sounds, from the reports, like this fella was just at the beginning of a plan to build and detonate a "dirty" bomb, and he was given up by Abu Zubaida (sp?), the high ranking Al Qaeda guy in custody in Cuba. Now, we have all learned that these terrorists are well trained, cunning, and dedicated foes. So the obvious question (to me) is, is this a setup? Is Mujahir a patsy? From what I understand, getting the materials for a "dirty" bomb would not be all that hard, and smuggling them into the US would also not be that hard (the Coast Guard isn't searching every ship, for example, and the INS and Customs agents at the borders are not equipped with Geiger counters, and even if they were, lead shielding is pretty easy to get). So maybe Zubaida gave up Mujahir to throw our agents off the real track? This seems like a pretty obvious point, and I am sure that the FBI and CIA wouldn't overlook such a possibility, right? right??

The most important thing to remember about a so-called "dirty" bomb, which is made of radioactive but not "fissile" material (ie it can't be used to start a nuclear chain reaction that would result in an atomic bomb type of detonation), is that it is truly a "terror" weapon, in that it would not be much more dangerous than a standard explosion, but would inspire a lot more panic. Interestingly, if Al Qaeda really wanted to scare people, they don't have to set off a dirty bomb, but they could make people think they were going to, and then set off a conventional bomb. Radiation is odorless and colorless, so no one would know whether the explosives were radioactive or not until someone got some geiger counters out there, by which time the panic might already have started. So all of this might be playing into their hands. That's a scary thought.