Month: January 2007

Study the behavioral disinhibition of parents.

One thing is not like the others:

Concurrent multiple sexual partners, low condom use, and low circumcision have fuelled HIV/AIDS transmission, a University of Zambia (UNZA) senior lecturer has said.
…

Giving Botswana, which reportedly has a high condom use and a high prevalence rate as an example, Dr Bowa explained that the problem was due to inconsistent condom use.

An individual’s irresponsible behavior will catch up with him, circumcised or intact, which is a nice way of introducing this study:

Background: Evidence for efficacy of male circumcision as an HIV prevention measure is increasing, but there is serious concern that men who are circumcised may subsequently adopt more risky sexual behaviors.

Before continuing, remember that the most recent trials investigating whether or not circumcision reduces HIV transmission ended prematurely because, having analyzed the initial results, the researchers deemed it unethical to continue the study without offering¹ circumcision to the intact participants. Okay, then. With that out of the way, the question is worthy. Will men engage in more risky sexual behaviors after circumcision?

Methods: Using a prospective cohort study, we compared sexual behaviors of 324 recently circumcised and 324 uncircumcised men at 1, 3, 6, 9, and 12 months after circumcision/study enrollment. The main outcome indicators were incidence of sexual behaviors known to place men at increased risk of acquiring HIV, namely, having sex with partners other than their wife/wives for married men or other than “regular” girlfriends for unmarried men.

And the glowing conclusion?

Results: During the first month following circumcision, men were 63% and 61% less likely to report having 0 to 0.5 and >0.5 risky sex acts/week, respectively, than men who remained uncircumcised. This difference disappeared during the remainder of follow-up, with no excess of reported risky sex acts among circumcised men. Similar results were observed for risky unprotected sex acts, number of risky sex partners, and condom use.

Supporters of circumcision – I’m only concerned about those who would force circumcision on infants – as an HIV prevention technique may draw the conclusion that circumcision does not encourage men to engage in riskier behavior. That conclusion is fine, and it gives a positive spin to this study, but it misses the point. The issue is not whether or not men refrain from risky behavior shortly after the procedure. Of course they’ll engage in less risky sex. The nature of an open, healing surgical wound immediately following circumcision almost guarantees that. I don’t need data to know that.

The issue is the long-term effect, especially considering how many now tout HIV prevention as an excuse to circumcise infants. Infants will not engage in sex for years, so the convergence of long-term behavior matters exclusively. If men continue to engage in unprotected sex with HIV-positive women after circumcision, those men will become infected. Regardless of the 50% reduction, the question becomes when, not if.

In our society, in the context of infants, circumcision alters nothing. It offers no change in the need for intelligent sex education. Personal responsibility and behavior will still matter most. However legitimate the protection is, and I have no reason to doubt it, the impact of circumcision on HIV prevention is miniscule, at least in the United States. We must require more than miniscule benefits to justify the risks and rights violation involved in infant circumcision. Every justification short of immediate medical necessity with no less invasive alternatives fails reason and should be discarded.

¹ Not offering the choice to adults is unethical, but taking the liberty to recommend forced circumcision for infants is not. Interesting lack of logic.

Fix it where it’s broken.

I doubt I’ll watch tonight’s State of the Union speech. The posturing and applause and general pomp is unappealing. I’m content to read the speech and grab the important bits out of it. I can add some Xbox 360 into the time I’d spend watching nothing happening. That’s always a winner.

One important indication in the pre-speech buildup is this story about President Bush’s proposed approach to the alleged health care insurance crisis in America. He’s correct to address this situation because there is a flaw. And although he’s not proposing the optimal solution, what he’s suggesting beats any other idea going. (Massachusetts and California) Consider:

President Bush will propose a deep tax break for Americans who purchase their own medical insurance and would finance it with an unprecedented tax on a portion of high-priced health-care plans that workers receive from their employers, according to the White House.

The initiative, which the president briefly previewed in his radio address yesterday [Saturday], has a dual purpose: It would create a financial incentive for the estimated 46 million to 48 million Americans who lack health insurance to buy it. And it would rein in the soaring cost of health insurance by encouraging workers in high-priced plans to seek more modest coverage.

“Today, the tax code unfairly penalizes people who do not get health insurance through their job,” Bush said. “It unwisely encourages workers to choose overly expensive, gold-plated plans. The result is that insurance premiums rise and many Americans cannot afford the coverage they need.”

That grasps the true problem. People want “everything under the sun” coverage, which is not surprising because perverse tax incentives have taught Americans to expect that. Like much in our society, we’ve hidden the costs and focused solely on the benefits. This should go away. We must understand that there are consequences to our choices that can’t be wished away through government involvement or incentive.

There are details to be worked out if Congress (Democrats) agree, but I don’t know that we’ll have quick agreement since the president’s plan isn’t socialistic enough. As such, I won’t comment until there are firmer reactions. But it might be useful to look at an editorial in today’s Washington Post about President Bush’s plan.

There are weaknesses in the president’s proposal. Rather than embracing tax deductions, which are most valuable to people in high tax brackets, Mr. Bush could have made his proposal even more progressive by recommending a refundable tax credit that would be worth the same to everyone. Moreover, there’s a danger that ending the tax privilege for employer-provided insurance will cause companies to discontinue coverage, driving more buyers into the individual market, where it’s hard to buy insurance at a reasonable price, especially if you already have a medical problem. The administration promises to support state efforts to redeploy federal Medicaid dollars in ways that would make the individual insurance market work better. But success here will depend on the states, and the details are sketchy.

The problem with the current system is not that it’s regressive, although it is. The problem is that our current system of tax incentives disrupts the normal private market that individuals could participate in by pushing efforts to group plans. Groups require many different things, and most corporations offering group plans are not in the health insurance administration business, so we ended up with a few plans offering everything. This is ineffective and expensive. (I don’t need pregnancy coverage or mammograms, for example, yet I had it in my corporate-sponsored plan before I went independent.)

The solution, though, is not to make the tax incentives progressive. Punishing a new group instead of the old group is still punishment. That is not the government’s job. The market will do that reasonably well. If “the rich” want super-extra coverage, they’ll pay for it. Most people, when seeing the cost in the individual market, will demand more specific coverage. In this regard, driving more buyers into the individual market is exactly what we want. We’ll get better, cheaper solutions that way because needs and cost will remain in view. They’ll tend to balance to meet customer demands, rather than the current system of hiding everything but the coverage.

The answer is to get government out of the insurance/health business altogether, not to encourage government to create the “correct” incentives. It can’t know the perfect mix, so it will screw it up. President Bush is not there, but he’s found the map.

MLB to fans: Go Eff Yourselves!

I could write a profanity-laden entry about this story, which is what I want to do. Even that wouldn’t begin to convey how angry I am at this move.

Major League Baseball is close to announcing a deal that will place its Extra Innings package of out-of-market games exclusively on DirecTV, which will also become the only carrier of a long-planned 24-hour baseball channel.

Extra Innings has been available to 75 million cable households and the two satellite services, DirecTV and the Dish Network. But the new agreement will take it off cable and Dish because DirecTV has agreed to pay $700 million over seven years, according to three executives briefed on the details of the contract but not authorized to speak about them publicly.

Where do I begin? I’ve been a baseball fan since I first started little league in the late 1970s. Through nearly three decades, I’ve followed the sport with a passion reserved exclusively to this one game. I ‘ve watched games when my choice was the Game of the Week on Saturday. Then we got TBS and the Braves. Then we got the Orioles. Then the Cubs and White Sox. With ESPN, we got a few games a week. Then Extra Innings came along, and instead of the Braves, Orioles, Cubs, and whatever random game involving the Yankees ESPN showed, we got the Braves, Orioles, Cubs, White Sox, Yankees, Phillies, Cardinals, Pirates, Giants, Mets, Angels, Tigers, and so on. I could watch (almost) any game every night of the week for six glorious months of the year.

And now Bud Selig and the Major League Baseball owners decided that a few million dollars for each team were worth selling out those of us who don’t subscribe to DirecTV.

I subscribe to cable because it suits suited my needs. I dutifully subscribe to the Extra Innings package every spring so that I can watch the Phillies throughout the summer. Living in the D.C. area, this is the only chance I get to see my team on a regular basis. Now, under this greedy, anti-fan move, I can choose between the Nationals, Orioles, Braves, Cubs, and White Sox. Notice that my Phillies are nowhere in that list. I assume Major League Baseball is indifferent.

I have little doubt that Major League Baseball will compare its decision to the NFL’s exclusive deal with DirecTV. The obvious difference was that the NFL was never on another service. Every time I moved, I knew that if I wanted the NFL package, I had to subscribe to DirecTV. Major League Baseball, on the other hand, is yanking a service it offered for years. Making me change technology hardware would be rude. Making me change the services I subscribe to is hostile. This is not progress, no matter how many extra pennies it might put into owner pockets. (Also, the NFL is appointment television because there are only 16 regular season games. Major League Baseball is every night of the summer.)

I’m not sure it will make money for DirecTV. The Extra Innings package had approximately 750,000 subscribers last year. Many of those undoubtedly subscribe via cable. Not all of them are going to switch. The price of the package last year on cable was $169, if I remember correctly. To recover $100 million per year, as well as whatever extra costs it will incur to carry high-def games, DirecTV will likely raise the price. How many of that now reduced subscriber base are so die-hard that they’re indifferent to price?

Looking beyond the basic economics, the nature of satellite versus cable is a bad harbinger for the deal. What if a customer doesn’t subscribe to DirecTV and doesn’t want to switch? Too bad. What if that customer lives in an apartment or a house with an obstructed southern view? Again, too bad. But all is not lost, Major League Baseball will say. That customer can still watch the same games on The Internets, in a small pop-up window on a computer. Watching a clip on YouTube is significantly different than watching a 3-hour game in a window the same size. This will not end well.

Major League Baseball is free to make whatever decisions it wants. I don’t have to like it, and I can certainly call bullshit on its stupidity. In the same way I don’t receive baseball radio broadcasts because I prefer Sirius over XM, I’m now screwed because I prefer cable over DirecTV. Making 162 games a premium purchase is an obscene abuse of common sense. But that’s what we’ve come to expect of Bud Selig, isn’t it? He failed to kill the sport in the ’90s, but he’s finally on the right path.

(Source: Baseball Musings)

Fine-tuning Perspective

In some ways, it’s easy to point at other countries and find proof of how to do things correctly. We’re not perfect, so such analysis can be beneficial. It can also be used as a blunt weapon against the United States. “Anything American is bad”, which could just as easily come from an American as another country’s citizens. Then something comes along to show that, just like brilliance, stupidity knows no bounds. We’re not perfect, but no one is.

Consider:

About one in three healthy baby boys is circumcised on Prince Edward Island, about double the national rate, despite the advice of experts who describe it as unnecessary and potentially risky.

The story offers a little analysis, which is useful (and obvious). That’s not the heart of the story, though. This is:

Dr. Doug Tweel is one of the few Island doctors who perform circumcisions.

“There are many procedures done in the hospital setting that are elective procedures,” said Tweel.

“If you’re coming at it from that perspective, I can give you a lot of procedures that are not medically necessary.”

By virtue of the “Dr.” before his name, I assume Dr. Tweel is an intelligent individual. But, really, can anyone be so mind-numbingly simple? No kidding he can name a lot of procedures that are not medically necessary. Any idiot could do the same. Examples abound all over society in the United States, so I assume the situation is the same in Canada. But how many of these elective, medically unnecessary surgeries do we allow to be performed on infants, at parental request? One, which Dr. Tweel knows. Unless the reporter omitted further comments to the contrary, he seems uninterested in that perspective. As long as we perform it on someone, everyone should be eligible to have it done. Even when it’s forced on them for someone else’s reason.

D.C. teaches basic economics.

I imagine New York faces a similar problem, although the scale is likely different.

People who work in the District make some of the highest wages in the United States — on average, higher than those in San Francisco and the Boston area. But every night a significant proportion of those handsomely paid workers take their earnings back to homes and stores in the suburbs.

Let’s gather our big brains and surmise the explanation. Could it be this?

That gap leaves the District with an imbalance that is growing worse, said Stephen S. Fuller, head of the George Mason University Center for Regional Analysis. “People have choices and want to buy homes with yards and good schools,” he said. “If those workers are taking out their income tax and going home to do their shopping, there isn’t much left behind for the District.”

I’ve never lived in a home with anything resembling a real yard since I moved to the D.C. area in ’98. It would be nice, but it’s not significant. More importantly, when I was younger, and it really made no difference, I lived in a high-rise apartment complex. D.C. can offer that type of accommodation without question. But that never kept me away from considering the District as a home. The obscene tax rates, however, factored significantly, as did the ineptness with which the city managed the revenue from those obscene tax rates. Why live in the District when I can live in Virginia and pay only a portion of what I’d pay in taxes as commuting costs? It’s really been a no-brainer. Incentives matter.

Where do Washingtonians learn to drive?

I’d planned to catch up on a few quick items yesterday, since I was away in New York for a few days. Unfortunately, the Great Blizzard of 2007&#153 struck, snarling traffic. Danielle and I made it back to Northern Virginia in about 3.5 hours. We stopped at the grocery store before finishing our journey home. This should’ve been a minor detour, but it turned into a giant misadventure. We left Whole Foods at 1:50. We pulled into our driveway at 5:20.

Witness the white-out conditions that caused this:

While Danielle’s Jetta handled the conditions without incident, even big vehicles can’t help most drivers in the area:

This happens every year at this time in D.C. It should scare everyone that these are the same people leading our nation through actual crises.

Okay, if your son is Teddy Roosevelt.

Very often, arguments so stupid as to warrant little more than an eye roll and a click to the next article come along to annoy the intelligent reader. Those are easy enough to set aside. Sometimes, though, someone will make an argument so mind-numbingly pointless that highlighting is necessary in an effort to remind others that such drivel will be exposed for what it is. Today, I found such an argument arrived in my rss feed.

Among pediatricians and obstetricians and some insurance companies, there are few topics that generate more controversy than whether newborn boys should undergo circumcision. In this country at this time it is the most common surgical procedure being done. Having done duty with troops in the tropics, the writer has some very strong opinions about the benefits of this operation, whereas most of the physicians (primarily pediatricians) who are opposed to the routine circumcision of boys seem to have escaped the experience of heat, humidity, dirt, and poor opportunities for good personal hygiene that is often the story in the tropics. Circumcising a 20 year old is a far more formidable procedure than taking care of a 20 hour-old baby. And the 20 year-old will be disabled for duty for about 20 days, which is a great loss to the overall effectiveness of the unit, plus misery for the 20 year-old.

The perpetrator of this irrelevant tangent is Dr. Richard S. Buker, Jr., Health Officer for Liberty County, Montana. That scares me. A doctor providing information to the community should provide factual information for use by patients. This is anecdotal hooey aimed at parents with blatant disregard for the child’s medical needs and rights.

Dr. Buker thinks it’s correct to hold every boy to a standard that might – might – be appropriate in a tropical environment with limited access to proper hygiene facilities. I’m fairly certain that Liberty County, Montana does not meet that requirement. (Money should be spent on proper hygiene facilities instead of circumcision, if that’s a problem.) As for any potential decrease in troop effectiveness if soldiers are intact, Dr. Buker posits that forced surgery on infants is a benefit in case he joins our volunteer army. This is not rational. The boy can have himself circumcised before joining the military, if he so chooses.

Or non-facts:

Good evidence keeps increasing to support the argument for routine circumcision, which people should be aware of. The single biggest recent finding is that HIV/AIDS transmission is 80% less when men are circumcised. The big push in Africa and South East Asia is to get all males circumcised to decrease the spread of this horrible scourge. What works in Africa works here as well.

I’m going to be kind to Dr. Kruger and say that he is mistaken instead of lying when he quotes an 80% decrease in HIV transmission. The rate mentioned in the few studies done so far indicate a decreased incidence of between 50 and 60%. That extra 20% or more is huge, aside from the obvious arguments against the other 60%. Dr. Buker is a public health official. He must get his facts correct. The burden is especially important when he’s advocating unnecessary, permanent alteration of a child’s body.

It has long been established that the statistical risks of circumcision are considerably less that the risks of not being circumcised. Cancer of the penis is almost unknown in circumcised men. Sexually transmitted disease is less common in circumcised males. In the experience of the undersigned, who has served as a venereal disease control officer (in the tropics), chancroid was 80 times as common in uncircumcised males as in circumcised men.

Cancer of the penis is almost unknown in intact men. Sexually transmitted disease can be prevented with condoms and responsible sexual behavior. No surgery necessary.

Urinary tract infections in children under 5 years of age are less common in circumcised males. Paraphimosis (the writer hated getting up in the middle of the night to treat this problem), balanitis, and getting foreskin caught in a zipper can all be avoided by routine circumcision plus it is no fun being teased in the locker room, all of which are arguments for circumcision of newborns. What about arguments against the procedure? It is a bit cruel to overpower a helpless baby and do an operation on him, and like all operations there is a small risk. As all readers will readily have concluded by this point, the writer is highly in favor of the procedure.

UTIs are more common in girls than in intact boys. Paraphimosis (the writer should not be a doctor if he doesn’t want to treat patients) and balanitis can be avoided by procedures less invasive than circumcision. Getting the penis caught in a zipper can happen with or without circumcision. Being teased in the locker room is not a medical condition justifying surgery. The only argument against infant circumcision that Dr. Buker can come up with is that it’s a bit cruel, and there are risks. No kidding. That should be enough, since it’s also medically unnecessary at the time it’s performed.

These are the arguments of a man who’s already made up his mind and is looking for excuses in the face of logic and facts.

Coalition of the Willing and Unwilling

From yesterday’s Washington Post, this report on a new “consensus” on healthcare reform:

On the surface, it looked to be just another Washington news conference, part of the white noise of the political and policy process.

But this one was different. There, at the National Press Club, stood the president of the Business Roundtable, representing the country’s largest corporations; the president of the Service Employees International Union, the country’s most vibrant union and one of its fastest-growing; and the president of AARP, the formidable seniors lobby. They put aside their usual differences to deliver a clear, simple message to President Bush and congressional leaders of both parties:

We stand ready to give you the political cover you need for a centrist, bipartisan fix for a broken health-care system.

Or, if you refuse, we stand ready to embarrass you and run you out of office.

That’s interesting enough, if it were actually true. But I reject any claim that those three groups have the authority to speak for the nation as a whole. Only the AARP represents a sizeable portion of the nation, and that’s not enough to provide any claim to policy making. Populist rent-seeking never appeared so obvious.

In my case, I’m a small-business owner. I’m only 33. I’m not in a labor union. Who’s got my voice? Me, of course, and willingly so. But this is no one’s concern. The only outcome that matters is coming up with a solution that represents 20th century forces in the 21st century. This press conference could have just as easily occurred in 1907 as 2007.

What does that consensus look like?

It starts with universal coverage, accomplished either through a mandate on everyone to purchase basic health insurance or a mandate on all employers to offer it.

That much we already know, because we think people just aren’t motivated enough (the former proposal) or that more of what we already have will fix the problem (the latter proposal). There is no need to understand why we got here. Once we have a solution worked out, we’ll find the path backwards to where we are to tell the correct story. It’s insanity.

A few of suggestions warrant consideration, and by consideration, I mean outright dismissal.

Finally, it sets a deadline for physicians and hospitals to switch to computerized health records, along with a program to provide no-interest loans to buy the necessary hardware and software.

I’m sure that physicians and hospitals have delayed computerizing health records because no-interest loans were not available. Or it could be that the economic efficiency created by the process wasn’t supported by the cost. Or maybe it’s that physicians and hospitals are in the business of providing care instead of information technology. Only in a world where universal assumptions pass as analysis for the multitude of scenarios in which physicians provide care can an outcome that a universal solution will work. Of course, it’s a lot easier to say that when you impose a no-interest loan requirement. I’m certain “no-interest” means taxpayers will pick up the cost to subsidize this. It would be important to remember that something economically-justified would pay for itself, despite the cost of interest. It’s silly to let that get in the way, though. PEOPLE ARE DYING IN THE STREET!

Hospitals and insurers would have to agree that 85 percent of their revenue would go to providing direct care, capping profit and administrative expenses at 15 percent.

Wow. Central planning at its most crass. We know what expenses should be, as well as a fair profit. There need not be a direct tie to quality here. Fifteen percent for admin expenses and profit is enough. This will not end well.

Health insurers would have to accept the obligation to sell insurance to everyone, with only modest variation in rates for age and health status.

I guess actuaries should start looking for other work. It hasn’t proven to be useful, anyway, since risk can just be ignored. What could go wrong?

Pointing fingers will help, I’m sure.

I guess if I want to be in with the cool kids in the blogosphere, I need to talk about Dinesh D’Souza’s new book, The Enemy At Home: The Cultural Left and Its Responsibility for 9/11. The problem is, with a title like that, I don’t care. It says everything necessary to dismiss the book without further contemplation. I haven’t read it, nor will I. But Mr. D’Souza’s first column for Townhall.com warrants a comment.

As I returned home to the United States, I wondered: are these students right? I don’t think American culture as a whole is guilty of the charge of moral depravity. But there is a segment of our culture that is perverse and pornographic, and perhaps this part of American culture is the one that foreigners see. Wrongly, they identify one face of America with the whole of America. When they protest what they see as the glamorization of pornography and vice, however, it’s hard to deny that they have a point.

“They hate us for our freedoms” is a tired slogan, but it takes an especially perverse anti-liberty sentiment to add on “they’re right to hate us for that freedom.” It’s absurd and should be shunned from the public sphere of ideas by everyone. Unfortunately, not everyone hates assaulting the Constitution. (There’s a nuance involving freedom in quotes, but that makes no sense because we’re talking about consensual choices.)

I think Mr. D’Souza’s mistake becomes clear here:

Groups like the ACLU have taken the approach that pornography rights, like the rights of accused criminals, are best protected at their outermost extreme. This means is that the more foul the obscenity, the harder liberals must fight to allow it. By protecting expression at its farthest reach, these activists believe they are fully securing the free speech rights of the rest of us.

There is no flaw in what Mr. D’Souza attacks. All rights must be protected at their extremes. Whatever limitations the majority desires still leaves the minority grasping to retain what inherently belongs to everyone. The right to not do something must include the corresponding right to do that something. No one will fight publishing “the bunny is grey.” But when the bunny starts attacking the chickens in the coop with a machete and blood and feathers are flying all over the page, someone must defend it when the moralists come charging to society’s rescue.

Mr. D’Souza believes that whatever is an outlier, especially if it’s repugnant to most, must therefore be unworthy of protection. Unfortunately, there are principles of rights and liberty that are more vision-impaired than Mr. D’Souza’s belief that his 20/20 analysis is enough.

Who defines “satisfactorily”?

The given title is “Seven Tough Choices We Will Not Make”, but the Washington Post should’ve titled Robert Samuelson essay in today’s newspaper to accommodate the fact that at least two choices are stupid. Consider:

Let me engage in a fantasy. Let me assume that Democrats and Republicans actually intended to address two serious national problems: first, our huge dependence on insecure sources of foreign oil; and second, the persistent mismatch between public resources (taxes) and public obligations (spending). What might they do? Herewith, a package of proposals:
…

  • Increase the top tax rate on dividends and capital gains (profits on stocks and other assets) from today’s 15 percent to at least 25 percent.

This list is clearly doomed, because Mr. Samuelson accepts the same garbage that the economically ignorant love to perpetuate, namely that only the rich have dividends and capital gains, and anyone rich enough to receive them is rich enough to pay their “fair share” without concern. No data actually backs this up, and principles of economics and fairness disprove it, but a lie told often enough, and with enough pleasant motivations can overcome truth.

  • Raise the eligibility ages for Social Security and Medicare gradually to 70 by 2029. At 65, people would have to buy into Medicare (that is, pay for coverage) until they reached eligibility for subsidized benefits.

If we’re going to force people to buy into Medicare for those five years before they turn 70, wouldn’t it make sense to stop the charade and let them spend the money they would currently contribute to Medicare (and Social Security) on their own private insurance? This is a better-than-nothing approach, but Mr. Samuelson’s solution offers little more than a blatant acceptance that Social Security is a shell game in which no one is much interested in correcting the foundational flaw. It’s stupid.

Reading Mr. Samuelson’s conclusion, much of this becomes obvious:

That something like this won’t soon be proposed — let alone passed — speaks volumes about our politics. Both parties have marketed government as a source of aid and comfort. Benefits are to be pursued, burdens shifted and choices avoided. Problems are to be blamed on scapegoats (“the liberals,” “the rich”). There is little sense of common interests and shared obligations. Politicians resort to symbolic acts that seem more meaningful than they actually are: the minimum wage, for instance.

Mr. Samuelson’s analysis of the problem seems to coincide nicely as an explanation for his recommendations.