Kevin Drum

The Placebo Effect

| Wed Aug. 26, 2009 1:50 PM EDT

In Wired, Steve Silberman writes about the well-known placebo effect: sometimes a sugar pill all by itself can help cure a disease or reduce its symptoms.  That's why it's not enough for drugs in clinical trials to work.  They have to work better than a placebo.

The placebo effect is mysterious enough on its own.  But there's more.  It turns out that placebos work better in some countries than other others.  It also turns out that ratings by trial observers vary significantly from one testing site to another.  But what's most mysterious is that the placebo effect actually seems to be getting stronger over time. Not only are new drugs having a harder and harder time beating out placebos, but older drugs that have been retested are having problems too:

In many cases, these are the compounds that, in the late '90s, made Big Pharma more profitable than Big Oil. But if these same drugs were vetted now, the FDA might not approve some of them. Two comprehensive analyses of antidepressant trials have uncovered a dramatic increase in placebo response since the 1980s. One estimated that the so-called effect size (a measure of statistical significance) in placebo groups had nearly doubled over that time.

It's not that the old meds are getting weaker, drug developers say. It's as if the placebo effect is somehow getting stronger.

....But why would the placebo effect seem to be getting stronger worldwide? Part of the answer may be found in the drug industry's own success in marketing its products.  Potential trial volunteers in the US have been deluged with ads for prescription medications since 1997, when the FDA amended its policy on direct-to-consumer advertising. The secret of running an effective campaign, Saatchi & Saatchi's Jim Joseph told a trade journal last year, is associating a particular brand-name medication with other aspects of life that promote peace of mind: "Is it time with your children? Is it a good book curled up on the couch? Is it your favorite television show? Is it a little purple pill that helps you get rid of acid reflux?" By evoking such uplifting associations, researchers say, the ads set up the kind of expectations that induce a formidable placebo response.

Unfortunately, that's about it.  The mystery of the increased response to placebos remains a mystery.  No one really knows why it's happening.  But it's all pretty fascinating anyway, and the whole piece is well worth a read.

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Grassley's Problem

| Wed Aug. 26, 2009 12:20 PM EDT

Chuck Grassly is in no danger of not being reelected.  So why is he being so bad-tempered about healthcare reform?  Ezra Klein says it's because he's under tremendous pressure from his fellow Republicans, who have the power to punish him if he supports a Democratic healthcare bill:

This is the final year that Grassley is eligible to serve as ranking member — the most powerful minority member, and, if Republicans retake the Senate, the chairman — of the Senate Finance Committee. His hope is to move over as ranking member of the Judiciary Committee, or failing that, the Budget Committee. But for that, he needs the support of his fellow Republicans. And if he undercuts them on health-care reform, they will yank that support. It's much the same play they ran against Arlen Specter a couple of years back, threatening to deny him his chairmanship of — again — the Judiciary Committee. It worked then, and there's no reason to think it won't work now.

This kind of discipline is normal in a parliamentary system where everyone on both sides is expected to support the party line.  But that discipline is the flip side of a system in which the majority party has the power to turn its campaign platform into law using only its own votes.

You really can't have one without the other.  If you have an intensely whip-based system, in which the opposition party is expected to oppose unanimously, then the majority party has to have to power to govern using only its own majority.  Conversely, if you have a system in which legislation only passes if party members cross lines, then discipline necessarily needs to be weak.

Not to be tedious about this, but this is yet another example of how Congress has become schizophrenic in the age of the routine filibuster.  We either need a system in which the majority rules, or we need a system in which party members cross lines to form temporary alliances.  Right now we have neither.

UPDATE: Via email from reader Thomas F.:

AAAARRRRGGGG!!!!

Grassley does not want health care reform. Grassley does not want health care reform. Grassley does not want health care reform.

As a result, he does not have a problem. He will string this along in the service of his very very very conservative ideology and in service of the Republican party. But he will not support or vote for it in the end, and he will participate in the Gang of Six only as a way to slow legislative progress as a tool to derail the whole thing.

This might go a wee bit too far, but point taken.  I was using Ezra's post as an excuse to blather about the filibuster, but I probably shouldn't have let his implicit Grassley appraisal stand without comment.

Durable Goods

| Wed Aug. 26, 2009 11:33 AM EDT

This is a little bit confusing.  Durable goods orders were up in July, but it turns out it was mostly because Boeing had a good month:

As encouraging as the report appeared at first glance, it also suggested businesses were still cutting back. Orders for non-defense capital goods excluding aircraft, a barometer of business investment, fell 0.3 percent in July after rising 3.6 percent in June. New orders for computers and related products fell 2.8 percent after rising 0.5 percent in June.

The report today is likely to bolster the view, shared by a growing number of economists, that the recession is winding down or has already ended. It was further proof the manufacturing sector has begun to stabilize as businesses start to restock. Businesses had been slashing inventories for months as they tried to catch up with falling demand.

Aside from commercial jets, orders for durable goods fell 0.3% after rising in June, which "suggested businesses were still cutting back."  But three sentences later this bolsters the view that the recession is winding down.  What am I missing?

Ted Kennedy Passes

| Wed Aug. 26, 2009 1:46 AM EDT

According to news reports, Sen. Edward Kennedy has died.  R.I.P.

Obama's Not-So-Tough Spot

| Wed Aug. 26, 2009 1:40 AM EDT

Scott Wilson and Joshua Partlow write in the Washington Post that Barack Obama is in a tight spot:

President Obama is caught between two important constituencies as he recalibrates his policy in Afghanistan — the generals who want more troops, and the base of his own party, whose tolerance for a worsening conflict is quickly evaporating.

...."Afghanistan is going to be a huge political challenge. There's no doubt about that," said a senior administration official, who spoke on the condition of anonymity because the military assessment is pending. "The key for us is to have a strategy and have the competency to execute that strategy. It's going to be hard to convey this. And it's never going to be popular."

Well, that sure doesn't sound like he feels caught.  It sounds, as usual, as if Obama is going to ignore his base and do whatever the Washington establishment wants him to do.  The fact that he's aware that his base doesn't like this is an entirely different thing from feeling that he has a genuinely tough decision to make.

But then again, why not?  As the Bernanke reappointment shows, even the people who have been criticizing the DC establishment relentlessly for showing too much deference to the people who originally got the financial crisis wrong fell all over themselves to declare the Bernanke choice brilliant once it was made.  So maybe Obama figures the Afghanistan criticism is just a bunch of hot air too.  And maybe he's right.

Quote of the Day

| Wed Aug. 26, 2009 1:10 AM EDT

From 18-year-old Kristen Nagy, proving that the kids are all right:

I just think it’s weird and I don’t feel like everyone needs to know what I’m doing every second of my life.

She's talking about Twitter.  Turns out it's mostly an adult phenomenon, according to the New York Times, which speaks well for our nation's youth and not so well for our nation's grownups.

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Mideast Peace Talks Set To Restart?

| Tue Aug. 25, 2009 8:10 PM EDT

The Guardian reports that a deal to restart Mideast peace talks is close at hand.  President Obama has promised to push for expanded sanctions on Iran, including its oil and gas industry:

In return, the Israeli government will be expected to agree to a partial freeze on the construction of settlements in the Middle East. In the words of one official close to the negotiations: "The message is: Iran is an existential threat to Israel; settlements are not."

....Obama has pencilled in the announcement of his breakthrough for either a meeting of world leaders at the UN general assembly in New York in the week beginning 23 September or the G20 summit in Pittsburgh on 24-25 September.

The president, who plans to make his announcement flanked by Netanyahu and the Palestinian leader, Mahmoud Abbas — plus the leaders of as many Arab states as he can muster — hopes that a final peace agreement can be negotiated within two years, a timetable viewed as unrealistic by Middle East analysts.

....Israel is offering a nine- to 12-month moratorium on settlement building that would exclude East Jerusalem and most of the 2,400 homes that Israel says work has already begun on.

I'm not a Mideast wonk, so I don't really know how to judge this.  But my initial reaction is that substantively there's not an awful lot here: the expanded sanctions depend on agreement from both China and Russia in the Security Council, which seems unlikely, and Israel's settlement moratorium is pretty anemic.  If it's enough to get everyone talking, that's great, but it's not much of a sign that either side is ready to make much in the way of serious concessions yet.

Still: getting talks restarted on almost any terms is better than doing nothing, and there's not much downside.  Iran is pretty obviously in no mood to talk with the U.S. right now, so pushing for sanctions probably won't do a lot of harm.  And the settlement semi-freeze is at least a minor step in the right direction.  I wonder if Bruce Bueno de Mesquita thinks it has any chance of working?

The Torture Docs

| Tue Aug. 25, 2009 5:49 PM EDT

Do the recently released torture documents demonstrate that torture worked?  Back in April Dick Cheney said they would, but now that they're out in the open he's backing down:

The documents released Monday clearly demonstrate that the individuals subjected to Enhanced Interrogation Techniques provided the bulk of intelligence we gained about al Qaeda.

In case the fudge factor in that statement isn't crystal clear, here's a different version:

The documents released Monday clearly demonstrate that the individuals who received academic scholarships provided the bulk of the correct answers on final exams.

Well, no kidding.  But that doesn't mean that getting a scholarship made you smart.  It means that scholarships were given to people who were already smart to begin with.  Likewise, the "enhanced interrogation techniques" were used on the prisoners who were the most valuable in the first place.  They would have provided the bulk of the intelligence no matter what we'd done.  Michael Scherer comments:

Now that the memos have been released — with redactions — they provide no clarity to the question Cheney claimed they would answer: Did the enhanced techniques produce results? Rather the two memos describe the value of information provided by Al Qaeda detainees, which one memo calls a "crucial pillar of counterterrorism efforts." The memos, as redacted, are silent on the role of harsh interrogation in producing that information. One memo describes another effective technique — dubbed the "building block" process — that dd produce significant information. This process is an standard technique, of confronting one detainee with information from another detainee to produce more information. It does not involve any physical coercion. Does Cheney want other parts of the same memo, which were redacted in the latest release, made public? It is unclear.

Glenn Greenwald adds this:

(1) The fact that we are not really bothered any more by taking helpless detainees in our custody and (a) threatening to blow their brains out, torture them with drills, rape their mothers, and murder their children; (b) choking them until they pass out; (c) pouring water down their throats to drown them; (d) hanging them by their arms until their shoulders are dislocated; (e) blowing smoke in their face until they vomit; (f) putting them in diapers, dousing them with cold water, and leaving them on a concrete floor to induce hypothermia; and (g) beating them with the butt of a rifle — all things that we have always condemend as "torture" and which our laws explicitly criminalize as felonies ("torture means. . . the threat of imminent death; or the threat that another person will imminently be subjected to death, severe physical pain or suffering . . .") — reveals better than all the words in the world could how degraded, barbaric and depraved a society becomes when it lifts the taboo on torturing captives.

We managed to get through WWI, WWII, the Korean War, the Vietnam War, the Gulf War, and a dozen smaller engagements without making the torture of prisoners into official government policy.  We can get through this one without selling our souls too.

Keeping the Bribe Reasonable

| Tue Aug. 25, 2009 3:01 PM EDT

I guess I thought this was fairly obvious, but maybe not.  Here's libertarian Alex Tabarrok offering a defense of including a public option as part of any healthcare reform:

If insurance companies must take all customers regardless of pre-existing conditions it is obvious that sooner or later and probably sooner the government will require that everyone purchase health insurance.

In short, insurance reform will mean that everyone will be required to buy a product that will be tightly regulated and more homogeneous.  Both of these factors will increase the market power of insurance firms.  Since escape via non-purchase will no longer be a potential response to higher prices, mandatory purchase will reduce the elasticity of demand giving firms an incentive to increase prices.

....It's true that mandatory purchase doesn't necessarily lead to market power, auto insurance is quite competitive.  Nevertheless, given the potential of insurance reform to increase the market power of insurance firms the search for some disciplining device like the public option is reasonable.

The healthcare bills currently on the table are huge windfalls for insurance companies.  That's why the industry supports them.  It gives them more power and it ensures them more customers.  Liberals who back this approach are basically doing it because we figure that's just the way the world works: if you want the support of a big, powerful player, you have to bribe them.  And that's what we're doing.

But yes: if we're doing this, a "disciplining device" that gives customers a greater choice of insurance options is indeed reasonable.  Even from a conservative point of view, it's reasonable.  There's a limit to just how big the bribe should be.

Double Dip for the GOP?

| Tue Aug. 25, 2009 1:52 PM EDT

James Fallows goes medieval on yesterday's New York Times profile of Ezekiel Emanuel, the highly respected medical ethicist who's become a punching bag for the "death panel" crowd:

And now we have the New York Times, in a big take-out story, saying that Dr. Emanuel, in his role as Obama health-care advisor, is in an "uncomfortable place" because he is being criticized by:

1) Betsy McCaughey !
2) Rep. Michele Bachman (look her up) !!
3) Sarah Palin !!!
4) Lyndon LaRouche !!!!

McCaughey, Bachman, Palin, LaRouche — shaping American debate and media coverage about health policy? Was Zsa Zsa Gabor not available?

...."Out of context" and "false" are useful caveats. But why is the story about Ezekiel Emanuel being on the hot seat in the first place — and not about the campaign of flat lies by McCaughey, Bachman, Palin, and LaRouche? Why are real newspapers quoting what they say any more? (Interestingly, LaRouche's claims rarely get NYT coverage. In in this case, he is apparently "legitimized" by ... McCaughey.) If I start a campaign of lies against somebody and get Soupy Sales plus Lynette "Squeaky" Fromme to agree with me, can I expect them to be regularly publicized in the mainstream press?

But that's the problem: McCaughey, Bachman, and Palin are de facto leaders of the Republican Party, just like Rush Limbaugh and Sean Hannity.  And the actual leaders — people like John McCain, Michael Steele, John Boehner, and Chuck Grassley — are happily taking their cues from the goofballs.  What's more, it seems to be working.  Last year, a lot of us wondered how long the GOP would have to spend in the wilderness before they regained their sanity and became electorally significant again.  We still don't know the answer to that, but at this particular snapshot in time it looks as if the answer is: no time at all.  They don't need to become sane again.  Their public face is death panels and Sarah Palin and Fox News and the birthers and the town hall shriekers — and that seems to be working for them.  All the mainstream political analysts say their midterm prospects are looking up.

Who knows?  Maybe the GOP is in for the political equivalent of a double dip recession: they'll start to recover, but then in a few months they'll suddenly implode again and be in even worse shape than before.  I sure hope so, because given the fecklessness of the Democratic Party, it looks like they're going to need a majority of about 70 in the Senate before they can manage to get their own caucus to actually act like Democrats.  FDR must be spinning in his grave.