Here’s Klein with an anecdote that captures Oregon’s drive to invest in preventing health problems, rather than just continuing to treat costly disease episodes:

Oregon Gov. John Kitzhaber (D) loves to tell the air-conditioner story. He loves to tell it so much, in fact, that it has become something of a running joke in Oregon health-policy circles. At this point, even Kitzhaber is in on it. Before he repeats it to me, he says, “I probably shouldn’t bore you with my air conditioner story.”

Here’s the air conditioner story: There’s a 90-year-old woman with well-managed congestive heart failure who lives in an apartment without air conditioning. That’s actually the whole story.

Kitzhaber, a former emergency room physician, sees this as the perfect example of what’s wrong with our health-care system. “A hot day could send the temperature in her apartment high enough that it strains her cardiovascular system and kicks her into full-blown congestive heart failure,” he said. “Under the current system, Medicare will pay for the ambulance and $50,000 to stabilize her. It will not pay for a $200 window air conditioner, which is all she needs to stay in her home and out of the hospital. The difference to the health-care system is $49,800. And we could save that $49,800 without reducing her benefits or her quality of life.”

…“The fundamental problem with our health-care system is the growing discrepancy between the cost of care, the resources available to pay for it and the tenuous connection between that expenditure and actual health,” Kitzhaber said. “What we’re doing is instead of putting our budget into the ER and paying for congestive heart failure after congestive heart failure, we’re putting it into care coordination and community health workers. We’re investing in health. It’s just a paradigm shift.”

Oregon is getting $1.9 billion from the federal government to overhaul its Medicaid program, in exchange for a commitment by the state to keep its Medicaid cost growth below the rate in the rest of the country, saving a total of $11 billion over the next decade. (Sarah Kliff has more details on Oregon’s plan.) The state may find that giving free air conditioners — and, I’d hope, vouchers to help with related electric bills — to residents with congestive heart failure reduces medical costs.

Oregon’s 15 coordinated care organizations (CCOs) will likely come up with many such prevention projects, and see which ones are worthy of continued investment. In addition to interventions that deliver an immediate benefit, like air conditioners, the state and individual CCOs could invest in programs and infrastructure that increase physical activity and improve access to healthy food, which can reduce disease occurrence and severity years into the future. In fact, these are the kinds of interventions that the Prevention and Public Health Fund — one of the less-noticed pieces of the Affordable Care Act — was designed to support. Congress and the Obama Administration have repeatedly diverted money from this fund, however, so it can’t do all that Congress envisioned when it first included the Fund in the ACA.

Oregon is betting that investing in prevention will save money over the long run. It’s important to note, though, that prevention investments are worthwhile if they improve people’s quality of life, whether or not there are savings. But governments have limited amounts of money to spend, and they have to prioritize. Here’s Bill Gates giving Ezra Klein an example of a problematic spending tradeoff:

My deep interest in this came somewhat because it’s fascinating but also because our big cause in the U.S. is education, and if you look at state budgets, they are moving money from education to health. They have to because the health costs are just exploding. So very quickly say to yourself, gosh, if there’s going to be any money left for university education and adequate money for K-12, even to stay flat, you have to figure out health-care costs.

Unfortunately, in rich-world health, innovation is both your friend and your enemy. Innovation is inventing organ replacement, joint replacement. We’re inventing ways of doing new things that cost $300,000 and take people in their 70s and, on average, give them an extra, say, two or three years of life. And then you have to say, given finite resources, should we fire two or three teachers to do this operation? And with chemotherapies, we’ve got things where we’ll spend our dollars on treatments where you’re valuing a life here at over $10 to $20 million. Really big, big numbers, which if you were infinitely rich, of course that would be fine.

So most innovations, unfortunately, actually increase the net costs of the healthcare system. There’s a few, particularly having to do with chronic diseases, that are an exception. If you could cure Alzheimer’s, if you could avoid diabetes — those are gigantic in terms of saving money. But the incentive regime doesn’t favor them.

The reason we’re worried about the rate of healthcare-cost increase (which has generally outpaced GDP growth over the past decades) is that ever-growing healthcare spending will crowd out spending in other areas, like education. Given that better-educated populations tend to have better health, reducing education spending to pour ever-greater shares of federal and state budgets into Medicare and Medicaid could itself contribute to higher healthcare costs in the future. Governments will need to prioritize spending on the most worthwhile interventions. We should be paying close attention to Oregon’s experiment to see what they learn about getting the most bang for their healthcare bucks.

I do, however, want to take issue with one thing in the post. When assessing the historical place of American physics, he writes:

Here’s my personal list for the title of greatest American physicist in history, in no particular order: Joseph Henry, J. Willard Gibbs, Albert Michelson, Robert Millikan, Robert Oppenheimer, Richard Feynman, Murray Gell-Mann, Julian Schwinger, Ernest Lawrence, Edward Witten, John Bardeen, John Slater, John Wheeler and Steven Weinberg. I am sure I am leaving someone out but I suspect other lists would be similar in length. It’s pretty obvious that this list pales in comparison with an equivalent list of European physicists which would include names like Einstein, Dirac, Rutherford, Bohr, Pauli and Heisenberg; and this is just if we include twentieth-century physicists. Not only are the European physicists greater in number but their ideas are also more foundational; as brilliant as the American physicists are, almost none of them made a contribution comparable in importance to the exclusion principle or general relativity. [...]

More importantly though, the sparse list of great homegrown American physicists makes two things clear. Firstly, that America is truly a land of immigrants; it’s only by including foreign-born physicists like Fermi, Bethe, Einstein, Chandrasekhar, Wigner, Yang and Ulam can the list of American physicists even start to compete with the European list. Secondly and even more importantly, the selection demonstrates that even in 2013, physics in America is a very young science compared to European physics. Consider that even into the 1920s or so, the Physical Review which is now regarded as the top physics journal in the world was considered a backwater publication, if not a joke in Europe (Rhodes, 1987). Until the 1930s American physicists had to go to Cambridge, Gottingen and Copenhagen to study at the frontiers of physics.

I would argue that there’s a word missing near the end of that last sentence, namely “theoretical.” It’s absolutely true that American theorists like Oppenheimer studied in Europe in order to learn from the quantum pioneers, but I would say that even by the 1930′s, American experimental physics was nearly equal to that in Europe. Michelson, Millikan, Lawrence are a trio to put up against anyone Europe has to offer in that same time period (Thomson and Rutherford are the big names on that side of the pond), and you can throw in people like Compton and Davisson and Germer as well. Depending on whether you count cosmology as part of physics, you could probably get Hubble into the mix on the American side, as well.

Now, it’s true that they didn’t contribute “foundational” ideas to physics, which tends to see them pushed somewhat down the list of “greats,” but I think that’s a mistake. Yeah, the exclusion principle and general relativity are great ideas, but big ideas are meaningless unless you can measure them, and Americans were essential to that process. Einstein famously proposed a revolutionary particle theory of light to explain the photoelectric effect, but it was Millikan’s measurements (which grudgingly confirmed the photon model) that forced people to take it seriously, and Compton’s gamma-ray scattering experiments helped seal the deal.

This is, of course, a personal obsession with me, but I think it’s essential to remember that theory and experiment go hand in hand. Revolutionary theories arise because they’re needed to explain experimental results, and they’re ultimately accepted because they’re found to agree with further measurement. Experiments get downplayed because they’re full of fiddly technical details and harder to explain and interpret, but they’re absolutely essential, and the US was pulling its weight in experimental physics even before top theorists started fleeing fascist regimes. (This is prompted in part by a bunch of recent reading on the history of 20th century physics, where even some big European names grudgingly admit that the Americans were good experimenters…)

So, while Europe is still ahead, I think it’s a somewhat closer thing than Jogalekar suggests, when you properly weight the two facets.

As for the general question of who was the greatest American physicist, I’d probably cast my vote for John Bardeen, who is, after all, the only person to share two Nobel Prizes in Physics. He’s the “B” in the “BCS” theory of superconductivity, but more importantly helped invent the transistor. It’s hard to think of anyone whose contributions to physics had a bigger influence on the way we live today, and if that’s not greatness, I’m not sure what is.

Ethically, this conclusion is a deep affront to my liberal* sensibilities. The idea of basing our public policy on racism and bigotry is abhorrent.

Politically, this is dangerous territory. This is especially true after the 2012 election, when republican politicians were making noises about inclusiveness and reaching out to minorities – and in fact, the Heritage Foundation dropped Richwine almost as soon as the offending dissertation came to light (I’m not sure if they’re disavowing the conclusions of their position paper though).

But what I want to talk about here is what this idea means academically. Jon Wiener at The Nation wrote a piece questioning why Harvard would award Richwine a PhD, and gave a fairly thorough accounting of why the conclusions are questionable based on recent scholarship. My friend and fellow Sbling Ethan Siegel wrote a post on Sunday going further, not just questioning why Richwine got his PhD, but flat out saying,

This. Is. Not. Okay.

This is the point at which my ethical and political sensibilities bump up against my academic principles, and for me, academic freedom wins. I don’t think academics should be in the habit of silencing any scholarship, regardless of how much it offends our sensibilities. If Jason Richwine put in the work, met the requirements for his program and had his thesis approved by three independent faculty members (he did), then he deserves his PhD.

Both Jon Wiener at The Nation and Ethan here on ScienceBlogs assault Richwine’s thesis based on the fact that “race” is an outdated term, “hispanic” is tough to define and doesn’t actually represent a coherent group of people etc. This may be true – I largely agree with both of them on these points. Then again, I am not a sociologist, anthropologist or political scientist, and neither are Jon Wiener nor Ethan Siegel. Based on Wiener’s reporting, the thesis was signed off on by three faculty members, one of whom is a strong liberal whose research specifically refutes the very premise of race as a valid category for scholarship.

The third member of the committee is the big surprise, and the big problem: Christopher Jencks, for decades a leading figure among liberals who did serious research on inequality—a contributor to The New York Review of Books, the author of important books, including Inequality: Who Gets Ahead?, The Homeless and The Black White Test Score Gap. Christopher Jencks knows exactly what’s wrong with the studies purporting to link “race” with “IQ.” [emphasis mine]

Why is this a big problem? Wiener doesn’t say, but I think it seems like a big problem because someone who likely disagrees strongly with the conclusions of this academic work still endorsed it. In fact,  that’s a success, not a problem. If the thesis was empirically sound, I would consider it a scandal if Jencks had not signed off because the conclusions conflicted with his own work. This would be like someone in the 70′s being blocked from doing a thesis that supported affirmative action. That’s what’s not OK. I’m not worried about Richwine and his thesis – his ideas are archaic and I’m confident that they will be relegated to the dustbin of history. What I worry about is other scholars, that have politically risky but correct ideas, being silenced for going against the prevailing wisdom.

Academic freedom, like freedom of speech, means that sometimes noxious ideas are going to be studied and espoused. To adapt a well-known phrase – The best defense against offensive scholarship is not to silence it, but is instead more scholarship.

—-

*Here, I mean liberal in the philosophical sense, not the political one, though I am politically liberal as well.

Imagine standing next to Parable Creek, an imaginary rocky brook in New England. The water is rushing past you from left to right, around the rocks that emerge tall above the surface of the stream, mounding over the top of those that are lower down. The deepest parts of the steam are relatively flat but show ripples that belie the presence of other rocks and sunken branches that are well below the water line.

While you are observing a young boy of about 11 years old comes along, carrying his fishing pole. “Hey mister, how’s it going?” he says, as he steps into the stream. “I’m going fishing over there,” he says pointing in the direction of a mill pond a mile or so away. As he crosses the stream you notice that whenever he puts is foot down, some of the water mounds up on the upstream side as it rushes by him. He continues across the stream and climbs the opposite bank, running off to his destination. You wish him good luck with his fishing and return to your observations.

You can see large eddies here and there that seem to persist though they may change shape or grow or shrink a little. Smaller eddies, mini vortexes, form in certain parts of the stream, and rush down slope only to disappear as the water crashed into an obstruction. Every here and there there is a splash caused by the rushing water hitting a rock or branch just the right way.

Now, imagine that you are a compulsive data collecting scientist standing next to the rocky brook with nothing else to do for a while. So you start measuring things. Every where you see a mound of water built up in the current alongside a rock, that is a bit of kinetic energy (water moving) converted momentarily in to potential energy (water rising against gravity). So you estimate the number of mounds and their collective mass. This is a measurement of one form of energy in the stream.

You make a prediction. If the amount of water coming down this stream increases for a while, the total energy of the stream will increase, and this will be visible as an increase in total potential energy in the mounds you’ve been measuring.

Coincidentally it has been raining heavily upstream and just as you have formulated your hypothesis you see the water rising. Aha! A chance to test your prediction. At first, your hypothesis seems supported. As the water rises, the relative height of the mounds increases, and some new mounds form. You take some quick measurements, by eye, and note that the total potential energy stored in water mounds has increased, presumably as an effect of more overall energy in the stream. You gain confidence in your theory and congratulate yourself on your brilliance.

But then, as the water level continues to rise something different happens. More and more of the stream is now above the obstructing rocks. Therefore, there is less conversion of kinetic to potential energy. Most of the mounds disappear and the overall surface of the stream is much smoother. You take a new set of measurements and estimate that the total potential energy stored in water formed into mounds is an order of magnitude LOWER than your original measurement. Apparently, you think, something is wrong with this stream.

Just then a troop of Brownies comes along. The little girls want to cross the stream to take a short cut to their picnic grounds. They ask, “Hey, Mister, do you think it is safe to cross this stream?”

You had a nice theory linking total energy and a specific observation, which seemed to be confirmed by some of your research. The total energy of stream flow is linked to the total mound-i-ness of the stream’s surface. Now, the stream’s surface is smoother than it was before. Therefore, the total energy of the stream is at the low end of its known variation. A while back you saw a small boy cross the stream with no problem. Clearly, it is safe to cross now.

So, you say, “Actually, I’m sure it is quite safe. Go ahead and cross, and have a nice day!”

The brownies jump happily into the stream and start wade through the water. Half way across the stream, one by one but over just a few seconds of time of time, they are carried away by the water and drown.

“Hmmmm,” you think. “Maybe I had that wrong.”

Rivers Of Air

Air flowing over the surface of the land is a bit like water running down a stream or river. The air interacts with the ground (especially things like mountains). There are different layers, mounds, streams, and eddies of air that interact with each other. The overall form of movement is shaped by the spin of the earth, the tendency of warm air to form in certain areas (i.e., near the equator, or over water during winter and over land during summer, etc.) which causes the air to pile up and spill into nearby eddies. There are all sorts of ways in which batches of air interact, and when you thrown in differential amounts of moisture in different air masses, and things like night vs. day, and so on, you get the surface of Parable Creek. Metaphorically. In real life, we call the The Weather.

When the total energy in the system of air movement changes the way those crazy zany air masses move and what sorts of weather form can also change. For example, there is in total more energy on the hemisphere (north vs south) that is sticking its face towards the sun. It seems that one result of this is that the hemisphere with more energy (the summer end of the earth, as it were) has hurricanes, severe thunder storms, tornadoes, and so on while the hemisphere with less energy has less of that stuff.

However, a tornado is like a small eddy in the stream, and a hurricane like a large eddy, and a line of thunderstorms like the outer edge of one the mounds and the rainstorms are like the splashes at the edge of the log and so on and so forth. As Parable Creek’s level rises, exactly which phenomena are predominant changes, even as the total ability of the stream to wash away Brownies increases to the level where it can also wash away Girl Scouts and eventually Brawny Construction Workers and Bikers. Having said that, while a rocky stream converts to a large and deep river by adding a LOT of water, which may have a smooth surface despite the total energy of the river being orders of magnitude greater than Parable Creek’s energy, the system of air movement is not likely to become smoother owing to various limitations in the system.

Too Much Variability

You can’t measure the energy in the stream by only looking at one of the many phenomena that are the manifestations of that energy. In order to understand the relationship between global warming and storminess, it is minimally necessary to measure all of the storminess and find some way to combine it.

I remember when I first moved to Minnesota. That summer we had numerous straight line wind events of the sort never seen before. Maplewood, a community near where I lived famous for it’s tree lined streets lost almost all of its trees in one storm. That same storm also took out most of the stock of most of the new car companies in that town, famous for its numerous car lots. The cars were pitted with hail stones. Every single home for about three miles along a street right near where I lived had it’s vinyl or aluminum siding drilled with hundreds of holes and dents from large hail stones being driven by a 60–100 mile per hour wind. It was one of the worst weather years in Minnesota, with insurance companies practically going bankrupt.

There were only a few tornadoes in the area that year.

The next year there were hardly any straight line wind storms of the magnitude just described. But that is the year of the Saint Peter tornado. It was one of the largest tornado events ever; It was a twister that lifted and dropped a couple of times, so ‘nato-pedants divide it into multiple events, but that’s absurd. It was an F3 and F4 event, and it tracked for 67 miles and was up to one and a half mile wide.

There were a lot of tornadoes that year.

The atmosphere over central and southern Minnesota had a lot of energy those two years, for whatever reason. If we want to understand the total energy, and its effects on life and property, we would be doing a disservice to our pursuit of understanding if we failed to consider both straight line winds and tornadoes together (though obviously also separately).

The Big Picture

Weather comes in bands. The biggest and most obvious band is the Intertropical Convergence Zone, a band of thunderstorms that rings the entire planet and is pretty much always active. Another band is the arid band that rings the earth; actually there are two of them, one in the Northern Hemisphere and one in the Southern Hemisphere. Almost every major desert on the earth is in one of those bands. In fact, any desert that is not in one of those bands has to explain itself, and the excuse is usually a mountain rain shadow. Conversely, any wettish areas in those bands also have some ‘splainin to do. The southeastern US is in the Northern Hemisphere’s arid band, but the Gulf of Mexico keeps that region pretty wet much of the year.

Severe weather is also patterned in these bands, to some extent. Hurricanes form in the bands just north or south of the Intertropical Convergence Zone. Tornadoes tend to be confined to subtropical and southern temperate bands away from the equator. In a sense, one could say that most tornadoes that are not spinoffs from hurricanes occur in a certain band either north or south of the equator, and if we are going to count tornado activity, measure its total intensity, etc., we should be looking more globally at those zones, not just parts of those zones.

This of course applies to national borders as well. Tornadoes occur in the US but also in Canada, but the most easily available tornado data for North America is always presented as US tornadoes. Also, years are tricky. Events that span Jan 1st are hard to track if we count things by calendar years.

Some have been harping about the “tornado drought of 2012” as evidence that there is not an increase in tornadoes owing to global warming. Well, there are very few US tornadoes in January, but the January with the most tornadoes ever (in our records) was January 2012. Also, Canada had a lot of tornadoes in 2012. Has anyone looked to see what the combined US and Canadian count would be? And, how do you count a Canadian Tornado? The very fact that a tornado forms 1000 miles north from where most occur has something to do with the nature and distribution of atmospheric energy across the plant’s surface. I’m not making a specific claim about the distribution of tornadoes across time and space. I am saying, rather, that counting tornadoes within an arbitrary boundary in space (or time) can be misleading.

Then, there is the problem we have with all of these storm types, especially tornadoes and hurricanes, of how to actually measure them. Even using standard severity scales, tornadoes can be very different from each other in ways that are not counted in the usual statistics. An F3 tornado that is extra wide and stays on the ground for 100 miles involved significantly more energy than an F4 that formed momentarily and disappeared. Indeed, the different kinds of tornadoes (funnel vs. wedge, for example) really may be very different (but closely related) weather phenomena that should be examined separately at the very same time we combine vastly different storm types to measure and understand at a larger, global scale.

Tornadoes are not a good canary, in the canary in a coal mine sense. But they are obviously important. When we see people stating clearly and plainly that we need not be concerned about the frequency of tornadoes increasing with global warming, we should ask why they are saying that. We should be concerned with increasing storminess … there is almost no way that is not going to happen, and likely, it already has. If tornadoes are part of that increase storminess, we may want to get smart about it fast. For instance, we might want to take seriously the problem of schools and workplaces, where people tend to concentrate, having actual storm shelters instead of just hallways that some administrators says is a storm shelter, for protection when a big tornado comes along. Don’t you think?

See also this post which more directly addresses the question of tornadoes and global warming.

Looking at the raw data, it is clear that there are “more tornadoes” over time in the US. Have a look at this graph:

Annual number of tornadoes for the period 1916-1995; the dashed line connecting solid circles shows the raw data, the red heavy solid line is the result of smoothing. Also shown in the green light solid line is the number of tornado days (i.e., days with one or more tornadoes) per year.

At first glance, his graph makes it look like there are a lot more tornadoes, but there is a strong effect of observer error; earlier tornadoes were simply missed much of the time, so the big increase you see here, while it may reflect an underlying increase in number of tornadoes, is not reliable and cant’ be taken as evidence. However the later years shown here, from 1950-something to the 1990s, seems to show an increase that could be taken as meaningfull

However, when people speak of tornadoes they often show this graph as evidence that there are not more of them over time:

Looks like the number of tornadoes does not go up over time.

Looking only at this graph it looks like the number of tornadoes per year in the US is pretty variable but not increasing, as one would expect if global warming was causing more of them.

There is a problem with this graph, however. Actually, a couple of problems (other than those pointed out here). The main problem is that the most frequent tornadoes are left off this graph. If we look at F0 grade tornadoes, not included here, we see that they have actually increased in frequency over time. If we include ALL tornadoes, and not just the kinds that don’t seem to increase in frequency over time, we get this graph:

Huh. Maybe the number of tornadoes DOES increase over time!

Compare the scales of the last two graphs. It turns out that the number of tornadoes at the smaller end of the scale goes up quite a bit. It might be hard to see. The upper graph goes up to 900, the lower graph goes up to 1900. So, if we add all the data instead of just select data, we get many hundreds more tornadoes per year.

The proportion of tornadoes that are F0 increases over time as shown here:

… and the overall distribution of tornadoes by strength changes over time as shown in this very cool graph:

It isn’t just the F0 tornadoes changing over time. The overall pattern of tornadoes shifts with time.

As I point out here, one of the contributing factors to variation over time in tornado frequency is the fact that we have somewhat arbitrary boundaries in which we measure them. For instance, the US-Canada border provides an arbitrary line across our data set. By not counting all North American tornadoes the same way, we may be adding unnecessary variability to the data. To demonstrate this, have a look at this graph showing tornado frequency per year in France and Germany, two countries that are right next to each other:

Frequency of tornadoes in France and Germany … seems to be uncorrelated.

This shows a few things. For one thing, they don’t have too many tornadoes in that part of the world. For another thing, there is an increase in overall frequency over time, and this is not because of lack of reporting. The reporting problem in the US is partly because the western and central states were relatively empty in the old days, and also more technology was available for spotting tornadoes later. But the European and US data have the same shape over a similar time span, but France and Germany do not have the missing observations owing to vast unoccupied (sort of) territories.

But the main thing I want to demonstrate with this graph is the fact that dividing a largish area of land up into arbitrary units can cause your data go go all flooey. Increased variability in data owing to partitioning is a well known phenomenon and this is what it looks like.

Another part of the problem is that the largest storms, which may be the most important ones, have a great deal of variation in their occurrence. Compare any of the graphs above of all tornadoes or all excluding the F0 tornadoes of this graph of just the largest storms:

Pay attention to the vertical scale, but note that there is a lot of variation over time in these large events. This kind of data almost has too much variability to track change over time meaningfully

Not only is there a lot of variation in numbers of tornadoes at the larger end of the scale, but I suspect there is a lot of variability among the tornadoes in each class in terms of overall energy represented. An F4 tornado that lasts five minutes compared to an F4 tornado that lasts 20 minutes are hugely different, but this is not reflected in this sort of data.

Here is a graph showing the amount of storm damagein adjusted dollars over time in the US (pink) with average temperature (blue). Clearly, the total amount of damage goes up, and probably for a number of reasons including there being more stuff to damage, but also, likely overall increases in storminess including hurricanes, tornadoes, severe thunderstorms, etc.

More storm damage over time

Here is another graph that shows something similar:

Increasing bad stuff over time.

There are many who do not want to link increases in severe weather to global warming. They are probably wrong. Global warming seems to increase severe weather overall. The best way to deny this is to cherry pick the data by ignoring variability across space, leaving out entire categories of storms, or focusing on just some kinds of storms. I suspect the size and severity of tornadoes at the larger end is increasing now, but did not start increasing until recently; time will tell if this is right. But overall tornadoes are so variable across time and space that they are not a reliable canary, as it were. But overall storminess seems to be on the increase, in accordance with expectations from the basis physics of climate, under warming conditions.

Here is one of the nicest demonstrations of the relationship between parasite load and reproduction that I’ve seen in a while. And, as is so often the case, we gain valuable knowledge by closely observing great tits.

Such is the dilemma of reading and reviewing a wonderful book like Lance Fortnow’s The Golden Ticket: P, NP, and the Search for the Impossible. I’ll be tempted to start throwing around terms that Fortnow has explained so well and so clearly. A temptation I should resist. Instead I should recommend this book.

Anyways, what’s the book about? As the title indicates, the purpose is to explain to a popular audience the computer science concept of P vs. NP, in other words is P = NP or is P != NP.

Yeah, not helpful put that way.

A rather nice explanation from the jacket blurb:

The P-NP problem is the most important open problem in computer science, if not all of mathematics. Simply stated, it asks whether every problem whose solution can be quickly checked by computer can also be quickly solved by computer.

And from page ix:

P refers to the problems we can solve quickly using computers. NP refers to the problems to which we would like to find the best solutions. If P = NP, then we can easily find the solution to every problem we would like to solve….If P != NP, by contrast, then there are some problems we cannot hope to solve quickly.

And Fortnow takes it from there, sketching the history of the P vs NP pursuit since it was first formulated in the 1970s up until the present. He also sketches out a bit of a utopian vision of how society would change, how it would become what he calls a beautiful world, if P = NP. If we can know for sure that all problems ultimately have fast solutions, then it’s only a matter of time before we discover them. And solve all our problems.

However, Fortnow doesn’t think that P = NP. He thinks that there is no possible ultimate beautiful world, but that we will have to strive to find “good enough” solutions to those hard problems. And yes, he does talk about what those hard problems are in theoretical computer science and how they affect our everyday lives. Cryptography is perhaps the most well-known application area for those hard problems. Fortnow doesn’t think we are anywhere near to solving P vs NP, that we may even be hundreds of years away. Or that we may never solve it.

Overall a fine book. Comparable in level to a physics book by say, Sean Carroll or Lee Smolin. In other words, you will have to challenge your mind a little to grasp every example and problem description. I would recommend the book for any academic library collection collects popular science. In particular, since there seems to be fewer popular computer science books than other fields, Fortnow’s book fills a gap. I would normally not suggest this type of book for smallish public libraries, but again it does fill that gap. As for school libraries, mathematically gifted students at the high school level would find a lot to love about this book.

At the end of the day, it’s also wonderful to see a computer science book that thanks the library for its print and digital collections in the Acknowledgements. Thanks for the hat tip, Lance, we appreciate it. And thanks for the nice bibliography of sources worth checking out.

Fortnow, Lance. The Golden Ticket: P, NP, and the Search for the Impossible. Princeton: Princeton University Press, 2013. 176pp. ISBN-13: 978-0691156491

(Review copy provided by publisher)

The second part of the scandal is the auditing of political activists who have opposed the administration. The Journal’s Kim Strassel reported an Idaho businessman named Frank VanderSloot, who’d donated more than a million dollars to groups supporting Mitt Romney. He found himself last June, for the first time in 30 years, the target of IRS auditors. His wife and his business were also soon audited. Hal Scherz, a Georgia physician, also came to the government’s attention. He told ABC News: “It is odd that nothing changed on my tax return and I was never audited until I publicly criticized ObamaCare.”

Franklin Graham, son of Billy, told Politico he believes his father was targeted. A conservative Catholic academic who has written for these pages faced questions about her meager freelance writing income. Many of these stories will come out, but not as many as there are. People are not only afraid of being audited, they’re afraid of saying they were audited.

Anecdotes. Powerful stuff. But Silver brings the bucket of cold water:

Ms. Noonan is surely correct that many conservative taxpayers were audited. In fact, based on some simple math that I’ll present in a moment, it’s likely that hundreds of thousands of Mitt Romney voters were selected for an audit in 2012.

However, it’s also likely that hundreds of thousands of Mr. Obama’s supporters were audited. Although the percentage of taxpayers who are audited is relatively low — about 1 percent — the number of taxpayers in the United States is so large that this still yields well more than a million audits every year, across the political spectrum.

That’s just the beginning. The details come later.

OK, I know I use that line entirely too much, but I also don’t really care. When something fits, wear it. And if it doesn’t fit, you must acquit. Sorry, I’ll stop. I’m in a weird mood as I write this. But it’s really hard not to get into a weird mood after reading the lastest bit by that crank to rule all cranks, that quack who tries to rule all quacks, Mike Adams, founder of NaturalNews.com. Last week, he laid down the vile stupid fast and furious to attack Angelina Jolie’s decision to undergo bilateral prophylactic mastectomy. It was hard not to note his fixation with referring to the surgery as “mutilation” and to rant about how surgeons don’t remove other organs to prevent cancer in patients with gene mutations that predispose them to very high risk of specific cancers. It turns out, as I pointed out, that we do. It was also hard not to note his fixation with testicles and prostate and why men supposedly don’t undergo surgery to remove their reproductive parts in order to prevent cancer. He might have had a tiny spore of a point, buried in a black hole of pure pseudoscientific crazy, if there were in fact a gene mutation that conferred an 87% chance of testicular cancer or prostate cancer.

Then I woke up yesterday morning, and you, my readers, were bombarding me with yet one more article by Mike Adams, entitled Angelina Jolie copied by men! Surgeons now cutting out healthy prostate glands of men who carry BRCA gene. In it he references a story about a 53-year-old British man who underwent a prostatectomy after testing positive for a BRCA mutation. The news titles were almost as bad as Adams’ title: UK Man has Prostate Removed after Tests Reveal ‘Jolie’ Gene Flaw (International Business Times) and British father, 53, becomes first man in the world to have his prostate removed to beat cancer flaw which struck Angelina Jolie (Daily Mail). Indeed, the Daily Mail even began its article by writing, “A British father has made medical history by having his healthy prostate removed after discovering that he carries a defective gene that boosts his risk of cancer, it was reported last night.” As you will see, this sentence is every bit as much a misrepresentatino as Adams’ rant and the statement in the IBT article that proclaimed, “After receiving the news the man asked doctors to remove his prostate, which tests had shown to be healthy.”

Characterizing the decision as “Medical self-mutilation… a new fashion statement for the chronically stupid” and speculating that surgeons (yeah, that’s me) are pushing people into having surgery (we’re usually not), Adams couldn’t help but let his imagination run away with him:

Hey, I want to see Brad Pitt’s prostate gland stuffed into a glass tube and hanging around Angelina Jolie’s neck like she used to reportedly do with Billy Bob Thorton’s blood. That wouldn’t be weird, would it?

I think we should start a “Skin Removal Foundation” to have all the skin surgically removed from people who might someday have skin cancer… which includes everyone.

Or better yet, the “Young Women Breast Cancer Prevention Society” which chops off their breasts at age nine, before puberty really kicks in. Just tell your little girls how much you love them before the anesthesia kicks in. That’s what good mommies do, isn’t it?

And for the young boys, why stop at slicing off their foreskin at birth? Penis mutilation is just a warm-up for today’s insane medical monsters. Why not remove their colons at birth so that they never run the risk of dying from colon cancer? Why not cut off their testicles and make sure they never face the future possible risk of testicular cancer, too?

I know, it’s insane. Disgusting. Outrageous. And yet it’s happening right now thanks to women like Angelina Jolie who are publicizing and pushing this idea that women should have healthy breasts cut out of their bodies even though there is no rational medical justification for doing so.

He finishes up with “satire” (which is about as unsubtle and heavy-handed as you would expect from Adams) in which he advertises “1-800-CHOP-OFF,” drive-through double mastectomies, and the Organ Whacker Saw for “do-it-yourself medical mutilation.” Yeah, that’s just Mikey being Mikey. He’s terminally vile.

But what about the story itself? I didn’t even bother with the Daily Fail or the other article. I happened to see a description of this case on Medscape. it was obvious I should go with that over other accounts. The first thing that I noticed about the man who underwent preventative prostatectomy is that he was part of a research study:

The man who underwent surgery was participating in a clinical trial, conducted by the Institute of Cancer Research (ICR), that involved more than 20,000 men. Previous results from this trial have shown that a man with a BRCA2 mutation has an 8.6-fold increased risk of developing prostate cancer, and with a BRCA1 mutation has a 3.4-fold increased risk. Just weeks ago, the ICR researchers reported that prostate cancer in men with the BRCA2 mutation is more aggressive and more likely to be fatal (J Clin Oncol. 2013;31:1748-1757).

“Knowing you are a carrier is like having the sword of Damocles hanging over you,” Dr. Kirby said in an interview with the Sunday Times. “You are living in a state of constant fear. I am sure more male BRCA carriers will follow suit.”

The man who underwent the surgery is described as a 53-years-old businessman from London who is married with children and has several family members who have had breast or prostate cancer. When he found out he was carrying the BRCA2 mutation, he asked to have his prostate removed.

Initially, the ICR researchers were reluctant, the newspaper reports, because there was no indication of a problem, either from prostate-specific antigen tests or from a magnetic resonance imaging scan. However, a biopsy showed microscopic malignant changes.

Here’s the thing that’s not being emphasized, however. This was not preventative surgery. It’s being represented that way in the press or, if it’s mentioned, the fact that there was already cancer there is mentioned but not put in proper context So I will say it again: This is being represented as a case of a man “emulating” Angelina Jolie, but that’s not what it is. This man did not, as the Daily Mail and IBT reported, have a “perfectly healthy prostate.” He had early stage prostate cancer. We don’t know the details, but his surgeon said that he normally wouldn’t have operated, which implies that the cancer cells seen on the biopsy were considered to be of the kind and level that urologists would consider it safe to watch and only intervene if the cancer showed signs of progressing. But this man’s case was different. He had a BRCA2 mutation, and the clinical trial that he was on had shown that BRCA2 mutations are associated with much nastier, more lethal prostate cancers than your run-of-the-mill sporadic prostate cancers. That put his surgeon in a bind over what to do.

Indeed, let’s take a look at the study cited above, which was published just last month. It’s entitled Germline BRCA Mutations Are Associated With Higher Risk of Nodal Involvement, Distant Metastasis, and Poor Survival Outcomes in Prostate Cancer, and the title pretty much says it all. BRCA-associated prostate cancers are nastier cancers. But how much nastier?

The study examined tumor features and outcomes of 2,019 patients with prostate cancer, 18 of whom had BRCA1 mutations and 61 of whom had BRCA2 mutations. Investigators looked at prognostic factors correlating with overall survival (OS), cause-specific OS (CSS), CSS in localized PCa (CSS_M0), metastasis-free survival (MFS), and CSS from metastasis (CSS_M1). What they found is that BRCA1/2 mutation carriers were more likely than noncarriers to have poorly differentiated cancer when diagnosed (35% versus 15%), locally advanced ancer (37% versus 28%) or cancer that had already metastasized (18% versus 9%). In patients whose cancers had spread past the capsule of the prostate at diagnosis, more carriers had metastatic disease within five years (23% versus 7%). While it is true that this study was a retrospective study, with all the shortcomings of retrospective studies, its results were sufficiently clear that it’s hard not to take them as a strong indication that BRCA2 associated prostate cancer tends to be a lot more aggressive and lethal, with the five year OS being 86% for noncarriers and 58% for BRCA2 mutation carriers. That’s a big difference.

Of course, given my discussions of lead time bias and length bias, in which it is not always clear that earlier treatment actually results in better treatment outcomes, you might reasonably ask if more aggressive surgery earlier in men with BRCA2 mutations who have prostate cancer will really improve their odds of surviving the disease (or, more specifically, significantly decrease their odds of dying from it). After all, this man had no indication of prostate cancer by standard measures, including serum PSA levels and a magnetic resonance imaging scan. It was only an prostate biopsy (a procedure for which he had no standard clinical indication to undergo and apparently only underwent because he was on the study and was a BRCA2 carrier). If you look at it another way, he underwent far more intensive screening than the average 53 year old, and it early stage cancer, leading to the question: What to do?

It’s an open question. However, it’s also a question that can’t be answered until a prospective clinical trial is done, a clinical trial that might never be done because of the difficulty between randomizing men with BRCA2 mutations with early stage prostate cancer that normally would be observed, with intervention reserved for men who show evidence of progression on followup ultrasound and biopsy to either immediate surgery or standard “watchful waiting.” At least, such a trial will be very difficult to do because BRCA2 mutations are relatively uncommon causes of prostate cancer, making it difficult to accrue enough subjects, particularly when the two groups are immediate surgery versus delayed surgery. Most men with BRCA2 mutations would very likely want early surgery and would be unlikely to be comfortable being observed knowing that BRCA2 mutations are associated with significantly worse outcomes in prostate cancer. According to Ros Eeles, MBBS, PhD, professor of oncogenetics at the ICR and honorary consultant in clinical oncology at The Royal Marsden NHS Foundation Trust in Surrey:

“It must make sense to start offering affected men immediate surgery or radiotherapy, even for early-stage cases that would otherwise be classified as low risk. We won’t be able to tell for certain that earlier treatment can benefit men with inherited cancer genes until we’ve tested it in a clinical trial, but the hope is that our study will ultimately save lives by directing treatment at those who most need it,” she said in an ICR statement.

Exactly. This man and his surgeon made a difficult decision based on data with a great deal of uncertainty over what the right thing to do was. In the context of a BRCA2 mutation that is associated with a nastier and potentially more lethal variety of breast cancer, it is not unreasonable for a man with early stage prostate cancer to opt for immediate surgery. For all we know, if this were the US, surgeons might very well have recommended immediate surgery anyway even if the man didn’t have a BRCA2 mutation. In the US we tend to treat prostate cancer more aggressively, and only relatively recently have urologists and radiation oncologists become more comfortable with “watchful waiting” for low risk early stage prostate cancer. This man’s decision had nothing to do with Angelina Jolie. It had nothing to do with prevention. It was a therapeutic surgery. One might argue if it was necessary or not. It’s hard to know without knowing the full pathology found on prostate biopsy. But it was not “preventative” surgery. Given that BRCA2 mutations do increase the risk of prostate cancer by around 8-fold, it might actually make sense to consider prophylactic prostatectomy in men with BRCA2 mutations, but that’s a question for future research, and this case is not a case of doing that.

I expect idiotic nonsense from people like Mike Adams. It’s just a shame that this man’s story is being misrepresented by mainstream news organizations as somehow being an indication that men are rushing to emulate Angelina Jolie.

It also squirts cyanide at you if you annoy it.