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Re: (damn) [Re: sirfun] #2907138
02/01/19 11:06 AM
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First time I've ever opened this thread.....no idea what its about. Just felt like quoting sirfun's too long cut & paste.

Originally Posted By: sirfun
https://www.nytimes.com/2018/11/07/magazine/placebo-effect-medicine.html


By Gary Greenberg
Nov. 7, 2018



The Chain of Office of the Dutch city of Leiden is a broad and colorful ceremonial necklace that, draped around the shoulders of Mayor Henri Lenferink, lends a magisterial air to official proceedings in this ancient university town. But whatever gravitas it provided Lenferink as he welcomed a group of researchers to his city, he was quick to undercut it. I am just a humble historian, he told the 300 members of the Society for Interdisciplinary Placebo Studies who had gathered in Leidens ornate municipal concert hall, so I dont know anything about your topic. He was being a little disingenuous. He knew enough about the topic that these psychologists and neuroscientists and physicians and anthropologists and philosophers had come to his city to talk about the placebo effect, the phenomenon whereby suffering people get better from treatments that have no discernible reason to work to call it fake medicine, and to add that it probably works because people like to be cheated. He took a beat. But in the end, I believe that honesty will prevail.

Lenferink might not have been so glib had he attended the previous days meeting on the other side of town, at which two dozen of the leading lights of placebo science spent a preconference day agonizing over their reputation as purveyors of sham medicine who prey on the desperate and, if they are lucky, fool people into feeling better and strategizing about how to improve it. Its an urgent subject for them, and only in part because, like all apostate professionals, they crave mainstream acceptance. More important, they are motivated by a conviction that the placebo is a powerful medical treatment that is ignored by doctors only at their patients expense.

And after a quarter-century of hard work, they have abundant evidence to prove it. Give people a sugar pill, they have shown, and those patients especially if they have one of the chronic, stress-related conditions that register the strongest placebo effects and if the treatment is delivered by someone in whom they have confidence will improve. Tell someone a normal milkshake is a diet beverage, and his gut will respond as if the drink were low fat. Take athletes to the top of the Alps, put them on exercise machines and hook them to an oxygen tank, and they will perform better than when they are breathing room air even if room air is all thats in the tank. Wake a patient from surgery and tell him youve done an arthroscopic repair, and his knee gets better even if all you did was knock him out and put a couple of incisions in his skin. Give a drug a fancy name, and it works better than if you dont.

You dont even have to deceive the patients. You can hand a patient with irritable bowel syndrome a sugar pill, identify it as such and tell her that sugar pills are known to be effective when used as placebos, and she will get better, especially if you take the time to deliver that message with warmth and close attention. Depression, back pain, chemotherapy-related malaise, migraine, post-traumatic stress disorder: The list of conditions that respond to placebos as well as they do to drugs, with some patients is long and growing.

But as ubiquitous as the phenomenon is, and as plentiful the studies that demonstrate it, the placebo effect has yet to become part of the doctors standard armamentarium and not only because it has a reputation as fake medicine doled out by the unscrupulous to the credulous. It also has, so far, resisted a full understanding, its mechanisms shrouded in mystery. Without a clear knowledge of how it works, doctors cant know when to deploy it, or how.

Not that the researchers are without explanations. But most of these have traditionally been psychological in nature, focusing on mechanisms like expectancy the set of beliefs that a person brings into treatment and the kind of conditioning that Ivan Pavlov first described more than a century ago. These theories, which posit that the mind acts upon the body to bring about physical responses, tend to strike doctors and researchers steeped in the scientific tradition as insufficiently scientific to lend credibility to the placebo effect. What makes our research believable to doctors? asks Ted Kaptchuk, head of Harvard Medical Schools Program in Placebo Studies and the Therapeutic Encounter. Its the molecules. They love that stuff. As of now, there are no molecules for conditioning or expectancy or, indeed, for Kaptchuks own pet theory, which holds that the placebo effect is a result of the complex conscious and nonconscious processes embedded in the practitioner-patient relationship and without them, placebo researchers are hard-pressed to gain purchase in mainstream medicine.

But as many of the talks at the conference indicated, this might be about to change. Aided by functional magnetic resonance imaging (f.M.R.I.) and other precise surveillance techniques, Kaptchuk and his colleagues have begun to elucidate an ensemble of biochemical processes that may finally account for how placebos work and why they are more effective for some people, and some disorders, than others. The molecules, in other words, appear to be emerging. And their emergence may reveal fundamental flaws in the way we understand the bodys healing mechanisms, and the way we evaluate whether more standard medical interventions in those processes work, or dont. Long a useful foil for medical science, the placebo effect might soon represent a more fundamental challenge to it.

In a way, the placebo effect owes its poor reputation to the same man who cast aspersions on going to bed late and sleeping in. Benjamin Franklin was, in 1784, the ambassador of the fledgling United States to King Louis XVIs court. Also in Paris at the time was a Viennese physician named Franz Anton Mesmer. Mesmer fled Vienna a few years earlier when the local medical establishment determined that his claim to have cured a young womans blindness by putting her into a trance was false, and that, even worse, there was something unseemly about his relationship with her. By the time he arrived in Paris and hung out his shingle, Mesmer had acquired what he lacked in Vienna: a theory to account for his ability to use trance states to heal people. There was, he claimed, a force pervading the universe called animal magnetism that could cause illness when perturbed. Conveniently enough for Mesmer, the magnetism could be perceived and de-perturbed only by him and people he had trained.

Mesmers method was strange, even in a day when doctors routinely prescribed bloodletting and poison to cure the common cold. A group of people complaining of maladies like fatigue, numbness, paralysis and chronic pain would gather in his office, take seats around an oak cask filled with water and grab on to metal rods immersed in the water. Mesmer would alternately chant, play a glass harmonium and wave his hands at the afflicted patients, who would twitch and cry out and sometimes even lose consciousness, whereupon they would be carried to a recovery room. Enough people reported good results that patients were continually lined up at Mesmers door waiting for the next session.

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It was the kind of success likely to arouse envy among doctors, but more was at stake than professional turf. Mesmers claim that a force existed that could only be perceived and manipulated by the elect few was a direct challenge to an idea central to the Enlightenment: that the truth could be determined by anyone with senses informed by skepticism, that Scripture could be supplanted by facts and priests by a democracy of people who possessed them. So, when the complaints about Mesmer came to Louis, it was to the scientists that the king at pains to show himself an enlightened man turned. He appointed, among others, Lavoisier the chemist, Bailly the astronomer and Guillotin the physician to investigate Mesmers claims, and he installed Franklin at the head of their commission.

To the Franklin commission, the question wasnt whether Mesmer was a fraud and his patients were dupes. Everyone could be acting in good faith, but belief alone did not prove that the magnetism was at work. To settle this question, they designed a series of trials that ruled out possible causes of the observed effects other than animal magnetism. The most likely confounding variable, they thought, was some faculty of mind that made people behave as they did under Mesmers ministrations. To rule this out, the panel settled upon a simple method: a blindfold. Over a period of a few months, they ran a series of experiments that tested whether people experienced the effects of animal magnetism even when they couldnt see.

One of Mesmers disciples, Charles dEslon, conducted the tests. The panel instructed him to wave his hands at a part of a patients body, and then asked the patient where the effect was felt. They took him to a copse to magnetize a tree Mesmer claimed that a patient could be treated by touching one and then asked the patient to find it. They told patients dEslon was in the room when he was not, and vice versa, or that he was doing something that he was not. In trial after trial, the patients responded as if the doctor were doing what they thought he was doing, not what he was actually doing.

It was possibly the first-ever blinded experiment, and it soundly proved what scientists today call the null hypothesis: There was no causal connection between the behavior of the doctor and the response of the patients, which meant, as Franklins panel put it in their report, that this agent, this fluid, has no existence. That didnt imply that people were pretending to twitch or cry out, or lying when they said they felt better; only that their behavior wasnt a result of this nonexistent force. Rather, the panel wrote, the imagination singly produces all the effects attributed to the magnetism.

When the panel gave dEslon a preview of its findings, he took it with equanimity. Given the results of the treatment (as opposed to the experiment), he opined, the imagination, directed to the relief of suffering humanity, would be a most valuable means in the hands of the medical profession a subject to which these august scientists might wish to apply their methods. But events intervened. Franklin was called back to America in 1785; Louis XVI had bigger trouble on his hands and, along with Lavoisier and Bailly, eventually met with the short, sharp shock of the device named for Guillotin.

The panels report was soon translated into English by William Godwin, the father of Mary Shelley. The story spread fast not because of the healing potential that dEslon had suggested, but because of the implications for science as a whole. The panel had demonstrated that by putting imagination out of play, science could find the truth about our suffering bodies, in the same way it had found the truth about heavenly bodies. Hiving off subjectivity from the rest of medical practice, the Franklin commission had laid the conceptual foundation for the brilliant discoveries of modern medicine, the antibiotics and vaccines and other drugs that can be dispensed by whoever happens to possess the prescription pad, and to whoever happens to have the disease. Without meaning to, they had created an epistemology for the healing arts and, in the process, inadvertently conjured the placebo effect, and established it as that to which doctors must remain blind.

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It wouldnt be the last time science would turn its focus to the placebo effect only to quarantine it. At a 1955 meeting of the American Medical Association, the Harvard surgeon Henry Beecher pointed out to his colleagues that while they might have thought that placebos were fake medicine even the name, which means I shall please in Latin, carries more than a hint of contempt they couldnt deny that the results were real. Beecher had been looking at the subject systematically, and he determined that placebos could relieve anxiety and postoperative pain, change the blood chemistry of patients in a way similar to drugs and even cause side effects. In general, he told them, more than one-third of patients would get better when given a treatment that was, pharmacologically speaking, inert.

If the placebo was as powerful as Beecher said, and if doctors wanted to know whether their drugs actually worked, it was not sufficient simply to give patients the drugs and see whether they did better than patients who didnt interact with the doctor at all. Instead, researchers needed to assume that the placebo effect was part of every drug effect, and that drugs could be said to work only to the extent that they worked better than placebos. An accurate measure of drug efficacy would require comparing the response of patients taking it with that of patients taking placebos; the drug effect could then be calculated by subtracting the placebo response from the overall response, much as a deli-counter worker subtracts the weight of the container to determine how much lobster salad youre getting.

In the last half of the 1950s, this calculus gave rise to a new way to evaluate drugs: the double-blind, placebo-controlled clinical trial, in which neither patient nor clinician knew who was getting the active drug and who the placebo. In 1962, when the Food and Drug Administration began to require pharmaceutical companies to prove their new drugs were effective before they came to market, they increasingly turned to the new method; today, virtually every prospective new drug has to outperform placebos on two independent studies in order to gain F.D.A. approval.

Like Franklins commission, the F.D.A. had determined that the only way to sort out the real from the fake in medicine was to isolate the imagination. It also echoed the royal panel by taking note of the placebo effect only long enough to dismiss it, giving it a strange dual nature: Its included in clinical trials because it is recognized as an important part of every treatment, but it is treated as if it were not important in itself. As a result, although virtually every clinical trial is a study of the placebo effect, it remains underexplored an outcome that reflects the fact that there is no money in sugar pills and thus no industry interest in the topic as anything other than a hurdle it needs to overcome.

When Ted Kaptchuk was asked to give the opening keynote address at the conference in Leiden, he contemplated committing the gravest heresy imaginable: kicking off the inaugural gathering of the Society for Interdisciplinary Placebo Studies by declaring that there was no such thing as the placebo effect. When he broached this provocation in conversation with me not long before the conference, it became clear that his point harked directly back to Franklin: that the topic he and his colleagues studied was created by the scientific establishment, and only in order to exclude it which means that they are always playing on hostile terrain. Science is designed to get rid of the husks and find the kernels, he told me. Much can be lost in the threshing in particular, Kaptchuk sometimes worries, the rituals embedded in the doctor-patient encounter that he thinks are fundamental to the placebo effect, and that he believes embody an aspect of medicine that has disappeared as scientists and doctors pursue the course laid by Franklins commission. Medical care is a moral act, he says, in which a suffering person puts his or her fate in the hands of a trusted healer.

I dont love science, Kaptchuk told me. I want to know what heals people. Science may not be the only way to understand illness and healing, but it is the established way. Thats where the power is, Kaptchuk says. That instinct is why he left his position as director of a pain clinic in 1990 to join Harvard and its why he was delighted when, in 2010, he was contacted by Kathryn Hall, a molecular biologist. Here was someone with an interest in his topic who was also an expert in molecules, and who might serve as an emissary to help usher the placebo into the medical establishment.

Halls own journey into placebo studies began 15 years before her meeting with Kaptchuk, when she developed a bad case of carpal tunnel syndrome. Wearing a wrist brace didnt help, and neither did over-the-counter drugs or the codeine her doctor prescribed. When a friend suggested she visit an acupuncturist, Hall balked at the idea of such an unscientific approach. But faced with the alternative, surgery, she decided to make an appointment. I was there for maybe 10 minutes, she recalls, when she stuck a needle here Hall points to a spot on her forearm and this awful pain just shot through my arm. But then the pain receded and her symptoms disappeared, as if they had been carried away on the tide. She received a few more treatments, during which the acupuncturist taught her how to manipulate a spot near her elbow if the pain recurred. Hall needed the fix from time to time, but the problem mostly just went away.

I couldnt believe it, she told me. Two years of gross drugs, and then just one treatment. All these years later, shes still wonder-struck. What was that? she asks. Rub the spot, and the pain just goes away?

Hall was working for a drug company at the time, but she soon left to get a masters degree in visual arts, after which she started a documentary-production company. She was telling her carpal-tunnel story to a friend one day and recounted how the acupuncturist had climbed up on the table with her. (I was like, Oh, my God, what is this woman doing?  she told me. It was very dramatic.) Shed never been able to understand how the treatment worked, and this memory led her to wonder out loud if maybe the drama itself had something to do with the outcome.

Her friend suggested she might find some answers in Ted Kaptchuks work. She picked up his book about Chinese medicine, The Web that Has No Weaver, in which he mentioned the possibility that placebo effects figure strongly in acupuncture, and then she read a study he had conducted that put that question to the test.

Kaptchuk had divided people with irritable bowel syndrome into three groups. In one, acupuncturists went through all the motions of treatment, but used a device that only appeared to insert a needle. Subjects in a second group also got sham acupuncture, but delivered with more elaborate doctor-patient interaction than the first group received. A third group was given no treatment at all. At the end of the trial, both treatment groups improved more than the no-treatment group, and the high interaction group did best of all.

Kaptchuk, who before joining Harvard had been an acupuncturist in private practice, wasnt particularly disturbed by the finding that his own profession worked even when needles were not actually inserted; hed never thought that placebo treatments were fake medicine. He was more interested in how the strength of the treatment varied with the quality and quantity of interaction between the healer and the patient the drama, in other words. Hall reached out to him shortly after she read the paper.

The findings of the I.B.S. study were in keeping with a hypothesis Kaptchuk had formed over the years: that the placebo effect is a biological response to an act of caring; that somehow the encounter itself calls forth healing and that the more intense and focused it is, the more healing it evokes. He elaborated on this idea in a comparative study of conventional medicine, acupuncture and Navajo chantway rituals, in which healers lead storytelling ceremonies for the sick. He argued that all three approaches unfold in a space set aside for the purpose and proceed as if according to a script, with prescribed roles for every participant. Each modality, in other words, is its own kind of ritual, and Kaptchuk suggested that the ritual itself is part of what makes the procedure effective, as if the combined experiences of the healer and the patient, reinforced by the special-but-familiar surroundings, evoke a healing response that operates independently of the treatments specifics. Rituals trigger specific neurobiological pathways that specifically modulate bodily sensations, symptoms and emotions, he wrote. It seems that if the mind can be persuaded, the body can sometimes act accordingly. He ended that paper with a call for further scientific study of the nexus between ritual and healing.

When Hall contacted him, she seemed like a perfect addition to the team he was assembling to do just that. He even had an idea of exactly how she could help. In the course of conducting the study, Kaptchuk had taken DNA samples from subjects in hopes of finding some molecular pattern among the responses. This was an investigation tailor-made to Halls expertise, and she agreed to take it on. Of course, the genome is vast, and it was hard to know where to begin until, she says, she and Kaptchuk attended a talk in which a colleague presented evidence that an enzyme called COMT affected peoples response to pain and painkillers. Levels of that enzyme, Hall already knew, were also correlated with Parkinsons disease, depression and schizophrenia, and in clinical trials people with those conditions had shown a strong placebo response. When they heard that COMT was also correlated with pain response another area with significant placebo effects Hall recalls, Ted and I looked at each other and were like: Thats it! Thats it! 

It is not possible to assay levels of COMT directly in a living brain, but there is a snippet of the genome called rs4680 that governs the production of the enzyme, and that varies from one person to another: One variant predicts low levels of COMT, while another predicts high levels. When Hall analyzed the I.B.S. patients DNA, she found a distinct trend. Those with the high-COMT variant had the weakest placebo responses, and those with the opposite variant had the strongest. These effects were compounded by the amount of interaction each patient got: For instance, low-COMT, high-interaction patients fared best of all, but the low-COMT subjects who were placed in the no-treatment group did worse than the other genotypes in that group. They were, in other words, more sensitive to the impact of the relationship with the healer.

The discovery of this genetic correlation to placebo response set Hall off on a continuing effort to identify the biochemical ensemble she calls the placebome the term reflecting her belief that it will one day take its place among the other important -omes of medical science, from the genome to the microbiome. The rs4680 gene snippet is one of a group that governs the production of COMT, and COMT is one of a number of enzymes that determine levels of catecholamines, a group of brain chemicals that includes dopamine and epinephrine. (Low COMT tends to mean higher levels of dopamine, and vice versa.) Hall points out that the catecholamines are associated with stress, as well as with reward and good feeling, which bolsters the possibility that the placebome plays an important role in illness and health, especially in the chronic, stress-related conditions that are most susceptible to placebo effects.

Image

CreditPhoto illustration by Paul Sahre
Her findings take their place among other results from neuroscientists that strengthen the placebos claim to a place at the medical table, in particular studies using f.M.R.I. machines that have found consistent patterns of brain activation in placebo responders. For years, we thought of the placebo effect as the work of imagination, Hall says. Now through imaging you can literally see the brain lighting up when you give someone a sugar pill.

One group with a particularly keen interest in those brain images, as Hall well knows, is her former employers in the pharmaceutical industry. The placebo effect has been plaguing their business for more than a half-century since the placebo-controlled study became the clinical-trial gold standard, requiring a new drug to demonstrate a significant therapeutic benefit over placebo to gain F.D.A. approval.

Thats a bar that is becoming ever more difficult to surmount, because the placebo effect seems to be becoming stronger as time goes on. A 2015 study published in the journal Pain analyzed 84 clinical trials of pain medication conducted between 1990 and 2013 and found that in some cases the efficacy of placebo had grown sharply, narrowing the gap with the drugs effect from 27 percent on average to just 9 percent. The only studies in which this increase was detected were conducted in the United States, which has spawned a variety of theories to explain the phenomenon: that patients in the United States, one of only two countries where medications are allowed to be marketed directly to consumers, have been conditioned to expect greater benefit from drugs; or that the larger and longer-duration trials more common in America have led to their often being farmed out to contract organizations whose nurses only job is to conduct the trial, perhaps fostering a more placebo-triggering therapeutic interaction.

Whatever the reason, a result is that drugs that pass the first couple of stages of the F.D.A. approval process founder more and more frequently in the larger late-stage trials; more than 90 percent of pain medications now fail at this stage. The industry would be delighted if it were able to identify placebo responders say, by their genome and exclude them from clinical trials.

That may seem like putting a thumb on the scale for drugs, but under the logic of the drug-approval regime, to eliminate placebo effects is not to cheat; it merely reduces the noise in order for the drugs signal to be heard more clearly. That simple logic, however, may not hold up as Hall continues her research into the genetic basis of the placebo. Indeed, that research may have deeper implications for clinical drug trials, and for the drugs themselves, than pharma companies might expect.

Since 2013, Hall has been involved with the Womens Health Study, which has tracked the cardiovascular health of nearly 40,000 women over more than 20 years. The subjects were randomly divided into four groups, following standard clinical-trial protocol, and received a daily dose of either vitamin E, aspirin, vitamin E with aspirin or a placebo. A subset also had their DNA sampled which, Hall realized, offered her a vastly larger genetic database to plumb for markers correlated to placebo response. Analyzing the data amassed during the first 10 years of the study, Hall found that the women with the low-COMT gene variant had significantly higher rates of heart disease than women with the high-COMT variant, and that the risk was reduced for those low-COMT women who received the active treatments but not in those given placebos. Among high-COMT people, the results were the inverse: Women taking placebos had the lowest rates of disease; people in the treatment arms had an increased risk.

These findings in some ways seem to confound the results of the I.B.S. study, in which it was the low-COMT patients who benefited most from the placebo. But, Hall argues, whats important isnt the direction of the effect, but rather that there is an effect, one that varies depending on genotype and that the same gene variant also seems to determine the relative effectiveness of the drug. This outcome contradicts the logic underlying clinical trials. It suggests that placebo and drug do not involve separate processes, one psychological and the other physical, that add up to the overall effectiveness of the treatment; rather, they may both operate on the same biochemical pathway the one governed in part by the COMT gene.

Hall has begun to think that the placebome will wind up essentially being a chemical pathway along which healing signals travel and not only to the mind, as an experience of feeling better, but also to the body. This pathway may be where the brain translates the act of caring into physical healing, turning on the biological processes that relieve pain, reduce inflammation and promote health, especially in chronic and stress-related illnesses like irritable bowel syndrome and some heart diseases. If the brain employs this same pathway in response to drugs and placebos, then of course it is possible that they might work together, like convoys of drafting trucks, to traverse the territory. But it is also possible that they will encroach on one another, that there will be traffic jams in the pathway.

What if, Hall wonders, a treatment fails to work not because the drug and the individual are biochemically incompatible, but rather because in some people the drug interferes with the placebo response, which if properly used might reduce disease? Or conversely, what if the placebo response is, in people with a different variant, working against drug treatments, which would mean that a change in the psychosocial context could make the drug more effective? Everyone may respond to the clinical setting, but there is no reason to think that the response is always positive. According to Halls new way of thinking, the placebo effect is not just some constant to be subtracted from the drug effect but an intrinsic part of a complex interaction among genes, drugs and mind. And if shes right, then one of the cornerstones of modern medicine the placebo-controlled clinical trial is deeply flawed.

When Kathryn Hall told Ted Kaptchuk what she was finding as she explored the relationship of COMT to the placebo response, he was galvanized. Get this molecule on the map! he urged her. Its not hard to understand his excitement. More than two centuries after dEslon suggested that scientists turn their attention directly to the placebo effect, she did exactly that and came up with a finding that might have persuaded even Ben Franklin.

But Kaptchuk also has a deeper unease about Halls discovery. The placebo effect cant be totally reduced to its molecules, he feels certain and while research like Halls will surely enhance its credibility, he also sees a risk in playing his game on scientific turf. Once you start measuring the placebo effect in a quantitative way, he says, youre transforming it to be something other than what it is. You suck out what was previously there and turn it into science. Reduced to its molecules, he fears, the placebo effect may become yet another thing on the conveyor belt of routinized care.

Were dancing with the devil here, Kaptchuk once told me, by way of demonstrating that he was aware of the risks hes taking in using science to investigate a phenomenon it defined only to exclude. Kaptchuk, an observant Jew who is a student of both the Torah and the Talmud, later modified his comment. Its more like Jacob wrestling with the angel, he said a battle that Jacob won, but only at the expense of a hip injury that left him lame for the rest of his life.

Indeed, Kaptchuk seems wounded when he complains about the pervasiveness of research that uses healthy volunteers in academic settings, as if the response to mild pain inflicted on an undergraduate participating in an on-campus experiment is somehow comparable to the despair often suffered by people with chronic, intractable pain. He becomes annoyed when he talks about how quickly some of his colleagues want to move from these studies to clinical recommendations. And he can even be disparaging of his own work, wondering, for instance, whether the study in which placebos were openly given to irritable bowel syndrome patients succeeded only because it convinced the subjects that the sugar was really a drug. But its the prospect of what will become of his findings, and of the placebo, as they make their way into clinical practice, that really seems to torment him.

Kaptchuk may wish to help reconfigure biomedicine by rejecting the idea that healing is only the application of mechanical tools. He may believe that healing is a moral act in which caring in the context of hope qualitatively changes clinical outcomes. He may be convinced that the relationship kindled by the encounter between a suffering person and a healer is a central, and almost entirely overlooked, component of medical treatment. And he may have dedicated the last 20 years of his life to persuading the medical establishment to listen to him. But he may also come to regret the outcome.

After all, if Hall is right that clinician warmth is especially effective with a certain genotype, then, as she wrote in the paper presenting her findings from the I.B.S./sham-acupuncture study, it is also true that a different group will derive minimum benefit from empathic attentions. Should medical rituals be doled out according to genotype, with warmth and caring withheld in order to clear the way for the drugs? And if she is correct that a certain ensemble of neurochemical events underlies the placebo effect, then what is to stop a drug company from manufacturing a drug a real drug, that is that activates the same process pharmacologically? Welcomed back into the medical fold, the placebo effect may raise enough mischief to make Kaptchuk rue its return, and bewilder patients when they discover that their doctors bedside manner is tailored to their genes.

For the most part, most days, Kaptchuk manages to keep his qualms to himself, to carry on as if he were fully confident that scientific inquiry can restore the moral dimension to medicine. But the precariousness of his endeavors is never far from his mind. Will this work destroy the stuff that actually has to do with wisdom, preciousness, imagination, the things that are actually critical to who we are as human beings? he asks. His answer: I dont know, but I have to believe there is an infinite reserve of wisdom and imagination that will resist being reduced to simple materialistic explanations.

The ability to hold two contradictory thoughts in mind at the same time seems to come naturally to Kaptchuk, but he may overestimate its prevalence in the rest of us. Even if his optimism is well placed, however, theres nothing like being sick to make a person toss that kind of intelligence aside in favor of the certainties offered by modern medicine. Indeed, its exactly that yearning that sickness seems to awaken and that our healers, imbued with the power of science, purport to provide, no imagination required. Armed with our confidence in them, were pleased to give ourselves over to their ministrations, and pleased to believe that its the molecules, and the molecules alone, that are healing us. People do like to be cheated, after all.



“I always thank God I didn't go to film school because I would have learned that I couldn't be doing what I've been doing already.” - Bruce Brown,
Re: (damn) [Re: GromsDad] #2907152
02/01/19 12:49 PM
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Originally Posted By: GromsDad
First time I've ever opened this thread.....


WELCOME to the (damn !! ) POLITICS that never end !! )

Originally Posted By: GromsDad
Just felt like quoting sirfun's too long cut & paste.


You are getting better at expressing your feelings and your intellect is evolving too !! )



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https://www.nytimes.com/2019/01/29/upshot/can-technology-help-fix-the-housing-market.html


We the People of the United States, in Order to form a more perfect Union .. cheers
Re: (damn) [Re: sirfun] #2907678
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Re: (damn) [Re: sirfun] #2907937
02/03/19 10:55 AM
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GET OFF OF MY LAWN !! ) roflmao


the counsel vote !! )


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I was first elected to the Iowa legislature in 1978, when I was still in my late 20s. I served for seven terms in the House and another three terms in the Senate. I worked on passing nonpartisan redistricting legislation, creating REAP (a program enhancing and protecting Iowa’s natural resources), developing sentencing-reform legislation, protecting the elderly from abuse, and floor-managing one of the toughest drunk-driving laws in the nation.

While my emphasis was on bipartisan legislative undertakings, I was comfortable with my party’s priorities and felt at home in the Republican caucus. Governor Robert Ray, a Republican, was in office when I first served and was a wonderful mentor. I continue to believe that he epitomizes what is best about public service—integrity, compassion, moderation, and a spirit of rational inquiry.


But after 24 years in the legislature, I made the decision to return to Jones County to serve as a county supervisor. My four children were in or approaching their teenage years, and I felt I was needed at home. I had missed some important moments in my children’s lives—school concerts, parent-teacher conferences, sport events—and wished to make up for the time I had lost. And with college expenses on the horizon, I also needed to put more time into my law practice.


Fifteen years later, after my kids were grown and I retired from my law practice, I decided to return to the state capitol. I wasn’t quite ready for retirement and felt that I had more to contribute. What I found, however, was very different from the legislative body I had once served in.

The legislature is considerably more partisan and regimented than it used to be. I believe the increased partisanship often stands in the way of good legislation, and I’m also deeply concerned by the growing influence that big money exerts on the legislative process.

I also found a very changed Republican caucus. While I have great respect and personal regard for my Republican colleagues, I found myself more and more uncomfortable with the stance of my party on the majority of high-profile issues, such as gutting Iowa’s collective-bargaining law and politicizing our method of selecting judges. I worked for changes to improve legislation that I had concerns about, but also voted against many of these priorities.

I might have limped along—attempting to work within my caucus for what I felt was best for the people I represent—if it hadn’t been for another factor. With the 2020 presidential election looming on the horizon, I felt, as a Republican, that I needed to be able to support the standard-bearer of the party. Unfortunately, that is something I’m unable to do.

I believe that it is just a matter of time before our country pays a heavy price for President Donald Trump’s reckless spending and shortsighted financial policies; his erratic, destabilizing foreign policy; and his disdain and disregard for environmental concerns.

Furthermore, he sets a poor example for the nation and our children. He delivers personal insults, often in a crude and juvenile fashion, to those who disagree with him, and is a bully at a time when we’re attempting to discourage bullying, on- and offline.

In addition, he frequently disregards the truth and displays a willingness to ridicule or marginalize people for their appearance, ethnicity, and disability.

I believe that his actions have coarsened political discourse, contributing to unprecedented polarization and creating a breeding ground for hateful rhetoric and actions.

Some would excuse this behavior, claiming Trump is just telling it like it is—and that this is the new normal. If this is the new normal, I want no part of it. Unacceptable behavior should be called out for what it is—and Americans of all parties should insist on something far better from the man holding the highest office in the land.

All of which is to say that my decision to switch political parties has been a very difficult decision for me and has only come after considerable reflection, much prayer, and many restless nights. I had been a registered Republican for close to half a century, a Republican officeholder for 35 years, and the longest-serving Republican currently in the Iowa legislature. I am proud of many good things that the Republican Party has accomplished over the years.

I am all too aware that my decision is a disappointment to many friends and colleagues who have supported me over the years. However, the time comes when you have to be true to yourself and follow the dictates of your conscience. For me, that time is now.

I want the people I represent in Jones, Jackson, and Dubuque Counties to know that I’m still the same Andy McKean today that they knew yesterday. We still share the same basic values, are proud of our families and our communities, and want to make Iowa an even better place. I’ll continue to work for the same goals and priorities that I always have during my years in public service.

I look forward to continuing my service in the Iowa House and bringing people together to improve the quality of life for all Iowans.



https://www.theatlantic.com/ideas/archive/2019/05/andy-mckean-why-im-becoming-democrat/589240/


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Re: (damn) [Re: sirfun] #2957164
05/21/19 08:50 AM
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Jared Diamond’s new book, Upheaval, addresses itself to a world very obviously in crisis, and tries to lift some lessons for what do about it from the distant past. In that way, it’s not so different from all the other books that have made the UCLA geographer a sort of don of “big think” history and a perennial favorite of people like Steven Pinker and Bill Gates.

Diamond’s life as a public intellectual began with his 1991 book The Third Chimpanzee, a work of evolutionary psychology, but really took off with Guns, Germs, and Steel, published in 1997, which offered a three-word explanation for the rise of the West to the status of global empire in the modern era — and, even published right at the “end of history,” got no little flak from critics who saw in it both geographic determinism and what they might today call a whiff of Western supremacy. In 2005, he published Collapse, a series of case studies about what made ancient civilizations fall into disarray in the face of environmental challenges — a doorstopper that has become a kind of touchstone work for understanding the crisis of climate change today. In The World Until Yesterday, published in 2012, he asked what we can learn from traditional societies; and in his new book, he asks what we can learn from ones more like our own that have faced upheaval but nevertheless endured.

I obviously want to talk about your new book, but I thought it might be useful to start by asking you how you saw it in the context of your life’s work.
Sure. Here’s my answer, and I think you’ll find it banal and more disappointing than what you might have hoped for. People often ask me what’s the relation between your books and the answer is there is none. Really, each book is what I was most interested in and felt most at hand when I finished my previous book.

Well, it may be a narrative that suggests itself to me because I’m thinking of Guns, Germs and Steel, Collapse, and this new one, Upheaval, but for me it’s interesting to note that each of them arrived when they did in a particular cultural, intellectual moment. That begins with Guns, Germs and Steel — it’s obviously a quite nuanced historical survey, but it was also read coming out when it did, as a kind of explanation for Western dominance of the planet …
I would say you’re giving me more credit than I deserve. But one-third of the credit that you give me I do deserve. And that’s for Collapse. Guns, Germs and Steel, I don’t see it as triumphalist at all.

No, I don’t either. I don’t mean to say that. But it met the moment of Western triumphalism in our culture, I think.
The fact is that you and I are speaking English. We’re not speaking Algonquin and there are reasons for that. I don’t see that as a triumph of the English language. I see it as the fact of how history turned out, and that’s what Guns, Germs and Steel is about.

If you don’t mind dwelling on Collapse for a second … Has your view of these issues changed at all over the intervening years? I mean, when you think about how societies have faced environmental challenges, how adaptable they are and how resilient they might be, do you find yourself having the same views that you had a decade and a half ago?
Yes. My views are the same because I think the story that I saw in 2005, it’s still true today. It still is the case that there are many past societies that destroyed themselves by environmental damage. Since I wrote the book, more cases have come out. There have been studies of the environmental collapse of Cahokia, outside St. Louis. Cahokia was the most populous Native American society in North America. And I when I wrote Collapse it wasn’t known why Cahokia had collapsed, but subsequently we’ve learned that there was a very good study about the role of climate changes and flooding on the Mississippi River in ruining Cahokia. So that book, yes, it was related to what was going on. But the story today, nothing has changed. Past societies have destroyed themselves. In the past 14 years it has not been undone that past societies destroyed themselves.

Today, the risk that we’re facing is not of societies collapsing one by one, but because of globalization, the risk we are facing is of the collapse of the whole world.

How likely do you think that is? That the whole network of civilization would collapse?
I would estimate the chances are about 49 percent that the world as we know it will collapse by about 2050. I’ll be dead by then but my kids will be, what? Sixty-three years old in 2050. So this is a subject of much practical interest to me. At the rate we’re going now, resources that are essential for complex societies are being managed unsustainably. Fisheries around the world, most fisheries are being managed unsustainably, and they’re getting depleted. Farms around the world, most farms are being managed unsustainably. Soil, topsoil around the world. Fresh water around the world is being managed unsustainably. With all these things, at the rate we’re going now, we can carry on with our present unsustainable use for a few decades, and by around 2050 we won’t be able to continue it any longer. Which means that by 2050 either we’ve figured out a sustainable course, or it’ll be too late.

So let’s talk about that sustainable course. What are the lessons in the new book that might help us adjust our course in that way?
As far as national crises are concerned, the first step is acknowledge — the country has to acknowledge that it’s in a crisis. If the country denies that it’s in a crisis, of course if you deny you’re in a crisis, you’re not going to solve the crisis, number one. In the United States today, lots of Americans don’t acknowledge that we’re in a crisis.

Number two, once you acknowledge that you’re in a crisis, you have to acknowledge that there’s something you can do about it. You have responsibility. If instead you say that the crisis is the fault of somebody else, then you’re not going to make any progress towards solving it. An example today are those, including our political leaders, who say that the problems of the United States are not caused by the United States, but they’re caused by China and Canada and Mexico. But if we say that our problems are caused by other countries, that implies that it’s not up to us to solve our problems. We’re not causing them. So, that’s an obvious second step.

On climate in particular, there seem to be a lot of countervailing impulses on the environmental left — from those who believe the only solution to addressing climate is through individual action to those who are really focused on the villainy of particular corporate interests, the bad behavior of the Republican Party, et cetera. In that context, what does it mean to accept responsibility?
My understanding is that, in contrast to five years ago, the majority of American citizens and voters recognize the reality of climate change. So there is, I’d say, recognition by the American public as a whole that there is quite a change in that we are responsible for it.

Right.
As for what we can do about it, whether to deal with it by individual action, or at a middle scale by corporate action, or at a top scale by government action — all three of those. Individually we can do things. We can buy different sorts of cars. We can do less driving. We can vote for public transport. That’s one thing. There are also corporate interests because I’m on the board of directors for the World Wildlife Fund and I was on the board of Conservation International, and on our boards are leaders of really big companies like Walmart and Coca-Cola are their heads, their CEOs, have been on our boards.

I see that corporations, big corporations, while some of them do horrible things, some of them also are doing wonderful things which don’t make the front page. When there was the Exxon Valdez spill off Alaska, you can bet that made the front page. When Chevron was managing its oil field in Papua New Guinea in a utterly rigorous way, better than any national park I’ve ever been in, that certainly did not make the front page because it wasn’t a good picture.

And then finally the Republican Party, yes. Government has a role. In short, climate change can be addressed at all these levels. Individual, corporation, and the national level.

In the book, when you write about the present day — you talk about climate, you talk about resources, but you also talk about the threat of nuclear war and nuclear weapons. It may be kind of a foolish question to ask, but … how do you rank those threats?
I’m repressing a chuckle because I know how people react when I answer that. Whenever somebody tells me, “How should we prioritize our efforts?” My answer is, “We should not be prioritizing our efforts.” It’s like someone asking me, “Jared, I’m about to get married. What is the most important factor for a happy marriage?” And my response is, “If you’re asking me what is the most important factor for a happy marriage, I’d predict that you’re going to get divorced within a few years.” Because in order to have a happy marriage you’ve got to get 37 things right. And if you get 36 right but you don’t get sex right, or you don’t get money right, or you don’t get your in-laws right, you will get divorced. You got to get lots of things right.

So for the state of the world today, how do we prioritize what’s going on in the world? We have to avoid a nuclear holocaust. If we have a nuclear holocaust, we’re finished, even if we solve climate change. We have to solve climate change because if we don’t solve climate change but we deal with a nuclear holocaust, we’re finished. If we solve climate change and don’t have a nuclear holocaust but we continue with unsustainable resource use, we’re finished. And if we deal with the nuclear problem and climate change and sustainable use, but we maintain or increase inequality around the world, we’re finished. So, we can’t prioritize. Just as a couple in a marriage have to agree about sex and children and in-laws and money and religion and politics. We got to solve all four of those problems.

What should we do? Are there lessons from history?
To conduct a happy marriage, it’s not enough to sit back and have a holistic view of marriage. Instead you need to discuss your budget and your in-laws and 36 other things. As far as the world is concerned, solving national crises, the checklist that I came up with in my book is a checklist of a dozen factors. Now, I could make a longer checklist, or I could make a shorter checklist, but if we have a checklist of three factors it would be obvious we’re missing some big things. And if we had a checklist of 72 factors, then nobody would pick up my book and they wouldn’t pay attention to it.

As an example of one of those factors that the United States is really messing up now, it’s the factor of using other countries as models for solving problems. Just as with personal crises, when someone’s marriage breaks down or is at risk of breaking down, one way of dealing with it is to look at other people who have happy marriages and learn from their model of how to conduct a happy marriage. But the United States today believes what’s called American exceptionalism. That phrase, American exceptionalism means the belief that the United States is unique, exceptional, therefore there’s nothing we can learn from other countries. But we’ve got this neighbor, Canada, which is a democracy sharing our continent and there are other democracies throughout Western Europe in Australia and Japan. All of these democracies face problems that we are not doing well with. All of these democracies have problems with their national health system. And they have problems with education. And they have problems with prisons. And they have problems with balancing individual interests with community interests. But the United States, we too have prisons and we’ve got education and we have a national health system, and we are dissatisfied. Most Americans are dissatisfied with our national health system, and most Americans are increasingly dissatisfied with our educational system.

Other countries face these same problems and other countries do reasonably well, better than the United States in solving these problems. So, one thing that we can learn is to look at other countries as models and disabuse ourselves of the idea that the United States is exceptional and so there’s nothing we can learn from any other country, which is nonsense.

Do you think of this as being a sort of book about the path forward for the U.S.? Or do you think of it as having a broader, global audience?
It is a book about the U.S. plus 215 other countries. The United States is one country in the world, and we’ve got our own problems, which we are struggling with. I came back from Italy and Britain. Britain when I was there was at the peak of Brexit, but Britain is still at the peak of Brexit.

They’re not leaving that behind.
They’re making, I would say, zero progress with Brexit. Italy has its own big problems. Papua New Guinea has its own problems. I’m trying to think what country does not have problems …

It’s hard.
Norway is doing pretty well. What else?

Portugal maybe is doing relatively well.
Which one is that?

Portugal, maybe.
Portugal, maybe. Costa Rica, all things considered. Well, Costa Rica has problems because I think all four of Costa Rica’s last four presidents are in jail at the moment. That’s a significant problem.

If there’s hardly a nation in the world that seems to be a good model, a thriving example for other nations of the world to follow behind, how much faith does that give you that we can find our way to a kind of sustainable, prosperous, and fulfilling future?
That’s an interesting question. If I had stopped the book on the chapter about the world without writing the last six pages, it would have been a pessimistic chapter, because at that point I thought the world does not have a track record of solving difficult problems. The U.N., well bless it, but the U.N. isn’t sufficiently powerful, and therefore I feel pessimistic about our chances of solving big world problems.

But then, fortunately, I learned by talking with friends that the world does have a successful track record in the last 40 years about solving really complex, thorny problems. For example, the coastal economics. So many countries have overlapping coastal economic zones. What a horrible challenge that was to get all the countries in the world to agree with delineating their coastal economic zones. But it worked. They’re delineated.

Or smallpox. To eliminate smallpox it had to be eliminated in every country. That included eliminating it in Ethiopia and Somalia. Boy, was it difficult to eliminate smallpox in Somalia, but it was eliminated.

I wonder if I could ask you about California in particular. It’s interesting to me in the sense that when I look at the example of California, I see a lot of reasons for hope in the sense that there’s quite focused attention on climate and resources used there — probably more sustained interested in those subjects than there really is anywhere else in the U.S. And it has policy that’s, by any metric, I think more progressive than the relevant policies elsewhere in the U.S.

And yet, it’s also a state that — maybe it’s an unfortunate phrase — by accident of geography is also facing some of the most intense pressures and dealing with the most intense impacts already, from water issues to wildfire and all the rest of it. As a Californian who’s informed by these concerns looking at the future and thinking about the future, how does the future of California look to you?
California has problems like every other place in the world. But California makes me optimistic. It does have the environmental problems but nevertheless we have, I would say, one of the best state governments, if not the best state government in the United States. And relatively educated citizens. And we have the best system of public education, of public higher education in the United States. Although, I, at the University of California, know very well that we are screaming at the legislature for more money. So we have problems but we’re giving me hope at how we’re dealing with those problems.

I’m a native New Yorker and lived my whole life in this environment on the East Coast. And when I see images of those wildfires and when I hear stories of people I know or people I meet, and the fact that they’ve evacuated, the fact that no matter where you are in Southern California, also in parts of Central California and Northern California, you have an evacuation plan in mind. I just don’t understand how you guys can live like that. It must begin to impose some kind of psychic cost.
Well, I understand psychic costs and I understand getting my head around it because I was born and grew up in Boston. The last straw for me was that in Boston I sang in the Handel and Haydn Society chorus, and we were going to perform in Boston Symphony Hall the last week in May and our concert was canceled by a snowstorm that closed Boston down. And for me that was the last straw. I do not want to live in a city where a concert in Symphony Hall is going to get closed down in the last week of May by a snowstorm.

That’s just one event, but the fact is that Boston is and was miserable for five months of the year in the winter and then it’s nice for two weeks in the spring and then it’s miserable for four months in the summer, then it’s nice for a few weeks in the fall. Similarly with New York. So when I moved here, my reaction is, “Yes, we have the fires and we have the earthquakes and we have the mudslide and we have the risk of flooding. But, thank God for all those things because they saved me from the psychic costs of living in the Northeast.”

http://nymag.com/intelligencer/2019/05/jared-diamond-on-his-new-book-upheaval.html


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Trippy.

RIP


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I heard the freight train and saw the debris spinning in the sky as it touched down less then a mile away !!


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https://youtu.be/52-wgeRoWX4

Russian spy in Estonia tells story

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