Human Nature: Science, Technology, and Life.

Ankles Away

Looks like I missed a joint.

A couple of months ago, I wrote about the artificial parts we've been putting into people: hips, knees, shoulders, spinal discs, and elbows. U.S. government stats show more than 1 million such replacements per year. Piece by piece, we're mechanizing the body.

Next up: ankles.

Lauran Neergard of the AP has the story. There's a healthy (actually, an unhealthy) market for new ankles: More than 200,000 patients go to doctors for ankle pain every year. The prevailing surgical option is to fuse the ankle bones, which gets rid of the friction, and therefore the pain, but skews the way you move your foot. That, in turn, increases the strain on other foot joints, causing more pain and more fusions.

So why hasn't ankle replacement become as popular as hip or knee replacement? Because ankles are smaller and have to shoulder (so to speak) more stress. The original generation of artificial ankles broke down under normal wear and tear. A new generation is just now taking off. They cost up to $50,000 but are designed to operate more like a natural ankle, which would avoid the downstream damage associated with fusion. Neergard explains how they work:

Each model is slightly different but consists of two attached parts. Surgeons drill a tunnel into the lower leg bone and slide in the stem of the artificial joint. A bottom piece connects to the top of the foot. Thin plastic hooked to one side functions as cartilage. Bone then grows into the implant, holding it in place. In Europe, doctors also can use a similar but three-piece artificial ankle, where the plastic cushion is free-floating.

So the artificial cushion relieves day-to-day strains on the ankle, while the body, through bone growth, adopts the new mechanism as its own. Biology absorbs technology. Very cool. Let's hope it works.

Droneheads

Several of you have implied in the Fray that I'm obsessed with drones. This is really quite unfair. If you want to see true obsession, visit Wired's military blog, Danger Room, where you can read more than 300 posts about unmanned aerial vehicles, or unmanned aerial systems, or whatever the hell the Pentagon (or is it the CIA?) is calling them now. The DR crew doesn't just follow the drone war in Pakistan from afar, as I do. They go straight to the Pakistani press.

Take a quick stroll through their recent archive and you'll see that they're way ahead of me in tracking the revolution. For example: Pakistan already has spy (not killer) drones. The Russians are buying drones ... from Israel. Iraq wants drones, too.

I could spend all day at that blog. But that might be a tad, you know, obsessive.

The Birthmark

Six years ago, President Bush's bioethics council opened its inaugural meeting with a discussion of The Birth-Mark, a Nathaniel Hawthorne short story. Council member Bill May summarized the plot, in which a scientist "loves his wife but kills her in the attempt to remove her single imperfection, a birthmark on her left cheek." For nearly an hour, the council sat around debating what the mark symbolized.

Today, the council has run its course—the Obama administration will probably replace it with a more sympathetic panel—but the news has come back to birthmarks. The Vascular Birthmarks Foundation and the Vascular Birthmark Institute of New York just held their eighth annual Vascular Birthmarks Conference, at which dozens of families met with doctors to discuss surgery and other medical options. The New York Times reports from the conference:

"We can no longer accept that a child can go through life being severely disfigured, and accept that as their lot," said Dr. [Milton] Waner, the co-director of the Vascular Birthmark Institute. "Something needs to be done, and I believe that every child has the right to look normal." ... Much of the concern, for many families at the conference, was financial. Doctors said insurance providers frequently refused to pay for the treatments, classifying them as cosmetic surgery. "Their definition of cosmetic is very broad," Dr. Waner said. "This is not cosmetic."

Strictly speaking, Dr. Waner is incorrect. Disfigurement per se is cosmetic. Merriam-Webster's medical dictionary, on which the National Institutes of Health rely, defines cosmetic as "of, relating to, or making for beauty." It defines cosmetic surgery as "correcting defects especially of the face." One question is whether insurers should cover such procedures. Beneath that question lies another: Do children need them?

When you read about these kids and the abuse they sometimes endure for looking unusual, your heart goes out to them. One mother tells the Times about a boy who walked past her son and said, "Look at your face. You look ugly." But which is the problem, the birthmark or the bad attitude? Something needs to be done, but is it surgery? Is every child entitled to "look normal"? Or is he entitled to respect regardless of how he looks?

As it happens, surgery for the kid who was called ugly is a no-brainer. That's because his disfigurement had functional effects, enlarging his tongue so he couldn't speak intelligibly. Dr. Waner and others who take on such cases pro bono are doing noble work. But the quest for normality can extend to iffier cases. The Times describes a baby at the conference who "has a circular, purple mark on her forehead about the size of a nickel." Such defects, known as hemangiomas, "often disappear or shrink in 10 to 12 years, but they can have a social and psychological impact—on children in particular, who must live with the stigma of looking different." Is that a good reason for surgery?

I'm not saying kids with purely cosmetic defects don't suffer. They do. But their suffering isn't medical. It's social. Cosmetic surgery changes an otherwise healthy body to fit culturally imposed aesthetic standards. If a purple mark on your forehead is too much to bear, what about male breasts? What about a flat female chest? How far should we extend the "right"—and, implicitly, the obligation—to look normal?

We had a vascular birth mark in my family. It was considerably bigger than a nickel. In time, it subsided and vanished. The child who was born with it had something more important than the right to look normal. She had the right not to.

P.S. It looks like our "discuss" link is still broken, so here's a handmade link to the HN fray in case you'd like to join the discussion: http://fray.slate.com/discuss/forums/2100253/ShowForum.aspx.

Eyes and Ears

A week ago, when we last checked in on the drone war in Pakistan, the news wasn't good. Insurgents had bombed a Pakistani hotel and a security checkpoint, apparently in retaliation for drone strikes on them. The Pakistani government, in turn, was asking the new U.S. commander in Afghanistan, Gen. David Petraeus, to call off the drones. Petraeus said he'd listen. It looked as though the United States might buckle.

Then Petraeus went to Afghanistan and praised the drones. "It is hugely important that three of 20 extremist leaders have been killed in recent months," he told the AP. And on Friday, the Pakistanis got their answer. A drone attack killed another dozen suspected militants at a Taliban commanders' house.

The machines have now racked up more than 100 kills in Pakistan since August. Petraeus has been lobbied, and Barack Obama has been elected, but the drone strikes go on.

How is Pakistan greeting this aggression? Is it threatening to fight? Hardly. Yesterday the country's president told the AP, "We feel that the strikes are an intrusion on our sovereignty, which are not appreciated by the people at large, and the first aspect of this war is to win the hearts and mind of the people."

"Feel"? "Not appreciated"? It's hard to come up with weaker language than that. The real message seems to be: Do what you must, but try not to give us political trouble.

From that standpoint, drones are a lot less harmful than the alternatives. The biggest popular anti-American protests in Pakistan recently were triggered not by drones but by a U.S. ground incursion. Likewise, in Afghanistan, recent politically incendiary mass killings of civilians have been inflicted (accidentally) by human operators on the scene. Yes, the drones have killed some Pakistani civilians. But not nearly as many, it appears, as Pakistani forces have killed in their own clumsy campaign against the insurgents.

Why do the drones have a better record of minimizing mistakes? For one thing, they don't have to make quick decisions. They can hover, watch, and wait. The intelligence they collect can be sifted and weighed by multiple supervisors before reaching a decision to fire. And in Pakistan, they seem to have an additional asset: human sources on the ground. The Washington Post explains:

Brig. Gen. Mahmood Shah, former longtime head of [Pakistani] government security in the tribal areas, said the missile attacks have become noticeably more precise, leading some to believe that local tribesmen in the border areas are supplying the U.S. military with better information about targets. Shah said rumors about so-called U.S. spies among the tribes have fed paranoia about the possibility that signaling devices have been deployed in area villages. Tribesmen have lately made a habit of sweeping the areas around their homes for such devices, he said. "They're not sitting outside in their compounds anymore because they are afraid that they will be struck by these missiles," Shah said.

All this time, I've been looking for technological answers to the mystery of the drones' precision, their increasing ability to find the bad guys. But maybe the answer isn't machines. Maybe it's people.

And if it's people, then the bad guys don't have to fight the machines. They can do what they already know how to do: kill some people and intimidate the rest. That seems to be what they're trying. A day after Friday's drone strike, Agence France-Presse reported:

Taliban militants killed two Afghan men Saturday in Pakistan's restive tribal belt after accusing them of spying for US-led forces. ... The executions were the latest in a string of similar killings and come a day after a suspected US drone fired missiles and destroyed an Al-Qaeda sanctuary in North Waziristan, killing 14. ... Executions routinely follow suspected US missile strikes against militant targets in Pakistan, which officials say are often conducted on intelligence provided by paid local informants.

According to the AP, the two bodies were thrown onto a road, each pinned with a note that said, "See the fate of this man. He was an American spy."

Were the men really spies? If so, were they scouting targets for the drones? I don't know. But for the last three months, somebody's been doing a heck of a job finding the bad guys in northwest Pakistan. Maybe, as U.S. military sources have let on, it's the drones themselves. Or maybe that's the cover story for what's still the world's greatest enemy-detection device: the human being.

Following Suit

Maybe you can ban steroids in sports because they're medically dangerous. And maybe you can ban carbon-fiber prosthetic legs because they're newfangled. But what about swimsuits? What do you do when a technology that's been around for ages—sleeker, tighter suits—becomes decisive? What can you say when the only objection to such technology is that most people can't afford it?

That's the situation today in collegiate and high-school swimming, according to Amy Shipley's enlightening report in Sunday's Washington Post. Swimmers wearing Speedo's LZR suits set 71 of the 77 new aquatic racing world records at, or just before, this year's Olympics. Now collegiate swimming programs are buying LZRs, and their competitors feel obliged to, um, follow suit. The trend extends to the high-school level, where the suits are showing up at state championship meets. Problem: LZRs cost around $500 retail. At best, with discounts, they go for about half that. And because of the fancy fabric, they wear out after just a few meets. Bottom line: Swimmers who can afford these suits will beat equally talented swimmers who can't.

Athletic federations are divided over what to do. Two months ago, USA Swimming prohibited kids under 13 from competing in the suits. The NCAA imposed a moratorium on the suits but then withdrew it.

In general, I don't like sports equipment bans based on sheer cost. Composite tennis racquets were pricey when they first came out. Should they have been prohibited? What about golf clubs or bike frames? Innovative materials are usually expensive at the outset. The way they become cheaper is by gaining notice, spreading to a broader market, and being produced more efficiently in subsequent iterations. If you ban them, you block this process.

In the swimsuit case, it looks to me as though a logical compromise is already unfolding. What makes the suit prohibitively expensive isn't just the outlay, but the fact that it wears out so fast. The crucial number is the per-meet cost. And that number can be sharply reduced by using the suits only at championship events late in the season. This is exactly what some college programs are already doing. You don't need a Ferrari to pick up your groceries. Swim your regular meets in cheaper suits, and save your LZRs for the big events.

This policy coincides with Speedo's discount strategy. The company says it offers LZR discounts to sponsoring colleges. At conference championships, the discount is 40 percent. At the NCAA championships, it's 65 percent. The higher you go in competition, the more the suit matters, and the more worthwhile it is for the company to put you in its suit.

Don't ban the LZR. The unfairness at issue is cost, and cost is adjustable. Let's see how the players adjust before the supervisors go in with a heavy hand.

The Future as We Don't Know It

I just got back from a talk by David Friedman at the Cato Institute. Fascinating guy, thinks a mile a minute. He must have spat out 100 provocative ideas in his half an hour or so. I can draw you a mental picture of him pretty quickly: bubbly, balding, not much over five feet tall, wears a backpack over his tweed jacket (did I mention the "recreational medievalism"?) and asked the audience whether anybody could give him a ride to Charlottesville tonight. There's still time--if you're going from D.C. to Charlottesville, try him at DDFr@DavidDFriedman.com.

Friedman touched on a range of topics covered in his new book, Future Imperfect. I haven't read the book yet, but he gave a pretty good sense of it. Here's the Cato summary (the podcast will be up later):

[Friedman] looks at a variety of technological revolutions that might happen over the next few decades, their implications, and how to deal with them. Topics range from encryption and surveillance through biotechnology and nanotechnology to life extension, mind drugs, virtual reality, and artificial intelligence. One theme of the book is that the future is radically uncertain. Technological changes already begun could lead to more or less privacy than we have ever known, freedom or slavery, effective immortality or the elimination of our species, and radical changes in life, marriage, law, medicine, work, and play. "If it can be done, it will be done," David Friedman has said. "So the interesting thing to me is not what should you stop but how do you adapt." We do not know which future will arrive, but it is unlikely to be much like the past.

In short, the book covers nearly everything Human Nature covers but with a libertarian bent. Which is sort of my bent, too, except that I'm less theoretically confident than Friedman is--or, to put it the other way, I'm more daunted by practical developments. Three years ago, for example, I wrote a series based on the idea that scientists would try to grow embryos beyond the conventional two-week limit, raising icky possibilities. The scenario made sense to me at the time, but in the three years since, it hasn't happened. A theorist would say, well, it'll happen eventually. I'm not so sure. My reaction is: Maybe I was just wrong.

So this is what I asked Friedman: Is there a contradiction between his technological optimism and his premise of radical uncertainty? When I say optimism, I don't mean a belief that technology will be good; I mean a belief that it will work. His talk was full of bold scenarios: conquering aging, developing artificial intelligence 100 times smarter than us in the next 30 years, and administering mind-control drugs that induce credulity. I agree that these scenarios are fascinating, and when I first came into this field, I took them very seriously. But everywhere I look, the news is telling me another story. The story is that in many fields, and in biology in particular, causality is turning out to be way more complex than we anticipated. The immediate manifestation of that complexity is that even our most conventional attempts to manipulate biology are producing unexpected and often decisive ill side effects.

Take the most obvious case: drugs. Friedman talked about three classes of mind drugs: those for pleasure, those for performance, and those for controlling other people. I've been to visionary or bioethics conferences where theorists have talked up these drugs and how cool or scary they'll become in the near future. But look at the news: Drugs are being restricted or pulled off the market because they're inducing ugly side effects. Not just drugs for the body, like Vioxx, but drugs for the mind, like Chantix. Steroids are boosting athletic performance but causing violence and circulatory trouble. Marijuana is being linked to heart attacks, brain shrinkage, and psychosis. I had high hopes for Bremelanotide, a new sexual-dysfunction drug, aka aphrodisiac. But last year its developer, Palatin Technologies, had to abandon that project due to "blood pressure increases" in some study participants. The company now touts the drug for "organ protection." It's turning out to be very hard to tinker with one function of the mind or body without affecting others.

Friedman's reply to all this was that we do better off "on net" by encouraging biotechnology than by limiting it, and that proposals to restrict it should be subject to the same skepticism that we might apply to the technology itself. That makes sense to me. Still, it's just a political answer. It doesn't address the underlying question of how soon--or even whether--biotechnology will achieve its promises.

I agree with Friedman that the future is radically uncertain. Too uncertain, in fact, to count on its arrival in the form that he envisions--or I do--anytime soon.

Robot Proxy War Update

I can't keep up with the drone war in Pakistan.

This morning, I posted a piece on the evolution of the Pakistan border conflict into the world's first robot proxy war. There have been so many drone strikes along that border in the last four weeks that when I linked to the reports on all of them, it felt like-pardon the reverse metaphor-overkill.

Now it turns out I missed one. The machines' body count is now 20 higher, thanks to a strike last night. It's the 19th drone attack since August. According to an update this morning on the New York Times Web site, the strike occurred 20 miles inside Pakistan and took out two Taliban commanders who have launched raids on U.S. troops in Afghanistan.

How good are the drones? According to the Times, one of the targeted commanders "was believed to have been visiting the compound ... to pay his respects to the families of those killed in an American drone strike on Friday" in a different location. The machines find and kill you, and then, when your boss shows up somewhere else to console your relatives, the machines are waiting for him there, too.

Down the road, we should all be scared of what this technology can do. But for now, I'm enjoying our ability to find and kill these guys without putting boots on the ground.

Now, about those other 18 casualties ...

Miss Conceptions, Confirmed

Sarah Palin spent her first days as John McCain's running mate being pounded over her daughter Bristol's out-of-wedlock pregnancy. In this predicament, critics saw Puritan hypocrisy, maternal neglect, and the predictable consequences of abstinence-only education.

There are many good grounds for criticizing Palin. This isn't one of them. The only reason we know about Bristol's pregnancy is that she's taking it to term. If she had aborted it, we'd never have known. Last month, I counted up the daughters of previous presidential and vice-presidential nominees going back to 1964. Of these, 37 were between the ages of 17 and 30 when their parents ran for national office. Based on unintended-pregnancy rates in this age group among higher-income families, I said it was almost inconceivable that "none of these young women got knocked up before their parents' nominations or elections." From the data, I inferred that at least one of them had probably had an abortion.

Readers and bloggers pounced on this inference, calling it unwarranted, perverted, and sexist. Call it whatever you want. It's now confirmed.

Actually, the evidence has been available for a while. It just didn't show up in Nexis, and the two best sources weren't searchable online. Fifteen years ago, Lee Edwards, who had worked on Barry Goldwater's 1964 presidential campaign, interviewed Goldwater's daughter Joanne for a biography of the senator. Based on the interview, he reported that in 1955, when Joanne, "not yet twenty and still in school, became pregnant with the child of her intended husband and told her father that she did not want to have the child, Goldwater said, ‘I'll take care of it.' He arranged for Joanne to fly back to Washington and have a then-illegal abortion."

Two years ago, Zeitgeist Films released Mr. Conservative: Goldwater on Goldwater, a documentary produced and narrated by C.C. Goldwater, the senator's granddaughter. In it, Joanne Goldwater tells the story:

I was getting engaged. ... It was actually in the Christmas of 1955. And in January, I—I found out that I was pregnant. And I had planned—I had planned this engagement party and a wedding. And—we had—we had planned to have children. We both were still in school. I was getting my degree. And I—I wasn't ready to have a child. And I got an abortion. ... And this was when it was just totally forbidden and very, very dangerous. And young girls were dying by trying it themselves. My father, being conservative, he felt that the government should not decide what women do with their bodies or anything else, you know. The government should stay out of all that. My mother started Planned Parenthood in Arizona in the '30s. And that's why I felt that it was easy to go to them and tell them. And they were very, very supportive.

Why didn't Joanne Goldwater get the Bristol Palin treatment in 1964? Because nobody knew she'd been pregnant. And the reason they didn't know is that she and her parents got rid of the problem.

The point isn't that abortion should be legal or illegal. The point is to exercise humility before accusing somebody else of bad parenting or a dysfunctional family. Was Joanne Goldwater's mom, a founder of Planned Parenthood of Arizona, a bad parent? Do you imagine that she taught her daughter abstinence-only? And how about Goldwater himself? If Palin can be judged by a daughter's pregnancy, why can't he? Shouldn't dads be held to the same standard? And shouldn't parents be held accountable for their sons, too?

You don't know how many of your friends or your friends' daughters have been pregnant. Unless they carry the baby to term or tell you about the abortion or the miscarriage, you just don't know. So before you open your mouth about the Palins, remember the Goldwaters.

Palin and Biden on Abortion

Tomorrow night, Joe Biden and Sarah Palin will meet in their only vice-presidential debate. Most of the discussion will be about economics and foreign policy. On the social issues, here are two questions moderator Gwen Ifill should ask.

1. Gov. Palin, you were asked this week whether it should be illegal for a girl to get an abortion in the case of rape or incest. Your answer was that the girl herself should not go to jail. What about the doctor? Should the doctor who performs that abortion face criminal penalties?

2. Sen. Biden, you said four weeks ago that you believe life begins at conception but that you can't impose your personal beliefs on other people. Yet you also voted for a law against gay marriage called the Defense of Marriage Act, and two years ago, you said this law expresses your view that "marriage is between a man and a woman and states must respect that." Why is it OK to impose your beliefs on gay marriage but not on abortion?

Here's all the background information Ifill will need when the candidates start fudging.

Palin's interview with Katie Couric, aired yesterday:

Couric: If a 15-year-old is raped by her father, you believe it should be illegal for her to get an abortion. Why?
Palin: I am pro-life. And I'm unapologetic about my position there on pro-life. And I understand good people on both sides of the abortion debate. In fact, good people in my own family have differing views on abortion and when it should be allowed. So ... I respect people's opinion on this. ...
Couric: But, ideally, you think it should be illegal for a girl who was raped or the victim of incest to get an abortion?
Palin: I'm saying that, personally, I would counsel the person to choose life, despite horrific, horrific circumstances that this person would find themselves in. And, um, if you're asking, though, kind of foundationally here, should anyone end up in jail for having an ... abortion, absolutely not.

Biden on Meet the Press, Sept. 7, 2008:

Biden: I'm prepared as a matter of faith to accept that life begins at the moment of conception. But that is my judgment. For me to impose that judgment on everyone else who is equally and maybe even more devout than I am seems to me is inappropriate in a pluralistic society. ...
Tom Brokaw: But if you, you believe that life begins at conception, and you've also voted for abortion rights.
Biden: No, what [I] voted against curtailing the right, criminalizing abortion. I voted against telling everyone else in the country that they have to accept my religiously based view that it's a moment of conception.

Biden's recorded vote for DOMA, Sept. 10, 1996.

Biden on Meet the Press, June 4, 2006:

We already have a law, the Defense of Marriage Act. We've all voted—not, where I've voted, and others have said, look, marriage is between a man and a woman and states must respect that. Nobody's violated that law, there's been no challenge to that law.

Biden on CNN, June 5, 2006:

We have already passed a law saying that—and the Defense of Marriage Act, defining marriage between a man and a woman.

The Biden campaign's evasive response to a same-sex marriage question on the Human Rights Campaign's 2007 survey of presidential candidates:

Senator Biden supports letting states determine how to recognize civil unions and how to define marriage. He believes that legal recognition should not be denied to same-sex couples.

Bonus peg: Biden will speak at HRC's annual dinner Saturday night.

All yours, Gwen. Go for it.

Evolving Predators

Is this technology for real? If so, what is it? Since the government isn't telling, I poked around a bit and asked readers for ideas.

Here are some possible leads. First, Slate reader mark_925 flags a list posted Friday on Aviation Week's Ares blog. The list includes several technologies that have improved U.S. efficiency at hunting and killing adversaries in Iraq. They include:

1. Communications intercept sensors "so sensitive that they can pick up the low-power emissions of handheld cell phones."
2. A targeting system called NCCT, which "instantaneously links the intelligence taken from several aircraft, ships or UAVs at once to locate, identify and target electronic emissions, including communications, and associate them with air, ground and sea radar targets."
3. An "IDM communications module" that links communications signals to visible sources, such as cars.
4. Software that facilitates "change detection" from spy aircraft.
5. Helmet sights that immediately translate a physically viewed object into spatial coordinates that enable fast targeting and destruction.

Second: Walter Pincus of the Washington Post flags an article in the U.S. military journal Joint Force Quarterly, written by the general who, as of today, is replacing David Petraeus as commander of multinational forces in Iraq. It credits the upturn in Iraq in part to a "surge of ... full motion video (FMV) assets." Early in the war, "Commanders were rarely allocated more than an hour of FMV a week," says the article. "Since 2003-2004, FMV within the corps has increased tenfold. ... Today, the corps can count on daily support from at least 12 FMV systems," and each brigade combat team "has an organic tactical UAV platoon that provides 18 hours of FMV coverage a day." Drones are dramatically improving military performance, not by doing the killing themselves, but by providing instant, on-demand customized intelligence to ground forces.

Third: Pincus reports that last week, a Senate subcommittee appropriated $750 million for "intelligence, surveillance and reconnaissance initiatives." This compounds a $1.3 billion shift of money to ISR programs, approved by the Pentagon in July. According to Defense News, the programs include:

1. "$262.6 million to buy digital data links for Raven UAVs, data links and laser designators for Hunter unmanned aircraft, and various improvements for other unmanned aircraft."
2. "$168.5 million to buy eight Medium Altitude Reconnaissance and Surveillance airborne systems, including with $52 million for three new Constant Hawk airborne surveillance and target acquisition systems."
3. "$17 million to extend a contract for Scan Eagle UAV services, $15 million to buy a new Northrop Grumman-made Global Hawk UAV and associated gear and services, $26 million to purchase four Boeing-made Scan Eagles."
4. Imaging systems and "sensor packages" for the Air Force.

So there are some possible clues to the recent turnaround in Iraq and the more recent escalation in Afghanistan and Pakistan: more UAV deployment and video, faster integration of UAV data into ground operations, more acute communications sensors, and instant targeting data on visible objects. Some combination of these technologies might account for the key breakthrough attributed to the devices now being deployed to Afghanistan: nonvisual identification and tracking of targets. Or not.

Over to you, Danger Room.

Terminator 2: Attack of the Drones

Speaking of Terminators: The drone war over Pakistan is escalating.

Boom. Sept. 4: Seven people killed in a strike on Chaar Kehl, near the Afghan border.

Boom. Sept. 5: Six to 12 more killed in a hit on Al Must.

Boom. Sept. 8: 23 dead and at least 18 wounded in a five-missile barrage on Daande Darpkhel.

Boom. Sept. 12: Twelve more dead in an attack on Tole Khel.

That's about 50 fatalities in four strikes in a single week, all at the hands of unmanned vehicles. An impressive warning from the bloodless killers of tomorrow. Even before the hit on Tole Khel, the Washington Post reported, "The number of Hellfire missile attacks by Predators in Pakistan has more than tripled, with 11 strikes reported by Pakistani officials this year compared with three in 2007." According to the Wall Street Journal, "One official in Afghanistan estimated that drone usage in Pakistan has doubled since the summer, and he said missiles are now being fired at Pakistani targets virtually every day."

Why the increase? Media reports from the ground and military sources indicate several factors: 1) Pakistan isn't really helping, so we've taken the killing into our own hands. 2) We don't want to literally use our own hands, since our ground forces might be captured. So, where possible, we're using drones instead. 3) Drone attacks cause less friction with Pakistan than ground incursions do, since U.S. personnel are never at the scene. 4) We're sick of our troops being picked off in Afghanistan, so we're using drones to even the score. 5) We're relying more on drones to spy in Pakistan because we've failed to develop informants on the ground. 6) Or maybe we're getting better ground intelligence, which is giving us more hot targets to shoot at.

The most intriguing factor, however, seems to be an upgrade in drone technology. In Friday's Los Angeles Times, Greg Miller and Julian Barnes report that Predator drones "above the tribal belt along Afghanistan's eastern border" are now "equipped with sophisticated new surveillance systems." The new systems permit

the tracking of human targets even when they are inside buildings or otherwise hidden from Predator surveillance cameras. Equally important, officials said, the systems have significantly speeded up decisions on when to strike. The technology gives remote pilots a means beyond images from the Predator's lens of confirming a target's identity and precise location. ... The technology allows suspects to be identified quickly. "All I have to do is point the sensor at him," said a military officer familiar with the system, "and a missile can be off the rail in seconds." The devices are roughly the size of an automobile battery, but are heavy enough that outfitted Predators in some cases carry only one Hellfire missile instead of two.

Tracking invisible targets? Nonvisual identification? Miller and Barnes don't explain how the system works. All they disclose is that it "was developed as part of a special project within the CIA's Directorate of Science and Technology." But if U.S. drone managers are willing to shed 50 percent of their missiles to make room for these target trackers, they must be pretty valuable.

The arrival of these devices in Afghanistan is only half the story. The other half is where they're coming from. They've been "instrumental in crippling the insurgency in Iraq," according to Miller and Barnes:

A military official familiar with the systems said they had a profound effect, both militarily and psychologically, on the Sunni Arab insurgency in Iraq. "It is like they are living with a red dot on their head," said a former U.S. military official familiar with the technology who, like others, spoke on condition of anonymity because it has been secret. ... Officials said introduction of the devices coincided with the 2007 U.S. troop buildup in Iraq, and was an important, but hitherto unknown, factor in the subsequent drop in violence in that country.

How much of the credit we've given to the troop surge in Iraq actually belongs to these devices? Are they working some similar magic now in Afghanistan and Pakistan? And, if so, what the heck are they? I don't know, and the U.S. government doesn't want to tell us, but I'll keep looking for answers with my primitive human eyes. In the meantime, if you've got any good intel on them, let's hear it.

Cyborg Seniors

If you get the Human Nature RSS feed but don't check the Slate home page, you may have missed an article worth reading: How seniors became cyborgs. It's about the mechanical and electronic components we've been putting into old people to replace failing body parts. It's part of our "Geezers" issue. Take a look.

Contraceptive Fudge: Addendum

In yesterday's post on the proposed HHS abortion "conscience" regulation, I overlooked a very important quote from Secretary Leavitt. Rob Stein of the Washington Post relates the following exchange from Leavitt's Aug. 21 conference call with reporters:

But when pressed about whether the regulation would protect health-care workers who consider birth control pills, Plan B and other forms of contraception to be equivalent to abortion, Leavitt said: "This regulation does not seek to resolve any ambiguity in that area. It focuses on abortion and focuses on physicians' conscience in relation to that."

Ambiguity is precisely what pharmacists have asserted in lawsuits demanding the right to withhold hormonal contraceptives. While framing the regulation as neutral, Leavitt is lending support to their position. And, as noted yesterday, the regulation explicitly applies to pharmacies (see page 24 of the PDF) which dispense contraceptives but do not perform surgical abortions.

When it comes to conscience rights, I'm a libertarian. As a pharmacist, you have every right to refuse to fill contraceptive prescriptions. But your customers have every right to boycott your store, and your employer has every right to fire you. If you don't like your employer's policy, open your own pharmacy.

The HHS regulation is not neutral. It uses government leverage to prevent employers from insisting that their employees honor consumer choice. In the name of one freedom, it suppresses another. And in the name of ambiguity, it lends official support to lawsuits that would extend this government intervention from abortion to contraception.

You can add your own views, pro or con, at consciencecomment@hhs.gov.

Contraceptive Fudge

HHS Secretary Michael Leavitt has issued a final version of his proposed regulation to protect medical conscience (PDF). As predicted, he has dropped the sentence that originally defined abortion as "any of the various procedures—including the prescription, dispensing and administration of any drug or the performance of any procedure or any other action—that results in the termination of the life of a human being in utero between conception and natural birth, whether before or after implantation."

Leavitt has also chosen to leave open the possibility that the regulation will be applied that way. In that case, it would protect a provider's right to withhold oral contraception, which theoretically could prevent implantation of an embryo. Pharmacists and Catholic hospitals are already waging legal battles to assert this right.

The proposed regulation is 42 pages long. I'm embarrassed to tell you that I read it last week during my vacation. I was looking for a definition of abortion. I'll save you the trouble: There is none. The regulation draws no distinction between abortion and contraception.

In his blog, Leavitt has twice addressed the contraception question. On Aug. 7, he said his intent was to protect the right of conscience, not to define contraceptives as abortion. This left open the obvious next question: Intent aside, does the right of conscience protected by the regulation include the right to withhold hormonal contraception on the grounds asserted by pharmacist litigants: that it might be abortifacient? Two weeks ago, I invited Leavitt to answer that question. He has ignored it.

He has, however, answered a similar challenge from Mary Jane Gallagher, the president of the National Family Planning and Reproductive Health Association. In an Aug. 11 blog post, Leavitt quoted and rebutted her:

"Who's going to provide access to contraceptives services if the administration provides this large loophole to deny services?" [said Gallagher.] CQ reported Ms. Gallagher continued: "Providers are ‘given an oath—now they get to pick and choose what they want to do' if a regulation is issued, she said."

So, according to Ms. Gallagher's ideology, if a person goes to medical school they lose their right of conscience. ... There is something I'd like to point out to Ms Gallagher and the people she represents. It is currently a violation of three separate federal laws to compel medical practitioners to perform a procedure that violates their conscience.

Gallagher is explicitly talking about contraception. And Leavitt's response is to invoke conscience rights.

Last week, Leavitt said some practitioners might "press the definition" in the final HHS regulation and argue that hormonal contraception is abortion. They certainly will. Pharmacists for Life International is already on the case. So is the Christian Legal Society. Concerned Women for America says the equation of hormonal contraception with abortion, explicit in the original draft of the regulation, was right all along.

And when these litigants argue that the regulation implicitly covers contraception, they'll have lots of help from Leavitt. They can cite his response to Gallagher. They can also point out that the regulation explicitly lists pharmacies as a category of "affected entities." (See Page 24.) Last time I checked, pharmacies didn't do surgical abortions.

The argument on the other side will be that Leavitt has said he's not targeting birth control. "This regulation is not about contraception," he said in a conference call last week. "It's about abortion and conscience." But Leavitt has said the same thing about abortion itself. "This is not a discussion about the rights of a woman to get an abortion," he wrote in his blog. "This is about the right of a doctor to not participate if he or she chooses for reasons they consider a matter of conscience." Leavitt's point, in other words, is that the regulation doesn't ban anything; it just protects the right not to facilitate it. As he put it in the conference call, "There is nothing in this rule that would in any way change a patient's right to a legal procedure." But in asserting this right of refusal, the rule doesn't distinguish between surgical abortion and theoretically abortifacient drugs.

Phelps-Cavic Reconsidered

Yesterday I asked whether Michael Phelps lost to Milorad Cavic in the 100-meter butterfly final at the Olympics. I took a pretty good pounding in the Fray.

Looks like I deserve it.

The reason I looked back at Phelps-Cavic this weekend is that Omega finally released its pictures of the finish. Because Omega is the official timekeeper and its pictures had previously been withheld, I attributed great importance to them. And the company's characterization of the pictures as proving Phelps won was total garbage.

As many of you point out, the fact that these pictures prove nothing proves nothing, since we had better pictures from underwater to begin with. I'd seen the underwater shots on TV, but I hadn't looked at them closely on the Web.  Look at the sequence:

Right before the swimmers touch

The touch

A closeup of Cavic's fingers, cropped from the preceding photo (No. 5):

Phelps has clearly touched at this point. Has Cavic touched? His left middle finger is bent back. But if you look at the first of these three photos (No. 4), you can see that the finger is also bent back slightly as he's approaching.

My eye says the finger isn't touching yet. But my eye, as a judge of Olympic photo finishes, sucks. So here are two ways of resolving the question.

1. Do a CSI-style 3-D analysis of photo No. 6, the close-up. See if you can assess the height of Cavic's fingers relative to the cross on the wall. Assuming the fingers are pretty well below the top of the cross, case closed.

2. Calculate the delay between touch and pad compression using the speed of the race. If the speed is fast enough that the delay can't equal one one-hundredth of a second, case closed. There's already a Fray thread pursuing this calculation.

One fascinating thing in underwater photo No. 5: Even if Cavic is touching, you can see that Phelps is touching harder. Theoretically, thanks to the touch pad, that could be enough to win him the race, even if the touches were virtually simultaneous.

Olympic Inflation

Can we please stop fussing over every new Olympic record?

A new record means that an athlete using today's equipment outperformed an athlete using yesterday's equipment. It's not a fair fight.

In swimming alone, today's advantages include:

1. LZR Racer suit. It reduces friction (compared with skin) and is structurally designed to compress and streamline the body for maximum speed. Estimated drag reduction: 5 percent to 10 percent. Estimated average improvement in top swimmers' best times: 2 percent. Designed by NASA scientists and computers, among others. Cost: $500.

2. Pool depth. This is the deepest pool ever used in the Olympics. Depth disperses turbulence, reducing resistance.

3. Pool width and gutters. Two extra lanes at the margins disperse waves to gutters, reducing ricochet and resistance.

4. Lane dividers. The plastic ones in Beijing deflect turbulence down instead of sideways, reducing resistance.

5. Starting blocks. Nonskid versions have replaced the old wooden ones, boosting dive propulsion.

6. Video. Recordings and analysis identify target variables such as stroke distance and turns.

7. Medical tests. Swimmers are blood-tested after each race to measure lactic-acid buildup.

8. Sports scientists. They run the monitoring and analysis. The U.S. swim team has four.

And here's a partial list of advances in other sports:

1. Lighter shoes. The latest material is carbon nanotubes.

2. Asymmetric shoes. Stronger carbon base in the right shoe tilts you to the left to increase speed as you round the track. Left shoe is designed to stabilize you.

3. Ice vest. It lowers your temperature before the race so you can delay overheating for better performance.

4. Hypoxic tents. Sleeping in low-oxygen chambers increases red blood-cell levels.

5. Aluminum javelins. They reduce vibration compared with the old carbon ones.

6. Bicycle wheels. Front wheels with fewer spokes (eight instead of 32) reduce weight and air resistance. So do composite one-piece rear wheels. All frames are carbon.

Michael Phelps' coach says the LZR suit is fair. "Everybody is in the suit so it's across the board," he argues. That may be true of today's top swimmers. But it's not true of yesterday's. So comparing today's performances to the performances of 20, eight, or even four years ago—which is what "new Olympic record" means—is generally unfair.

If you want to compare today's athletes to yesterday's, the ideal method would be an inflationary formula. We already calculate how much $1 in 1980 would be worth today, based on price increases. We ought to be able to devise a similar multiplier for each Olympic event, based on average year-to-year improvement among top athletes. Averaging would wash out idiosyncratic ups and downs. The effects of aging could be measured and factored out.

Olympic inflation indexing wouldn't devalue new records. It would isolate and elevate records that truly stand out. Scores of media reports have boasted that every team in this year's 4 x 100 men's swimming relay beat the time that won that event four years ago. But by inflationary standards, the British, who beat the 2004 winning time by three-tenths of a second in constant time, actually failed to keep pace with it. The Americans, who beat it by five seconds, produced a genuine achievement.

And now, if you'll excuse me, I'm off to watch the latest high-definition broadcast from Beijing on my 46-inch flat-screen TV. It beats the crap out of the 20-inch tube I was squinting at in 2004. But that doesn't make my eyesight any better.

Birth-Control Blur

Last Tuesday, I wrote about a draft regulation, circulated by the Department of Health and Human Services, that would protect the right of private employees to refuse to facilitate any abortifacient chemical or activity. The draft rule defined abortion as "any of the various procedures—including the prescription, dispensing and administration of any drug or the performance of any procedure or any other action—that results in the termination of the life of a human being in utero between conception and natural birth, whether before or after implantation." It would thereby encompass the right to withhold oral contraception, which theoretically could prevent implantation of an embryo.

On Friday, HHS Secretary Mike Leavitt wrote a blog post about the draft rule. According to the Washington Post, Leavitt "denied that [the] draft regulation would redefine common birth control methods as abortion and protect the rights of doctors and other health-care workers who refuse to provide them."

Really? Where's the denial?

Here's the relevant part of Leavitt's post:

An early draft of the regulations found its way into public circulation before it had reached my review. It contained words that lead some to conclude my intent is to deal with the subject of contraceptives, somehow defining them as abortion. Not true.
The Bush Administration has consistently supported the unborn. However, the issue I asked to be addressed in this regulation is not abortion or contraceptives, but the legal right medical practitioners have to practice according to their conscience and patients should be able to choose a doctor who has beliefs like his or hers.
The Department is still contemplating if it will issue a regulation or not. If it does, it will be directly focused on the protection of practitioner conscience.

Leavitt's post says his intent is to protect the right of conscience, not to define contraceptives as abortion. It doesn't deny that the final version of the rule will have the effect of treating some contraceptives as abortion. And there's every reason to believe it will do just that.

Leavitt writes as though conscience protection is a separate issue from the blurring of abortion with contraception. It isn't. A rule that guarantees the pro-life conscience rights of doctors, pharmacists, and other private employees is limited only by what those employees believe. And what many of them believe, as the Post's Rob Stein has documented, is that oral contraceptives are wrong because they can prevent implantation.

If you think Leavitt won't extend conscience protections that far, you haven't met his boss. Nine years ago, when George W. Bush was running for president, Tim Russert asked him: "Do you believe life begins at conception?" Bush replied: "I do." Two years later, as he prohibited federal funding of embryo-destructive stem-cell research, Bush repeated, "I think life begins at conception." Referring to pre-implantation embryos, Bush wrote that "it is unethical to end life," even to save the lives of others.

How can Leavitt fail to extend conscience protections to a pharmacist who refuses to fill a birth-control prescription because, like Bush, he believes that life begins at conception? If that belief is good enough to bar funding of stem-cell research, why isn't it good enough for the pharmacist?

If Leavitt really wants to clarify this question, he can do so by writing one more post in which he stipulates that the HHS rule, if issued, will not extend to drugs or procedures that act prior to implantation. I'm betting a month's supply of birth-control pills that he won't.

The Price of Survival

When is a life-threatening disease not worth treating? When something else will kill you first.

This week, the U.S. Preventive Services Task Force issued new guidelines for prostate cancer screening. The New York Times explains:

Prostate cancer often progresses very slowly, and a large number of these cancers discovered through screening will probably never cause symptoms during the patient's lifetime ... Past task force guidelines noted there was no benefit to prostate cancer screening in men with less than 10 years left to live. ... The new guidelines take a more definitive stand, however, stating that the age of 75 is clearly the point at which screening is no longer appropriate.

Well, sort of. The new guidelines do draw the line at 75. But the rationale hasn't really changed. Here's the key paragraph from the report:

In men age 75 years or older, the USPSTF found no direct evidence of benefits of prostate cancer screening. However, the USPSTF was able to establish an upper bound for the potential magnitude of the benefit of treating screening-detected prostate cancer in this age group, by extrapolating from evidence of treatment for clinically detected prostate cancer in this age group. For a population of men with an average life expectancy of 10 years or fewer, the USPSTF determined that the benefits of prostate cancer screening and treatment would range from small to none.

In other words, men 75 years or older aren't worth screening because their life expectancy is 10 years or less. This matches the logic of the previous guidelines ("Older men ... who have a life expectancy of fewer than 10 years are unlikely to benefit") and, as the report notes, similar guidelines issued by professional medical associations. It also matches a study, cited in the key paragraph, that compared "radical prostatectomy" to "watchful waiting" in two groups of men. The study found that with prostate removal, "The absolute reduction in the risk of death after 10 years is small."

More to the point, the 75-10 equation matches current U.S. life expectancy tables. The guidelines clearly identify life expectancy as a key factor in setting limits to screening:

The USPSTF found convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death. These harms are especially important because some men with prostate cancer who are treated would never have developed symptoms related to cancer during their lifetime.

According to the latest U.S. government data, remaining life expectancy for a 75-year-old man is 10.8 years. But that number applies only to the most recent year on the table, 2005. If you scan up the column of numbers, looking back in time, you'll see that remaining life expectancy for men at 75 has been edging up. Since 1980, it has increased by two years. And if you look at tables going further back, you'll see that a 75-year-old man today can expect as much remaining life as a 70-year old man could expect in 1975.

In other words, life expectancy is increasing, and as it does, the age at which slow diseases are worth testing and treating also increases. Three decades ago, by the logic of the 10-year limit, a 70-year-old man wasn't worth screening for prostate cancer. Today, he is. We have extended his remaining life to the point at which prostate cancer would shorten it. By preventing and treating other diseases, we have made this one worth preventing and treating, too.

So don't count on the screening line to hold at 75. Over the next few decades, it could easily rise to 80.

One way to look at this trend is that the job never ends. The more we accomplish, the more work we have to do. It's exhausting. Maybe we should back off and respect nature's limits.

The other perspective is that there's nothing more liberating -- nothing more human -- than shattering old expectations. This boring little tweak in the recommendations for prostate cancer is actually this week's episode of the biggest story in the universe: biological emancipation. In the beginning, we accept a cause of death as nature's course. Then we call it a disease and study it. Then we push life expectancy to the point at which the disease is worth treating. The truest measure of progress isn't what we achieve. It's what we undertake.

No Chubby For Old Men

 If you're looking for interesting bathroom reading, allow me to recommend Urology. The July issue is chock full of page-turners: "Robotic Prostatectomy," "Scrotal Mass with Bladder Outlet Obstruction," "Histologic Comparison of Pubovaginal Sling Graft Materials," "Multi-Drug-Resistant Bacteremia After Transrectal Ultrasound Guided Prostate Biopsies," and my favorite, "Modern Management of Adult-Acquired Buried Penis" (it's "a result of obesity" - don't ask).

Seriously, though, I want to talk about an article in the July issue. It's called, "Does ‘Normal' Aging Imply Urinary, Bowel, and Erectile Dysfunction?" Here are key excerpts from the abstract:

We assessed if urinary, bowel, and sexual dysfunction and associated bother were part of the "normal" aging process in the general male Dutch population. ... Three thousand eight hundred ten (3810) men responded (81%), mean age 67 years, range 58 to 78. ... Bowel dysfunction and bother were not related to age. Erectile dysfunction was reported by 19%, ranging from 12% in the youngest to 26% in the oldest group ...

Conclusions: Urinary and bowel dysfunction were not part of the "normal" aging process. Erectile dysfunction was significantly more prevalent in older men.

And here's the headline on the Reuters write-up: "Erectile dysfunction may be ‘normal' with age."

The curious thing here is the word normal. It's being used in this context to mean age-related. Most men in the sample didn't have erectile dysfunction. But because ED's frequency increases with age, and because we think of aging as a universal process accompanied by physical decline, ED seems normal.

Since "urinary and bowel dysfunction were not part of the ‘normal' aging process," the authors conclude, they "may well be related to prior treatment" in men who have been treated for prostate cancer. This appears to make them logical targets for prevention or remedy. Does the opposite implication follow for ED? Does its "normality" make it a less compelling target?

There are many plausible ways to think about normality and health. Age-dependence is one of them. To me, the authors' framework makes sense: Medicine should focus first on maladies that strike some people unusually early in life. Maladies that accumulate with age are less unfair. They're also less tractable, since they're more biologically inherent.

ED, however, is a confounding example because it's in the process of being transformed from a "normal" to a commonly treated condition. Bob Dole made his famous ad for Viagra  in 1999, when he was 76. In the last decade, 35 million men have used Viagra. Millions more have taken similar drugs such as Cialis or Levitra. Modern man has set out to conquer the ancient loss of manhood.