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Sep 22, 2010 | ABC News
A former official who helped promote the procedure now has new warnings.
Sep 11, 2010 | NYTimes.com
The Congressional Budget Office estimates that an astonishing half or more of the increased spending for health care in recent decades is due to technological, surgical and clinical advances.
For the most part, such advances are a cause for celebration. But an expensive new drug is not always better than an older, cheaper drug, and sometimes a new technology or treatment that is highly effective for some patients is unnecessary or even dangerous for others.
The system almost seems designed to keep driving up costs.
To win approval, drugs and many devices must undergo tests for safety and effectiveness. For drugs, there is usually no comparison to products already approved. For both, there is no consideration of cost. Once drugs or devices are approved to treat one class of patients or illnesses, doctors can use them for virtually any ailment they please. Manufacturers eagerly promote their most expensive products to doctors and patients.
Patients have few ways to judge what is best for improving health or saving money. They must rely on doctors who may have insufficient information - or economic incentives to pick the costliest treatment.
The new health care reform law makes a start at figuring this out. It sets up a new system to evaluate the comparative effectiveness of drugs, treatments and medical devices. But, after all of the cynical demagoguing about "death panels," it limits the extent to which the studies can be used to help hold down costs.
No one wants to bar patients from getting the treatment they need. But without curtailing the use of unnecessary, overly costly and even dangerous new technologies and surgical procedures, there is little hope of restraining the relentless rise in health care costs.
That is a truth that American politicians and taxpayers cannot afford to ignore for much longer.
The good news on medical advancements is undeniable. Doctors can now keep patients alive with improved dialysis treatments while they await a kidney transplant, replace disintegrating hips and knees with artificial joints, and spot internal growths with high-tech imaging devices that avoid the need for exploratory surgery.
Even costly therapies can end up saving money as well as lives. Studies by respected economists have shown that spending on new cardiac treatments, neonatal care for low-birth-weight infants, and mental health drugs have more than paid for themselves.
This is not always the case. Consider the prostate-specific antigen test, which is widely used to screen men for possible prostate cancer. In an Op-Ed piece in The Times in March, Richard J. Ablin, the doctor who discovered prostate-specific antigen, described the test as "hardly more effective than a coin toss" at distinguishing who is at risk, and lamented that the test's popularity has led to "a hugely expensive public health disaster."
Each year some 30 million American men undergo the test at a cost of at least $3 billion, and many go on to have surgery, intensive radiation or other damaging treatments that may not have been necessary.
Or consider complex fusion surgery to relieve lower back pain. An article and an editorial in the April 7 issue of The Journal of the American Medical Association deplored the rapidly rising use of this surgery, which fuses multiple disks in the spine, in patients who would have done better, and faced fewer risks, with simpler surgery that eases pressure on the nerves without fusion.
The explanation for the boom was likely economic. Surgeons were paid 10 times as much for the complex surgery, hospitals were paid three and a half times as much, and manufacturers reaped a bonanza selling $50,000 worth of implants for the complex surgery, compared with little or no profit from the simpler surgery.
Research that systematically compares the effectiveness of different treatments and drugs is clearly needed.
The Obama administration started the process, committing $1.1 billion from stimulus funds to finance comparative studies. The new reform law will move that ahead, setting up a nonprofit, independent institute to organize the work. The comptroller general will appoint a governing board of 19 members, representing patients, doctors, manufacturers and others, including two designated federal health officials.
If the institute works the way it is supposed to, patients, doctors and the government will have better information about what works and what does not, what may be worth the extra cost and what does not make sense. Even then, the legislative language is so convoluted there is no guarantee that even the most credible findings will help ensure that patients get the best and most cost-effective treatment.
With critics wrongly charging that these studies would insert government bureaucrats between patients and their doctors and end up denying access to essential care, reformers pulled their punches.
The institute is supposed to make regular reports of its findings but is carefully restricted as to what it can say. It cannot make recommendations to Medicare or private insurers about what they should or should not cover. It cannot tell doctors what treatments to use, or recommend how much doctors and hospitals should be paid for any services.
Depending on how the White House decides to proceed, the effort could begin to change things. The law says the secretary of health and human services cannot deny Medicare coverage of services "solely" on the basis of comparative effectiveness research, but it does not prevent the use of such findings in conjunction with other factors in making coverage decisions. Those decisions generally influence what private insurers cover as well.
The secretary needs to press the panel to get the research going and then begin including the findings in Medicare coverage and reimbursement decisions. Critics will howl. If the panel does its job right - and politicians have the courage to make the case - both patients and taxpayers will benefit.
September 3, 2010 | The Mess That Greenspan Made
It's nice to see that at least one sector of the U.S. economy continues to do well, earning profits and creating jobs consistently (more than 40,000 last month) while the rest of the economy goes in and out of recession. McClatchy reports on where an increasing share of the money to fund those profits and new jobs has been coming from.
It must really suck to be an HR person around this time of the year as you prepare to tell all the company employees how much more they'll be paying for their health insurance premiums in the year ahead. Of course, most workers are probably just happy to have a job, so the push back is likely not what it was just a few years ago before the recession began
August 30, 2010 | Wired September 2010
'You have to decide who you trust before you decide what to believe.'
For a while there, things didn't look too good for British writer Simon Singh. The best-selling author of the science histories Big Bang and Fermat's Enigma knew he was heading into controversial territory when he switched tracks to cowrite a book investigating alternative medicine, Trick or Treatment? What Singh didn't count on, however, was that writing a seemingly innocuous article for London's The Guardian newspaper about especially outrageous chiropractic claims-one of the subjects he researched for the book-would end up threatening his career. The British Chiropractic Association sued Singh, hoping to use Britain's draconian libel laws to force him to withdraw his statements and issue an apology. Losing the case would have cost Singh both his reputation and a substantial amount of his personal wealth. Such is the state of science, where sometimes even stating simple truths (like the fact that there's no reliable evidence chiropractic can alleviate asthma in children) can bring the wrath of the antiscience crowd. What the British chiropractors didn't count on, however, was Singh himself. Having earned a PhD from Cambridge for his work at the Swiss particle physics lab CERN, he wasn't about to back down from a scientific gunfight. Singh spent more than two years and well over $200,000 of his own money battling the case in court, and this past April he finally prevailed. In the process, he became a hero to those challenging the pseudoscience surrounding everything from global warming to vaccines to evolution. It's not necessarily a role he sought for himself, but it's one he has embraced-he's currently touring the world, talking about his case, libel reform, and how important it is to make sure scientists can speak truthfully and openly. Wired spoke with Singh about his case and the struggle against the forces of irrationality.
Wired: The British Chiropractic Association wanted you to apologize for your Guardian article. Why didn't you? What would that have meant?
Simon Singh: It would have meant that whenever somebody typed "Simon Singh" into a Web search, it would say, "science journalist found guilty of libel." People could dismiss anything I'd ever written about alternative medicine. But more important, it would have implied that there is some validity to these claims that chiropractic can help with things like asthma and colic. And that would have an impact on parents and their children. Faced with that, I couldn't apologize. If you've written something that you believe is true, and if you can afford to defend it, then you've got to defend it.
Wired: Do you think that this is part of a broader trend? Is science under assault?
Simon Singh: What shocks me is people who have no expertise championing a view that runs counter to the mainstream scientific consensus. For example, we have a consensus amongst the best medical researchers in the world-the leading authorities and the World Health Organization-that vaccines are a good thing, and that MMR, the triple vaccine, is a really good thing. And yet there are people who are quite willing to challenge that consensus-film stars, celebrities, columnists-all of whom rely solely on the tiny little bit of science that seems to back up their view.
Wired: Yet the celebrities sometimes seem to be winning.
Simon Singh: Part of the problem is that if anybody has a gut reaction about an issue, they can go online and have it backed up. That said, they can also find support for their ideas in the mainstream media-because when the mainstream media gives a so-called balanced view, it's often misleading. The media thinks that because one side says climate change is real and dangerous, the other view is that it's not real and not dangerous. That doesn't reflect the fact that something like 98 percent of climate scientists agree that global warming is real and dangerous. And this happens with everything from genetically modified foods to evolution. But, at the end of the day, all that this misinformation does is slow progress-it doesn't stop it. Antiscientific and pseudoscientific attitudes will get corrected; it's just a question of how painful that process is going to be.
Wired: Should scientists do more to get real science out there?
Simon Singh: Scientists aren't necessarily good communicators, because they aren't trained to be good communicators. A researcher could be doing really important work on global warming, and then somebody writes a column in a national newspaper that completely undermines what they're saying. But the scientist doesn't think the column is important-it's just some nincompoop writing a column-so they don't take that writer to task in the way they should. It's a case of saying, "How do we make a difference?" We certainly don't make a difference by just moaning over coffee the next day.
Wired: What about nonscientists? How are we supposed to know what's true?
Simon Singh: Don't come up with a view, find everybody who agrees with it, and then say, "Look at this, I must be right." Start off by saying, "Who do I trust?" On global warming, for example, I happen to trust climate experts, world academies of science, Nobel laureates, and certain science journalists. You have to decide who you trust before you decide what to believe.
Wired: Why is it so hard to convince people, even when the science is so clear?
Simon Singh: Science has nothing to do with common sense. I believe it was Einstein who said that common sense is a set of prejudices we form by the age of 18. Inject somebody with some viruses and that's going to keep you from getting sick? That's not common sense. We evolved from single-cell organisms? That's not common sense. By driving my car I'm going to cook Earth? None of this is common sense. The commonsense view is what we're fighting against. So somehow you've got to move people away from that with these quite complicated scientific arguments based on even more complicated research. That's why it's such an uphill battle. People start off with a belief and a prejudice-we all do. And the job of science is to set that aside to get to the truth.
Articles editor Robert Capps ([email protected]) wrote about the advantages of "good enough" technology in issue 17.09.
You might think that modern chiropractors restrict themselves to treating back problems, but in fact they still possess some quite wacky ideas. The fundamentalists argue that they can cure anything. And even the more moderate chiropractors have ideas above their station. The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.
I can confidently label these treatments as bogus because I have co-authored a book about alternative medicine with the world's first professor of complementary medicine, Edzard Ernst. He learned chiropractic techniques himself and used them as a doctor. This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions.
But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic.
In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.
More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures.
Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.
Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: "Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck."
This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Professor Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher.
Bearing all of this in mind, I will leave you with one message for Chiropractic Awareness Week - if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.
∑ Simon Singh is the co-author of Trick or Treatment? Alternative Medicine on TrialAbout this article
This article appeared in the Guardian on Saturday April 19 2008 on p26 of the Comment & debate section. It was last updated at 00:06 on April 19 2008.
Mish's Global Economic Trend Analysis
"Dr. P" a front line working family physician for 30 years writes ....Hello Mish
Thank you for exposing some of the many scams on health care insurance. Here is another example of industry wide ripoffs:
Many generic medications now cost $4.00 for 30 days or $10.00 for 90 days without insurance. Sadly, many mail in companies require patients to pay a $15.00 - 30.00 dollar co-pay for 90 days for the same drugs.
Just this week one of the mail in companies informed a patient of mine that they will be only filling the prescriptions for 30 days and will require a $15.00 co-pay monthly for a medication which is only $4.00 per month.
My patients were surprised when I told them to just go to a local pharmacy and not use their insurance. One patient had 4 medications he was paying more than double for. In the most flagrant example, a patient paid $60.00 per month for his medications that he could get for 90 days for $40.00 if he did not use his employer paid insurance. That is $180 instead of $40!
The insurance company walks away with the money on the back of the patient in all of these instances. I find this way over the top in the ethics department.
To your health,
Drugs from Canada
"CB" writes ...
Keep up the good fight.
I want to let you know, however, that Americans can buy drugs from Canada - as individuals. No bulk purchasing for resale is allowed, but to get one's own drugs at a big discount (like I do), the place to check out is called Canada Meds. Their phone number is 1 877 542 3330. I save 50%. I pay directly for them, so trying to buy from Canada under an insurance plan might not be possible. I don't know.
The drugs I get from Canada Meds come from other countries, and are usually made in India, but they are the exact same thing and I've been taking them for years now with no ill effects.
August 22, 2010
Relevant to our soda post ("Pseudo-variety": Soft Drink Industry Structure) JWagner points us to this video from Robert H. Lustig, MD, UCSF Professor of Pediatrics in the Division of Endocrinology.
Robert H. Lustig, MD, UCSF Professor of Pediatrics in the Division of Endocrinology, explores the damage caused by sugary foods. He argues that fructose (too much) and fiber (not enough) appear to be cornerstones of the obesity epidemic through their effects on insulin. Series: UCSF Mini Medical School for the Public [7/2009] [Health and Medicine
Jun 08, 2010 | Angry Bear
I am late to the news, but so far reported on healthcare law implementation:
1. www.HealthCare.gov, a new online portal where anyone can go to find insurance options in their state, went live. It's a very handy resource for information that used to be difficult to find. It's available to help millions who need insurance find it, and as a resource for those who want to shop around for new options or find out their new benefits under the new law.
2. States are starting to create new insurance pools for hundreds of thousands of people with serious medical conditions who had previously been unable to get insurance. Federal grants to help with setup are on their way to states right now.
3. In June, 80,000 checks were mailed to seniors to help with prescription drug costs not covered by Medicare.
And of course, many of the key insurance reforms-allowing young adults to stay on their parents' insurance until age 26, and making it illegal to deny a child or baby insurance because of a "pre-existing condition"-have already started to take effect.
Now, many of the major reforms-the new health insurance exchanges, an end to pre-existing condition discrimination for adults, and more-have yet to go into effect.
You've read a dozen times about good posture & wrist position, but else can I do? We put together a short list of [creative] tips.
- Swap out your keyboard & mouse 3 times a day. This one comes from some Google engineers who have a daily rotation of peripherals. This forces your hands into more of a variety of hand positions which is quite beneficial. Remember, we're trying to make what you do all day less repetitive.
- Stretch more than just your forearms. A lot of problems higher up in the arm & shoulder areas manifest in other areas like your wrists (think about how acupuncture needles are placed in other parts of the body than the area in pain). A full range of stretching [yoga is excellent] in the upper body can make a big difference.
- Non-smoking smoke breaks. You don't have to be a smoker to have an excuse to step outside!
- Pay attention to your posture when you go to sleep. Are you curled up into a ball or stacking 3 pillows for your head at night? Good posture increases circulation, which [in theory] helps you extremities heal. Sleep accounts for 1/3 of your day, so give it thought around the clock.
- Create macros for two-key keyboard combinations. The fewer keys you press, the less stress on you fingers right? For example ctrl-C [copy], ctrlX [cut], ctrl-V [paste] can all be made single keystrokes by various keystroke macro programs out there, or by specialty keyboards such as the logitech g13/g15. We did a writeup on using the g15 to consolidate key combos to a single button here.
The buttons are very solid and have a nice click to them. If you have severe 'trigger finger' then you might want something with a softer click. I will say the right button is softer than the left, so it might be a manufacturing inconsistency. The scroll wheel is the same story. While it's has an excellent feel and is very high quality, it doesn't exactly glide like butter like some mice. This is a mouse oriented towards relieving wrist pains & hand aches more so than trigger finger. For people with both trigger finger and wrist problems, you might consider this mouse in conjunction with perhaps a foot pedal for the mouse click.The verdict? I like it a lot. The build quality is excellent and it has a nice weight to it. The downside is that it costs $130
... ... ...
Update: It's now been 3 months since I initially wrote this post. So far I think this mouse takes the crown in effectiveness against RSI. My wrist pains have mostly subsided and my fingers aren't cramping like they used to. It strikes a great balance between a vertical & horizontal mouse. I'm starting to think there's something concrete here, like this mouse might be the magic bullet. It's pretty funky & gets a lot of comments from my coworkers, but if you're not afraid to be different and you're serious about your RSI, then this mouse should be near the top of your list.
With computer, desk, assembly or other types of hand intensive work, the neck and shoulders round forward and the upper arm tends to rotate inward. The chest muscles become tight. The muscles of the back weaken and stretch. The upper trapezius (the big, bulky muscles that make up the top of the shoulder) try to compensate by working harder than they should. Muscle knots and tension develop. The arms feel tired and weak. Eventually, this muscular imbalance can cause a tendonitis in the rotator cuff (supraspinatus) or in the biceps where it attaches to the humerus. Or the fluid cushion (bursa) between the rotator cuff and the shoulder bones can become inflamed (bursitis).
Poor posture can be the primary factor in developing shoulder pain. Other activities that tend to cause problems are prolonged or repetitive overhead reaching (such as when lifting binders or books down from shelves above the computer) or holding the arms elevated while typing, using the mouse, or performing other hand work. Tichauer (1978, The Biomechanical Basis of Ergonomics) discovered that a chair height that was 3 inches too low for a worker caused excessive shoulder movements and reduced productivity by as much as 50%.
RSI Prevention for Shoulder Pain
- Neutral and Relaxed Shoulder Positioning
- Postural awareness is of major importance in injury prevention.
- The shoulders (upper trapezius muscle) should be relaxed while working.
- Arms should be positioned at your side with the ears, shoulders and elbows in line.
- Avoid rounding the shoulders or hunching forward
- Maintain a neutral neck posture.
- Chair height should allow you to reach the work surface/keyboard/mouse with the elbows opened slightly greater than 90 degrees and the shoulders relaxed, not elevated.
- Use of arm supports has been debated in the therapeutic community. The shoulders should be allowed to move freely to position the hands so that excessive movement is not required at the more vulnerable elbows, wrists and fingers. However, unsupported use of the arms is a contributing factor in shoulder pain.
- If using arm rests, they should be positioned at a height that allows the shoulders to be relaxed. Do not plant the forearms down on the rests while typing. Allow the forearms to glide over the rests unless taking a break from hand activity.
- Articulating Arm Rests are a good option for providing support with movement.
- Position your activity and supplies so that repetitive or sustained lifting or reaching is avoided.
- If you do need to reach frequently overhead, use a step-stool so that the object you are reaching for is closer to you with less shoulder stretch needed.
- Keep the keyboard and mouse in close to the body
- Place frequently needed items in a close work envelope between hip and shoulder height.
- Tension and Stress
Many people hold tension in their shoulders. When feeling stressed, try to break the cycle by practicing diaphragmatic breathing techniques or taking a quick break away from the demanding situation. Perform some shoulder rolls emphasizing the backwardsmovements.
- Stretch frequently throughout the day.
- Take frequent micro-breaks.
- Try these exercises to recreate muscular balance in the shoulder complex. Remember, these exercises should not cause pain. Start slowly using a light weight. Add additional weight and repetitions gradually.
- Strengthen the Rotator Cuff with Side-Lying External Rotation
- Hold a light weight in your right hand. Lying on your left side, hold your right elbow tucked in at your side. Not moving the elbow away from your side, lift your hand towards the ceiling, then smoothly and slowly move your hand towards your stomach. Repeat 8-12 times. Perform 1-2 sets. Repeat with the other arm.
- Stretch the Pecs with the Doorway Stretch
- Stand in a doorway facing the doorway jam. Bend your elbow placing one forearm along the doorway jam with the hand at about head height. Slowly rotate your body away from the doorway jam until you feel a nice stretch in your chest muscle close to your shoulder. Hold for 20-30 seconds. Repeat 2-3 times. Repeat with the other arm.
- Towel Stretches for Internal and External Rotation
- Drape a towel over your left shoulder holding to the upper end of the towel with your left hand. Place your right arm behind your back and grab on to the end of the towel. With your left hand, pull your right hand up along the spine as if you are trying to scratch an itch as high up your back as possible. Hold for 20 seconds. Repeat 2-3 times. Then with your right hand, pull the towel down, stretching the left hand along the spine as if you are trying to scratch an itch as low on the back as possible. Hold for 20 seconds. Repeat 2-3 times. Repeat with the other arm.
- Shoulder Opener
- Lie on a Foam Roller with the spine and heal supported and the arms relaxed at your sides. Support the arms with pillows if needed. Let the shoulders roll back around the foam roller. Stretch for a minimum of 3 minutes. Perform diaphragmatic breathing while stretching.
Feb. 18 (Bloomberg) -- People who are naturally happy appear to have a lower risk of developing heart disease or dying from heart attacks, according to a 10-year study from Canada.
Those who scored the highest on a five-point scale measuring joy, happiness, excitement, enthusiasm and contentment were the least likely to have heart disease at the end of the study, according to the report today in the European Heart Journal. The dispositions of the 1,739 volunteers were evaluated by nurses at the start of the 1995 Nova Scotia Health Survey and in 2005.
While positive emotions have been tied to a stronger immune system, less diabetes and higher survival rates, few studies examined whether it protects the heart, said Karina Davidson, director of the center for behavioral cardiovascular health at Columbia University Medical Center in New York. The results show increased levels of positive emotions, known as positive affect, are linked to a 22 percent lower risk of heart disease.
"Those with positive affect may have longer periods of rest or relaxation physiologically," Davidson, the lead author of the study, said in a statement. They "may recover more quickly from stressors, and may not spend as much time re-living them, which in turn seems to cause physiological damage. This is speculative, as we are just beginning to explore why positive emotions and happiness have positive health benefits."
The researchers ranked the 1,739 volunteers on a five-point happiness scale. For each one level increase on the scale, which ranged from none to extreme, the risk of heart disease fell 22 percent, according to the study.
The study is one of the first to document an independent relationship between positive emotions and heart disease. While additional research is needed, the results suggest heart disease prevention may be helped by increasing positive feelings as well as reducing symptoms of depression, the researchers concluded.
"At this point, ordinary people can ensure they have some pleasurable activities in their daily lives," Davidson said. "Some people wait for their two weeks of vacation to have fun," she said. "Essentially, spending some few minutes each day truly relaxed and enjoying yourself is certainly good for your mental health, and may improve your physical health."
Studies are under way to determine if specific methods to improve mood and attitude in people who already have heart disease will also boost their health, wrote Bertram Pitt and Patricia Deldin, from the University of Michigan School of Medicine, in an editorial that accompanied the report.
"The 'vicious cycle' linking cardiovascular disease to major depression and depression to cardiovascular disease deserves greater attention," they wrote. If the findings stimulate additional work on the link between mental and physical heart health, perhaps it will be time for all of us to smile,'' they said.
To contact the reporter on this story: Michelle Fay Cortez in London at [email protected]
Reader C.K., who writes as "The Healthy Skeptic," penned the article, which is well-sourced and thought-provoking. It reminds us not to accept the standard "wisdom" without submitting it to a healthy skepticism.
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Last modified: January, 20, 2021