Author: Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor of Psychiatry at Stanford University and an Honorary Professor of Psychiatry at Kings College London. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans, drugs, crime and correctional systems. Professor Humphreys' over 300 scholarly articles, monographs and books have been cited over thirteen thousand times by scientific colleagues. He is a regular contributor to Washington Post and has also written for the New York Times, Wall Street Journal, Washington Monthly, San Francisco Chronicle, The Guardian (UK), The Telegraph (UK), Times Higher Education (UK), Crossbow (UK) and other media outlets.

Up in the Air II: Why Airlines now Charge for Same Day Standby

I try to fly only on a single airline so as to be treated less like an anonymous bovine by a company that somewhat values my business. But I got stuck the other day flying an airline on which I have no elite status, and thereby discovered that some airlines no longer allow free “same day standby” for the average Joe or Josephine. In the past, someone whose first leg flight landed early and was thereby able to grab an earlier connecting flight was whisked aboard without question or charge.

No charge standbys reflected the longstanding airline industry principle that there is nothing worse than an empty seat on a plane as it takes off (Again I recommend to RBCers the book Hard Landing, which explains how dilligently all the airlines worked to avoid the curse of empty seats up in the air). An empty airline seat is an unusual commodity: Its value increases over time as departure approaches but the moment the plane takes off, it becomes valueless.

I was puzzled by this airline wanting to charge me to move to an earlier connection, given that moving me into an empty seat of a plane that is about to depart opens up my seat on a later flight, which gains the airline more time to sell it to another customer (or to allow a bumped passenger to have a seat thus avoiding the “we are in an oversold situation” auction). It seemed they were refusing to give away something that was about to become valueless for the chance of making money later. Rather than be irritated, I decided to do some reading to figure out why the airline had reversed the long standing, seemingly rational industry practice of granting free same day standbys. Continue reading “Up in the Air II: Why Airlines now Charge for Same Day Standby”

Up in the Air: I. How Airports Coerce Sales of Bottled Water

On my current trip to South Dakota, I felt thirsty as I waited for my plane. I walked to one end of the terminal and did not see a water fountain. I walked to the other end and did not see one either. I was sure I had missed it, so I repeated a loop around each of the 12 gates between security and the end of the terminal. No water fountains.

There were however merchants selling bottled water. I was stubborn enough to go into the men’s restroom and run sink water into my hands for a rebellious slurp to slake my thirst, but most everyone else was lining up to buy bottled water.

In my youth, airports had massive phone banks. Pittsburgh took pride in having the largest in the world. As those disappeared, we were essentially forced to decide between not being able to make a call or purchasing our own personal cell phone. The same process is now forcing us to buy bottled water, which is (1) A ripoff (2) A contributor to landfills overflowing with plastic bottles. A small example of how the disappearance of shared public amenities drives personal consumption.

Christopher Hitchens’ illness: II. Responding to the rising rate of esophageal cancer

If anything good can come out of Mr. Hitchens’ diagnosis, it may be greater attention to the astonishingly large increase in esophageal cancer in the U.S. During the last quarter of the 20th century, its incidence increased six fold. It’s a case where scientists know the cause but not the solution.

How can the incidence of esophageal cancer be soaring in a period of declining alcohol and tobacco consumption? The drops in heavy drinking and smoking have helped to lower the incidence of the squamous cell esophageal cancers that typically occur near the mouth and neck. But in a case of “if it’s not one damn thing, it’s another”, rising overeating and obesity have more than canceled out these gains because they increase risk for a different type of cancer (adenocarcinoma) lower down in the esophagus.

Obese people (as well as people with bad eating habits who are on their way to obesity) are prone to chronic gastric reflux, the splashing of powerful stomach acids into the lower esophagus. In addition to being painful, over time this can cause changes in esophageal cells which make them much more cancer prone. This raises the health policy question of whether a campaign to promote mass prescription of proton pump inhibitors (e.g., Prilosec) to overweight people would pay off in terms of a lower esophageal cancer rate. Unfortunately, the answer is almost certainly no. Continue reading “Christopher Hitchens’ illness: II. Responding to the rising rate of esophageal cancer”

Christopher Hitchens’ illness: I. How atheists die.

The normal jolt most of us get when we run into someone well-known was accentuated for me when I turned to see Christopher Hitchens standing a few feet away from me at a party on the night of the recent UK election. On top of “Wow, there is someone famous” was a more intense, visceral response: “Wow, that man looks really sick”. He was being his usual animated, talking, smoking, drinking, larger than life self, but his pallor suggested underlying physical disquiet. I don’t know if he had been diagnosed with cancer by then, but I was not surprised to hear the sad news not long afterwards.

Jeffrey Goldberg at The Atlantic has a revealing interview with Mr. Hitchens on line, in which among other things they discuss Hitchens’ atheism. I suspect many religious people who hated Hitchens’ book about atheism are praying that he will have a conversion in the face of his serious illness (esophageal cancer). The more hard-hearted will wish that as an atheist he will pass from this life in fear and trembling because he has no hope of heaven. The likelihood of either of these of things happening are as close to nothing as makes no odds. Continue reading “Christopher Hitchens’ illness: I. How atheists die.”

Are there benefits from AIDS becoming so boring, and if so, who gets the credit?

Feeling my way as a new RBCer, I have been attempting to discern what readers find interesting of all of the varied content that is posted here. As part of that process I have been looking at the volume of comments per post, which led me to notice that the only post since I started blogging that got no comments at all was Harold Pollack’s words of praise for the new federal needle exchange funding guidelines. RBC readers are following the larger trend in this case: President Obama’s National HIV/AIDS strategy points out that the proportion of the U.S. public who considers HIV/AIDS the nation’s most urgent health problem has declined from 44% to only 6% over the past 15 years.

The costs of complacency about HIV/AIDS are substantial and well-known: Young people born before the greatest horrors of the epidemic do not bother to find out their HIV/AIDS status or to practice safer sex, funding and enthusiasm for prevention wanes, and the financial and human costs of caring for more infections pile up. Complacency also feeds cynicism in some quarters (which I believe does not take sufficient account of how the country has changed since the epidemic started) — that most Americans just don’t care about any problem that primarily affects African-Americans, gay and bisexual men, and injection drug users.

Yet I see some benefits to the public’s ennui. Continue reading “Are there benefits from AIDS becoming so boring, and if so, who gets the credit?”

Science supports the 12 steps for addiction

Dr. Bankole Johnson, a justly respected addiction researcher, published an op-ed in the Washington Post last week that lambasted 12-step mutual help organizations such as AA. In the Washington Post today, I correct Johnson’s assertion that there are no randomized clinical trials supporting 12-step interventions. The amount of benefit to addicted patients in the trials I mention (One published by Christine Timko and colleagues in Addiction, the other by Leonard Jason and colleagues in American Journal of Public Health) not incidentally surpasses that found in most studies of the alcoholism medications for which Johnson advocates. We have some promising developments in terms of medications, but we clearly don’t have a blockbuster drug yet and certainly don’t have a basis for saying that we don’t need the 12-step approach anymore.

What I didn’t have space to say in a 200-word letter I will say here: I agree with Dr. Johnson’s questioning of the value for money from $50,000/month day-spa-with-massage-rehabs for addicted movie stars in Southern California, but am mystified that he lumped a free, non-profit mutual help organization together with such boondoggles. My research with Professor Rudolf Moos on these organizations shows that they take an enormous financial burden off of society because they substantially lower health care utilization. That means lower tax burden and reduced insurance premiums for the rest of us while at the same time saving lives…..which as a cost-benefit arrangement is the other end of the world from Malibu rehab inc.

A better process for setting marijuana possession penalties in California

Although I have made clear my opposition to Proposition 19, I find something admirable about a different ongoing effort to change marijuana law in California. California Senate Bill 1449, introduced by Senator Mark Leno, defines possession of an ounce or less of marijuana as an “infraction” warranting a fine of up to $100 and no jail time. Technically, that’s what the punishment has been for many years, except that marijuana possession is formally defined as a misdemeanor under current law, which brings judges and courtrooms into the picture. The proposed law, which will lead marijuana possession offenses to be handled much like speeding tickets, has already cleared the Senate and is out of committee in the Assembly.

I don’t know if the end law will be a good one because the amendment process is still underway, neither do I think its effect is entirely predictable. Laws changing marijuana penalties can have unexpected effects, depending on how law enforcement on the street respond (e.g., net widening when police see a penalty as slight, more selective enforcement if police see a penalty as too tough). But whatever happens de jure and de facto, the process by which this legislation is being developed and deliberated deserves praise for two reasons.

First, going at least as far back as the disastrous property tax revolt initiative (Prop 13), the state legislature has repeatedly kicked political hot potatoes into the initiative process instead of having the courage to govern. This takes critical policy debates out of the deliberative process and into one where bad reasoning, volatile emotions and misunderstanding are the norm. In this case though, our elected leaders in Sacramento are acting like elected leaders and try to legislate, so good on them.

Second, the legislators are being realistic about what is and is not possible within the framework of the federal Controlled Substances Act. By endorsing legalization, Proposition 19 inherently provokes a confrontation with the federal government if it passes, a situation which I think will not end well for California (see Mark Kleiman and Eric Sterling‘s latest posts for other perspectives). What the progress of S.B. 1449 shows is that a state can change marijuana possession penalties without making a federal case out of it, so to speak.

Take this flight attendant job and shove it

Particularly in a recession, many Americans in the service industry are going to sympathize with Steve Slater, the JetBlue flight attendant who fled his airplane after being struck and treated like garbage by a passenger. My heart goes out to him, but my head says that no matter what punishment he receives or what help he gets (and he deserves both), he can never go back to his old job.

Jonathan Zasloff is right on point when he says that President Carter is in many ways the father of airline deregulation, although Senator Ted Kennedy and then-Congressman (later Secretary of Transportation) Norman Mineta were also key players. As it happens, I just read Hard Landing by Thomas Petzinger Jr., a truly brilliant book about the airline industry that makes clear that flight attendants were probably the biggest losers in deregulation. More often than not, the airlines have been able to cut deals with the big boys (and I used that gender-specific term advisedly) — the pilots’ unions — and thereby outmaneuver and crush the flight attendants’ union.

It’s a poorly paid job that wreaks havoc on family life and mental health. Mr. Slater’s experience is not unique in terms of abuse by passengers: The worst story I have heard concerned a passenger smacking a flight attendant on the head with her baby’s recently discarded diaper. Yet the perceived romance of travel keeps the number of young job applicants high, weakening the ability of current flight attendants to bargain for better labor conditions.

Mr. Slater was coping with all that, and apparently based on news coverage he also had other stresses in his life, including caring for his ailing parents. Were I a judge, I would order him to repay the financial damage he caused and get some sort of mental health care, but certainly not jail him for even a day (the entitled passenger who got up when he was not supposed to, hurt Mr. Slater with his luggage and then refused to apologize should get zero compensation).

All that said, Slater simply can’t go into the air again. Predicting rare behavioral events, like violence, has been extremely difficult for social scientists. We usually end up falling back on the completely accurate cliché that the best predictor of future behavior is past behavior. The odds of any member of the flight crew losing it at altitude and doing something to endanger the passengers and crew are very very low, so low that we will never be able to predict it for any one individual…with the sole exception of those who have committed such an act before. That’s why for his own safety and everyone’s else, Mr. Slater needs to find a new career.

State-level disparities in crack vs. powder cocaine sentences: Unfinished business

The effects of the federal crack vs. powder cocaine sentencing disparity were well-documented at the federal level, but such assessments did not capture the damage inflicted in the states that adopted doppelganger legislation in the late 1980s. Collectively, the states imprison over six times as many people as does the federal government, making state-level reform essential in any effort to broadly implement more equitable incarceration policies.

Now that Congress and the Obama Administration have eliminated mandatory minimums for simple possession of crack and reduced the size of the powder-crack disparity substantially for dealing offenses, a window has opened for reformers to go back to state legislatures and ask them to copy the federal government again, only this time by reducing crack cocaine sentences rather than ramping them up. South Carolina has already done so, and I am informed that the changing federal landscape was one of the rationales successfully invoked by reformers to persuade the state to drop its own crack-powder disparity.

That leaves I believe, about 10 states with a bad law handed down from another era. I tried to make the case earlier this week that California is the most important to reform because of the size of its prison system. California gives a “bonus year in prison” for crack versus otherwise identical powder cocaine dealing convictions, which at the peak of the epidemic were meted out to over 2,000 people a year. My back of the envelope calculation is that dropping the crack penalty to the level of powder penalties in California would have an immediate effect of reducing imprisonment by about 6,000 total years (assuming retroactivity) in the first year, and then a further 1,200-1,800 years per year after that, depending on whether the crack epidemic continues to wane or kicks up again. At $40,000/year of incarceration, that’s roughly $60 million in savings for California annually.

It’s hard to work out the collective impact of reform in their rest of the states, because they passed different types of powder-crack disparities. But their collective overall population is more than California’s, so projecting another $60 million in reduced prison costs to spread around is quite conservative.

That said, the best reason for states to follow the federal reform is that the remaining laws are simply unjust, and would be so even if there were no financial savings to be realized from changing them (or for that matter even if it cost money to be rid of them). With the federal reform complete, and a zeitgeist of criminal justice reform blowing through the country, all of us who care about this issue should be descending on our state capitals to demand change.

Nation building on the Internet: Why I am grateful to join the RBC

A few years back, while I was teaching a psychiatry short course in Iraq to about 80 mental health professionals from around the country, an Iraqi physician took me aside one day to caution me: “Don’t be fooled by those of us who have gathered here, we are not the real Iraq. This country is like Russia under Peter the Great. Our educated middle class is a thin veneer of civilization spread over a teeming mass of people who are misinformed, angry and radicalized. You can’t build a nation here: We have nothing to build on.”

The relational structure of many political websites recalls this comment about Iraq to my mind. One of the website’s authors will write an intelligent, thoughtful and nuanced post on some controversial topic and beneath the post in the comments section will issue forth a sea of bile, misunderstanding and misinformation Continue reading “Nation building on the Internet: Why I am grateful to join the RBC”