Map of life expectancy at birth from Global Education Project.

Friday, May 27, 2016

The Economics of Medical Miracles

The Academy Health* blog presents an interesting quandary in health economics. We aren't quite there yet, but the day may come soon when it is possible to essentially cure genetic diseases like cystic fibrosis and sickle cell. That sounds great!

The problem is that these are fairly rare diseases, and that the treatment would be administered only once. So, in order to recoup their research and development costs, the purveyors would have to charge enormous prices -- on the order of a million bucks a pop. That's going to make you think, "Oh, this is like those other moral dilemmas about the allocation of scarce resources. We could use that money to save 50,000 African infants or something instead."

Well, yes, but actually we already are spending it on the people with cystic fibrosis and sickle cell anemia -- actually a lot more than that in many cases. We don't begrudge with CF a lifetime of treatment that may cost $6 million, and they would be much happier getting a single treatment that actually cures them. But somebody has to finance it, which means we need to radically rethink how we organize the financing of medical services.

Then there's Norwegian physician Jarle Breivik who discusses Obama's cancer "moonshot" in the NYT. Apart from the well-known problem that cancer is innumerable diseases and there will never be a cure for "cancer" per se, it is true that we can make progress against the multiple diseases called cancer and maybe achieve something we define as a "cure" for a growing percentage of people. The problem is that the rate of cancer increases relentlessly with age; whoever we cure today is very likely to develop cancer again, either from fugitive cells from the original cancer, side effects of chemotherapy and radiation, or because it just happens. And then we're all going to die eventually anyway. Meanwhile, of course, there are still those starving African kids with diarrhea and malaria.

Medicine, in other words, faces a problem of technological imperative. If we can do it, people will demand it, but we have no fair and reasonable way of sorting out competing demands for scarce resources. 

*Academy Health is the research society in health services and policy. Yeah, yeah, it ought be the Health Academy, but it isn't.

Thursday, May 26, 2016

A Couple of Observations about Wrongdoing

Those of us old enough to remember Whitewater would prefer to forget. In a pistachio shell, the Clintons, while in Arkansas, invested some money in a real estate deal. The promoter turned out to be a sleazebag, and they lost their investment. That is all.

But the New York Times, which for reasons unknown hated the Clintons, produced a long-form investigative piece (written by Jeff Gerth, whose inexplicabe, irrational hatred for Hillary Clinton is as boundless as Donald Trump's ego), which insinuated that the Clintons had somehow been guilty of wrongdoing in the affair. The piece actually made no sense and added up to nothing, but was extremely convoluted and sufficiently difficult to follow that few readers bothered to deconstruct it and figure out that it was a complete nothingburger.

Michael Tomasky tells the story of what happened next. Briefly, a hyperpartisan pathological liar named Kenneth Starr wound up being appointed as a special prosecutor by a panel controlled by ultraconservative judges, and spent 3 years persecuting and tormenting everybody associated with the Clintons and finding absolutely nothing. Then Monica Lewinsky happened, so he switched to that, and we got impeachment.

Starr is now the president of Baylor University. He has suddenly taken to praising Bill Clinton for some inexplicable reason -- to which Clinton's friend say no thanks. He has also (okay, allegedly) swept sexual assaults by Baylor football players under the rug, for which he may (we are all desperately hoping) end up losing his job.*

 Meanwhile, Ronald T. Dump is planning to dredge up the Whitewater hoax as a campaign tactic. Since the corporate media has never accepted that it was, in fact, a hoax, since that would embarrass them, it will probably work.

So, in politics the simulacrum is as good as the reality. Or as Cokie says, it doesn't matter if it's true or not, it's out there.

Turning now to the world of art, a Manhattan gallery sold $80 million worth of works by such modern luminaries as Motherwell, Pollock and Rothko which were in fact painted by a Chinese immigrant in a garage in Queens. Now that this is known, the paintings are worthless. But they are in fact the same paintings they were when they were worth $80 million -- to some of the most discerning collectors on earth.

Think about it, it must mean something.

*Update: They kicked him upstairs. Once you're a big enough asshole, there's no way to fall but up.

Wednesday, May 25, 2016

The Bully

Josh Marshall discusses the Republican presidential candidate's attitude toward women, and his specific attacks on Hillary Clinton, which in Marshall's view are not based on tactical consideration but are rather a direct expression of the Trumpian id. Excerpt:

Listen to Trump's words and you hear repeated lines about hurting Clinton, warning her to back off and not forcing him to hurt her again. Cut and paste them out of the context of a campaign article and they read like dialog from a made for TV movie about a wife-beater. . . .

As I've written in similar contexts, when we look at the messaging of a national political campaign we should be listening to the score, not the libretto, which is, like in opera, often no more than a superficial gloss on the real story, mere wave action on the surface of a deep sea. You're missing the point in trying to make out the logic of Trump's attacks on Clinton. The attacks are the logic. He is trying to beat her by dominating her in the public sphere, brutalizing her, demonstrating that he can hurt her with impunity.
I think that this, as much as his racism and xenophobia, his hyper-aggressive nationalism, and his anti-intellectualism, explains his appeal. Many working and middle class white men are stinging from loss of privilege. Even as their economic status is stagnant or declining, the racial and gender privileges they once took for granted are eroding. The election of Barack Obama obviously drove home the loss of racial privilege, and we have seen the intense backlash. Now along comes the prospect of a woman president and it's the end of the inheritance to which they felt entitled.

The nation, and the world, are in grave danger. I am sufficiently distressed by this that it's been hard for me to post here. I'll get back to it.

Thursday, May 19, 2016

The Visible Hand

Jonathan Alpern and colleagues in NEJM discuss the plague of pharmaceutical locusts that is depriving some of the most vulnerable people of health and life. Yes, there have been a couple of famous examples, such as the psychopath Martin Shkreli who bought the rights to a decades old drug and then jacked the price up 500 times. It turns out, however, that this sort of scam has become commonplace.

As Alpern discusses, the targets are typically treatments for relatively uncommon infectious diseases, such as tropical diseases and opportunistic infections. This is because the market for the drug is small enough that it isn't likely to attract competitive manufacturers. These are people who cannot afford high out of pocket costs and may be uninsured or underinsured. As Alpern et al explain:

It seems that a new business model has emerged: companies are acquiring drugs in niche markets where there are few or no therapeutic alternatives in order to maximize their profits. Unlike new brand-name drugs, the patents of the drugs being targeted by this model expired years ago. These companies seem to have no interest in adding value to the health care system by developing new drugs. . . .

What makes this business model particularly disturbing is that vulnerable patients — such as immigrants, refugees, and people of low socioeconomic status — are often disproportionately affected, since many of the medications are for tropical or opportunistic infections. These patients often have limited or no access to insurance, or have access only through public programs, so already stark health disparities are compounded.
This is a problem only in the United States. In Europe, drug prices are regulated. The reason they aren't regulated here is because the obscenely wealthy psychopaths who have bought the U.S. political system -- including politicians, the corporate media, and economics departments -- have brainwashed us all into thinking that letting rich bastards screw us is the definition of "liberty." So that's what congress does.

Monday, May 16, 2016

The collapse of civilization

Yes, it has happened in war zones, but it's also happening in Venezuela right now due to gross misrule and the collapse of oil prices. The Gulf monarchies prepared for this eventuality by putting money away. They won't be able to live on their savings forever, but the Saudis have acknowledged that the end of the era when money gushes from oil wells is coming, and they have vowed to diversify their economy. Norway, though not as dependent on petroleum as the Saudis, is also preparing for the gravy train to end.

Alaska and Louisiana did not plan; nor did West Virginia plan for the collapse of the coal industry. All three states are in financial trouble, although of course nothing like Venezuela. (It helps that they have the federal government to help them out, although of course their political leaders won't admit that.)

The point is that it is very difficult for people to contemplate that their long accustomed way of living will have to change. The depth of denial can be astonishing. Joe Romm walks us through the climate shock we are experiencing right now. Not thirty years from now -- right now and starting last year. Scientists who specialize in this area are by constitution conservative in what they will say publicly, but obviously the positive feedbacks in the climate system are terrifying -- disappearing sea ice, burning forests, melting permafrost all amplify the process. What we are seeing now is consistent with an accelerating trend which is on the highest end of the projected range.

This is a global emergency. But it's much more important to bully and humiliate transgendered people, because that's what Jesus wants us to do.

Wednesday, May 11, 2016

We already knew this, but it's disturbing

Gillis and Fountain in the NYT discuss the fate of the boreal forest. That is the vast coniferous regime that wraps the earth south of the tundra, across Siberia, Alaska and Canada. Something like 1,000 square miles of it just burned in Alberta, which made the news, but it's burning more and more everywhere. You already know why: hotter temperatures, earlier snowmelt, pine bark beetles.

You may also ask why there was a city of 80,000 people by the banks of the black-fly infested Athabasca river in the desolate arctic forest -- you know, the one the people just had to flea before the conflagration. It's because they were occupied in mining tar sands, ultimately to pump the C02 into the atmosphere which was responsible for destroying 10% of their city. There's worse news, which is that if the forest keeps burning like this it will cease to be a carbon sink and will become a net emitter of carbon.

Joe Romm makes it crystal clear. We can't afford even the 2 degree warming target. We can't delay action, wait for a technological fix or afford ourselves the luxury of time. The time is now.

Monday, May 09, 2016

John Oliver Smashes

If you haven't seen this already, it is everything you need to know. Scroll down for the embedded video. It's a long form riff, so make sure you have enough time.

It's stuff I talk about here all the time, but it's better when it's funny.

Friday, May 06, 2016

Medical Nemesis

You may have heard about this analysis in the BMJ that says medical error is the third leading cause of death in the U.S., after heart disease and cancer. This isn't actually supposed to be news, what the authors are really saying is that we need to keep track of it better and deal with it better.

A bit more about that anon, but let me also say that it isn't exactly, precisely true. Although they give as an example a case in which a botched medical procedure affirmatively caused a death, some of the cases that counted are more examples of medical error failing to prevent death from disease or an unrecognized lesion. It's sort of like saying that a faulty guardrail, rather than a driver who falls asleep at the wheel, is a cause of death. In other words we have an expectation that effective medical intervention will be provided when it is possible, and we're willing to call failure to prevent death a cause of death.

On the other hand, medical intervention can cause death when there is not any error per se, or at least it's not clear that there is. There is a certain risk associated with surgery or pharmaceutical treatment, which has to be weighed against the likely benefits. At what point less than perfect judgment or execution gets defined as an error is not usually clear, either. We don't know the details of Prince's case yet, but soon we might be asking, "Should his doctor have written that prescription for opioids after his surgery?" At what point did continuing to give him percocet become an error?

So what Makary and Daniel are saying is not that we should blame health care providers and that those incompetent, careless doctors are killing us all. What they are saying is precisely the opposite: that we need to create a culture that doesn't blame, but fixes problems. Medical professionals are human. They will make mistakes. The difference is that in most professions, mistakes are seldom or never fatal.

So they propose, first of all, that death certificates include a notification that medical error was a factor in the death. I'm not sure how well that would work -- the physician responsible would likely be the one filling out the certificate, there are liability issues, and as I say, how do we really know when what happened qualified as an "error"? This seems unrealistic to me.

On the other hand, we could have a culture and a practice in which avoidable death and injury are discussed openly within the provider institution, and procedures are put in place or reinforced to prevent recurrences. In order to have continuous quality improvement, you need to limit blame and negative consequences of mistakes so that you don't just drive them underground. But on the third hand, some individuals should not be practicing, or should be required to take time out to be retrained or solve personal problems such as addiction that are interfering with their performance. You can't make quality improvement entirely blame free.

So this is really about balance. It isn't about a dichotomy, and it isn't simple.   

Wednesday, May 04, 2016

Political Science

I've been pretty sure that Ronald T. Dump was going to be the Republican nominee for president for a while now. Nevertheless, it does smack my gob. Sure, with a party that nominated George W. Bush and a country that actually elected him, at least the second time around, it may not seem that big of a stretch. But Chimpy was disciplined enough to repudiate white supremacists, not call his opponents "pussy," or accuse their fathers of murdering JFK, just to offer a few examples. He also managed to stick to a script and articulate reasonably consistent policy positions, even if they were untethered from reality. His racist dog whistles generally stayed above 20,000 Hz.

While I'm still pretty confident that reporters will be asking questions of Madam President at the first press conference of the next administration, the triumph of the malignant clown, even within the party of Goehmert, has many people questioning the fundamental premises behind electoral democracy. Could the smoke-filled rooms of yore possibly have produced such a result?

Scott Lemieux points to Sarah Palin to say "Well, yes." But Palin came along after the really decisive factor, which was not the primary process but the television. Reality today is what lies behind the glass in your living room. That's what made both candidates possible. Remember that democracy in the past produced plenty of atrocious outcomes -- presidents who supported slavery, and then segregation; the Native American genocide; the Vietnam war. Name your poison. We've never expected it to particularly yield good results, just candidates who are reasonably presentable in public. Trump would not necessarily be a worse president than Herbert Hoover or William McKinley -- although he would be scarier since they didn't have an atom bomb. He's just cruder and more impulsive. But the stakes today are much higher. 

Tuesday, May 03, 2016

Relative Risk and Tort Law

Now here's a difficult problem -- mull it over and see what you think. A woman has been awarded $55 million in damages from Johnson & Johnson based on the claim that talcum powder caused her ovarian cancer.

Here's the 4-1-1 the actual relationship between talc and ovarian cancer. (I'm not sure if you can read it -- I have a magic cookie.) Summary:

Case control studies suggest that women who use talcum powder on their genitalia have about a 20%  increased risk of ovarian cancer, or maybe as much as 30%. That sounds pretty serious, but case control studies aren't conclusive about proving causation. Prospective cohort studies haven't confirmed this, but it would be nearly impossible for them to do so, because of what is called statistical power.

Ovarian cancer isn't all that common. In a 10 year follow-up period, 2 out of 1,000 women will be diagnosed with it. If the increased risk from talcum powder really is 20%, you would have to follow more than 100,000 exposed women and 100,000 unexposed women for 10 years in order to prove it. Put it another way -- the chances that an exposed woman will develop ovarian cancer attributable to talcum powder use is (2/1,000) * .2 = .0004, or 4/10,000.

Is the verdict justified? You decide.

Thursday, April 28, 2016

No, both sides don't do it

While surfing around and commenting on various blogs I have encountered an ineluctable phenomenon. Whenever the discussion is Republican/Conservative denial of the science of global climate change, evolution, and cosmology, people chime in with "Well, liberals are anti-vaccines and GMOs."

Not The Truth. Republicans are far more likely to think vaccines are unsafe than are Democrats, while doubting the safety of genetically modified organisms is completely unrelated to political party or ideology. And, in general, liberals are far more likely to say they trust scientists than are conservatives.

As Dana Nucitelli says at the link:

This rising distrust of science is particularly high among higher-educated conservatives, in what’s been coined the “smart idiot” effect. Essentially, on complicated scientific subjects like climate change, more highly-educated ideologically-biased individuals possess more tools to fool themselves into denying the science and rejecting the conclusions of experts.

Wednesday, April 27, 2016

Player Piano

That was Kurt Vonnegut's first published novel. It presents a dystopia in which automation has created massive unemployment. A few engineers and managers have jobs and with them a purpose in life, and affluence, but pretty much everybody else is pretty much useless. Oh yeah, they are geographically segregated as well. Which is also happening in the real world today.

Eduardo Porter, in the Gray Lady, speaks the hard truth to the presidential candidates. The disappearance of decent jobs in the United States has very little to do with globalization or international trade agreements. We can't bring factory jobs home from China or Mexico because that's not where most of them went. The jobs were taken by machines. Employment in manufacturing is declining globally. Quoth Joseph Stiglitz:

The observation is uncontroversial. Global employment in manufacturing is going down because productivity increases are exceeding increases in demand for manufactured products by a significant amount.

That's a fact. And it will continue. Porter notes that at the beginning of the 20th Century, 41% of Americans worked on farms. Today it's 2%. Stopping food imports from Mexico and Chile isn't going to solve our need for good jobs. It's the same story in manufacturing. This is a looming disaster for the developing world, because growth in manufacturing employment has stopped while they are far poorer than the U.S. and Europe. They cannot possibly get rich by building factories, because workers cannot compete with machines. So what are they going to do?

Porter says we have to make a shift to a service-based employment economy. The idea is that the few people who get rich will spend their money to be entertained or massaged or have their gardens tended, I suppose. But obviously they aren't spending enough on that to make up for the loss of good jobs and most of those jobs are lousy anyway. And many service jobs are being replaced by machines as well -- from telephone receptionists to bank tellers. (If the self-driving cares ever become real, so long country music songs about truckers not to mention Uber and Lyft.)

Of course, government could invest in physical infrastructure, scientific and biomedical research, renewable energy, education. That would put people to work and maybe help to build a sustainable future. Well we know that isn't happening.

Unfortunately not even Bernie is telling us the inconvenient truth. NAFTA and the TPP aren't what did in the middle class, and he is not offering the only real and urgent solution. We need to invest collectively, as a nation, to build a livable future. And that does not include border walls.

Tuesday, April 26, 2016

Chetty, et al, on income and life expectancy . . .

in the U.S. is all the buzz, so I reckon I should say something about it.

It has long been known, and observed very consistently in various countries, that there is a relationship between people's socioeconomic status (SES) and longevity. SES can be measured in various ways, and it still holds -- income, education, occupational status (i.e. position in the hierarchy), wealth, membership in relatively advantaged groups such as white vs. black. Of course these are all correlated, but each of them tends to hold even when controlling for the others.

Chetty and colleagues used income tax data from the IRS matched with death records from the Social Security Administration. They estimated life expectancy at 40 years, controlling for race/ethnicity, and looked at gender and area of the country as covariates.

The main news in this is:

  • Life expectancy increases with income continuously throughout the income distribution. The richer you get, the longer you live, right up to the good old 1%. The difference in life expectancy at 40 between the lowest and highest 1% for men was 14.6 years. It was 10.1 years for women.
  • The impact on life expectancy of being poor was different in different parts of the country. 
  • Inequality in life expectancy increased from 2011-2014, with the lowest 5% gaining almost nothing, particularly for women.
  • Regional characteristics associated with lower life expectancy in the lowest 25% included the prevalence of behaviors such as smoking, but not access to medical care or labor market conditions. Regional characteristics favorable to life expectancy for low-income people were the fraction of immigrants (take that, Donald), fraction of college graduates, and government expenditures (take that, Mr. Cruz).

In making sense of this all it's important to keep a few technical points in mind. In order to have a life expectancy at 40, you have to make it that far. This isn't telling us anything about mortality at younger ages. Of course you can't do anything about mortality of infants and children, because they're largely dependent on their parents' income, so that's pretty much a separate question. "Life expectancy" assumes that people will continue to die at the same rates as others with their particular characteristics do today, as they go through the future life course. Obviously that isn't true. This is telling us what will happen if the world does not change. Also, controlling for race/ethnicity reduces the apparent effect of income -- it's actually greater. There are some other technical caveats and limitations, but these I think are the most important.

The main takeaway, for me, is one more brick in the wall of solid knowledge that spending all this money on medical care is not the answer to our lousy health compared with other wealthy (and some not-so-wealthy) countries. We could spend less on medical care and a lot of other social expenditures if we would a) tax the rich and b) invest in our people. The only reason that is the opposite of the conventional wisdom is because rich people buy the conventional wisdom.

Thursday, April 21, 2016

This won't end the opioid epidemic . . .

. . . but it might help. The CDC has come up with new guidelines for opioid prescribing in outpatient care which are heavily promoted in the leading medical journals. (The link is to NEJM, which proffers it for free to the subscriptionless rabble.)

The story of how we got where we are is pretty well known, I think. But I'll recap it for convenience.
Chronic pain (CP) is the most prevalent and expensive health condition in the United States, estimated to cost up to $635 billion per year in health care costs and lost productivity. Often pain is from osteoarthritis or other identifiable physical causes, but as I have discussed here previously, it can also be a malfunction in the brain-nervous system circuits that creates pain without an identifiable physical lesion. That makes effective treatment elusive. 

Obviously, having chronic pain can be a serious drag. It is associated with depression, social withdrawal, loss of employment. So, back in the 1990s a movement arose claiming that chronic pain was undertreated because doctors were too afraid to prescribe opioids. People claimed that when they were used to treat pain, people rarely became addicted, that there was little harm in long-term use, and that opioids were the magic balm that doctors were callously refusing to suffering people. No big surprise, the companies that make them sang the lead part in the chorus. 

So now we have an epidemic that is devastating communities all over the U.S., of overdose from prescription opioids, and of addicts who have switched to illicit heroin and fentanyl. Along with this comes ruined lives, crime, HIV and hepatitis C, and death. 

The truth is that long term opioid use for chronic pain does not work. Ever-increasing doses are needed to maintain analgesia, with ever-increasing side effects, and eventually complete failure. In fact people who use opioids long-term may have more pain than people who do not. And yes, it is addictive, particularly as doses increase. The new guidelines make prescribing opioids for chronic pain in people who are not terminally ill a last resort, but if you look at the facts, it probably shouldn't be a resort at all. If you have acute pain, from surgery, or breaking your leg, you might want to go for three days, seven is really stretching it. But longer-term use really doesn't make sense for anybody. 

I had surgery and I took opioids for one day, then switched to high-dose ibuprofen, which was perfectly adequate. I took omeprazole concurrently to prevent stomach upset. Unfortunately, for chronic pain NSAIDs don't really work either, and they can have serious side effects if taken long term. There really isn't any good pharmaceutical option for most people. (A minority seem to respond well to gapapentin or similar drugs, but you need to get lucky and they can also have weird effects.) The most important thing is not to give in to it -- stay active, overcome the natural reaction that the pain signal is telling you not to use the affected limb, lose weight if that's a problem for you, and stay involved in your usual activities. It may well get better in time, but in any case, you can live positively. Dope is not the answer.

Tuesday, April 19, 2016

Betraying Confidences

My friend Gary has an essay on the NY Times web site about using stories about his psychotherapy patients in his books. It turns out that even though he disguises their identities every which way, the real problem isn't that a patient's confidentiality might be betrayed, it's that the patient might recognize herself. Using the therapeutic relationship as a means to an end feels exploitive to the patient, even if nobody could possibly recognize her.

I don't exactly have the same problem -- when I interview people or record their medical encounters, they know that I'm doing it for research and some version of their story may appear in print, without sufficient detail to identify them. But I still have to be very careful. There's this, for example, which I have published:

Well, I went to three actually detoxes. I said - 'cause when I got out there, they kept on switching me from one to another. I wasn’t - I was quitting and, well, I got kicked out of one of them 'cause I had sex in a closet with a nun . . . .  So they said, "You gotta get out." But I went to three detoxes. I don't want to get off.

(She did eventually quit drinking and she's doing okay now.) No matter what I did to disguise her identity, there must be people who are familiar with this incident, and would know who this likely was if they read the paper. Fortunately, it's very unlikely they will ever read it. But still.

We always exploit our research subjects to some extent. I get the grants and the salary and whatever prestige comes with publishing. They get 20 bucks for an hour of their time. I get to decide what parts of what they tell me matter and what parts don't, and how to present and interpret their experience. I do my best to give them a voice but in the end, it's really mine after all.