The NYWT has an interview yesterday (Aug. 30) by Cornelia Dean with John D. Miller, Director of the Center on Biomedical Communication at Northwestern U. (I've checked out their web site and they aren't giving up anything worthwhile, so you'll have to depend on Dean's interview for the info on this.)
According to surveys done by Miller's outfit, fewer than 1/3 of U.S. adults know what DNA is and what it has to do with heredity. 10% know what radiation is. And oh yeah -- 20% think the sun goes around the earth. Yup, that's what it says, right there in black and white.
In other news, the Pew Research Center released poll results , shown below:
So, about 1/4 of Americans believe in evolution by natural selection, and fewer than half believe evolution has happened at all. But why would they believe in evolution if they don't know what DNA is? (Darwin didn't know either, but he deduced that there must be something that functions as we now know DNA does, as a modifiable repository of instructions for making organisms.) If people don't have the most basic information about the world, then why would they choose an incomprehensible explanation over a simple and understandable one?
The preachers have their attention every Sunday and on lots of occasions in between. The scientists just talk to each other, in their $400 a year journals full of strange symbols and incantations about transposons, epigenetically labile targets, and gamma amino butyric acid. So whose fault is it anyway?
Wednesday, August 31, 2005
The NYWT has an interview yesterday (Aug. 30) by Cornelia Dean with John D. Miller, Director of the Center on Biomedical Communication at Northwestern U. (I've checked out their web site and they aren't giving up anything worthwhile, so you'll have to depend on Dean's interview for the info on this.)
I actually have a lot to talk about today, but I can't get past the one compelling topic, and there is too much to say about that. I think that many people share my own fear about responding immediately because a day or a month later it might not feel appropriate, but what the heck, this is an ephemeral medium.
The political and civil authorities in Louisiana and Washington all knew that one day, if nothing was done, New Orleans would be under water. The experts on regional hydrology predicted precisely what is happening today, in all of its horror. We knew this. But while we have spent untold billions of dollars preparing for the possibility that somebody might set off a bomb in a subway or hijack and airplane, nobody spent a nickel to either prevent or prepare for a catastrophe that is beyond what a thousand terrorists could hope to achieve in decades.
On the contrary. The federal government subsidized flood insurance, making it possible to build in places that would have been completely undevelopable given a "free" market. The Army Corps of Engineers channeled the Mississippi and caused the destruction of the marshes that formerly protected the city. And oh yeah, we kept spewing CO2 into the atmosphere, increasing the risk of powerful storms.
There are innumerable observations one can make. How it is the poor and vulnerable who were left behind to suffer the immediate consequences. How the situation and behavior of the survivors is framed and interpreted in racist and elitist terms. How disgracefully self-centered and ineffectual has been the response of the "president" of the country. Here he is on August 30.
But I'm going to talk about denial. Yesterday, the Army Corps of Engineers confidently predicted that they would have the levees repaired within a few hours. The Governor continues to say that they'll have the city dry within a month, the electricity back on, and people going home. The American Public Health Association just sent me an e-mail saying that the downtown business district is not badly damaged and they're planning to go ahead with the annual meeting on November 5. The New York Times is editorializing that we all need to pitch in and help New Orleans rebuild.
Here's what I think. Let us suppose that eventually -- I do not believe it will be less than a month, or even close to it, but eventually -- they get the levees sealed up and the water pumped out. Then they start to cart away the bodies and debris, shovel out the toxic muck, demolish the structurally damaged buildings, somehow raise tens of billions of dollars from the taxpayers of Lousiana and/or the United States to replace the washed out streets, water mains, sewers, electrical system, communications systems, bridges. Then they start to build again.
Wait, let's stop right there. You're a developer. You're considering investing tens of millions of dollars to build or repair a high rise in downtown New Orleans, or rebuild a residential subdivision on the outskirts. It's still below sea level. There are still hurricanes. Nobody will sell you insurance in a million years. What do you decide?
Tuesday, August 30, 2005
. . . or nearly as well. A great rant by Marion Nestle in the new American Journal of Public Health. Subscription only (of course), and as I get tired of saying, they could put the public into public health by making it open access. Well, the rest of the issue is about as entertaining as Seinfeld alumni marathon. Here are some of the good parts. (I've clipped out the footnotes.)
Unless current trends reverse, it seems likely that one third of all children born today—and even higher proportions of Hispanic and Black children —will develop type 2 diabetes during their lifetimes and can expect a shortened life expectancy because of it. Such alarming estimates are based on the demonstrated connection between overweight and the type 2 form of diabetes, which comprises as much as 95% of diabetes cases. Among adults with diabetes, about 85% are overweight and 55% obese (as defined by body mass index cutpoints of 25.0 and 30.0 kg/m2, respectively). . .
Obesity is causally related to type 2 diabetes, and this disease is not something you would wish on any child. It not only raises risks for heart disease, stroke, kidney failure, blindness, and neurological problems but also requires management of insulin resistance through medication, diet, and physical activity—not easy to accomplish in adults, let alone children. . .
As grammar school students in post–World War II Manhattan, my friends and I had the run of the city. We walked to school, went to after-school lessons, biked, roller-skated, played ball, and took subways on our own. In that pretelevision and precomputer era, we were too busy playing to be overweight. Today, a parent allowing that kind of freedom to a young child would risk arrest for child abuse. Working families, unsafe neighborhoods, and lack of after-school supervision do not allow children to play freely. Schools cannot be expected to fill the gap. Most lack funding for supervised in-or after-school games, and some forbid children to play at school at all in fear of lawsuit-generating injuries. On the food side of energy balance, children of my era did not have access to large amounts of high-calorie foods with minimal nutritional value ( junk foods), which are now considered normal fare. It is now normal for children to spend their free time at home watching televised commercials for such foods or using computers to view clever food advertisements disguised as games. It is now normal for children to expect to eat foods marketed in these ways. . . .
In 1980, the US food supply (production plus imports minus exports) provided 3300 kcal (13.8 MJ) per day per capita; by 2000 the supply had grown to 3900 kcal (16.3 MJ) per day. Even with wastage, this amount greatly exceeds the caloric needs of most adults and virtually all children. One effect of caloric overabundance is fierce industry competition to sell those calories. Wall Street requires companies to demonstrate growth every quarter. In this investment environment, food companies have 2 choices: they can entice people to buy their products instead of anyone else’s, or they can encourage people to buy more food in general. In an economy of overabundance, obesity and diabetes are just collateral damage.
From a business perspective, social norms that encourage people to eat more food make perfect sense. If you are in the food business, you want people to snack instead of eating regular meals. You are happy to serve larger portions: food is cheap, relative to labor costs, and customers love bargains. You want people to eat frequently throughout the day, drink sodas instead of water, and eat in formerly food-free places (e.g., clothing stores, bookstores, and libraries). You want it to be socially acceptable for children to bring snacks to school, have access to vending machines, and eat branded drinks, snacks, and fast foods during school hours.Marketing to children also makes good business sense. It establishes brand loyalty early in life, encourages children to pester their parents to buy specific products, and undermines parental authority about food issues. It teaches children to believe that they are supposed to eat packaged foods designed especially for them. Food marketers want children to demand food that is sweet, candied, oddly shaped, amusingly colored, and in packages illustrated with cartoons. They want children to influence family food purchases, which is why McDonald’s spent more than $1.2 billion on US media advertising, PepsiCo spent $211 million on advertising soft drinks, and Kraft Foods spent $20 million on Kool-Aid ads and $25 million on Lunchables ads in 2004.. . .
But advice focused on individuals has not succeeded in reversing current health trends. Food companies cannot be expected to take actions contrary to their own economic interests. Government agencies cannot easily act in the public interest if doing so runs contrary to the interests of food companies. Public health approaches to preventing diabetes must address the societal changes that have led to the current predicament. As the Institute of Medicine eloquently argues, prevention of obesity in children must become a national priority for government, the food industry, and health professionals, and pursuit of this goal must involve strong leadership with accountability for an action plan that involves the industry, schools, and communities.
I trust this constitutes fair use. In any event, I am pretty sure Dr. Nestle would want you to read this.
As Congress returns from its vacation next week, the good Christians who govern our country will take up various cuts in federal spending mandated by the budget act. Among these are $10 billion [editor's note: arggh! I originally wrote "million." I'm worse than NBC news.] in annual reductions in spending on Medicaid, whose financing is shared between the federal government and the states. Various proposals are floating in the DC smog, some of which would squeeze providers such as community health centers and hospitals, others of which would limit eligibility and benefits. Efforts are also underway to shift costs to the states by changing accounting rules. The states are responding to their increasing costs by throwing people off of the roles and reducing covered services.
Medicaid is an entitlement program, which means that overall spending increases when more people are eligible and the cost of health care increases. These tend to go together, because as health insurance gets more expensive, more of the working poor lose employer-provided coverage and are forced onto the Medicaid roles. Overall spending on Medicaid has been increasing at about 10% a year recently. But there is a big payoff to society. Medicaid pays for health screenings for poor and low-income children, and for treatment of conditions that would compromise their futures, such as hearing and vision impairment, lead poisoning, and congenital abnormalities. It pays for childhood immunizations, and for preventive services for adults. It provides essential support for institutions as well, such as community health centers, community mental health clinics, and safety net hospitals. Medicaid keeps people out of emergency rooms. It pays for long term care for the elderly. The services for kids are important to our future, but the largest share of expenditures is for adults with disabilities, followed by poor elderly people. Cutting Medicaid means killing people -- children, people with disablities, frail and disabled elders.
The American Public Health Association has produced a good, succinct report describing the current state of Medicaid, and critiquing various reform proposals, and making recommendations for the future of the program. (Click the top link on the page.)
Meanwhile, here in the Culture of Life, although we can't afford to pay for poor children's eyeglasses or grandma's nursing care, the Cost of War is rolling past $191 billion. This war, which has only killed about 100,000 people so far, is apparently succeeding in the president's goal of establishing a Shiite theocracy closely associated with Iran's clerical rulers. In order to assure the security of the Islamic Republic of Sumer, the U.S. will continue to occupy the country for many years to come, at least if the leadership of the Democratic Party has anything to say about it. But clearly that is a much higher priority than taking care of our own children, disabled and elderly people. Just ask your minister, he'll tell you.
Monday, August 29, 2005
My employer is going to be recruiting people to participate in trials of HIV vaccines. Well, that's not exactly correct. Right now, there are nearly three dozen experiments underway in which humans are injected with various substances which it is hoped will stimulate an immune response of some kind to HIV. However, it is not expected that any of these will actually turn out to be a usable preventive vaccine. These are actually just experiments intended to learn more about how HIV interacts with the immune system, in the hope that the knowledge will lead to an effective strategy.
When HIV was first identified more than 20 years ago as the cause of AIDS, we heard predictions that a vaccine would be developed quickly. That we are still not much closer to that goal is partly because HIV turns out to present very difficult problems, and partly because of a problem with how we finance medical research.
The technical problems are a bit beyond the scope of this site, but to summarize as best I can:
- HIV's outer envelope proteins -- the targets of the immune system's antibody response to most viruses -- hide from antibodies under a cloak of sugar molecules;
- HIV incorporates itself into cellular DNA and can hide out there indefinitely, even while the immune system is competent to suppress the viral load in the blood stream;
- HIV continually mutates and can change its presentation to the immune system.
The structural problem is that we depend on drug companies for most large-scale research, and they aren't particularly interested in HIV vaccines. Of course, they're already making tons of money selling anti-retroviral drugs, which must be taken by people with HIV every day, for their entire lives. A vaccine, which people get as one shot or perhaps a brief series of shots, would be far less profitable. (I won't be so cynical as to suggest that the loss of potential revenues from anti-retroviral drugs is a factor in their thinking.) As a result, most HIV vaccine research is sponsored by the National Institute of Allergy and Infectious Diseases at NIH, and that funding is far less than drug companies spend on developing drugs with high profit potential.
There are ethical problems with HIV vaccine research as well. Most vaccines cause volunteers to test HIV positive in standard tests, which detect the presence of antibodies. This makes it much more difficult and expensive to determine in the future whether they have in fact become infected. There is also a danger that volunteers, due to misunderstanding or wishful thinking, will believe they have some protection against HIV and hence take fewer precautions against infection than they would otherwise. Since these trials are "blinded," volunteers don't know whether they have received the experimental agent or a sham injection, but for ethical reasons, volunteers in both arms need to be intensively counseled to avoid the risk of infection. Yet, for the trial to yield meaningful results, some volunteers do need to become infected.
This perplexing ethical problem makes me somewhat skeptical about whether my agency ought to be recruiting our clients to participate in these experiments. What do others think?
An HIV vaccine would be about the best news we've had in a long, long time. But the prudent thing to do is plan, and act, as though it will never come.
Sunday, August 28, 2005
The Annual Meeting of the American Public Health Association is scheduled for New Orleans this November. I'm planning to be there. We may have to change our plans.
This is from an American Public Media documentary that aired earlier this year:
When emergency management officials think about the worst natural disasters that might befall America, San Francisco is always on the list. They say there's a 70 percent chance that a major earthquake will hit that city in the next 30 years and potentially cause thousands of deaths. But they say there's another disaster that could be far worse—and many people don't know about it. The chances that this tragedy will happen are much lower, but the death toll would be staggering. Government officials are trying to figure out if there's any way to prevent it.
The improbable disaster is that a Category 5 hurricane would strike New Orleans. The city lies below sea level, protected by a system of levees and continually drained by enormous, electrically powered pumps. A direct hit from a powerful hurricane will cause the Gulf of Mexico to surge over the levees, inundating New Orleans and surrounding communities to depths of up to 20 feet. The flooded, powerless pumps will stop. The water will have nowhere to go. The city will be destroyed.
This situation has been exacerbated by human activities that changed the flow of the Mississippi into the Gulf, resulting in the continual erosion of marshlands. Over time, this has brought the coast steadily closer to the city, reducing the natural barriers that protect the Big Easy and making the prospect of horrific damage more lkely.
It is now 10:00 am on Sunday, August 28. Hurricane Katrina in the Gulf of Mexico is now a category 5 hurricane, with maximum sustained winds of 160 MPH -- one of the most powerful storms in history. The National Hurricane Service predicts a direct hit on New Orleans, some time early Monday morning. It may not happen -- predictions of hurricane tracks are imprecise, and the storm could also weaken unexpectedly. Nevertheless, that highly improbable event is, as of this moment, very probable. News coverage, by the Associated Press and even the New Orleans Times-Picayune, has been oddly nonchalant. The city is under an evacuation order, and the authorities are predicting flooding, but the possible extent of the calamity is never mentioned.
While we can still hope that the worst will not occur, it is already time to try to draw some lessons from this situation. People are not well-equipped psychologically to deal with prospects of radical discontinuity. Whatever we may learn intellectually, our behavior, both individually and collectively, is much more powerfully shaped by the assumption that our environment will continue to be essentially as it has been. Recent decades in the U.S. have seen massive development on hurricane-prone beaches, and in low-lying areas around New Orleans. The risk to metropolitan New Orleans has long been known, but nothing has been done about it. People just don't seem to accept the prospect of a novel disaster as real.
As we confront the possibility of a worldwide, killer influenza pandemic (discussed briefly here by YT and far more extensively over the months by Revere at Effect Measure, we reflect sadly on this non-intelligently designed human trait. Let's try once again not to learn the hard way.
Friday, August 26, 2005
In case you haven't caught on yet, the place to read the medical and health science news in your daily paper is the business section. It's not important because of how it may affect the health of the general public, but because of how it may affect stock prices, hospital finances (even though many are technically non-profits, they are huge businesses whose executives are often paid salaries of well over $1 million), employer costs, taxation, etc. In other words it's all about money.
Today's Boston Globe business section has five health care related stories, which is about average. An FDA advisory panel has decided that medicinal leeches and maggots should be available by prescription only. They aren't going to require new approval applications for the critters as medical devices, but they do recommend stricter scrutiny of suppliers. So this may not be a good time to try to get in on the ground floor of the maggot business, you'll face significant capital requirements. (For those of you who don't know, maggots are used to clean dead flesh out of ulcers and traumatic wounds. Leeches are used to drain blood from appendages after surgical reattachment. No comment required.)
In a somewhat more urgent story from a business news standpoint, Merck is facing about 5,000 individual lawsuits over Vioxx. My editorial:
On the one hand, in the absence of effective regulation and any more rational method of compensating victims and taking care of the injured but not yet dead, the civil tort system will discourage companies from concealing adverse information about their drugs and marketing products they know are dangerous, and it will provide money to some victims and lots of money to lawyers. However, this is not a very good solution. Most of the time, drug companies will get away with irresponsible marketing and slanted research because they won't be as blatant or careless as Merck has been. And most victims won't be cared for or compensated. Even in this case, some will win their trials and some will lose, and the compensation people receive will vary wildly, without any particular rhyme or reason. We need a better way.
Guidant, the company that is in hot water over defective implantable defibrillators that it decided not to inform patients about (see below), has been cleared for sale to Johnson and Johnson by the EU, but they're still waiting for U.S. regulatory approval. The consolidation of the medical device and drug industry continues apace. What will this mean for prices, and for the political power of the industry? That's probably worth discussing.
California is suing an additional 37 drug companies for bilking its Medicaid program by providing false information about the costs of their drugs. The companies include Amgen, Wyeth, Abbot Labs, and GlaxoSmithKline. But we know they're really in business to benefit humanity.
Finally, Massachusetts hospitals have applied to install 10 additional PET scanners, at a cost of $3 million each. Regulators fear that hospitals will be under pressure to recover their costs by encouraging doctors to order unnecessary tests. Proponents claim the machines can save money by supporting better decision making, and avoiding unnecessary surgery. Who knows? We always have claims that new medical technologies will improve efficiency and save money, but empirically, we know that overall, over time, they increase medical spending.
Is it worth it? Arguably yes, from the point of view of the individuals who get access to high tech treatments. But only a narrow segment of humanity does. Spending the same money to reduce poverty and inequality, provide basic preventive services, combat marketing of junk food and tobacco, prevent alcohol abuse, and do a few other less glamorous things like providing universal health care, would do much more to improve the public health.
I hope that's enough for y'all to chew on for a while, I probably won't post again until Sunday.
Thursday, August 25, 2005
It is a continuing annoyance that the important medical and public health journals are available by subscription only, and subscriptions cost hundreds of dollars a year. A lot of what is in there really matters to you, but the public has to depend on the corporate media to tell them about it. The criteria for what stories make it into your newspaper or your local TV "Healthcast" or whatever they call it are not closely related to how much it actually matters for the public to know about the subject. What's worse, the reporters usually don't understand the studies or their context and they get the information wrong, or they miss the real point.
Here are some highlights from the new JAMA (which used to stand for Journal of the American Medical Association but now apparently doesn't stand for anything).
- A bit of a theme on opioid dependence and treatment. Bridget Kuehn reviews the 40th anniversary of methadone maintenance, Collins and colleagues report on a study comparing detoxification under anaesthesia with standard methods (not safe, not effective), and Patrick O'Connor discusses what he calls detoxification vs. methadone maintenance as treatment. (It's actually a false dichotomy -- people who go onto methadone maintenance commonly go through detoxification first. What he really means is abstinent recovery vs. maintenance.) The bottom line is clear: only a small percentage of opioid addicts succeed without methadone or a newer alternative, buprenorphine. Unfortunately, like all questions concerning addiction, this undeniable reality runs up against ideology. Maintenance therapy is just morally offensive to some people. Sure, you don't get high, you function perfectly well, you can work, take care of your kids, go to school -- but you're on drugs, and that's bad! Access to these therapies is therefore restricted in many ways. Result? People relapse.
- William Maisel reviews regulation of medical devices in the context of the recent flap about malfunctioning defibrillators. Implantable defibrillators do work, and do save lives. Like any machine, they aren't perfect and sometimes they don't work. Amazingly, it took decades for Congress to give the FDA authority to regulate and approve medical devices prior to marketing. Today, manufacturers still don't have to publish useful data on the reliability of their devices; they have to report malfunctions to the FDA but not to physicians or patients; and physicians, as a result, do not know how reliable the devices are. As a matter of fact, physicians have false beliefs about this. Patients are not notified if the device in their chest has been recalled! A million people have been affected by advisories about implantable defibrillators and pacemakers in the past 15 years, but there are no standards for how to report on these advisories or how to inform the public.
- Ah yes, those good old nosocomial infections. Hospitals are full of the nastiest bugs anywhere. With a lot of debilitated people who have holes in them and tubes going into the holes, the bugs get around. In the antibiotic saturated environment, they get drug resistant. In the U.S. each year, there are 2 million nosocomial infections, that kill 88,000 people and cost $4.5 billion. Youch. Now there are recommendations for public reporting of nocosocomial infections, with process and outcome measures, endorsed by the leading relevant associations. Now let's do it!
- Mike Bamshad discusses race, actual geographic ancestry (somewhat correlated but not the same thing since race is a social construction) and how much this actually has to do with frequencies of specific genetic characterstics that have something to do with health and drug efficacy. Complicated. Bottom line: "Race" is pretty vaguely associated with what's actually in your genes. Better to find out what your individual characterstics are, and proceed accordingly.
- At last, the one you may already have heard about. Susan Lee and colleagues, with senior author Mark Rosen, figure out when human fetuses may be able to feel pain, based on when the necessary brain structures develop. Their bottom line? 29-30 weeks gestation. This conclusion is uncongenial to opponents of abortion, who are trying to pass laws requiring that fetuses be anesthetized prior to abortion (which is dangerous to the mother, the real agenda being to discourage her from the decision), so we have yet another public argument over scientific conclusions in which the desired outcome (whether it be the literal truth of the Bible or the contribution of burning fossil fuels to global warming) trumps the truth for one camp.
Funny how it's always the conservative position that is in opposition to scientific conclusions. Reality has a liberal bias. We have to balance all those liberals in the universities, who believe in reality, with conservatives, who can provide students with the alternative viewpoint to reality.
Wednesday, August 24, 2005
It isn't really new news, Peter Meunnig and colleagues, writing in a forthcoming (November) issue of Social Science and Medicine, have calculated the the difference in life expectancy in the U.S. between the top 20% of income earners, and the rest of us. It's 4.3 years, and that translates into 11 million years of life lost each year by the bottom 80%. (An earlier study found that the top 5% live 25% longer than the bottom 5%.)
They also get into something called Health Adjusted Life Years, which I probably ought to talk about at some point, but it's a little off topic here. Anyhow, us non-rich people are also more likely to become sick or disabled. (I won't go into the bogus quantification of that finding right now.)
The greater longevity and health of the rich pertains everywhere, but the U.S. has more inequality than other wealthy countries, and our inequality has been growing throughout the reign of the current Defenders of Life. We could preserve a hell of a lot more human life by reducing inequality than we can by keeping people without cerebral cortexes "alive" with machinery.
Of course, that's a very un-Christian thing to say.
Your Internets changed the world incredibly fast, by a lot, and we hardly noticed it. I remember when I first got access to medline oh, a decade ago I suppose, and I thought to myself, "Holy collapse of the space-time continuum Batman, here I am sitting on my ass in Boston and I'm in the National Library of Medicine." Then it just seemed perfectly normal and pretty soon, if my Internet access went down, I couldn't get any work done.
This and all the other millions of weblogs, the new kinds of relationships we make with people thousands of miles away, the erosion of the power of the corporate media, and yup, the demolition of distance and national borders in the sphere of information are all a big deal. Riverbend appears to have stopped writing her blog -- which makes us all worry -- but she had a huge impact on many people's understanding of the war in Iraq.
I have had the pleasure of making the acquaintance of Dr. Kanthraj Garehatty Rudrappa, a dermatologist from India, who shares my interest in language barriers in medicine. Dr. Kanthraj, in an Indian journal, has described the sorts of problems that arise in India's multilingual society, which are very much like the problems we encounter here. It would please me greatly if weblogs such as this one, Effect Measure, and the many other blogs devoted to public health (there's a good start at a listing on Effect Measure) could facilitate international communication, since public health is inescapably global.
If anyone out there is from outside of the U.S., please introduce yourself! Let us know what's on your public health agenda, and what we yanks can learn from you. If not, I'd be interested in anybody's ideas about how we can globalize the sorts of conversations we have here.
Tuesday, August 23, 2005
Many people -- okay, somebody -- have implored me to address direct to consumer advertising of drugs. I haven't gotten around to it until now because, believe it or not, the issue strikes me as a bit complicated and I hadn't really settled my thinking about it.
Companies advertise all kinds of stuff that is potentially dangerous, harmful, or worthless, from Hummers to Twinkies to Barry Manilow records. Advertising is mostly about deception -- trying to associate the product with the self image people aspire to, the sexual objects they crave, happiness and fun, peace and beauty. All of this is done by juxtaposition of imagery, not by logic. The actually useful or desirable properties of the product (if any) aren't even mentioned much of the time, but if they are, we obviously don't expect a balanced presentation of advantages and disadvantages. Most important, the vast majority of advertised products are no better than considerably cheaper alternatives. Advertisers are trying to get people to pay more for brand name products, not tell us about products that are unique or better in some way.
All of this is equally true of drug advertising. On the other hand, in order to buy a Hummer, a Twinkie, or Barry Manilow, we don't need permission from an expert. We don't need to go and talk to John Kunstler about the social depravity of driving a military truck to the grocery store and back, we don't need to consult a nutritionist or a music critic. But we can't get Celebrex or Prempro or Prozac without talking to a doctor about it, and the doctor has to write a prescription. At least we have some protection from our folly, in theory. So if we have a problem with DTC advertising of drugs, logically we ought to examine all advertising, much of which is arguably more dangerous than drug advertising. Food can kill, and we did get tobacco advertising off of television but it's still going strong in a lot of other places, while SUVs are degrading the whole planet.
I guess the important difference is that politically, we have a chance to powerfully regulate drug advertising. We could go back to the old regime in which all advertising claims about drugs must be accompanied by the full drug information sheet including all of the adverse effects and counter indications. We could also require advertisers to state why an advertised drug is superior to a cheaper generic alternative, and why it isn't. For example, consumers assumed from watching the ads that Celebrex and Vioxx were more effective than aspirin at releving pain. They aren't.
If we did all that, I would predict that DTC advertising would pretty much stop. However, the real problem is that all of the distortions incorporated in DTC advertising are also present in the drug evaluation and approval process, and in the marketing of drugs to physicians. Undoubtedly, for reasons which are not entirely clear, the Cox-2 and HRT ads did cause physicians to prescribe more of these drugs than they would have otherwise. But I believe that phenomenon would have been minimized if physicians had accurate information and perceptions, and were not themselves being seduced by the drug companies; and if the FDA had been working for us, rather than Merck and Pfizer.
The FDA has now become a bit more diligent about scrutinizing DTC advertising, and the companies' lawyers are also advising them to be more circumspect. But even if the ads are more honest with respect to their literal content, they still use the same sleazy tricks -- happy, healthy looking beautiful people, uplifting imagery, seductive music. So yeah, drug advertising makes me sick, but no more so than advertising in general. It helps to regulate it, but the bottom line is that people need to learn how to think critically and see through all the pink smoke. That's a major priority for society, with all sorts of implications.
Monday, August 22, 2005
Okay, Chimpy's overall approval rating is now down to 36%. That it is even detectable is an embarassment to the nation, but still, he appears to be trailing Herbert Hoover in the all-time presidential popularity rankings.
The really bad news? It just doesn't matter. The gang of murderous thieves is still in control, the corporate media still has its lips attached, remora-like, to their pasty butts, and the Democratic "leadership" still appears scared to death of making anyone suspect they might even think about dreaming of being disrespectful to the God King or mildly unenthusiastic about his Great Patriotic War.
But the worst part is, even if Chimpoleon and the rest of the gang were to be raptured up this afternoon, leaving us behind to try to fix the mess, I'm not sure we could do it. Juan Cole is thrashing around desperately for a solution, but first he lays out what he sees as the problem. Yes, there is already a low grade civil war going on in Iraq, but if the U.S. troops were to leave now -- well, you ain't seen nothin' yet. He anticipates a real old fashioned war, with large, organized formations marching against cities, slaughtering each other, ethnically cleansing. The neighbors -- Iran, Jordan, Saudi Arabia, Syria, Turkey -- all get drawn in to protect their affinity populations, their economic interests and their borders. Guerillas blow up pipelines in Iran and Saudi Arabia. 20% of the world's oil supply goes off line and there is a world-wide second Great Depression.
Okay, that doesn't sound so good. But now we have Anthony Shadid and Steve Fainaru in the WaPo telling us that much of Iraq is now controlled by sectarian militias, mostly wearing Iraqi Army uniforms and using its weapons and equipment. And no wonder -- they are units of the Iraqi army. These courageous Iraqi patriots are engaging in organized campaigns of mass murder, torture, ethnic cleansing, theft, political thuggery. Yep, they've already started the civil war, and we're just training, arming and equipping more of them. It's our "exit strategy." Chimpy's going to go on TV this week and explain how it's all because of 9/11 and we're bringing the light of freedom -- untidy as it may be -- to the dark masses.
The great Robert Fisk tell us a bit of what life is really like in Iraq today. But we're still pouring billions of dollars and American lives down the rathole, and I don't see any way that it's going to stop, even as the situation around the occupation continues to deteriorate until the occupation itself collapses entirely and our young people find themselves huddling in island fortresses in the midst of violent chaos.
When that happens, you'll just have to slap another yellow ribbon on your SUV and sing God Bless America while you pump your paycheck into the tank. Remember, it's a noble cause.
So you're worried about computer programmers losing their jobs to India, and the textile jobs fleeing to China? At least our health care industry can't escape to cheaper climes.
Think again. From Richard Marosi in the Los Angeles Times:
About 160,000 California workers — farm laborers as well as working-class Latinos employed at hotels, casinos, restaurants and local governments in San Diego and Imperial counties — are getting their annual checkups and having surgeries through health networks south of the border, insurers say.
The arrangement is cheaper for both employers and employees. In Mexico, healthcare costs are about 40% to 50% lower than in California, freeing some employers to offer services that they couldn't otherwise afford.
Employees enjoy lower premiums and co-payments, typically $5, and the comfort and convenience of describing their aches and pains in Spanish to doctors who, they say, tend to take more time with them.
"The rate is good, the service is good," said David Ouzan, a city councilman in Calexico, where about a third of the city's workers use dental and medical clinics in Mexicali, just across the border. "I myself have used dentists in Mexico."
Of course, for those of us who don't live near the Mexican border the trip isn't usually worth it. But I know someone who went to South Africa for cancer surgery, and we all know about drug shopping in Mexico and Canada. The radiologist who reads your CT scan is very likely in India -- yup, they do it over the Internet.
The gravy train won't run forever, folks. The future of the U.S. economy will not consist of all of us lying on gurneys, giving each other IVs, drugs, surgery and diagnostic procedures, and making each other's boat payments.
Sunday, August 21, 2005
The incidence and prevalence of psychiatric disorders -- mental illness -- has risen steadily in recent decades. Estimates are that 20% of Americans are currently mentally ill, and that 50% will be mentally ill at some time in their lives. These rates are far higher than 50 or 100 years ago.
Are we all going crazy, because of something in the water, or because modern life is so stressful, or because of television? Maybe so, but the incidence and prevalence of mental illnesses is really driven by the availability of diagnostic labels that fit more and more people, and the opportunity of psychiatrists and psychologists to apply them. As I pointed out in another context, Robert Kennedy Jr.'s assertion that autism did not exist prior to 1943, when Dr. Leo Kanner described it and gave it a name, confuses classification with existence. But while most people will agree that autism is a real entity whether we have a name for it or not, the ontological status of the majority of the constantly growing catalogue of psychiatric illnesses is far more questionable.
Psychiatric diagnoses are based on behaviors. Once a specific biological basis for abnormal behavior is known, the disease is usually classified as neurological rather than psychiatric (viz. tertiary syphyllis, Huntington's Disease, Mad Cow Disease, etc.) Whether a complex of behaviors is pathological is a judgment strongly influenced by cultural norms. Indeed, changing cultural norms inspired the American Psychiatric Association to stop classifying homosexuality as a disease. However, the trend has been for there to be more and more psychiatric diseases over time.
You've undoubtedly seen the ads on TV for drugs intended to treat diseases like Social Phobia. This is a new disease -- but is shyness new? Schoolchildren are expected to sit quietly in rows, concentrate on boring tasks, and speak only when authorized. Children do not like to do this, and many, most often boys, have traditionally refused to cooperate. But now they have a disease, Attention Deficit Hyperactivity Disorder. Those who engage in the modern equivalent of dipping little Suzy's pigtail in the inkwell have Conduct Disorder. Those who sass the Principal when sent to the office have Oppositional Defiant Disorder, and so on. I exaggerate slightly -- people need to display these symptoms consistently over a period of at least a few weeks, in order to be deemed mentally ill. Nevertheless, while these behaviors have always existed, we have not previously called them diseases.
Many of these diseases are commonly treated with drugs. A provocative, iconoclastic and disturbing take on psychiatry and psychiatric drugs in particular is offered by Robert Whitaker, a former health care reporter who blames the current "epidemic" of mental illness in large part on psychiatric drugs. I would criticize some of his arguments. For example, he points to a steady rise in people who are disabled due to mental illness, but these statistics reflect people who have become eligible for Social Security Disability Income or Supplemental Security Income, and are influenced powerfully by factors other than people's underlying ability to hold some form of remunerative employment. In particular, people are better off being on disability than taking low wage work, because if you are officially disabled, you will have comprehensive health insurance, paid for by the state, whereas if you work, you will have none. Whether more people really are disabled in some (hard to define) "objective" sense by psychiatric illness is not really known.
He is correct that antipsychotic medications have severe, often irreversible side effects including neurological damage. On the other hand schizophrenia is a terrible, disabling illness that people clearly have before they start taking these drugs. Many people would choose to take their chances in the hope of having at least some of the most disturbing symptoms of schizophrenia suppressed -- but it is also true that doctors usually do not fully disclose the dangerous side effects of these drugs to patients.
But I believe Whitaker is completely correct about Selective Serotonin Reuptake Inhibitors, the massively promoted "miracle cure" for depression -- and now for all sorts of other diseases including Social Phobia. I've written about SSRIs earlier, here, and now my beliefs have become even more definite. Even the trials showing some efficacy -- which even in the best cases can only be interpreted as a small effect in 10-15% of people diagnosed with depression -- are cancelled by other trials showing no efficacy at all. And such efficacy as there may be is short term. In the long term, all of the available evidence, as Whitaker says, is that people who take SSRIs do worse than people who do not -- and by worse, I mean they are more prone to depression.
There is a strong response to placebo in depression. SSRIs can produce various physical symptoms and feelings of agitation, perhaps they really do elevate some people's mood although that is far from proven. People sense that "something" is happening, and since they want to get better, this conviction may help some people actually feel better, more so than an entirely inert substance would. For others, it may help them to follow through on suicidal or antisocial impulses, or intensify their preoccupations with thoughts about such things. But in the long run, as with any drug that affects brain chemistry, the brain adapts -- hence the addictive process with cocaine, heroin, etc. These changes in the case of SSRIs have not been carefully studied, and we do not really understand anything about them. If Mr. Whitaker wants to say they are damaging, no-one has any evidence to contradict him.
(Thanks to my friend Dr. Y for the link.)
Friday, August 19, 2005
From JAMA "100 Years Ago" (a regular feature):
Medical men long have wondered at the inconsistencies of the popular dread of epidemics. People and newspapers became hysterical a few years ago over a score or two cases of Asiatic cholera on the seaboard, while around their offices and homes thousands suffered and died from tuberculosis, syphilis, gonorrhea and typhoid. The small but new enemy seemed infinitely more terrible than the great but familiar ones. . . . The newspapers of August 11 presented a dramatic example of the same peculiar mode of thought. New Orleans reported a total to that date of 756 cases of yellow fever, with a total of 129 deaths, nearly all the mortality being among the Italians. New York reported up to August 5, 1,496 cases of typhoid, with 395 deaths, many of them among Americans of the better class. Think of the fright, brutality and migration inspired by the smaller figures as compared with the virtual indifference that meets the greater ones! Yet we know that, apart from popular apathy, it is easier wholly to prevent typhoid in the North than yellow fever in the South. Uncontaminated water and food insure freedom from epidemic typhoid, while the prevention of yellow fever necessitates the destruction of myriads of insects as well as the absolute isolation from the mosquitoes of every case of the disease during the first three days of fever. Verily man is yet an illogical animal.
Yes yes, it's amusing that they distinguish between Italians and Americans of the better class. But what's even more amusing is how nothing has changed. The public health news this year in my local birdcage liner has been dominated by the following stories:
- West Nile Virus. There have been no cases in the state this year but there have nevertheless been several articles about mosquitoes that have tested positive, the latest research news, etc.;
- A rare, normally harmless virus that affected three recipients of organ transplants, who were of course immunocompromised. It was ultimately traced to a pet hamster owned by the organ donor (who died of completely unrelated causes) leading to mass hysteria about hamsters and gerbils;
- A medical intern diagnosed with tuberculosis, who didn't actually infect anybody but possibly could have;
- A couple of kitchen workers diagnosed with Hepatitis A, a completely curable disease. The hysterical coverage caused dozens of people who had never eaten in the restaurants to line up for vaccinations.
The Civil Rights movement achieved its original stated goals with the Civil Rights Acts of 1964 and 1968, the 1965 Voting Rights Act, and important Supreme Court rulings from the 1950s through the '70s. These changes in the law were accompanied by a growing societal consensus that discrimination based on race or ethnicity is completely unacceptable. Basking in the glow of these achievements, during the 1980s and 1990s most people involved in the medical institution presumed that racial or ethnic inequality in the provision of medical care was in the past. Racial and ethnic disparities in health status persisted, but most people presumed that this resulted from social determinants of health, and perhaps from lack of access to medical care for financial reasons, and had little or nothing to do with the health care people actually received once they did get in the door.
In the New American Century, we have learned the truth. In 2002, the Institute of Medicine published its famous report Unequal Treatment (Smedley BD, Stith AY, Nelson AR eds. Unequal Treatment: confronting racial and ethnic disparities in health. Institute of Medicine (U.S.), Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington, D.C. 2002), which reviewed hundreds of studies and concluded that racial and ethnic disparities in the provision of medical services are ubiquitous. Congress mandated the Agency for Healthcare Research and Quality to produce an annual report on healthcare disparities, and yup, they're still happening. (U.S. Agency for Healthcare Research and Quality. 2004 National Healthcare Disparities Report. Available at the AHRQ web site. The Commonwealth Fund does national surveys of healthcare consumers every five years and they find that consumers report unequal treatment. (Collins KS, Hughes DL, Doty MM, Ives BL, Edwards JN, Tenney K. Diverse communities, common concerns: assessing health care quality for minority Americans. Findings from the Commonwealth Fund 2001 Health Care Quality Survey. The Commonwealth Fund. New York, 2002.)
Now three articles in the new New England Journal of Medicine inform us that these disparities have not spontaneously disappeared, indeed have remained the same or have even increased. What this means is that people don't prescribed the drugs they need, don't get surgery that can save their lives or alleviate disabilities, don't get appropriate diagnostic tests, stay sick, stay disabled, and die, when other people whose ancestors mostly happen to come from western Europe don't.
This should not come as a surprise. To quote Brian K. Gibbs of the Harvard School of Public Health, speaking at a symposium sponsored by the New England Coalition for Health Equity in December of last year:
To present a historical context, let me use the example of the experience of African Americans in health care. From the time that Africans were brought to America in 1619 and for the next 246 years -- or about 64% of the African experience in America so far – they experienced a slave health sub-system. Slaves were provided with health care, and the basic conditions for health, only if there was an economic benefit to the owner. From 1865-1965, the period from the Emancipation Proclamation to the Civil Rights Movement, for another 100 years – the next 26% of our time here -- there were no citizenship rights, inferior housing, education, healthcare – in much of the country a separate subsystem of healthcare. From 1965 to 2004, which is 10% African Americans’ experience, they have enjoyed most of the rights of citizens, at least under the law.
Now today, although we can create policies that specifically address the health care system or perhaps address specific disease categories, is this enough to overcome the internalized and interpersonal types of racism experienced in society? For 385 years, this racism has existed, it didn’t start with the IOM report.
In discussing the issue of "disparities," we always look for other explanations: African American and Latino patients have different preferences -- they want less health care, for some reason they don't want their coronary arteries unblocked; they have difficulty communicating with their physicians; there must be some mysterious biological differences among people of different ethnicity who have the same diagnosis, that causes physicians to make appropriately different treatment choices.
Nope. Racism is deeply internal. It is an infection of the mind, and highly resistant to treatment. We need a Manhattan Project of research and treatment.
Thursday, August 18, 2005
Some months ago, I resolved to limit discussion of religious beliefs and institutions here, and to reserve the Dialogue Concerning the Two Chief World Systems site for the purpose. The Dialogue blog was lively for a while, but we could not recruit sufficient interlocutors who wanted to contribute from the point of view of religion and faith.
I have at times discussed ethics from a humanist perspective, and contrasted typical religious forms of ethics in the process. During the Terry Schiavo circus I took on specific religious institutions and leadership, as they were obviously highly salient. But I have not focused very much on general problem of faith in the 21st Century.
Now I have come to feel there is a certain urgency to basic philosophical questions. Public health is global. The expectation each of us can have for life and health, and our children and grandchildren and beyond, depends on events of planetary scale -- burning of fossil fuels, depletion of marine life, cutting of forests, the application of pesticides and the evolution of insects, the evolution of microorganisms, conflict and violence, erosion of topsoil, international cooperation, the size of the human population, the global allocation of medical and public health resources, and on and on. Religion, it turns out, has a bearing on all of these problems.
So I will tell you that I am a humanist. That means that my loyalty is to humanity. I'm with the home team. That is all of us. Not Americans. Not Christians, or Muslims, or anything more specific. It also means that I recognize that we have to depend on ourselves and each other. The human future is up to us. No supernatural being is going to save us, or destroy us. We are on our own, for better or for worse.
It means we must understand and use the powers that we have, our senses and our reason, to understand the world, to understand ourselves, and to figure out how we can live in the world. It is obvious that the beliefs people had when they wrote ancient books like the Bible and the Upanishads and the Koran have been shown to be incorrect. Scientists like Edwin Hubble did not imagine the universe, they discovered it. It turns out to be far more grand and wonderful than anything the biblical scribes could possibly have imagined.
It also turns out that we are not at the center of it. We are slime on a grain of dust. We don't matter to anyone but ourselves -- but that is more than enough for me. I don't find that a depressing thought at all. It is liberating. Religious people, in my view, are delusionally arrogant, to think that they are made in God's image and that they matter in the least to a supreme, omnipotent being. Just open your eyes. That is obviously false.
If we wish to solve our many, urgent problems, we must accept these facts. They are the essential foundation to the human future. That is what I believe, and I thought I ought to make it clear.
Wednesday, August 17, 2005
Competent adults in the United States have the right to refuse any medical treatment, for any reason or no reason . . . ah, err, no, they don't. In most places, people with tuberculosis can be detained and medicated against their will, as Lawrence O. Gostin discusses here.
Then there is the question of immunization. Children may not attend school without demonstrating that they have undergone a schedule of vaccinations, although most states allow exceptions for religious reasons. Not everyone is happy about this, including these folks, who describe themselves as:
Vaccination Liberation is part of a national grassroots network dedicated to providing information on vaccinations not often made available to the public so that one can make the only informed choice, complete avoidance and refusal.
Then there is the question of quarantine. This has come up in the past in the U.S., but it's gotten new life with all the hoo hah about bioterrorism. I'm not sure why we are only permitted to think about this in terms of a deliberately introduced plague, as opposed to a non-intentional epidemic, but that seems to be the fashion. David B. Fidler, writing in Clinical Infectious Diseases, says:
Neither public health law nor the law on emergency management has ever (fortunately) been implemented in a real biological weapons attack. Tabletop exercises and simulated bioterrorism incidents, such as the May 2000 TOPOFF exercise in Denver, Colorado, demonstrate that neither public health law nor emergency management law could currently support an effective response to a major biological weapons incident . The ineffectiveness of existing legal frameworks in a real bioterrorism crisis would exacerbate pressure on governments to take drastic actions that might sweep away the rule of law in the midst of panic or uncertainty.
Of course, as we have seen in the run-up to the Iraq war, panic and uncertainty can be manufactured based on false information. We may indeed confront compelling reasons -- or apparent reasons -- for authorities to ban travel out of or into certain parts of the United States; to confine law abiding people to their homes or to institutions; to close businesses that are in compliance with the law; to seize private property; to enter people's homes unbidden; to vaccinate or medicate people against their will.
Should the federal government have such powers? If so, how can we trust them to use them only for the right reasons, in the right way, on the right occasions; and to stop when necessity has passed? (And keep in mind that we know the President of the United States does not always tell us the truth.) How can such powers be granted, yet constrained and made accountable? Or are such powers of government simply unacceptable?
If so, how can we protect you against people who refuse to do the right thing voluntarily? After all, we use compulsion against people who would drive while intoxicated, operate unsanitary restaurants, build unsafe houses, etc. Lately we use it in more and more places against people would expose us to their exhaled tobacco smoke. What's the difference?
I'm just asking. As usual, I reserve any opinions of my own.
Here's a simpler way (I hope) of explaining why most scientific findings are wrong, but science is still right.
The terrain of science is not knowledge, but ignorance. Scientists spend little time with what they already know, except perhaps in the classroom. They are obssessed with what they don't know.
I may call the advancing edge of science -- in every direction -- the epistemological foam. Here is where scientists dredge through mountains of observations for sparks of concordance; where they conjecture, dispute, and squabble; build long and fragile chains of inference; criticize each other's equipment, methods, analysis, and conclusions; clobber each other with contradictory theories and apparently inconsistent observations. Here, instead of knowledge, is the foam of uncertainty, a whirling boil of beliefs that are constantly merging, dividing, dissolving, devouring one another.
Start to move back from the edge, and the foam becomes less active. The bubbles of belief grow fewer, larger, more stable. At last they dissolve into a single fluid, at first turbulent, then rippled, then placid. Here is the Lagoon of Knowledge, whose warm and perfumed waters make us feel langorous and happy. (Some of us anyway. There are those afraid to swim who huddle on the icebergs of faith. Sorry, my metaphors are getting out of hand.)
Swim back out into the foam, and the skin begins to tingle. It's exhilerating, energizing, but also uncomfortable, stinging us with doubt, dissatisfaction, confusion. Out there on the agonizing edge, the foam dissolves truth out of the rock face of the universe, which distills out of the foam and flows back into the ever-growing lagoon.
Wow. Sorry about that. But I hope it makes the point. There is a great deal that we know, far more than we knew even a decade ago, incomprehensibly more than the biblical scribes could ever have imagined. Nevertheless, where science is most active, we know the least, and we are usually wrong.
BTW: One way of putting Ioannidis's argument is that the domain of ignorance is unbounded. Most scientific inferences nowadays are based on statistical reasoning, and chance playing over a boundless terrain inevitably creates spurious appearances of concordance. Of course there are other kinds of discovery, that are more certain but usually less grand. For example, send a robot to Mars, take a picture. Yep, that's really what it looks like. But that barely qualifies as a scientific discovery.
Tuesday, August 16, 2005
Putting mercury in childhood vaccines was a fairly dumb idea in the first place. It sounds, based on common sense, like it might not be entirely safe, and it's obviously going to make people worry and maybe distrust vaccination. I'm glad they've taken it out, since it isn't necessary.
It's still used in parts of the world where it is difficult to keep vaccines cold. That's a bit of a judgment call. Reasonable people may disagree. But it is not a conspiracy to inflict an epidemic of autism on the poor children of the world. Nor to harm them in any other way. Nor is there the least evidence that it has done so.
We have been discussing the crusade of Robert Kennedy Jr. to convince the world that the preservative thimerosal, once used in childhood vaccines, has caused a massive epidemic of autism. In previous posts, we have seen that Kennedy grossly misrepresents a meeting of public health officials in June 2000, at which a study that indicated a possible connection between thimerosal and autism was discussed. Kennedy falsely accused the participants of immediately believing that thimerosal did indeed cause autism, and immediately conspiring to concealing the truth from the public. On the contrary, the participants considered the evidence far from convincing, and discussed how best to investigate the question further.
Next, we discussed the purported epidemic of autism. We found that the data usually cited to show that there has been an explosive increase in the prevalence of the disorder is unreliable. While it is possible that the condition has become more common, the assertion that autism did not exist prior to thimerosal and that the prevalence has neatly tracked children's exposure to the compound is completely unsupported by any credible evidence.
In op-ed columns, Kennedy has claimed that "hundreds of studies" support a link between thimerosal and autism. When challenged, however, he has come up, not with hundreds, but with essentially two. One is the study by former CDC employee Tom Verstraeten, which triggered the 2000 meeting. Subsequent analysis of Verstraeten's data has led to the conclusion that there is no association after all. Kennedy claims this reanalysis was ordered by CDC officials, who demanded that the new analysis not find any link. The other is essentially a single study, but Geier and Geier, which has been republished in various forms several times. Kennedy also claims that the only evidence refuting the link between thimerosal and autism comes from two "disastrously flawed" European studies, though he does not say how the studies are flawed.
Sarah Parker, Benjamin Schwartz, James Todd and Larry Pickering reviewed the evidence concerning thimerosal and autism in the Sept. 2004 issue of Pediatrics. I doubt that my readers are interested in all the boring details of their analysis. The Geier and Geier studies depend on the Vaccine Adverse Events Reporting system, which is a passive, voluntary system. People who think their child was harmed by a vaccine may report the "event" to CDC. Obviously, people whose children become autistic, who believe that vaccination was the cause, create the cases in the system. To use this system as evidence that thimerosal causes autism is circular reasoning. There are many other problems with this methodology, just as serious, which I won't take the time to discuss. Geier and Geier also use the Department of Education data, which we discussed previously, and perceive an association over time between thimerosal containing vaccines and the prevalence of autism. The DOE data, however, represent children who are deemed eligible for special education services. They do not provide any information at all about the actual prevalence of autism in the population.
Four other cohort studies do not find an association between thimerosal exposure and autism. These include the Verstraeten study. Parker et al note that this data was reanalyzed prior to publication, to address methodological problems. They acknowledge that such reanalysis could introduce "investigator bias," whereby the investigator's beliefs could affect the outcome. However, their own careful review conclues the finding of no association is sound. There is not space here to get into the complexities of this, but Kennedy never does either and since he makes no specific assertions about how the reanalysis was invalid, there is nothing to refute.
The "disastrously flawed" European studies are actually by far the most rigorous. Denmark has a so-called "civil registration" system which contains reliable medical information on all citizens. This creates an enormous data set in which children's thimerosal exposure can be matched with autistic spectrum diagnoses. This analysis finds a negative association -- a lower incidence of autism -- for children who received any thimerosal containing vaccinations compared to those who did not, although the confidence interval just barely contains zero (i.e., there is about a 5% chance that there is no association, vs. vaccination actually being protective). They did find a long-term increase in the incidence of autism, but it continued after thimerosal was removed from vaccines in Denmark. The other "disastrously flawed" study, conducted in the UK, was a retrospective cohort study. This study also found a protective effect against autism of thimerosal containing vaccines. (Personally, I doubt very much that thimerosal actually protects against autism; but it is possible that either vaccination in general, better health care, or family ability to obtain well child care, are somehow associated with a lesser risk.)
Now, this is all quite dry and uninteresting. There are a lot more ins and outs, details, and specific assertions Kennedy has made that I could discuss. But it isn't worth it.
Here's why this matters. A lawyer, who is famous for being the son of a murdered politician, has gained a very prominent public platform -- including a lengthy article in a high-circulation magazine, op-eds in the nation's leading newspapers, and appearances on many of the big-time TV yackfests -- to claim that "they" -- the secretive, corrupt, unaccountable cabal of public health scientists -- are all conspiring to conceal from the world the horrifying truth that the entire medical institution -- drug companies, the FDA, the CDC, physicians the world over, medical journal editors, academic researchers -- have collectively inflicted a devastating disease on millions of children the world over; and what is more, they are continuing to do it in poor countries where thimerosal is still used. What is most remarkable about this conspiracy is the absolute unity and the inviolability of the oath of silence taken by all those hundreds, or probably thousands, of co-conspirators.
Maybe you've been home sick some time, or channel surfing between innings of the big game, and seen those informercials with the guy selling a book about the miracle cures "they" don't want you to know about. It turns out there's a simple, natural cure for cancer; heart disease; arthritis; you name it. The reason people have these diseases is because they are caused by prescription drugs. Statins are the cause of heart disease. But just send this guy money, and he'll tell you the cures "they" are keeping secret.
What Kennedy is doing is utterly reprehensible. Apart from the exploitation and abuse of families coping with the heartbreak of having an autistic child, he is attempting to cause severe damage to the culture. (Fortunately, despite the podium he has been given by irresponsible corporate media, he hasn't gotten much traction.) As I have said a thousand times, the democratization of science is critical to the future of democracy, indeed the future of humanity. That means we need to expose corruption and self-dealing in scientific enterprise, to be sure. But it also means that we must have respect for the cause of science, the quest for truth using human senses and reason, and the norms of honesty, openness, and intellectual integrity which the large majority of scientists and physicians try to honor.
Science is conducted by flawed human beings, working in flawed institutions. But it is not a conspiracy against the public. Kennedy deserves no respect, and no hearing, from anyone, ever again.
Monday, August 15, 2005
Now pay attention! We are treading on the burning ground. Don't leave the pathway, this is very dangerous!
Ioannidis has an essay, which you may read on Public Library of Science, entitled Why most published research findings are false. He writes:
Published research findings are sometimes refuted by subsequent evidence, with ensuing confusion and disappointment. . . . There is increasing concern that in modern research, false findings may be the majority, or even the vast majority of published research claims. . . It can be proven that most claimed research findings are false.
Uh oh! Is this the death of science? Does this mean that science is no better than faith, that we would do as well to follow the advice of that huckster with an informercial as our M.D.? That scientific belief is just one more orthodoxy, created by consensus, not evidence?
No, it doesn't mean anything of the sort. But it does mean that health and science reporters, the FDA, and for that matter, doctors and professors, need to have a better understanding of epistemological underpinnings of public health and medicine.
Ioannidis's argument depends on Bayes' Theorem. (If you didn't catch my explanation, it's here.) Bayes' Theorem is astoundingly simple, obvious once you see it, and yet disconcertingly counterintuitive. It's one of the most important tools of critical thinkers. Keep it ever in mind.
To make this as simple as I can, the bulk of research consists of looking for associations between two phenomena, e.g. eating twinkies and shooting city councillors, whatever. Now, let us say we decide that we won't call an association "statistically significant" unless we have a p value of .05 or less, i.e. the association would appear to be real purely by chance no more than 5% of the time. That's equivalent to a 95% specific test. But as we have seen, the positive predictive value -- the proportion of true positives -- of a test depends on the prior probability -- the proportion of true positives in the population -- as well as the specificity. Where the prior probability is low, even a highly specific test has a low positive predictive value.
In most fields of inquiry that we might define, we can think up a vast number of possible associations, the vast majority of which will not be real. Hence the prior probability for any given hypothesis is low, and most "statistically significant" findings will be false! Now, this is not at all fatal for science. It just means that a single study, in isolation, means little. It is only suggestive. We now need to go out and try to replicate the results, using if possible bigger samples and more rigorous methodology, specifically to test that hypothesis. If we continue to get positive results, the probability that the association is real goes up dramatically, and may well become a virtual certainty. Smoking and lung cancer.
This fundamental problem is compounded by several features of the culture of science. One is the bias toward publication of positive findings. If six teams investigate one question, and one has a positive finding while 5 do not, what will the world hear about?
Another problem is the psychological and/or financial and/or prestige investment of researchers in their hypotheses and their earlier findings. This creates a bias in favor of confirmation, and creates entrenched orthodoxies which are difficult to overturn. Another is the ill informed, credulous and sensationalistic field of journalism, which gets hyperexcited over single studies which merely suggest places we might want to look further, rather than settling questions.
Ioannidis asks us to look for larger scale studies, larger effect sizes, more rigorous and carefully defined methodologies, disinterested investigators (not a synonym for uninterested!), narrowly specified questions with substantial prior probabilities, and consideration of all studies done in a field rather than relying on a single study (i.e., systematic review). Trying to get a better understanding of the prior probability of a hypothesis (which he calls R) and how that relates to the interpretation of statistical significance is his final recommendation, although that is something of an epistemological tangle, in my view.
The bottom line for the perplexed citizen is this. There is a great deal that we do know. The reason you keep hearing that yesterday's conventional wisdom is false is not because scientific investigation of medical and public health problems doesn't work: it's that the wisdom becomes conventional prematurely. Ours is an impatient culture. We want answers, and we want them now. Where doctors and professors admit to ignorance or uncertainty, hucksters and charlatans will rush in gladly. The corporate media loves the narrative of heroic medical advances and triumph over sickness and death, and so does the drug industry. They'll hype it for all it's worth.
So be skeptical, but don't doubt everything. The truth really is out there, but it isn't always easy to find.
edit: Aarggh. This is what I get for trying to explain really complex ideas simply and in a hurry. I'm sure that some smartass out there (and you know who you are) will quibble with my explanation of the math. Yes yes, p values aren't exactly equivalent to the specificity of a test. The latter is plugged in a priori, based on giving the test to a bunch of people you know are not true positives. The p value is computed from your data, and we can only apply baesian reasoning to its use in hindsight, under certain idealized conditions. But qualitatively, the analogy is basically accurate, okay? I'm trying to make things easy for people, not confuse them.
From the Commonwealth Fund:
New analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey reveals that an estimated 77 million Americans age 19 and older—nearly two of five (37%) adults—have difficulty paying medical bills, have accrued medical debt, or both. . . .Unpaid medical bills and medical debt can limit access to health care: two-thirds of people with a medical bill or debt problem went without needed care because of cost—nearly three times the rate of those without these financial problems.
Report available here.
But actually doing something about this problem would be blasphemy. Jesus says the Free Market will take care of it.
For those of you who aren't part of the Secret Society, I'm going to give up some of the dark doctrine. Here's how scientific and medical journals work.
Imagine that you are a hard working person of scientificness. You do some research and you want to get it published, possibly for the good of humanity, possibly for the good of your tenure application, and possibly for the good of the drug company that sponsored your work, or any combination of the above. It's not like applying to college. Rule #1 is that you are allowed to send your manuscript to one, and only one journal. You have to wait for them to reject it before you apply to your back up. It can take anywhere from a month to three months or longer to get a decision, so you have to make a decision. Do I go for the big prestigious journal that would get my work noticed and cited, and get me tenure, but probably get rejected and not get my work published until much later (when somebody else probably will have published similar results, and/or the committee on tenure and promotions has already met)? Or do I go for a relatively obscure journal that is just grateful to get a MS written in complete sentences?
Whatever you decide, the editor who receives your MS, who is overworked and underpaid, will give it a quick look and either immediately send you a form letter saying no thanks, or send it out to peer review. The editor's decision will have a lot to do with where you work and whether she or (far more likely) he recognizes your name.
The so-called peer reviewers, of which there are usually two but conceivably three, will also have this information, but you will never know anything about them. They have an absolute shield of anonymity. I have been a peer reviewer for some well known journals -- including Public Health Reports, Social Science and Medicine, and the Journal of General Internal Medicine. That doesn't mean I'm any great shakes in the world of public health and medicine, however. They're pretty desperate for volunteers, so my main qualification was that they had my e-mail address because I had submitted papers to them myself. (And been published in two out of three of them.) I have also been asked to review because an author suggested me, which some journals allow.
So this is a task for which I am not paid, for which I receive no credit, and for which I have absolutely no accountability. The worst that can happen is that the editor won't ask me to do it again, which is not exactly punishment. Nevertheless, because of how my mama raised me, I take it very seriously. I always start by doing a medline search on the subject, so that I have an idea of the state of the relevant art and science. (Once I discovered that the author was attempting redundant publication, which is a major no no.) Then I read the article very carefully, think about its overall logic and coherence, then I write thorough criticism, paragraph by paragraph.
Unfortunately, I do not have access to the data, but only the tabulations the authors choose to present. Sometimes I can do some calculations of my own to make sure everything adds up and is consistent (which it occasionally is not!) but I have to take it on faith that they did the analysis accurately. I usually have the expertise to assess some aspects of the study, analysis and conclusions, but not necessarily all. I have even gone so far as to ask for help from a statistician or medical doctor on occasion. Then I make my (secret) recommendations to the editors. The authors get to read the critique I wrote for them, but I continue to hide behind my cloak of absolute anonymity. After the editors make their decision, they inform me, and send me a copy of the other reviewer's critique, which is inevitably, in my experience, cursory and frequently highly credulous.
So, I take this very seriously and I put in time, thought and extra effort. But most peer reviewers don't work at it nearly as hard as I do. I have also had the experience -- and I managed to ferret out the truth later, by means I cannot reveal -- of receiving a negative review because the reviewer was about to submit similar findings for publication. I had to argue with the editor very hard to get our study accepted as a brief report. Then, when the reviewer finally got his study published a 18 months later -- with essentially identical findings -- he did not cite our work. I ended up shaming him into writing a letter to the editor of the journal acknowledging our priority.
I am certain that in the case of studies of potentially high importance, the editors make more of an effort to obtain thorough, competent peer review. However, under ordinary circumstances even the most conscientious peer review can only assure that the methodology as stated is sound, that the analysis as stated is plausible, and that the findings as stated follow from the analysis. We simply have no information to assess the rigorousness and integrity of the data collection process, the accuracy of the data processing and analysis, or for that matter the truthfulness of the authors. At the same time, for any number of possible ulterior motives, we can encourage publication of studies that should not be published, and discourage publication of studies that should be published. Nobody is checking up on us and we face no consequences for our actions.
You just have to trust us.
Actually, in my view, Kranish somewhat conflates two issues. He writes here about peer review of medical journal articles (link only good for 24 hours), but his hook is the two famous, and subsequently discredited studies, that found that Hormone Replacement Therapy and vitamin E reduce the risk of heart disease. Kranish discusses a study by John Ioannidis who found that about 1/3 of widely cited studies in medical journals are found, after subsequent research, to have incorrect or overstated conclusions. He suggests that these may have been flawed or somehow incompetently done, and that the peer review process failed to catch the errors.
I don't think there was necessarily anything wrong with these studies, such as they were. The Ioannidis study actually comes to a very different conclusion: that associations found in ecological or cohort studies, or small-scale randomized trials, don't always hold up after large-scale randomized controlled trials. This is scarcely news, it's epidemiology 101. However, it can be very confusing to the general public.
Although Ioannidis's article in JAMA is available by subscription only, he has written an essay for the Public Library of Science entitled "Why most published research findings are false," which you can read here. And no, it isn't because of faulty peer review.
So in my next two posts, I'm going to take on peer review, and then Ioannidis's provocative thesis -- separately.
Sunday, August 14, 2005
The new Health Affairs (abstract only available to non-subscribers) has an analysis by Gerald Anderson, Peter Hussey, Blanca Frogner and Hugh Waters regarding the relative levels of spending on health care in the developed countries. These pieces appear annually (see Reinhardt, Hussey and Anderson from last year), and they always come to the same conclusions. Yet it is necessary to do the analysis, come to the conclusions, and repeat them, over and over, because we do not have reality based politics and we continue to have the same feckless debates between truth and falsehood.
The United States spends, currently, 53% more per person on health care than the number two country, which is Switzerland. Canada by the way -- whose publicly funded system was recently described by a commenter here as inefficient compared to the U.S. -- spends 56% as much as the U.S. This basic disparity, with health care spending being far higher in the U.S., has existed since the Organization for Economic Cooperation and Development, OECD, began collecting this information more than a quarter century ago. (These comparisons, by the way, are made in what is called "purchasing power parity dollars," based on what currencies actually buy in the home country rather than international exchange rates.)
No-one can deny these disparities, but defenders of the U.S. system claim that we have much higher quality than the other countries; that people in other countries have long waits for diagnostic and elective procedures; or that the whole problem is litigiousness and high malpractice insurance costs (the Bush administration's explanation).
Every year, Health Affairs considers these explanations anew, and debunks them. Specifically, this year:
- "Surprisingly, American have access to fewer health care resources than people in most other OECD countries, measured in . . .hospital beds per capita, physicians and nurses per capita, and . . . MRI and . . . CT scanners per capita."
- Although some OECD countries do tend to have longer wait times for elective procedures than are typical in the U.S., others do not. But there is little difference in spending per capita between those that do and those that don't, and it's no surprise -- the procedures for which waitig lists exist in some countries account for less than 3% of U.S. health care spending.
- The U.S. does have more malpractice claims filed per capita than the UK, Australia and Canada. Two-third of these are dropped, dismissed, or unsuccesful; in 1/3, plaintiffs receive compensation, but the average payment in the U.S. is less than in the UK or Canada. The net result is that total malpractice payouts per capita in 2001 were $16 in the U.S., $12 in the UK, $10 in Australia, and $4 in Canada (where few claims are filed in the first place). Adding the cost of defending malpractice suits and insurance underwriting expenses, malpractice payments are less than 5% of health care spending in the U.S.
Let us never forget that those other countries provide coverage to everyone, while here in the U.S. there are about 45 million citizens and legal residents who have no health insurance coverage whatever. This contributes to huge disparities in access to care, which in turn contributes to disparities in health status and longevity among various parts of the population.
It also follows that the greater proclivity of Americans to sue for malpractice may not represent a defect in our national character, but rather the unfortunate reality that people injured by medical intervention or negligence have no other way of having their need for further care met. In the other OECD countries, a child disabled at birth or someone who suffers neurological damage from surgery will be cared for like everyone else. Here, you have to sue -- and even if your need is genuine, you won't get any money if the doctors weren't negligent.
And the bottom line hasn't changed either: Americans are healthier than people in the poor countries, but not as healthy as people in the other wealthy countries, including a lot of countries that aren't nearly as wealthy as we are.
The reasons we pay so much more, and get less, haven't changed:
- Salaries are higher here, especially for physicians. That's probably appropriate up to a point, this is a rich country. (We can dispute specifics, particularly the relative compensation for various specialties.) However, even after adjusting for the higher per capita income and cost of living in the U.S., health care spending here is still more than $2,000 higher than would be predicted if everything else were equal.
- Those other countries have centralized purchasing power, so they drive a bargain with drug and device manufacturers, and get much better prices.
- We squander something like 25% of our hard earned dollars on administrative expenses, billing multiple payers, keeping track of multiple formularies and benefits structures, billing for copays, and probably most important, figuring out ways to deny care to people.
I'm feeling a bit redundant and repetitive here. So are all my friends. How many times do we need to say that the earth is round before the politicians and the corporate media get it?
We need universal, comprehensive, single payer national health care. Like other civilized people.
Friday, August 12, 2005
Take note the next time something really bad happens. Maybe some high school kids are killed in a car crash on prom night, or a deranged former employee shoots up an office, or a radical Christian terrorist bombs a women's health clinic, or maybe a popular high school athlete collapses and dies on the practice field. What does your local TV news tell you is being done about it, while showing you the growing pile of teddy bears and balloons?
Grief counselors. They're sending in the grief counselors.
Simon Wesseley of King's College, London, writing in the latest NEJM (sorry, subscription only) about the July 7 bombings in London, tells us that:
There have now been more than a dozen controlled trials in which people who have been involved in . . . traumatic events have been randomly assigned to receive or not to receive such counseling. The results have shown conclusively that such immediate psychological debriefing does not work. Those who received it were no better off emotionally than those who did not. Worse, the better studies with the longer follow-up periods showed that receiving such counseling actually increased the likelihood of later psychological problems. In fact, the people who seemed to be harmed by this intervention were those who had been especially upset at the time -- precisely those who one might think ought to be treated.
Well, that ought to put a stop to this nonsense. But try googling "grief counselor" and you will get endless pages of links to programs, sponsored by school boards, cities, universities, etc.; training programs; how-to manuals; advertisements for services; and so on. Hardly a discouraging word.
This is just one example of our cultural compulsion to medicalize every part of the human condition. Menopause, sadness, baldness, shyness, boredom and restlessness in class, road rage, loss of interest in your sex partner, grief -- all diseases, all needing appropriate professional and/or chemical intervention.
When we suffer loss, we grieve. If the loss is sudden and traumatic we may feel shock, numbness, fear, confusion, anger, and then grief comes later. That's what happens. We just need to do it. That's life. Let it be.
And all you grief counselors out there -- learn how to do smoking cessation.
PS: Don't get me wrong: Post traumatic stress disorder (whether the diagnostic label is particularly helpful or not) is for real. People can suffer the aftereffects of trauma for a long time, and the right kind of counseling, at that point, can help. But professional intervention in the process of grieving does not prevent PTSD, it just makes it worse, it seems.
Thursday, August 11, 2005
Here's a little essay I wrote with my colleague Anthony Schlaff, MD, MPH. (He asked me to tell you that the MPH is the important part.) We couldn't get it published anywhere respectable, so you'll just have to put up with it here.
Lost in Space
Imagine you are on a scientific team planning a trip to Mars. NASA tells you to prepare based on the following assumptions:
1) There is a breathable atmosphere on Mars
2) There is drinkable water on Mars
3) The temperature on Mars averages 60o Fahrenheit.
4) You can travel faster than light
Edgar Rice Burroughs did exactly that. But would you sign up for the trip?
Those who claim we can solve the problems of health care access and cost through the “free market” are thinking like Edgar Rice Burroughs. If you ever took an economics course, your teacher probably introduced you to the key assumptions of market systems. They include:
1. Perfect information – Buyers know everything, or at least enough, about products offered for sale and the possible alternatives to make a “rational” decision.
2. Consumers generate demand, all transactions are voluntary – Buyers decide what they want, and when to buy it.
3. Balance of market power – There are many sellers and many buyers for every product, who freely compete.
4. No externalities – All of the costs and benefits to society that result from a transaction are felt by the buyer and seller.
5. Adequate circumstances and justice.
Do any of these apply to health care delivery? Not a one!
Information: Fundamentally, what we buy from our health care providers is expertise. Because we usually can’t assess their competence ourselves, doctors, nurses and therapists have to go through legally approved training and be licensed by the state.
Demand: Imagine if Ford and GM could decide when we needed to buy a car – that doesn’t sound much like anybody’s idea of the free market. But doctors tell us we need surgery. That’s called provider-induced demand. While doctors try to be responsible and objective in their decisions, it has been shown that the way in which they are compensated does affect the amount and kind of medical services that they prescribe.
And our consumption of medical services is frequently not voluntary at all. If we have a dissected aorta, you could argue that in some abstract sense we could choose whether or not to have surgery, but common sense tells us we are compelled. We could even go into the Emergency Department unconscious, and only find out later what services we had received.
Market power: We can go to the supermarket and pick from a dozen brands of toothpaste, and most of us can also choose where to shop. But outside of the major cities, most regions are served by only a single hospital. Hospitals are very expensive to build, equip and operate, so it would be wasteful to have more, but that means our choices are limited. There are also structural reasons why most of us have at most two or three insurance companies to choose from, and of course many drugs are patented.
Externalities: Although we are most familiar with so-called negative externalities, such as air pollution from automobiles, medicine actually has many positive externalities. Treating and preventing infections benefits people who would otherwise catch the disease. People who can’t work due to preventable or treatable disease and disability contribute less than they could to the economic support of their families, the net economic production of society, and non-monetized but socially important activities such as child rearing, homemaking, etc. And there are what might be called moral externalities. Most of us would be troubled by large numbers of people with treatable illnesses in our midst, and even more distressed if those included people we knew and cared about.
Justice: We never know when we or our loved ones might suffer from a serious disease or an injury. Most people cannot possibly save enough money to pay for their care if they are badly injured in a car crash, or their child is diagnosed with leukemia. Such events can bankrupt people and destroy their lives. That is why we have insurance – to spread risk, so that everyone pays an amount they can afford, and those of us who suffer misfortune are taken care of.
Last year, our old friend William Frist, M.D. (of the long distance diagnostic powers), in a lecture at the Massachusetts Medical Society, said, “We must agree on a guiding principle: all Americans deserve the security of lifelong, affordable access to high-quality health care." It's nice to have a principle that says people deserve it, but it's even nicer to have a plan that will give it to them. This Senator Frist does not have. His system of "consumer driven health care" is driven by consumers in the sense that they pay for it, out of their own pockets. People who earn more than $40,000 per year "should be encouraged, through changes in the tax policies, to buy themselves and their children high-deductible catastrophic insurance coverage." They would then pay for routine care through tax-free Health Savings Accounts (HSAs). Frist also wants to eliminate the tax policies that encourage employers to provide insurance. He says that the system of employer-provided health care "has been universally blamed by economists for inflating health care costs." However, the reference he gives says no such thing, and the assertion is false.
The truth is that economists blame our fragmented system for our high costs, but Frist's solution is to make it even more fragmented. The other wealthy countries spend much less on health care than we do, and get better results, because they have concentrated market power on the purchasing side, either single payer systems or multiple payers who work within budgets established by governments (e.g., Germany). By driving a bargain, they get lower prices for drugs, medical devices, etc. Also, in our complex system, each provider needs systems for billing dozens of different payers, while the payers have their own overhead and marketing expenses. A quarter of total U.S. health care spending is on administrative costs. Note that in our public insurance programs -- Medicare and Medicaid -- administrative costs are far less.
In the real world, the people who establish HSAs will mostly be healthy and wealthy. These people will no longer be in the pool for comprehensive insurance, the price of which will then rise. Although Frist appears to believe that insurance will be more "affordable" because of competition among providers and health plans, the fact is, they already compete in a market with many large, powerful corporate buyers. By phasing out employer-provided insurance, leaving individuals try to buy insurance on their own, this concentrated purchasing power will disappear. Frist's world is a jungle in which the fortunate will be rewarded and the rest of us will be unable to pay for health care.
Medicine is not just a private good, it is also a public good, like park land, national defense, or law enforcement. It is in fact a mixed good, like education, benefiting both the individual and society. Hence, if we leave it up to the consumer to decide when and what to buy, the public good represented by medicine will be underproduced. Imagine if the "Ownership Society" included the elimination of public education -- the logic is the same.
Champions of market reform in health care have been getting away with proposing fiction as reality for far too long. Both theoretically and empirically, the key market assumptions described above have clearly been shown not to apply to health care. Let’s come back to earth and stop pretending that they do.