Map of life expectancy at birth from Global Education Project.

Saturday, April 22, 2017

This is amusing . . .


Someone (an anonymous coward) wrote this in a comment:

Imagine trying to explain to a bunch of liberal professors that in the history of the world, no other economic system has created more wealth for more people than capitalism. It just goes against their deeply held socialist and political beliefs.
It's fascinating what people think goes on in universities. In all of my travels through Tufts, Brandeis,  Boston University and Brown University as a graduate student and faculty member, I have never met a single liberal (or other) professor who does not know that economies that fall broadly into the classification of capitalist have become the wealthiest. As a matter of fact (funny thing here!) Karl Marx believed that capitalism was the most dynamic economic system for creating wealth. Nowadays, there are very few professors anywhere in the U.S. who think that Marx mostly had things right, but even if there are a few, they do not need to be convinced that "no other economic system has created more wealth than capitalism." All those liberal professors, with their briar pipes and leather patches on the elbows of their tweed jackets, believe it or not, actually know this.

However, economists -- and other people who think about the economy, such as sociologists, political scientists, and historians -- have various viewpoints about how best to organize and manage complex, modern economies. Capitalism, as I have suggested, is quite a broad concept and there are many capitalist economies in the world today, and in history, that have had differing characteristics. I should also add that the term "socialist" has come to be conflated with Soviet communism, which leads to much misunderstanding.

In Europe, the term "democratic socialism" as most people use it refers to advocacy for a program in which government assures certain standards of welfare within an entrepreneurial, market economy. As in the U.S., there is also some amount of government enterprise and economic activity -- perhaps our correspondent has noticed that someone maintains the roads, puts out fires, educates children and so on. People who call themselves socialists may want to see government do more to invest in human, physical, and intellectual capital than it does now. But socialism as it is commonly used today really refers to a form of capitalism.

Economists today -- even respectable conservative economists -- understand that markets are not forces of nature. They are social constructs. They require various forms of regulation and public infrastructure to function. The question is how best to structure and regulate them, not whether they ought to exist.

If you are interested in what liberal professors really think and argue about the economy, you might check out the blog of Bradford DeLong, a Berkeley (I know) professor, which is very active and has all sorts of interesting material pretty much daily. He's an economic historian, so there's a lot of emphasis on that, but there's plenty of other stuff as well.

Educate yourself, is always my advice.

Friday, April 21, 2017

Science and Politics

I would imagine I don't have to tell you that I think objections to the March for Science on the grounds that science shouldn't be "politicized" are absurd. Science is already politicized, which is exactly the point. Here's one take that's worth reading from Tim Requarth.

We eggheads get all scrambled trying to understand why people just won't listen when we 'splain the scientific truth to them. As Requarth explains, the problem isn't that they have a knowledge deficit that we can plug with our smart words. It's that they are motivated to believe by particular interests or loyalties. Scientists spend years getting their brains trained to apply certain standards of evidence and to change their conclusions when the evidence calls for it. But that makes us weird.

Here's Dave Levitan on the ways politicians deny and distort science. One pull quote I like:

Q. The “I’m not a scientist” line has become all-too-common, and it’s the basis of your book title. Why is this refrain bullshit in your view?

Dave Levitan: The basic reason is it's absurd for politicians to have to tell us what they're not an expert in. They don't say I'm not an economist. They don't say I don't have a degree in Middle Eastern studies or civil engineering, yet they're still perfectly willing to opine on these issues. So it's sort of a bizarre subset that they think it's a reasonable thing to say.

Here's why this is hard to talk about. We do claim to be experts in our fields, and we do make a privileged claim to truth. Cosmologists do not consider the age of the universe to be subject to debate (within a margin of error); biologists do not consider the fact of evolution and the antiquity of life (again, within a range) to be matters of opinion; climate scientists state that anthropogenic global warming is a fact, no longer a hypothesis. An if you disagree, you are just wrong. We know more than you do.

People don't like to hear that. However, as Levitan suggests, they commonly make exceptions. They respect the expertise of their physicians, plumbers and auto mechanics. On the other hand, I have to agree, all three categories of professional are capable of corruption, and of fudging or even lying in the service of a bigger paycheck. People might think that scientists are doing the same, to get grants or whatever.

Here's what's wrong with that. We aren't one auto mechanic trying to sell you a transmission rebuild that you don't really need. Science is a community of millions of investigators, graduate students, research assistants, and administrators. There is nothing that a scientist wants more than to prove that everybody else was wrong and get credit for a breakthrough. And there is no way that all those people are somehow going to successfully conspire to fool the entire world, and nobody is going to blow the whistle on them.

But it's also hard to explain to people that errors do happen -- in fact, we think that in some sense, everything we think we know is wrong because we can ultimately find a more precise answer. But the errors get fixed, the precision increases. Newton's theory of gravitation has been supplanted by Einstein's. In a sense Newton was "wrong," but he was a lot closer to the truth than Ptolemy. There is some question now about whether general relativity is exactly correct. Maybe physicists will improve on Einstein some day. They're trying really hard! But relativity works well enough for the Global Positioning System and robot probes to Jupiter, so you'd be a fool to deny it.

So I'm not sure what to do. Trying to explain stuff to people that they are motivated not to understand isn't going to get us very far, especially if they feel they are being talked down to or what they think is their own expertise isn't respected. Well sorry, but if you aren't an expert in physics and biology then no, you don't know as much as somebody who is. You should try to learn more if you are interested, but you need to approach that learning with a truly open mind. And if you can't be bothered, that's fine too, but then you need to stop thinking you know better.





* Mine is policy and practice related, so it's factual basis does inevitably get mixed up with values. But I find a lot of critics here don't succeed in separating out my factual assertions -- they end up arguing against facts because they are unwilling to state their value disagreements.

Tuesday, April 18, 2017

Too Long, you don't have to read . . .

. . . because I'll tell you, as a follow-up to my previous post. David Gorski has good things to say, as he does here, but if brevity is the soul of wit Dr. Gorski is not at all witty. (I think he already knows that but he can't help himself.)

Anyway, so-called "Right to Try" legislation has passed in 33 states, and an effort is underway to pass a federal version. This is one of those policy ideas that looks great on a bumper sticker and is impossible to refute in 30 words or less. Since the voting public gets turned off by wonkery, politicians who know better duck and cover when these proposals come along, so they pass.

The idea is that terminally ill people should have the right to try experimental treatments. Maybe they haven't been proven safe and effective yet, but they got through the first round of trials so it appears they might work, and what have you got to lose? You're dying! Why would the nanny state deprive people of a chance to extend their own lives if that's what they want to do?

Okay. First of all you need to know that the formal process for drug approval consists of three "phases" of trials. Phase one just consists of giving small and gradually escalating doses to a small number of patients, maybe 30, just to establish a level that doesn't produce acute toxicity. Passing this stage is all that is needed for the "right to try" to kick in.

But these drugs may not even have passed phase II trials. These are somewhat larger and last longer. They are underpowered to prove that a drug is safe and effective. They are intended to establish that the trends are in the right direction and that no obvious safety issues emerge in longer term use, so that the much larger investment in a Phase III trial can be justified. Only after successfully completing at least one Phase III trial can a drug be considered for approval.

It turns out that only 30% of drugs that enter Phase II trials even go on to Phase III, let alone win ultimate approval. So the first thing you need to know is that the likelihood that people could benefit from "right to try" is lower than you probably thought. Since the ostensible beneficiaries are already terminally ill, it's actually extremely low. Even safe and effective drugs are almost never miracle cures -- they might extend life for cancer patients if used early enough, but they almost never reverse advanced cancer. And yes, they can indeed harm people.

Terminal illness is actually a pretty loose concept. Doctors are very bad at predicting how long people have to live; it's very common to outlive a prognosis of 6 months to live, by a lot. So it's possible to significantly shorten the life of a person with a supposedly terminal illness. It's also possible to make them sicker. So gambling with an unproven treatment is not a no-cost bet.

And "right-to-try" legislation forbids insurance companies paying for these treatments, at their own insistence. That means the legislation affects only people with the means to pay out of pocket; and the drug companies can charge whatever they want, which is probably a lot. So you're handing over your kids' inheritance for something that is more likely to harm you than to help you.

Finally, the existence of "right-to-try" may deter people from participating in clinical trials in which they might get the placebo. Which means it will be harder for us ever to know for sure whether the stuff works. The proposed federal legislation is even worse because it actively forbids the FDA from taking adverse events in "right-to-try" patients into account in evaluating the treatment. The only point of that is to relieve the drug companies of all risk.

This is nothing but a cynical move to take money from desperate people and give it to drug companies, under cover of fake compassion and the usual nonsensical libertarian arguments. The FDA already has the authority to approve "compassionate use" of experimental medications on a case-by-case basis. That's how it should stay.

Thursday, April 13, 2017

Libertarian pharmacy policy


It's a famous story. Thalidomide is a sedative which was prescribed for morning sickness in pregnant women, starting in about 1960, in countries around the world. Not, however, in the U.S., because an official of the Food and Drug Administration named Frances Kelsey felt the application had insufficient data on safety, including whether the drug crosses the placenta. Turns out it does, and it can cause severe birth defects in which babies are born with flipper-like limbs.

At that time the FDA did not oversee clinical trials, and it pretty much took the drug companies' word for it about safety. As the linked article says:

The tragedy surrounding thalidomide and Kelsey’s wise refusal to approve the drug helped motivate profound changes in the FDA. By passing the Kefauver-Harris Drug Amendments Act in 1962, legislators tightened restrictions surrounding the surveillance and approval process for drugs to be sold in the U.S., requiring that manufacturers prove they are both safe and effective before they are marketed. Now, drug approval can take between eight and twelve years, involving animal testing and tightly regulated human clinical trials.

Drug companies don't necessarily like this. Some do, because they feel they depend on their reputation for safety, although as we have discussed here many times they frequently game the system by keeping unfavorable trial results hidden, and other unsavory practices. Recent efforts at reform have aimed at improving the system, by requiring registration of clinical trials and public availability of all results, among other reforms.

Comes now a reality TV star who wants to appoint as FDA commissioner a man with no research experience or academic background who is an investment adviser and member of pharmaceutical company boards. As Daniel Carpenter informs us in NEJM, "The Trump administration’s approach to the Food and Drug Administration (FDA) is guided by a libertarian belief in markets over science, and Gottlieb apparently shares this view." The idea is that bad drugs will be driven out of the market by consumer experience.

Of course, if your baby is born without arms it will be a bit too late for you, but that isn't the only problem with this philosophy. Lots of diseases and symptoms get better on their own. You can't necessarily tell whether the medication helped or not. Nor do you necessarily know that an adverse effect is attributable to the drug. You should read Carpenter's essay, but here's how he finishes:

The medical community and the Senate should greet this nomination with scrutiny. To this end, I propose some questions for Gottlieb. Perhaps the most important is one that can be answered only by his behavior: Will Gottlieb, if confirmed, listen more to FDA scientists or to his Trump administration superiors, corporate-board colleagues, and think-tank associates? At stake is not just the FDA, but the scientific regime of clinical pharmacology and the credibility of American therapeutics.

Questions for Scott Gottlieb.

  • • You will have to recuse yourself from decisions about certain companies’ products because of conflicts of interest. How many companies, and which ones?
  • • You have argued that there are “interim endpoints that can be used to more quickly gauge a medicine’s benefit.” Under your leadership, how would the agency commit to restricting the use of a drug or removing it from the market if later-stage evidence turns out to present a much weaker benefit profile?
  • • You have argued that the FDA has an “unreasonable hunger for statistical certainty.” How, then, do you explain the fact that the FDA approves new drugs and devices more quickly than any other regulatory agency? Do you see accelerated approval, compassionate use, and breakthrough designations as inadequate, and if so, why?



Wednesday, April 12, 2017

Saint Ronald


Iraq and Iran fought a horrific war from 1980 to 1988. Saddam Hussein was unquestionably the perpetrator. He repeatedly used chemical weapons against Iranian troops, then in 1988 he attacked the Kurdish village of Halabja, in northern Iraq, with mustard gas, killing thousands of civilians.

The president of the United States was conservative demi-God Ronald Reagan:

In 1983, President Reagan sent a special envoy to Baghdad. He was Donald Rumsfeld, and that visit resulted in the now famous picture of Rumsfeld shaking hands with Saddam Hussein. This was in December of 1983. This was at a time when the US was secretly aware that Iraq was using chemical weapons against the Iranians almost daily. There's evidence that the battlefield intelligence provided to Iraq helped the Iraqis better calibrate their gas attacks against the Iranians. Around this time, the administration concluded that Iraq's defeat in the war would be contrary to US interests in the Persian Gulf. The economic aid to Iraq started in 1983, and by the end of the war amounted to more than a billion dollars. . . .

Near the end of the war when Saddam Hussein used chemical weapons against his own citizens, the Kurds. We know a great deal about this now. At the time, the United States prevented a move in the UN to impose economic sanctions against Iraq, saying that the sanctions would be useless or counterproductive. So in effect, the United States defended Saddam Hussein's use of chemical weapons even as late as 1988, and this kind of a relationship continued through the Reagan administration and into the first President Bush administration until the very day that Iraq invaded Kuwait in early August 1990.
Just so you know.

Thursday, April 06, 2017

Gas Schmas


It's interesting that the Assad regime's nerve gas attack on a village in Idlib has generated sudden outrage, including from people who thought Assad was just peachy until yesterday such as the White House resident. We're having an emergency meeting of the UN Security Council and the U.S. is threatening to take unilateral action -- presumably meaning bombing some things and people -- if the UN doesn't act.

I agree that it is bad to attack civilians with poison gas. It is also bad to blow up 3,800 people using rockets and artillery shells, summarily execute tens of thousands in mass hangings, blow up hospitals and mosques, and starve people to death. The Assad regime did all of that, and more, before the nerve gas attack, which was apparently okay.

Look, I'm against all kinds of war. But to freak out over chemical weapons in this way is to imply that bombing, torturing and starving people is okay. This is an idiotic, meaningless distinction. We need to get over it.