Map of life expectancy at birth from Global Education Project.

Thursday, April 28, 2016

No, both sides don't do it

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

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

As Dana Nucitelli says at the link:

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

Wednesday, April 27, 2016

Player Piano

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

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

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

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

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

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

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

Tuesday, April 26, 2016

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

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

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

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

The main news in this is:

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

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

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

Thursday, April 21, 2016

This won't end the opioid epidemic . . .

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

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

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

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

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

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

Tuesday, April 19, 2016

Betraying Confidences

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

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

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

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

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

Friday, April 15, 2016

The Lipid Hypothesis

You may have heard that the long-standing conventional wisdom about the ill effects of saturated fats has come under sharp questioning.  A team of investigators led by NIH employee Christopher Ramsden has resurrected and reanalyzed data from the Minnesota Coronary Experiment, a nutritional trial done back in 1968-73, which was a foundation of the conventional wisdom that substituting vegetable fat for animal fat in the diet is protective against heart disease. They have also done a meta-analysis of published studies and had earlier re-analyzed data from the Sydney Diet Heart Study of the same era.

To make a very long story short, what they found is that diets high in linoleic acid -- a component found particularly in certain vegetable oils including safflower and corn oil -- and low in saturated fat do reduce LDL cholesterol. But . . . 

According to data from these studies which were never published, that did not correspond to a reduction in the risk of heart disease, coronary events, or death. I would say this conclusion is not quite definitive. For one thing, the Minnesota study had a non-representative population of residents of mental hospitals and a nursing home. They had a lot of comorbidity. Also the high linoleic acid diets they were fed are considerably more extreme than the diets people would have in real life. For one thing, olive and canola oil are not so high in in linoleic acid; and most people would continue to consume substantial animal at even if they did try to substitute some amount of vegetable oil. Other problems are that the available data from the study don't allow direct testing of the association between LDL levels and outcomes; and that autopsy data to assess atherosclerosis is available for only a small number of participants.

Still, this work has reopened what the conventional wisdom had long considered a closed can of worms. It's been extremely controversial and of course people who have been entrenched in the conventional wisdom their whole careers aren't about to suddenly "Oops, you got us." This is not my expertise and I'm certainly not going to pronounce a verdict. It is still pretty solid that trans-fats are bad for you, statins do protect against heart disease (although maybe not so much because of their cholesterol lowering effect after all -- something long suspected), and excess sugar is also bad.

But we don't really understand what's going on with lipids in the diet or the blood plasma. It's certainly not as simple as people have long believed. The "low fat" fad of a few years back was definitely a mistake.

Most important of all, science is not like religion. It's open to correction and change. However dug in some people are about the lipid hypothesis, it's not like the Bible. It can be rewritten, and it is being rewritten. Don't get cynical and start down that well-worn path of saying, they're always changing the advice about diet, so why pay any attention? Some advice has been changing lately, but some of it has gotten more solid than ever. It's always getting better, so I say you should keep paying attention.Keep eating your veggies and whole grains, and steer clear of the sugar bombs. But I would say you can relax about dairy if you're okay with it on ethical grounds.

Tuesday, April 12, 2016

No, you don't need to read the whole thing . . .

. . . but here are the new official U.S. government dietary guidelines for Americans. No, the Nanny State isn't actually forcing you to eat broccoli. (But try it, you'll like it!) They're just giving you information that you can take or leave.

There is one really important nugget in here. It really is very close to a magic bullet. That is the recommendation to limit added sugar to less than 10% of calories per day. This is the first time they've had the nerve to stand up to Big Soda and name a number.

Actually the number is still too high. The American Heart Association thinks it should be 5%. Anyway, just to be clear, one (1) single 16 ounce soda will take care of your 10%. That's it. If you want to eat a cookie or sprinkle sugar on your oatmeal, you can't drink a soda. Americans get almost half of their added sugar from sugary beverages, if you include coffee and tea which you should, because what you get at Starbucks is not actually coffee but sugar with added ingredients.

Want to lose weight? Forget about Atkins and Scarsdale and grapefruit and whatever other fad comes along. Don't drink soda, so-called "energy drinks," phony fruit juice (marketed as name-of-fruit cocktail or "drink"), or pretty much anything that's likely to be in the cooler at your local take-out. For most people, that's the single most important thing you can do. And even if you aren't seriously overweight, eating all that sugar increases your risk for diabetes, cancer and heart disease.

I am not a nut. This is the truth. It really is that simple. Yeah, once you've accomplished that there are still better and worse diets, and you still need to exercise and not smoke. But if people just stopped poisoning themselves with the products of Coke and Pepsi, it would be the single greatest advance in public health since sanitary sewers.

Thursday, April 07, 2016

Finishing up on the QALY thing . . .

Fortunately, just as I was beginning to lose the thread, Thomas A. Farley comes along in NEJM to make my point for me. A small explainer is needed -- in order to compare the benefits of various health-related interventions, we need a "common currency." It's not enough just to look at life extension. On the one hand, some interventions don't necessarily extend life at all, but they still have value because they relieve pain and disability. Others may extend life, but with very poor quality.

So Quality Adjusted Life Years are a commonly used measure of benefit. They're controversial and I actually buy some of the criticisms. Here's the Wikipedia article. There are a few different ways to calculate QALYs, but basically, they're based on survey data -- asking people how much life expectancy they would trade to be free of a disease state, for example. One major problem with this is that once you actually have the disease state, if it isn't horrific, you probably still want to go on living just as much. The QALY concept can be viewed as devaluing the lives of the sick and disabled. However, that's only when viewed retrospectively -- given the survey, most people can still answer the question.

Regardless, whether you go along with the QALY concept or not, as Farley explains, and as I have already said, resources are limited so we implicitly place a value on human life (or health) all the time. But our ethical intuitions lead us to bizarre conclusions. Farley gives the example of a woman with incurable cancer, whose life can be extended for a few months at a cost of $80,000. Most people insist on giving her the treatment, and by law, Medicare is not even permitted to consider cost in approving treatments. But . . .

We could extend far more lives for far longer for far less money, very easily, but we decide it costs too much. To take an obvious example, anti-tobacco campaigns in the mass media, according to Farley, cost less than $300 per QALY gained, which is a tiny fraction of the cost of cancer treatment; but they occur only sporadically. (Come to think of it, I can't remember seeing one for years.)

Why is cost the main consideration when it comes to prevention, and benefit the only consideration when it comes to treatment? Note that this is essentially the conservative or Republican approach to population health, with a weird exception -- provide every possible treatment, no matter what it costs, to everybody who is lucky enough to have insurance. (Which means that other people -- taxpayers or ratepayers -- are in fact paying for it.) Of course, people who can't afford insurance can just die in the street. But I thought human life was infinitely precious? I guess Sarah Palin's is, anyway. On the other hand, spending money to improve air and water quality, improve children's nutrition, provide better quality housing, or whatever the preventive measure may be that extends life and health, is Big Government, Nanny State, and deprives us of our Freedom.

This obviously makes no sense.

Wednesday, April 06, 2016

Civilization and its Discontents

The World Health Organization reports that the prevalence of diabetes world-wide has increased 422 million adults, which is an astonishing 8.5% of the population, essentially doubling since 1980. We tend to think of this as a disease of the rich countries,  but WHO says it's worldwide. Oh yeah -- more than 1/3 of adults on the planet are overweight.

Has the human population suddenly turned gluttonous and lazy? Obviously not. This is actually an environmental catastrophe. More and more people have sedentary jobs, and where people aren't starving due to conflict and social collapse, the world is awash in cheap calories. To a large extent this is a product of technological change for which we can't blame anybody in particular. However, it is also true that much of the world's food now consists of manufactured items that are scientifically engineered to induce overconsumption of low quality calories. Sugary soft drinks, sweet and salty snack foods, prepared cuisine -- they are all developed and tested in laboratories to hijack the neuro-endocrine systems that regulate our appetite.

There is no moral distinction between the merchants of soda and the merchants of tobacco. They are selling death, to satisfy their greed. This must stop.

Monday, April 04, 2016

The War On [some people who use some] Drugs

It's hard to believe we're still pissing into the wind on this particular subject. I remember sitting in the science library at Brandeis when I was a graduate student reading policy analysis in Science (the journal of the American Academy for the Advancement of Science) showing that most of the harm caused by illicit drugs was caused by,well, their illicitness. Now we have some 20 years later yet another authoritative finding that criminalization of drug use severely harms public health. Quoth:

"The goal of prohibiting all use, possession, production, and trafficking of illicit drugs is the basis of many of our national drug laws, but these policies are based on ideas about drug use and drug dependence that are not scientifically grounded," says commissioner Chris Beyrer, an epidemiology professor at the Bloomberg School. "The global war on drugs has harmed public health, human rights, and development. It's time for us to rethink our approach to global drug policies, and put scientific evidence and public health at the heart of drug policy discussions."
Oh right, we should base public policy on science. As if.

What is probably most enraging is that the politicians in the U.S. who want to continue to lock up hundreds of thousands of non-violent (mostly non-white) people just for using or selling small quantities of "drugs" -- which does not include alcohol or tobacco -- are the same ones who claim they are all about small government, individual liberty and personal responsibility.  Well, they aren't. They're liars and hypocrites.