Kids, Food, Junk

Not to get too nanny state on you all, but why shouldn't the "federal Congress" be able to pass laws mandating healthy foods in public school cafeterias and snack machines? When children are at school, the school is, according to the Courts, in loco parentis -- put simply, functioning in the place of the parent. Providing healthful foods, rather than utter junk, would seem an appropriate use of that power. Providing junk, particularly when deals are made with soda and candy companies, would be quite the opposite.

I realize this sort of thing gets libertarian hackles up, but I'm genuinely curious as to why. The Congress is simply deciding what can be sold at public schools, not what can be consumed on the grounds. Someone, somehow, is going to do the choosing as to what is stocked in cafeterias, and this legislation simply ensures that nutritional concerns will help govern that choice. If parents want to pack ding-dongs into their kid's lunches, they still can. But if they don't, they can rest easy knowing that their kids' purchasing choices are overwhelmingly healthy. It seems win-win, unless you've got stock in ding-dongs. Or really like this video:

Health Wonkery Watch

Shannon Brownlee explains the differences between managed care and (real) HMOs/group practices, and tries to rescue the shattered reputation of the latter:

The reason group practices and HMOs haven't flourished is that the market isn't set up to pay them. There isn't an insurer in this country, including Medicare, which consistently pays doctors and hospitals for the quality of care they provide. They pay for quantity. They pay for the volume of individual services provided, not for the value of those services to the patient. As Michael Hillman of the Marshfield Clinic (a group practice in Marshfield, Wisconsin) recently put it, our current payment system "is like buying a car based on how many parts it has and how long it takes to make it, without considering how well it runs.'' So even though HMOs and group practices have in effect built the equivalent of a better car, the market doesn't give a rip.

Patients don't care either, partly because they are insulated from the cost of medicine, so they have little stake in getting good value for their dollar. But they also have a bias against HMOs and group practices because the American Medical Association has spent the last century telling them that HMOs and group practices offer inferior care. The AMA's rallying cry has been the almighty "doctor-patient relationship." This might sound like a motto based on the needs of patients, but what it has meant in practice is the AMA has trumpeted the rights of individual doctors in private practice to treat patients as they see fit, without interference from the government or their peers, and more importantly, to charge whatever price the market will bear. According to the AMA anything that resembles organized medicine, including group practices and Medicare, is a Commie plot to saddle us with socialized medicine -- and constrain physician incomes.

Doesn't ring true? Think about this: HMOs came into being largely in order to better coordinate care. Much like the VA, they bring together doctors who're jointly tasked with individual patients, who share notes and generally work as a team. That's part of how they keep costs down. Now, all of you, just about, are in the Big Insurance version of the HMO: Managed care. How coordinated does your care feel?

In Praise of Slumber

New York Magazine has a terrifically interesting article on sleep research, and the overwhelming scientific consensus that even moderate reductions in shut-eye can do serious damage to our mental speed. In one study, "the University of Pennsylvania’s David Dinges did an experiment shortening adults’ sleep to six hours a night. After two weeks, they reported they were doing okay. Yet on a battery of tests, they proved to be just as impaired as someone who has stayed awake for 24 hours straight." Yikes. In another, we learn that "Sleep deprivation hits the hippocampus harder than the amygdala. The result is that sleep-deprived people fail to recall pleasant memories yet recall gloomy memories just fine. In one experiment...sleep-deprived college students tried to memorize a list of words. They could remember 81 percent of the words with a negative connotation, like cancer. But they could remember only 41 percent of the words with a positive or neutral connotation, like sunshine or basket."

We also get some data on the commonly heard, and totally accurate, complaint that schools start too early. "in Edina, Minnesota, an affluent suburb of Minneapolis...the high school start time was changed from 7:25 a.m. to 8:30. The results were startling. In the year preceding the time change, math and verbal SAT scores for the top 10 percent of Edina’s students averaged 1288. A year later, the top 10 percent averaged 1500, an increase that couldn’t be attributed to any other variable." And yes, as anyone who's ever stayed up all night and felt voraciously hungry in the morning knows, sleep deprivation stimulates your appetite, and makes you fat. "Three foreign studies showed strikingly similar results. One analyzed Japanese elementary students, one Canadian kindergarten boys, and one young boys in Australia. They all showed that kids who get less than eight hours of sleep have about a 300 percent higher rate of obesity than those who get a full ten hours of sleep....In Houston public schools, according to a University of Texas at Houston study, adolescents’ odds of obesity went up 80 percent for each hour of lost sleep. "

The risk of reading this article is that you'll do what I did this morning, which is wake up tired, tell yourself that your place of employment wouldn't want you functioning at 60% capacity, nor becoming really fat, and go back to sleep. A little sleep research is a dangerous thing, particularly at 7 in the morning.

Too Much Medicine?

As per usual, Robin Hanson's claims that we should cut the provision of medicine in half are, shall we say, a bit strong, but it is true that we've got enormous amounts of waste, and it's undoubtedly true that we should vastly enhance the amount of money we spend studying the effectiveness of treatments.

David Cutler's riposte, by contrast, seems quite on-point. Policy should focus on separating good care from bad care. There's no reason to go at this with a meat cleaver (unless you're Robin Hanson, and have made a career out of, um, "viewquakes," which sort of require you to make Shocking! Claims!) Also, if you are going to cut care, you'll want to do it on the supply side (i.e, with trained professionals helping decide where to slash spending), because all the available evidence shows that patients do not, themselves, know which care to cut, and when faced with higher medical bills, will just cut care indiscriminately.

Lastly, Hanson mentions that medicine is often used to "show that we care," which does not actually increase anyone's health. But medicine is also used to comfort. Take a patient with heart palpitations. Odds are they're just benign skipped beats. A doctor may even know those odds. But when your heart jumps, it's scary. So the doctor runs the set of tests that distinguish them from deadly arrhythmias. These tests are, in Hanson's telling, wasted medicine, as they do nothing to improve biological function and are very costly. But the assurances they offer do much to improve quality of life, which is, along with extending the length of life, rather the point of medicine.

There will always be some level of "wasted" medicine that isn't, at the moment of prescription, sure to be waste (i.e, a diagnostic that could find a deadly disease, but doesn't), and some amount of medicine that's used to calm fearful patients. Neither of those show up on yearly physicals, but nor are they necessarily wasted dollars if your metric is improving patients' quality of life.

A Free, Preventive Lunch

David Leonhardt has a smart column on health care spending today, in which he takes on the idea that preventive care will actually save us money:

The actual savings are also not as large as might at first seem. Even if you don’t develop diabetes, your lifetime medical costs won’t drop to zero. You might live longer and better and yet still ultimately run up almost as big a lifetime medical bill, because you’ll eventually have other problems. That would be an undeniably better outcome, but it wouldn’t produce a financial windfall for society.[...]

Intermountain Healthcare, a network of hospitals in Utah and Idaho that has saved money in recent years by reducing hospital infections and drug errors. Intermountain hospitals have also largely stopped inducing child labor for the sake of doctors’ or parents’ convenience. The hospital induces birth only for medical reasons — and the number of babies that spend time in the neonatal intensive care unit has fallen.

It’s this last example that holds the real key to cutting medical costs. I realize many people will react to the notion that preventive care usually costs money by saying, “So what? We should do it anyway.” And we should.

But by describing it as an easy win-win solution, the presidential candidates are gliding over an important part of the issue. Preventive care saves real money only when it replaces existing care that is expensive and doesn’t do much, if any, good. There are plenty of examples of such care — from induced labor to many lumbar surgeries and cardiac stent procedures.

The problem is that the people getting this care typically don’t consider it wasteful. We all like to believe that other people are the ones getting the unnecessary care. We, on the other hand, are probably not getting enough treatment.

This is all true. To be sure, in a perfect world, I could probably dream up a set of policy initiatives that, if broadly implemented and competently carried out, could reduce health spending off the bat. But the world continually disappoints with its stubborn lack of perfection. Instead, the more achievable goal is to move towards a universal system that's more cost-effective, which is, in fact, very much the same thing as saving money, and towards an integrated system that readies the ground for tougher cost control mechanisms down the road.

Electronic Medical Records Will Clean Your House

In answer to last week's study suggesting that initial installations of electronic health records aren't proving as effective as hoped, Overheard in Providence offers up a corrective to the doubters, and looks into a future filled with health information technology and the many fruits of its abundance:

If EMRs [electronic medical records] become widespread, they open the door to a huge new area of medical research. Computer-aided diagnosis is going to get a lot better if millions of anonymized medical records become available. A few years ago I went to a talk by MIT professor Peter Szolovits. He was able to use a computer to diagnose certain heart conditions from audio recordings better than most doctors. EMRs would greatly facilitate the development of automated screening procedures. More importantly, when new procedures are developed, they could be applied retroactively to data collected years earlier, even when a patient stops seeing a doctor. There’s absolutely no way to do this now.

EMRs would also be a huge boon to public health research. Researchers could be given access to a huge data base of anonymous medical records, all in a standard format. It would be trivial to check if two conditions are correlated, or if one disease occurs more often in some segment of the population. The amount of data would be so large, a doctor could even search for records similar to their patent, and use those records as a guide for what health problems to watch for.

Finally EMRs make much better use of healthcare we already provide. If you go in for surgery, all sorts of equipment is used to monitor your well-being. This data should be recorded and reviewed by a doctor who isn’t busy cutting you open. If you go in for a 3D bodyscan, even more data is collected. The scan could easily be reviewed by experts in other parts of the country, provided they have access to your EMR.

I tend to plug EMRs in terms of their immediate and obvious benefits: Reduction in paper, reduction in cost, reduction in lost records, simple programs that prescription errors, etc. But this is all correct, too. The widespread implementation of EHRs could trigger enormous change in the way medicine is practiced, and could accelerate many, many types of research. The downside here is that there are obvious and clear privacy concerns, but as genetic risk profiling inches ever closer to reality, these are issues we're going to have to deal with one way or the other.

Do Electronic Medical Records Help?

I often plug the possibilities of electronic medical records to vastly increase care quality while reducing costs, as they have in the Veteran's Administration System. But I'd be remiss not to point to this recent study showing that, in private practices, using electronic health records resulted in merely minor improvements in only two of the 17 tested metrics. And on one metric, the prescription of statins, they actually worsened physician performance. I don't have full access to the study and so can't tell you what hypotheses the researchers attached to their results, but the data is interesting on its own.

It's Pharma's World, You Just Live In It

A new study finds that older, cheaper diabetes drugs control blood sugar as well, with somewhat less harmful side effects, than newer, more expensive ones. In a sane health care system, this would mean a rush to prescribe these older agents, or at least to gather more data on the subject. In our health care system, where doctors take tens of thousands from pharmaceutical companies and patients are bombarded with advertising to make them think they want, or know they want, certain drugs, the more expensive, no more effective, compounds will almost certainly remain atop the market. There's simply no incentive for doctors to switch over, but plenty of incentive for them to prescribe the more costly drugs.

And if that doesn't work, maybe the drug industry will just take a page from their playbook for the epileptic drugs that are about to lose patent and go generic, and try and get state legislatures to pass laws making it illegal for pharmacists to switch patients over to cheaper, perfectly effective generic alternatives. Illegal. But that's no surprise: Pharma spent $44 million on statehouse lobbying in 2005 and 2006 -- and they weren't just buying good times. Hell, in this case, they donated tons of money to the Epilepsy Foundation and did the lobbying under their auspices.

But look, Andrew Sullivan tells me the pharmaceutical industry is great, and way better than in Europe, so I'm sure this is all some sort of big misunderstanding. If they don't keep patients from switching to generics, after all, how will they fund R&D!?

Things You Won't Learn From Industry Propaganda

I'm not entirely sure there are words to describe how bizarre it is to watch Andrew Sullivan rely entirely on research from the pharmaceutical industry's web site to make his case for why drug companies should get to charge anything they want. I mean, really, we're going to need a new term. Gullimarkable?

In any case, Sullivan's case is a mess even if you excuse his sources. He gets really excited about a 1994 European Commission report saying "Europe as a whole is lagging behind in its ability to generate, organise, and sustain innovation processes that are increasingly expensive and organisationally complex." The quote from the report then ends, and we have to rely on Pharma's interpretation of how it relates to drug research on the continent.

If Sullivan weren't just parachuting into the issue with a copy of Free to Choose and a tone of extreme indignation, he'd know that a similar study was released last year showing problems in the American pharmaceutical market -- notably, a precipitous drop in new drug development from the pharmaceutical industry.

A report by the General Accounting Office concludes that current patent law discourages drug companies from developing new drugs by allowing them to make excessive profits through minor changes to existing pharmaceuticals. While pharmaceutical research and development expenses have increased by 147% since 1993, applications for approval of "new molecular entity" (NME) drugs, or drugs which differ significantly from others already on the market, have risen only 7%. According to the report, the majority of newly developed medicines are so-called "me-too" drugs, which are substantially similar to existing drugs, are less risky than NMEs drugs to develop, and which "offer little in the way of therapeutic breakthroughs."

Entirely 68 percent -- two-thirds -- of the industry's new drug applications are for knock-off, me-too drugs. The incentives for copying tried-and-true products are far, far too high. So it turns out profit -- generated here by patents -- can actually harm drug development! Am I blowing your mind yet?

Here's a bit more: Those molecular advances Sullivan thinks come entirely from the magic of private enterprise? They're socialism in action. One survey found that taxpayer-funded research developed 15 of the 21 most important drugs introduced between 1965 and 1992. And these aren't joke pharmaceuticals:

A study of the 21 drugs introduced between 1965 and 1992 that were considered by experts to have had the highest therapeutic impact on society found that public funding of research was instrumental in the development of 15 of the 21 drugs (71 percent). Three-captopril (Capoten), fluoxetine (Prozac), and acyclovir (Zovirax)-had more than $1 billion in sales in 1994 and 1995. In addition to these drugs, other members of the group of 21 drugs, including AZT, acyclovir, fluconazole (Diflucan), foscarnet (Foscavir), and ketoconazole (Nizoral), had NIH funding and research to help in clinical trials.

Another study, this one from 1990, looked at 32 drugs on the market and concluded 60 percent would've never been developed without public funds. Yet another "traced more than 45,000 references from U.S. patents to the underlying research papers, and tabulated both the institutional and financial origins of the cited science. We found that more than 70 percent of the scientific papers cited on the front pages of U.S. Industry patents came from public science -- science performed at universities, government labs, and other public agencies."

Pharmaceutical companies don't develop all their drugs. They spend a lot of time buying, patenting, and bringing to market advances made in the public sector through NIH grants and university research. If you're curious as to how this works, take a look at the cancer drug Taxol. Discovered by the NIH and licensed to Bristol-Meyers-Squibb, Taxol is sold for $20,000, costs $1,000 to produce, and the NIH gets .5 percent of the royalties. The pharmaceutical industry was damn innovative, to be sure, but not in the development of this drug -- only in the selling of it.

But you won't find that on the pharmaceutical industry's web site.

Melamine Found In California Pork; FDA Launches Criminal Investigation

[litbrit wonders why this isn't front-page news...yet.]

I've been following the pet food poisoning story for a while, and with the advent of last week's revelation that not only wheat gluten, but also corn gluten and rice protein concentrate--all imported from China, all used in pet food, animal feed, and human food--had tested positive for melamine and may have been introduced into the human food supply, I knew it was only a matter of time before this happened: melamine has indeed been detected in the feed and body fluids of pigs meant for human consumption, and California authorities have issued both a quarantine and an advisory to not consume pork from at least one farm (along with weak assurances that eating pork tainted with the industrial chemical poses only "minimal" health risks); others may follow, since the tainted feed was also shipped to New York.

A hazardous chemical believed to have killed scores of pets nationwide has been found in California and New York hog farms, raising concerns for the first time that it could have been consumed by humans.

[.....]

California authorities have quarantined American Hog Farm, in Ceres  south of Sacramento, after melamine was detected in a least seven urine samples and three samples of the animal's food, news report said.

California officials and are trying to trace what happened to slaughtered animals.

      

About 100 pigs were killed on-site and sold privately, Don Agresti, co-owner of the farm, told The Oregonian.

 

American Hog Farm is a speciality operation in which people actually pick pigs for consumption and have them killed at a special slaughterhouse. The company's license requires that the meat must be stamped "not for resale."

 

California officials are conducting tests, trying to determine whether there was any melamine in the meat of the animals. They've warned people not to eat any pork purchased from the farm.

Meanwhile, the FDA has opened a criminal investigation into the melamine-tainting disaster (emphasis mine):

The Food and Drug Administration has opened a criminal investigation in the widening pet food contamination scandal, officials said yesterday, as it was confirmed that tainted pork might have made its way onto human dinner plates in California.

[.....]

Late Thursday, Royal Canin USA became the most recent company to recall pet foods. Some of its brands were contaminated with rice protein concentrate. Its South African subsidiary said contaminated corn gluten had been linked to the deaths of 30 pets there.

Five companies received the contaminated Chinese rice protein concentrate. Three firms have identified themselves by announcing recalls; the other two are not publicly known because the FDA will not name them until the companies say they used contaminants in their products.

 

Crossposted at litbrit and Shakesville.

Medical Innovations

Great post by Cactus on the medical innovation issue:

most of the folks on the right who make this point will point with pride at the American military-industrial complex (to use Ike's term). They will note that American military equipment is often the best there is...

Anyway... why is it that a monopsony buyer of military equipment, a buyer that puts its suppliers on a cost-plus arrangement most of the time, hasn't managed to kill off innovation in military equipment but a monopsony buyer of health care would strangle all medical advance forever more?

Not clear. To be sure, the spending bloat in the armed forces is undeniable, so it's not a perfect model given the emphasis reformers like myself place on cost controls. But nor is it clear that much of the R&D is productive, rather than profitable. Genuine advances in care technology would find a huge market under a nationalized system, and could be ushered in and tested through high-end private (supplemental) insurance. It's possible, though, that the very minor tweaks that allow Claritin to be renamed Clarinex and kept on patent won't prove a profitable R&D outlet anymore, and we'll all cry many a tear for the loss.

Meanwhile, the public sector already does an enormous amount of the innovative work anyway, and if it is indeed true that a restructured system would harm PhRMA's business model, we could easily move towards pumping more money into public research and creating, as Joseph Stiglitz has suggested, a prize structure, rather than patent structure, for medical research. It would probably be far more efficient, with far fewer perverse incentives.

Lastly, many of these medical innovation conversations take place on the cutting edge of care. That's how we're trained to think about all this. But the greatest gains in health aren't likely to come from that end. They'll come from better preventative services, electronic records and treatments systems like the VA's ViSTA program, wider access to basic care, and more testing and attention given to what care actually works. We currently spend an awful lot on treatments that do awfully little, and we'd do much more to improve health were we as intent on making sure every heart attack patient was given an aspirin when he reached the hospital as we are on getting them a bypass procedure. Our current system, sadly, doesn't have the financial incentives in place to emphasize such low-cost, high-value, treatments. Nevertheless, their implementation would do a lot more for health than the average innovation.

NIH Whiplash

On the sharp decline in NIH funding, a reader explains:

I'll interject a perspective from a longtime researcher who has funded his research primarily via NIH. The problem with the 15% per year during Clinton to the near zero today under Bush is not that we or anyone else expects 15% per year increases. Rather, the very sharp pull back in funding creates a funding whiplash because grants that are funded in 2007 for example, typically run for 3-5 years. Thus, each awarded grant encumbers a proportion of future money. Money for new grants each year come essentially from grants that have run out and from budget increases. New grants are critical to young researchers. The current situation is one of the worst case senarios for how you fund research. That is, fund lots of new grants (during the 15% increases), and now essentially freeze the budget. In previous years, if your grant was scored in the top 20% of all grants, you were likely to get funded. These days, the lack on funding increases means that the pool of money for new grants is such that you must score near the upper 10% for many of the institutes (e.g., National Institute of Mental Health grants have flirted with an 8% payline).[...]

Researchers understand that funding is in the mix of priorities along with everything else, we're not looking for more 15% increases. But, the damage of the current situation is real. I have seen laboratories severely curtail their work, and the researchers go from writing 2 or 3 grants per year to 6-7 per year. This isn't productive, it generates alot of work for everyone, and draws us out of the laboratory where we would normally be doing much more productive work.

Priorities

This is crazy:

Representatives from a consortium of major medical and scientific institutions testified at a Senate Appropriations Committee hearing on Monday that a lack of funding for grants at NIH has stymied scientific research, the Washington Times reports. In previous years, the federal health agency's budget typically increased by 15%. It grew by 2.5% in 2004, 2% in 2005 and one-tenth of 1% last year, for a total budget of $28.3 billion. The fiscal 2007 budget has yet to be released, but an increase of eight-tenths of 1% is projected for 2008, according to NIH figures. The researchers testified that NIH's recent funding levels have caused about eight out of 10 research grant applications to go unfunded and researchers to spend more time applying for grants than studying treatments for diseases.

I don't even know what to say. The NIH is, by all accounts, a remarkably successful government institution, and the research it funds has a proven track record of advancing science, spurring new treatments, and saving lives. And that doesn't even address the economic benefits of supercharging America's pharmaceuticals and biotechnology industries. But we're now slowing it's growth down to less than one percent...and for what? The war in Iraq? Deficit reduction?

Let's just be clear on this. Democrats, you listen up too. You do not reduce the deficit by defunding innovative research in growth industries. That's shooting yourself in the in the hip to spite your wallet.

Does Exercise Make You Smarter?

New research suggests it might:

[Neuroscientist Charles Hillman] rounded up 259 Illinois third and fifth graders, measured their body-mass index and put them through classic PE routines: the "sit-and-reach," a brisk run and timed push-ups and sit-ups. Then he checked their physical abilities against their math and reading scores on a statewide standardized test. Sure enough, on the whole, the kids with the fittest bodies were the ones with the fittest brains, even when factors such as socioeconomic status were taken into account.

The old explanation for the possible linkage between brawn and brains was that a stronger heart could pump more blood, better oxygenating brain cells and keeping jocks sharp. Turn out it's a bit more chemically complex than that:

The process starts in the muscles. Every time a bicep or quad contracts and releases, it sends out chemicals, including a protein called IGF-1 that travels through the bloodstream, across the blood-brain barrier and into the brain itself. There, IGF-1 takes on the role of foreman in the body's neurotransmitter factory. It issues orders to ramp up production of several chemicals, including one called brain-derived neurotrophic factor, or BDNF...It fuels almost all the activities that lead to higher thought.

With regular exercise, the body builds up its levels of BDNF, and the brain's nerve cells start to branch out, join together and communicate with each other in new ways. This is the process that underlies learning: every change in the junctions between brain cells signifies a new fact or skill that's been picked up and stowed away for future use. BDNF makes that process possible. Brains with more of it have a greater capacity for knowledge....In unlucky people with a faulty variant of the gene that makes BDNF, the brain has trouble both creating new memories and calling up old ones.

Exercise, it turns out, builds those cells, and those who make the greatest cardiovascular gains in studies also build the most neural capacity. The growth tends to happen in the sectors of the brain governing memory, and thus retards the earliest cognitive declines of aging. Sadly, though, this appears to be limited to cardiovascular fitness. Weight-lifting, stretching, and toning does little to nothing for the brain, unless by "brain" you mean "how cut your abs are."

Health Literacy

One real failure in the discussion over health policy is that it takes place largely among educated elites. So while I may not think patients have the training and judgment to always assume a leading role in their health decisions and others do, we're too often thinking of folks basically like us. Here's who we're not thinking about:

In a 2004 report, the Institute of Medicine defined health literacy as the ability to obtain and understand basic health information and services needed to make informed decisions. Low health literacy, the institute noted, affects an estimated 90 million Americans, who struggle to understand what a doctor has told them or to comply with treatment recommendations as essential as taking the proper dose of medication. A 1999 report by the American Medical Association found that consent forms and other medical forms are typically written at the graduate school level, although the average American adult reads at the eighth-grade level.[...]

A comprehensive national assessment of adult literacy conducted in 2003 by the U.S. Department of Education found that 43 percent of adults have basic or below-basic reading skills -- they read at roughly a fifth-grade level or lower -- and 5 percent are not literate in English, in some cases because it is not their first language.

So forget, for a moment, whether individuals have the interest or time to take charge of their treatment regimens. If 43 percent of Americans are reading at a fifth-grade level of lower, how many even have the capability? And how much damage will be done -- as in the article's example of a women who sought to save face and accidentally consented to a hysterectomy -- if we don't take these educational inequities seriously?

PTSD: Treating The Numbers, Not The Soldiers

[litbrit speaking]

According to the United States Department of Veterans' Affairs--as its information page reads this morning, at least--Post Traumatic Stress Disorder (PTSD) is defined as:

An anxiety disorder   that can occur following the experience or witnessing of a   traumatic event. A traumatic event is a life-threatening   event such as military combat, natural disasters, terrorist   incidents, serious accidents, or physical or sexual assault in   adult or childhood. Most survivors of trauma return to   normal given a little time. However, some people will have stress reactions that do not go away on their own, or may even   get worse over time.

Insofar as the government asserts, some   60% of men and 50% of women (overall, both military and civilian) experience a traumatic event at some point in their   lives.  Assuming, of course, that all traumatic events are reported or somehow noted--which of course they aren't--one can still be forgiven for being alarmed that such a staggeringly high number of human beings are at risk for developing PTSD.  And of course, many human beings do heal on their own, handling trauma in ways that don't threaten the safety and well-being of themselves and those around them; they work through the shock, terror, grief, flashbacks, and sense of needing to be on guard at all times, and with time and support, they return to a point where they can sleep a reasonably normal length of time without waking from re-enactment nightmares or go to a noisy, crowded place without feeling overcome by irrational waves of fear or violent urges.

For far too many who've witnessed war's indescribable tragedies firsthand, though, the notion of healing is itself a phantom concept, a dream.  From The Real Cost Of War (currently at Playboy Online):

 

Burgoyne had been brought into the hospital by one of the other soldiers in his unit after he had been found doubled over in his bunk, having tried to kill himself with an overdose of antidepressants. The attempted suicide, plus the lack of expression in his eyes and his "rapid cycling behavior" from rage to grief and back to rage, were the symptoms of a dangerously ill man. Koroll sensed he was looking at a severe case of post-traumatic stress disorder, the clinical term for someone who continues to experience trauma long after the event has passed. This reexperiencing of the original event can take the form of insomnia, flashbacks, paranoia, panic attacks, emotional numbness and violent outbursts.

These symptoms are treatable, Koroll knew. If he could transfer Burgoyne to a safe, comforting environment, the young man might be restored over time to full health and capacity. That meant getting the soldier out of the dusty chaos of the Kuwaiti Army base, where he was temporarily stationed after a bloody tour in Iraq, and sending him to a hospital in Germany where he could rest on clean white sheets in a quiet room in a first-class psychiatric facility.

It was Koroll's job as the on-duty nurse to make the decision about whether to evacuate Burgoyne. He was ready to do it based on what he'd seen. But he needed to ask one final question before he could order the evac in good conscience.

"So," Koroll said, "right now, at this moment, do you have thoughts of harming yourself or others?"

Burgoyne, he remembers, looked up through those flat, vacant eyes and said quite clearly, "Yeah. Yeah, I do."

Koroll picked up the soldier's chart and wrote in a clear hand, "Evac."

[...]

As it turns out, Burgoyne had not been evacuated to Germany as Koroll had ordered. According to Koroll, a colonel in Burgoyne's command pressured the hospital to allow Burgoyne to return to America with his unit, the Third Infantry Division, which was to be one of the first units lionized for its heroism in leading the fight north to Baghdad. "He's a hero. He should be with his men" is how Koroll remembers the explanation coming down to him. After he returned to Georgia, Burgoyne, according to his mother, spent a few minutes in an Army hospital, spoke briefly to an Army psychiatrist and then was released from medical supervision. Exactly two days later Burgoyne attacked a fellow soldier in the woods near Fort Benning, Georgia, killing him with 32 stab wounds from a three-inch blade and then burning his body with lighter fluid, because, as he explained at his subsequent murder trial, "that's how we disposed of bodies in Iraq."

Sadly, this story is not unique, but rather, is representative of the disturbingly underreported problem of PTSD.  More troubling than the fact that this serious anxiety disorder--and its devastating effects and costs--is shamefully underreported in the media is the reality that it is all too often underreported within the Unites States military.  Underreported, minimized, ignored, misdiagnosed, and, most frighteningly, untreated (my bolds).

Given the inevitability of psychological scarring in intense, prolonged conflicts, it is odd that the two bureaucracies most responsible for the mental health of American troops -- the Department of Veterans Affairs and the Department of Defense -- have taken steps to downplay the psychological toll of the war. According to sources I spoke to in the Pentagon and former officials in the VA, DOD and VA doctors are being pressured to limit diagnoses of PTSD in order to save the military money and manpower. The DOD's official medical policy toward PTSD was recently amended to include new criteria making it a virtual certainty that many soldiers who exhibit symptoms of the disease will not be diagnosed.  And the VA itself has been quietly working to arrive at new, stricter formulations of PTSD -- contradicting those of the American Psychiatric Association -- that would allow the agency to diagnose far fewer cases.

"Some people would argue that it's malicious and intentional, but to me it's a reflection of the military mind-set," says Steve Robinson, a 20-year veteran of the Special Forces who recently became a full-time policy advocate. "The Department of Defense is not a health care provider. It couldn't do the right thing if it wanted to because of how much money it would cost and how many doctors it would take. It's a matter of capacity. The number of people seeking care versus the number of doctors available to provide that care nationwide across the whole armed services is out of whack."

In the four years since Koroll's diagnosis of the young soldier was ignored, the anti-PTSD-diagnosis movement (for lack of a better phrase) within the military has grown, as evidenced by, among other things, the hard numbers.  The Department of Defense (DOD) reports diagnosing approximately 2,000 cases of PTSD a year, but according to a study by Army researchers that was published in The New England Journal of Medicine, PTSD rates are between 10 and 15 percent for soldiers in Iraq and Afghanistan; this translates to PTSD cases numbering between 13,000 and 20,000. (The study also notes, disturbingly, that only 23-40% of those veterans diagnosed with anxiety disorders and other psychological afflictions even seek treatement.) And according to figures obtained after repeated requests by Playboy, the evacuation rates for PTSD-afflicted soldiers--for example, those from January to July 2006, showing only 716 soldiers evacuated from Iraq for PTSD--fall well below the predictions of statistical models.  As reporter Mark Boal notes:

If the military diagnosed even half the cases in Iraq and Afghanistan that are thought to exist, the evacuation figures would be closer to 5,000 a year.

For their part, military officials deny any attempt to minimize or underplay the impact and magnitude of the situation.  This despite published forecasts that the cost of America's current involvement in the Middle East will soar beyond even the stratospherically high numbers around which most of us have just begun to wrap our heads; this despite officials having  gone on record with--and been roundly criticized for--statements like that of Pentagon undersecretary David Chu, in a January 25, 2005 article in the Wall Street Journal:

WASHINGTON—With the wars in Iraq and Afghanistan badly straining its forces, the Pentagon is facing an awkward problem: Military retirees and their families are absorbing billions of dollars that military leaders would rather use to help troops fighting today.

Congress, pressured by veterans groups, has in recent years boosted military pensions, health insurance and benefits for widows of retirees. Internal Pentagon documents forecast that the lawmakers' generosity since 1999 will force the federal government to find about $100 billion over the next six years to cover the new benefits.

"The amounts have gotten to the point where they are hurtful. They are taking away from the nation's ability to defend itself," says David Chu, the Pentagon's undersecretary for personnel and readiness.

As I read the profoundly upsetting Playboy article referenced throughout this post, I thought about my freshman economics class at Florida, which was taught by one very entertaining and sharp-witted professor named Dr. Denslow.  "Guns and butter," he said one day, actually plunking a box of unsalted butter sticks alongside a plastic toy grenade-launcher on his lecturn.  "Guns and butter.  The money stays the same, so how are you going to spend it--on guns, or on butter?"

Bombs or bodies?  Mines or minds?   Futilities or futures?

Cows R Us

Michael Pollan, author, most recently, of the excellent Omnivore's Dilemma, has a long attack on "nutritionism" in the latest NYT Magazine. This bit is particularly on point:

It might be argued that, at this point in history, we should simply accept that fast food is our food culture. Over time, people will get used to eating this way and our health will improve. But for natural selection to help populations adapt to the Western diet, we’d have to be prepared to let those whom it sickens die. That’s not what we’re doing. Rather, we’re turning to the health-care industry to help us “adapt.” Medicine is learning how to keep alive the people whom the Western diet is making sick. It’s gotten good at extending the lives of people with heart disease, and now it’s working on obesity and diabetes. Capitalism is itself marvelously adaptive, able to turn the problems it creates into lucrative business opportunities: diet pills, heart-bypass operations, insulin pumps, bariatric surgery.

There's similar chapter in The Omnivore's Dilemma about our treatment of cows. The short version of this is that we've taken an animal accustomed to feeding on forage and forced it to digest grain. Corn, after all, is cheaper, more plentiful, more engineerable, less land-intensive, and more subsidized than grass. But cows haven't evolved to eat corn. And so we drug 'em.

Bloat is perhaps the most serious thing that can go wrong with a ruminant on corn. The fermentation in the rumen produces copious amounts of gas, which is normally expelled by belching during rumination. But when the diet contains too much starch and too little roughage, rumination all but stops, and a layer of foamy slime forms in the rumen that can trap the gas. The rumen inflates like a balloon until it presses against the animal's lungs. Unless action is taken quickly to relieve the pressure, the animal suffocates.

A concentrated diet of corn can also give a cow acidosis. Unlike our own highly acidic stomachs, the normal pH of a rumen is neutral. Corn renders it acidic, causing a form a bovine heartburn...Acidotic animals go off their feed, pant and salivate excessively, paw and scratch their bellies, and eat dirt. The condition can lead to diarrhea, ulcers, bloat, rumentitis, liver disease, and a general weakening of the immune system that leaves the animal vulnerable to the full panoply of feedlot disease[...]

Cattle rarely live on feedlots for more than 150 days...Over time, the acids eat away at the rumen wallo, allowing bacteria to enter the animal's bloodstream. These microbes wind up in the liver, where they form abscesses and impair the liver's function. Between 15 and 30 percent of feedlot cows are found at slaughter to have abscessed livers...in some pens, the figure runs as high as 70 percent.

What keeps a feedlot animal healthy -- or healthy enough -- are antibiotics. Rumensen buffers acidity in the rumen, helping to prevent bloat and acidosis, and Tylosin, a form of erythromycin, lowers the incidence of liver infection. Most of the antibiotics sold in America today end up in animal feed...public health advocates don't object to treating the animals with antibiotics; they just don't want to see the drugs lose their effectiveness because factory farms are feeding them to healthy animals to promote growth. But the use of antibiotics in the feedlot confounds this distinction. Here the drugs are plainly being used to treat sick animals, yet the animals probably wouldn't be sick if not for the diet of grain we feed them.

When I first came across that passage, I was suitably shocked and outraged, and in fact stopped eating meat for a few months (a practice I've since been unable to maintain). It didn't occur to me that this strategy of using powerful drugs as health maintenance devices in service of an unhealthy but cheaper diet is precisely what we're all doing with Lipitor, and Tums, and all the rest.

Drug Costs

Joe Paduda spanks the Manhattan Institute:

Conservative think-tank Manhattan Institute is the source of these statistics, which are based on their analysis of the financial impact on big pharma if CMS adopts the VA's pricing. The analysis is based on a faulty premise, uses a flat-out wrong methodology, and produces results that are, in a word, hysterical.

MI's lead expert, economist Benjamin Zycher, claims that drug companies would lose the incentive to do research if the Feds based their prices on the VA, and investment in new drug research and development would (therefore) decline by approximately $10 billion per year. In turn, this would mean about 10 fewer drugs per year.

In all of his research efforts, Zycher evidently did not bother to look at pharma investment in Europe, where countries negotiate for drugs directly with manufacturers (like the VA does, and restrict the formularies to boot). As a result their costs for brand drugs are about 60% of US costs. One would think that European pharma companies would therefore spend less on R&D. And one would be wrong; there's more investment by European companies, not less.

Supersize This

The New Republic has a fantastic article attacking the obesity myth. Paul Campos, the author, calmly and methodically details the misuse and misinterpretation of epidemiological studies to show that, contrary to what's often reported, being overweight (particularly according to the deeply flawed Body Mass Index) is possibly healthy, and the most important predictor in any case is cardiovascular fitness -- weight is merely a crude stand-in. But mistaking correlation for causation when it comes to fat is but half the story. The hysteria's intensity owes much more to our cultural repulsion towards flab and the massive industry that has arisen to combat it:

Americans think being fat is disgusting. That psychological truth creates an enormous incentive to give our disgust a respectable motivation. In other words, being fat must be terrible for one's health, because if it isn't that means our increasing hatred of fat represents a social, psychological, and moral problem rather than a medical one.

The convergence of economic interest and psychological motivation helps ensure that, for example, when former Surgeon General Koop raised more than $2 million from diet-industry heavyweights Weight Watchers and Jenny Craig for his Shape Up America foundation, he remained largely immune to the charge that he was exploiting a national neurosis for financial gain. After all, "everyone knows" that fat is a major health risk, so why should we find it disturbing to discover such close links between prominent former public health officials and the dietary-pharmaceutical complex?

The issue isn't fat, but fitness. Problem is, though we all "know" a sedentary lifestyle and junk food diet are unhealthy, we spend our time combatting what we perceive as the aesthetic end point of such habits, not the root causes. And then, through diet pills, eating disorders, and neuroses, we try to slim down without shaping up.

So what should we do about fat in the United States? The short answer is: nothing. The longer answer is that we should refocus our attention from people's waistlines to their levels of activity. Americans have become far too sedentary. It sometimes seems that much of American life is organized around the principle that people should be able to go through an average day without ever actually using their legs. We do eat too much junk that isn't good for us because it's quick and cheap and easier than taking the time and money to prepare food that is both nutritious and satisfies our cravings.

A rational public health policy would emphasize that the keys to good health (at least those that anyone can do anything about--genetic factors remain far more important than anything else) are, in roughly descending order of importance: not to smoke, not to be an alcoholic or drug addict, not to be sedentary, and not to eat a diet packed with junk food. It's true that a more active populace that ate a healthier diet would be somewhat thinner, as would a nation that wasn't dieting obsessively. Even so, there is no reason why there shouldn't be millions of healthy, happy fat people in the United States, as there no doubt would be in a culture that maintained a rational attitude toward the fact that people will always come in all shapes and sizes, whether they live healthy lives or not. In the end, nothing could be easier than to win the war on fat: All we need to do is stop fighting it.

That bit about genetics isn't nearly so certain as Campos suggests, but his general gist is sound. America is an unhealthy society, and that has helped make us a fat one. But from a public health standpoint, the problems are too much time at a desk, too much processed food, too many hours at work, too little walking, and a host of other socio-cultural-political elements that incentivize poor habits, not our waistlines.

Modern Day Leeches

Just to freak folks out a bit, angioplasties and stents -- two canonical treatments for blocked arteries -- are rapidly being proven worthless. Not totally worthless in every case, but given their frequency, pretty damn worthless. A similar thing, incidentally, is happening to bypass surgeries, which don't exhibit anything near an efficacy justifying their ubiquity.

Libertarian response: If consumers had more "skin in the game" (and by skin we don't mean actual skin, which is already "in the game," but more financial vulnerability), they'd demand more comparative studies and begin weeding out such ineffective treatments.

Paternalistic liberal response: It's been so hard to conduct studies on these treatments precisely because desperate patients adore their promise and doctors know they'd be considered monsters if they put unsuspecting individuals in a "control group" that was denied a treatment that soon proved effective. Patients are terrible at evaluating care -- look at the holistic health industry, and the limitless range of unproven supplements and treatments -- and skin in the game will always be overwhelmed by lives-on-the-line. On the other hand, if doctors lacked their current incentives for providing such intensive medical procedures, we could begin to make a dent.

Bipartisan response: In 100 years, a good half of our medical treatments will look to our descendants like leeches look to us.

Update response: And yes, leeches are back in use in very limited contexts. Much as the research shows angioplasties should be.

Your Good Looks Or Your Life?

According to Laurence Wein, pandemic flu will kill us all. And hand-washing ain't gonna stop it. Indeed, researchers have apparently found that aerosol transmission -- where the virus in inhaled -- is dominant in influenza infection. That means hand-washing, which works against contact transmission, won't do much. So what're we going to do? Look ugly:

the single most effective intervention is face protection. And because roughly one-third of influenza transmissions occur before an infected person exhibits symptoms, these precautions should be taken whenever people are in the same room throughout the pandemic period.

There are two kinds of face protection: N95 respirators, as worn by construction workers, for instance, and surgical masks of the sort worn by dental hygienists. (The respirators cost roughly a dollar apiece, the surgical masks 10 cents.) Their efficacy in preventing aerosol transmission depends on three factors: the extent to which the face filter prevents virus particles from passing through, how tightly the device fits and — most important — how long people can be coerced into wearing them.

To our surprise, we found that the filters in surgical masks, although not as good as the filters in N95 respirators, are still quite effective. And although a surgical mask fits much more loosely and allows more leakage, it’s also more comfortable — and therefore likely to be effective because it’s used more. Wearing nylon hosiery over a surgical mask essentially eliminates the face leakage, making this combination a practical, albeit macabre, alternative. The less comfortable N95 respirators would probably result in lower compliance.

So surgical masks fitted with nylon hosiery. Well, at least STD transmission will fall as well.

Andrew Sullivan Has No Idea What He's Talking About

Andrew Sullivan writes:

The next phase in the Medicare prescription drug entitlement is pretty obvious: the law will be changed soon to ensure that the federal government negotiate with drug companies for the price for the drugs. You can see the logic here at the DailyKos. Once you have laid the groundwork for a new entitlement, the full power of the state is involved. Once you have conceded the principle that all seniors should be able to get the latest drugs by borrowing other peole's money, it's weird to put any restrictions on demand - it will soon grow exponentially, and the "donut hole" will surely be removed by a future Congress. So we'll soon shift to a system of fantastically expensive free drugs of all kinds for all seniors and a crippling of the pharmaceutical industry's research and development arm. The trade-off will be complete: a collapse in research in return for free drugs for the most pampered senior generation in history. Those boomers still have clout!

We can only hope!

More seriously, fretting that centralized bargaining authority will "cripple" Big Pharma's R&D arm is silly. If Pharma ceases being in the top three most profitable industries in the country (#1 for over two decades straight!), maybe they can dial back on the advertising and administration spending, which accounts for about 250 percent more of their budget than research and development. Or maybe the government should just step in further, as they already fund 36 percent of all medical research in the country and taxpayer-funded work developed 15 of the 21 most important drugs introduced between 1965 and 1992. Another study, this one from 1990, looked at 32 drugs on the market and concluded 60 percent would've never been developed without public funds.

Yeah, socialism sure is sucky.

Moreover, the whole idea that centralized bargaining destroys the market is self-evidently silly. Ever heard of the military-industrial complex? Who do you think they're negotiating with? The American government. And you don't exactly see companies fleeing that sector. Meanwhile, Pharma sells to Canada (where prices are lower than they'll ever be here) and the VA, which pays between 50 and 80 percent less for its drugs than Medicare. And unless you think Pharma is in the charity business (or don't understand capitalism), they're operating in those markets at some profit, otherwise they would simply sell to America and let Canadians and veterans alike perish till they increased their compensation. The worst that'll happen is Americans will stop subsidizing a massive discount for Canadians, Brits, Germans, and all the rest.

And by the way, in case you're wondering how some of that R&D works, take a look at the cancer drug Taxol. Discovered by the NIH and licensed to Bristol-Meyers-Squibb, Taxol is sold for $20,000, costs $1,000 to produce, and the NIH gets .5 percent of the royalties. Some deal us taxpayers are getting.

Ladies and Gentlemen

By Kate

Always pay your prostitutes. (warning: blood and guts when you click on the photos inside the post)

Drug Legalization Questions

One thing I've always wondered about drug legalization plans: how do you deal with new drugs? Is it simply assumed that whatever concoction some teenage chemist cooks up and finds a market for can be quickly absorbed by private producers and put in stores? Does it need to go through FDA testing? If it does so and fails, then does it become illegal, creating the same old problems? Is there a patent process, so we'll have scores of researchers trying to create new substances with trippier highs and more addictive qualities? How does the patent process work -- or are recreational drug compounds placed in the public domain?

I am, generally speaking, a friend of regulated legalization, particularly the sort described in Stamper's op-ed. It does seem to me, though, that there exist a fair number of hurdles that aren't well overcome. With alcohol and tobacco already legal, there's no guarantee that legalizing other drugs will reduce the market for newly-discovered, still-illegal substances that offer new experiences, which might end with us trapped in the same old cycle.

Score One for the Well-Off

Whether you're comfortable with America's gaping income inequality or not, I think we can all agree that this really shouldn't be happening:

People whose net worth is over $70,000, the median in the United States, are 30 percent less likely than poorer people to feel pain at the end of their lives, a difference that persists even when controlling for age and severity of illness, a new study shows.

The findings, which appear in the August issue of The Journal of Palliative Medicine, used information on more than 2,600 adults over 70 who died from 1993 to 1998. The researchers interviewed proxies, usually surviving spouses, to gather information about pain, depression, delirium and difficulties in breathing or eating at life's end.

Wealth was a strong predictor of how many different types of discomfort an older adult suffered, with those whose net worth was over $70,000 having a 9 percent lower risk of experiencing multiple symptoms.

There's much in life that I think is perfectly justified in being dependent on income. How nice your TV is, or how many square feet are in your home. Whether you drive a Corolla or an Avalon.

But not death. Never death. Working for low wages should not mean more pain, depression, and suffering than working for high wages. It should not mean worse medical care and fewer end-of-life options. Let the rich have vacations and homes and cars and cruises, but only if the poor have dignity and relief. At the end of their lives, we at least owe them that.

Our Nuclear Inheritance

File under "That's Freaky":

It was a dispute over whether the cortex ever makes any new cells that got Dr. Frisen looking for a new way of figuring out how old human cells really are. Existing techniques depend on tagging DNA with chemicals but are far from perfect. Wondering if some natural tag might already be in place, Dr. Frisen recalled that the nuclear weapons tested above ground until 1963 had injected a pulse of radioactive carbon 14 into the atmosphere.

Breathed in by plants worldwide and eaten by animals and people, the carbon 14 gets incorporated into the DNA of cells each time the cell divides and the DNA is duplicated.

So a variety of nuclear tests 40-some years ago blasted enough radioactive carbon into the atmosphere that we all carry bits of it in our DNA.

It's really a wonder that humanity hasn't destroyed itself yet.

The (Lack of) Power of Prayer

For the last few years, there's been a fair amount of talk about the medical power of prayer. A few interesting studies came out saying there might be some positive benefit and the excitement swelled from there, hitting every pulpit and spiritual book in the nation. But this week, a study of cardiology patients pretty well disproved it:

The study of more than 700 heart patients, one of the most ambitious attempts to test the medicinal power of prayer, showed that those who had people praying for them from a distance, and without their knowledge, were no less likely to suffer a major complication, end up back in the hospital or die.

I've never resented the hope that prayer could heal -- that's merely human. But the idea that it could, particularly in the scattershot way the other studies showed, always seemed fairly problematic. So if you pray God makes the ill 5-10% better? And He only does that for some of them? And what of the lonely, who have no one to pray for them? It almost seemed more theologic trouble then it was worth.

Competitive Pressures Can't Handle The Truth!

With all the hubbub, hullaballoo, a kerfluffle recently generated by unsafe, massively popular meds, a handful of our major pharmaceutical companies have begun posting their full, uncensored trial results on the web. Full transparency, the market calls it. But Merck and Pfizer, citing "competitive pressures", haven't followed suit. As Kate notes, this poses a problem as Merck's Vioxx, more than any other drug, is the one that started this rush to transparency by proving itself unsafe. And those competitive pressures Merck is citing really don't make sense. Indeed, competitive pressure would logically demand that they match their competitor's move towards transparency. At least, that's what it'd demand if doing so wouldn't cause grievous harm to the company. So all this calls into question exactly what Merck's internal trials have been showing. It's not the most reassuring move if you swallow any of Merck's products.

Further, and correct me if I'm wrong, but couldn't the FDA force this information forward? Or couldn't a congress that doesn't call Big Pharma's pocket "home" legislate that this information needs to be in the public domain? After all, if the Republicans really do want consumer-driven healthcare, consumers will need access to the data and studies that'll allow them to make wise, informed choices. If competitive pressures are keeping those results locked in a silo somewhere, one would think it would behoove legislators to pressure them out into the light and prove that patients can take an active role in their own health.

On another note, speaking of Kate's site, this really was in the top 5 funny things to ever happen to me.

Market 1, Consumer 0

Kate catches doctors surrendering to their inner capitalist and accepting the practice of giving project funders -- often pharmaceutical companies -- full control over their research projects. That means control over design, what's studied, how the material is presented...the whole deal. Why is this so attractive in such a service-oriented profession? She explains:

researchers at medical schools are often responsible for coming up with their own project funding after their first couple years on staff. Many will turn to pharmaceutical comapanies and other for-profit entities to foot the bill. This just perpetuates the conflict of interest cycle, from the researcher's petri dish to the doctor's prescription pad -- Big Pharma has their hand in all of it.

So there's a funding gap in research, researchers need funding to do their job, and Big Pharma altruistically steps into the void, with a few little sub-clauses. Another win for the magical market, I guess.

Vaccinate This

Rich Tucker writes about the link between vaccines and autism in children, and subsequently recommends that we slow down the rate of vaccination for young children.

Not being that well versed in the vaccine/autism link, I thought I might have misremembered, but I didn't - the area of conflict is over the use of thimerosal, a mercury-based vaccine preservative. It has little to do with how rapidly the vaccines are administered, but instead whether or not they include a dangerous preservative. If cars get in crashes (to borrow his analogy), you don't ban cars - you make driving safer. Vaccines (presumably) existed without mercury preservatives, and (presumably) can exist without them again - just as the potential to crash your car doesn't require you to ram it into something.

-Jesse Taylor

Crying Wolf

In Krugman's otherwise good article on bargaining for pharmaceuticals, he makes a really poor argument on a really important point:

Needless to say, apologists for the law insist that the prohibition on price negotiations had nothing to do with catering to special interests - that it was a matter of principle, of preserving incentives to innovate. How can we refute this defense?

One way is to challenge claims that the pharmaceutical industry needs high prices to innovate. In her book "The Truth About the Drug Companies," Marcia Angell, the former editor in chief of The New England Journal of Medicine, shows convincingly that drug companies spend far more on marketing than they do on research - and that much of the marketing is designed to sell "me, too" drugs, which are no better than the cheaper drugs they replace. It should be possible to pay less for medicine, yet encourage more real innovation.

Sigh.  That's not an important comparison, though.  The drug companies are saying reimportation from Canada will make new, expensive drugs less profitable to produce and thus diminish the incentive to produce them.  Whether or not they break the bank on marketing isn't really an issue here.  Here's what is an issue: drug company R&D is rarely spent on the life-saving, critical medicines that we imagine. 

Much of it goes towards "me-too" drugs, slight variations of popular, existing medications that don't increase their effectiveness at all, but allow drug companies to evade their competitors patents while still using their competitor's latest innovations.  So assume one company brings out a new, powerful, statin drug.  The others will rush it back to the labs, figure out how to change a few molecules in order to call it to evade the patent while retaining the effect, put it in for testing and, so long as it works better than the placebo, the FDA will approve it.  That, of course, is where the marketing comes in.  Since they've all got the same drugs -- and if R&D were truly on such shaky grounds, this would be the problem, not drug reimportation -- they have to use advertising strategies to get a leg up in the market. 

In addition, most of the research is done on the same few ailments, particularly those that offer high profits.  Now, that's often positive -- our society is better off with blood pressure, heart disease, and arthritis medications.  But you're seeing enormous redundancies at work, and it's much to the detriment of rarer, tough illnesses.

Beyond that, a vast amount of this research actually takes place in the hated public sector.  The federal government funds 36% of all U.S medical research.  In fact, of the 21 most important drugs introduced between 1965 and 1992, 15 were developed using taxpayer research.  A study done in 1990 looked at 32 drugs on the market and found that 60% wouldn't have been created without federally funded research.

So what we're seeing here are dual subsidies.  When the NIH discovers a drug, as they did with the cancer drug Taxol, they license it to drug companies at an absurdly low cost.  Bristol-Meyers Squibb is currently the proud owner of Taxol, they sell it for $20,000 when it only costs $1,000 to manufacture, and the NIH gets .5% of the royalties.  So taxpayer research ends up enriching the drug companies.  And then, because without shame you can do thing likes this, the drug companies demand that we don't switch to a Canadian system of bargaining in order to get lower prices.  So we don't, and we keep getting robbed while Canada and all other countries with sane health care systems by their drugs for a fraction of our price.  Brilliant.

And none of this even notes that drug company hyperbole has been tested before, and always proved a lie.  In 84, Congress passed the Waxman-Hatch Act, which increased the availability of generic drugs and created more competition for the brand names.  The drug industry said domestic R&D would grind to a halt.  IN fact, over the next five years, drug company R%D more than doubled, from 4.1 billion to 8.4 billion.  Then, in 1990, Congress created the Medicaid drug rebate forcing pharmaceutical companies to sell at reduced cost to Medicaid. Again, same sky-is-falling rhetoric from the drug companies.  But this time, rather than R&D doubling in the next five years, it tripled in the next eight, from $8.4 billion in 1990 to $24 billion in 1998. These companies are crying wolf, and it's time we stopped believing them.

Correlation is Not Causation

Watching David Brooks and John Tierney both race to write the same column extolling the virtues of obesity and mocking liberals for denying themselves cheeseburgers was pretty funny. Did no one warn David that Tierney got there first? Does David not even read his conservative competitor? Seems that the Times token righties need to coordinate a bit better.

But it was also sad to watch two supposedly powerful conservative minds use some of the most read newspaper real estate in the world to misinform their readers in the exact same way and in service on the exact same agenda. So let's get something straight: the study did not tell you to get fat. It did not tell you to get a little fat. It did not, in fact, tell you to do anything at all. We're dealing with observational data that's widely available and the authors are trying to divine a connection between weight and mortality rates from it. We're also focusing on the rate of death, rather than disability and disease (as the Times article on the study -- though not its op-eds -- notes, the connection between excess weight and diabetes, high blood pressure, and high cholesterol in undeniable). And what, exactly, did the study find?

Well, folks whose BMI rests in the normal category provided a baseline mortality, i.e, their death rate is considered the "normal" death rate. Folks in the overweight, though not obese nor extremely obese categories, die less than their "normal" counterparts. The obese, the severely obese, and the underweight die more than everyone else. Why?

First you've got to look at the basic measure used, the BMI. The central mistake of Tierney and Brooks is believing that the BMI is a body fat test. It's not. Instead, it's a purely mathematical calculation that takes your weight, divides it by your height in inches squared, and then multiplies the product by 703. So to give an example, my weight is 188. I'm about 72 inches tall (calculate yours here). So my BMI is 25.5, a shade into the overweight category (which goes from 25-29). But am I overweight?

Now things get interesting. I've lifted weights regularly since my first year of high school, making me a fair bit stronger than most folks. I also have a body fat scale, a relic from when I lost 50 pounds as a high school sophomore (I was a fat kid). My body fat is regularly around 15-16%, which'd put me in the "fitness" category, a good 10% under obesity and 3% under the beginning of "average". So I'm not overweight given my body's composition, but I am a bit overweight if judged via my height-to-weight ratio. To restate, I'm not overweight, but I am if the BMI is used.

This is a long way of saying that for many, many people, the height-to-weight ratio comprising the BMI is wholly inaccurate. And most of those people who throw it off are athletes, or fitter than the norm. So right off the bat you've got a group in the overweight category who're likely living healthier lifestyles than many in the "normal" category, but being categorically penalized by the BMI's inadequacies. Whoops.

Moving right along, folks who struggle with their weight, who've not accepted being overweight and are continually fighting to hold the line on 5-15 pounds of flab, are probably watching their eating much more carefully and exercising more regularly than those who benefit from a genetic predisposition to a good weight. I know that my body's constant threats to get fat, and my father's, and my sister's, have forced us all to live healthier, exercise more, and eat better than our naturally slimmer neighbors. So you've got another category now of people battling the scale, and living healthier lives because of it. As the study found, most people in the underweight category, and probably some at the bottom edges of the average category, are naturally slim and don't work to achieve it. Living a sedentary lifestyle is bad for you no matter what your BMI, and many of the slim and average are probably doing exactly that.

Next is the "obesity paradox". Most deaths occur after age 70, so most of what we're dealing with happens in life's twilight years. As it turns out, a bit of fat has a protective effect in old age, likely due to increased muscle and bone mass from toting it around. There's a real health problem in that so few elderly do any sort of weight training, and in fact often haven't for years and years beforehand. Some participate in aerobics, classes, walking -- but many are sedentary, and few pick up weights. It's a really serious health issue, and anything, even a bit of a pudge, that helps reverse the loss of muscle mass will be a boon. But that doesn't make fat the optimal way to gain muscle, it argues for a wider attention to and adoption of techniques to build muscle and preserve bone.

Now, there's countless more going on here. Cigarettes are an appetite suppressant, but we don't know exactly how many people are slimmer because of them. The BMI might simply be too low, or need to adjust better with age. But the above are a number of potentially confounding factors, and you should immediately judge anyone suggesting that you start bathing in tubs of saturated fat a loon. Tierney and Brooks are misappropriating the study in service of some weird, quasi-libertarian agenda to discredit authorities who advise you on what's good and bad for your health. Why the findings of experts that offer folks better information with which to make their decisions piss some libertarians off, I'll never know. But do yourself a favor and don't read right-wingers dead-set on making life a faith-based endeavor. Health is now, as it's always been, a simple affair. Eat well, exercise regularly, try to avoid stress, and get regular check-ups. If some op-ed columnists want to experiment with an all cheeseburger and decaf coffee diet, well, that's their business.

Scarier

Speaking of alarmism, this Marburg virus sure is scary. Big ups to Angola for doing nothing. Big ups to the tribal chiefs for inciting violence against epidemiologists who are risking their lives to help. Big ups to the radio speeches accusing hospital heads of creating the virus through witchcraft so they can get a promotion. Big ups to tribal superstition and customs which won't allow the sick to be quarantined nor the dead to be isolated. It's much more than tragic to watch such a ravaged country bring so much more pain on itself -- it's just unbelievably sad.

But I'm inspired by the epidemiologists and WHO workers and others who've parachuted into one of the most inhospitable countries and climates earth has to offer in order to confront one of the ugliest, deadliest diseases we've ever seen. That's not just dedication, that's towering courage. They're all heroes. And I sure hope they stop this thing.

Percentile Equality

Brad's point that:

The way things are going, in the future people are going to be choosing to spend X percent of their income on health care. X will get larger and larger over time, by choice. So let's say X is 40 percent. From one standpoint, it really doesn't make a difference whether you pay 40 percent of your income for private health care, or 40 percent of your income in taxes that then go to government-administered health care.

That's a very specific standpoint Brad's using. Because paying for government-provided health care leaves you in an enormous pool that guarantees you access to these procedures, no matter their cost and no matter your income. Private insurance, however, is different. If you want comprehensive health care, you have to buy into (or have your employer buy into) pretty expensive plans. For many, that much income simply cannot be spared and, thus, they simply won't have access to many of those treatments. To even try and get close to the top plans, poorer workers won't be paying out the same percentage of their incomes as richer workers, they'll be spending much, much more. The reason single-payer is worthwhile is precisely because everyone pays out roughly the same percentage of their income (with some income brackets a bit more and some a bit less) and receives comprehensive care in return.

Update -- The more I look at this post, the more I think I have Brad's point wrong. He knows health care way better than I do, and wouldn't have overlooked this. So I suggest reading his post in full, as I'm well open to other interpretations of it.

AIDS 2.0

This is the worst news we've had on HIV in a long while:

On Friday, New York City health officials issued this chilling announcement: A man is infected with a form of the AIDS virus that is not only resistant to three of the four classes of anti-HIV drugs, it is apparently so virulent that it causes full-blown AIDS in a matter of weeks rather than the usual decade or more. It will be super-difficult to treat, and it may be a super-fast killer.

New York City Health Commissioner Thomas Frieden first heard of the case on Jan. 22. Tests showed that the man had been infected for only a short time.

Frieden prudently had samples of the mysterious virus assessed by two independent labs. Both labs confirmed that it is resistant to all three of the classes of pill-form HIV drugs and that it attacks its victims with what are called CX4 cellular receptors, which are typically found only in those infected with HIV for a long time and in advanced stages of AIDS.

There is more bad news. The man is the victim of another U.S. epidemic — methamphetamine use. While high and uninhibited, he had sex with more than 100 men over the last two years, often without using a condom. And he recalls little about those encounters — certainly not the partners' names and addresses. There is little hope of tracing the virus, of studying the strain's transmission, of warning the victim's partners or stopping them from having more unprotected sex.

Read the whole thing.

Great Minds, Etc...

Brad Plumer jumps on a hobbyhorse of mine, namely, the need to build more medical schools. There are a mere 125 in the nation, and the competition is so intense that a B here and there disqualifies you. Fast forward a few years and doctors are so overloaded that they make patients wait hours but can only offer them minutes. Residents are in such high demand that they work inhuman shifts and their exhaustion leads to mistakes. Sounds like we need a supply increase.

Further, can anybody explain why the pre-med track makes sense for anyone who wants to be a primary care physician? In that job, which mainly consists of treating basic cases, reassuring harried parents, and referring complex problems, interpersonal abilities are the most important attribute. Yet the training ground is an absurd load of sciences that prizes the workhorses above the socially-adept. Maybe we can create a separate track for those wanting non-surgical, non-specialized, non-research based practices? Maybe we can codify Nurse Practitioners (who I've always found to be excellent, often superior, doctors) into an education path? What say you, world?

The Birds

Be afraid. Be very, very afraid.