Medicine

Analysts who have concluded that inequality in life expectancy is increasing have generally focused on life expectancy at age 40 to 50. However, we show that among infants, children, and young adults, mortality has been falling more quickly in poorer areas with the result that inequality in mortality has fallen substantially over time. This is an important result given the growing literature showing that good health in childhood predicts better health in adulthood and suggests that today’s children are likely to face considerably less inequality in mortality as they age than current adults.

We also show that there have been stunning declines in mortality rates for African-Americans between 1990 and 2010, especially for black men.

That is from Janet Currie and Hannes Schwandt.

The BBC has an interesting report on ambulance services in Beijing.  Up until now, ambulance drivers could decide themselves how much to charge people for their services.  I’m assuming these weren’t listed or known beforehand either.  This seems ripe for abuse given that the patient will be desperately wanting to get to the hospital and in no state for bargaining.  According to the article, most Chinese on social media didn’t even know that ambulances charge at all.  That must come as a big shock then when they get hit up by the driver.

So what did authorities decide to do?  Decree that ambulances “be fitted with taxi-style meters in an effort to allay public concerns about overcharging.”  Hmm, this doesn’t seem to be the most incentive compatible policy either.  As one social media cynic (read: realist) pointed out, “Don’t rule out ambulances taking a detour when using the meter.”  At least when you’re in the backseat of a cab, you can watch where the driver is going.  In the back of an ambulance in an emergency situation, that’s not going to be very feasible!  Don’t get me wrong, I’m in no way advocating free ambulance services, but there has to be a better policy than this.

That is from Cherokee Gothic.

It is also an example of great achievements in light of a disability:

As a teenager, following a severe head injury—the result of her efforts to protect another slave—Tubman developed a lifelong, chronic condition, with debilitating symptoms that have been described as being similar to those of narcolepsy and temporal lobe epilepsy.

Here is that source.  Here are many other sources.

Now here’s the bad news: There is plenty in the media today about Tubman being female and black, but I haven’t seen a single story even mention this angle.  Will anyone cover it?  I hope so but I fear not.

So long, good Samaritans.

In the first study of its kind, Cornell sociologists have found that people who have a medical emergency in a public place can’t necessarily rely on the kindness of strangers. Only 2.5 percent of people, or 1 in 39, got help from strangers before emergency medical personnel arrived, in research published April 14 in the American Journal of Public Health.

For African-Americans, these dismal findings only get worse. African-Americans were less than half as likely as Caucasians to get help from a bystander, regardless of the type of symptoms or illness they were suffering – only 1.8 percent, or fewer than 1 in 55 African-Americans, received assistance. For Caucasians, the corresponding number was 4.2 percent, or 1 in 24.

People in lower-income and densely populated counties were also less likely to get help, the researchers said. Conversely, those in less-densely populated counties with average socioeconomic levels were most likely to get assistance.

Here is more, via Charles Klingman.

More Lead, More Crime

by on April 16, 2016 at 7:28 am in Economics, Medicine | Permalink

In the second half of the nineteenth century, many American cities built water systems using lead or iron service pipes. Municipal water systems generated significant public health improvements, but these improvements may have been partially offset by the damaging effects of lead exposure through lead water pipes. We study the effect of cities’ use of lead pipes on homicide between 1921 and 1936. Lead water pipes exposed entire city populations to much higher doses of lead than have previously been studied in relation to crime. Our estimates suggest that cities’ use of lead service pipes considerably increased city-level homicide rates.

That’s from Feigenbaum and Muller in Lead Exposure and Violent Crime in the Early Twentieth Century. Lead, it ain’t just about Flint.

There is a new Raj Chetty paper out in JAMA ( with seven co-authors, including David Cutler), and it is garnering a lot of media attention.  Here is to my mind the main result, although it is not being presented as such (NYT here):

The JAMA paper found that several measures of access to medical care had no clear relationship with longevity among the poor. But there were correlations with smoking, exercise and obesity.

I enjoyed the NYC angle from Margot Sanger-Katz:

New York is a city with some of the worst income inequality in the country. But when it comes to inequality of life spans, it’s one of the best.

Impoverished New Yorkers tend to live far longer than their counterparts in other American cities, according to detailed new research of Social Security and earnings records published Monday in The Journal of the American Medical Association. They still die sooner than their richer neighbors, but the city’s life-expectancy gap was smaller in 2014 than nearly everywhere else, and it has shrunk since 2001 even as gaps grew nationwide.

That trend may appear surprising. New York is one of the country’s most unequal and expensive cities, where the poor struggle to find affordable housing and the money and time to take care of themselves.

But the research found that New York was, in many ways, a model city for factors that seem to predict where poor people live longer. It is a wealthy, highly educated city with a high tax base. The local government spends a lot on social services for low-income residents. It has low rates of smoking and has many immigrants, who tend to be healthier than native-born Americans.

Here is the accompanying NYT graphic about “your county.”  Here is Emily Badger and Christopher Ingraham, good graphics too:

The poor live shorter lives in Las Vegas, Louisville and industrial Midwest towns, such as Gary, Ind. Geography also matters much more for the poor than the rich. The health behaviors of the wealthy are similar wherever they live. For the poor, their likelihood of risky behaviors such as smoking depends a great deal on geography, on whether they live in a place where smoking is common or where, as in San Francisco, cigarettes have been shunted out of view.

It’s almost as if health care policy should be local in orientation.  The link to the paper includes three comments, including one by Angus Deaton.

After Easter was sedated, the surgeon recounted their dispute to the other doctors. “She’s a handful,” he said in the recording. “She had some choice words for us in the clinic when we didn’t book her case in two weeks.”

“She said, ‘I’m going to call a lawyer and file a complaint,’” he recalled with a laugh. (Easter said she never mentioned a lawyer.)

“That doesn’t seem like the thing to say to the person who’s going to do your surgery,” another male voice retorted.

The comments afterward became personal. The surgeon and the anesthesiologist repeatedly referred to her belly button in jest. “Did you see her belly button?” one doctor said, followed by peals of laughter.

At another point in the procedure, the anesthesiologist appeared to refer to Easter as “always the queen,” to which the surgeon responded, “I feel sorry for her husband.”

The surgeon also used the name “Precious” several times in a manner that Easter interpreted as racial.

…After the doctors concurred that there had been many “teaching moments” that day, the anesthesiologist asked, “Do you want me to touch her?”

“I can touch her,” the surgeon is heard saying.

“That’s a Bill Cosby suggestion,” someone interjected. “Everybody’s got things on phones these days. Everybody’s got a camera.”

Here is the full story.

There is a new NBER paper on this topic, by Victoria Y. Fan, Dean T. Jamison, and Lawrence H. Summers, here is the abstract:

Estimates of the long-term annual cost of global warming lie in the range of 0.2-2% of global income. This high cost has generated widespread political concern and commitment as manifested in the Paris agreements of December, 2015. Analyses in this paper suggest that the expected annual cost of pandemic influenza falls in the same range as does that of climate change although toward the low end. In any given year a small likelihood exists that the world will again suffer a very severe flu pandemic akin to the one of 1918. Even a moderately severe pandemic, of which at least 6 have occurred since 1700, could lead to 2 million or more excess deaths. World Bank and other work has assessed the probable income loss from a severe pandemic at 4-5% of global GNI. The economics literature points to a very high intrinsic value of mortality risk, a value that GNI fails to capture. In this paper we use findings from that literature to generate an estimate of pandemic cost that is inclusive of both income loss and the cost of elevated mortality. We present results on an expected annual basis using reasonable (although highly uncertain) estimates of the annual probabilities of pandemics in two bands of severity. We find:

1. Expected pandemic deaths exceed 700,000 per year worldwide with an associated annual mortality cost of estimated at $490 billion. We use published figures to estimate expected income loss at $80 billion per year and hence the inclusive cost to be $570 billion per year or 0.7% of global income (range: 0.4-1.0%).

2. For moderately severe pandemics about 40% of inclusive cost results from income loss. For severe pandemics this fraction declines to 12%: the intrinsic cost of elevated mortality becomes completely dominant.

3. The estimates of mortality cost as a % of GNI range from around 1.6% in lower-middle income countries down to 0.3% in high-income countries, mostly as a result of much higher pandemic death rates in lower-income environments.

4. The distribution of pandemic severity has an exceptionally fat tail: about 95% of the expected cost results from pandemics that would be expected to kill over 7 million people worldwide.

In other words, in expected value terms an influenza pandemic is a big problem indeed.  But since, unlike global warming, it does not fit conveniently into the usual social status battles which define our politics, it receives far less attention.

Most people dread going to the dentist’s for a check-up.

But the London-based dental boutique YourDentist.co.uk is changing dentistry’s reputation by offering nervous patients a luxury experience that includes a Bentley car service, a concierge lounge, and accommodation in 5-star hotels.

The high-end practice — which claims to be one of the world’s only 7-star dental boutiques on its website — was established in 2013, and moved to its flagship location on Harley Street in 2015.

The surgery also partners with clinics across the UK that “fit within a luxury private practice environment,” and considers its business model as “very similar to Uber or Airbnb.”

The story is here, via the excellent Samir Varma.

Catherine Rampell’s excellent column considers the case for a soda tax in Britain.  Here is one bit:

Why not just target the output, rather than some random subset of inputs? We could tax obesity if we wanted to. Or if we want to seem less punitive, we could award tax credits to obese people who lose weight. A tax directly pegged to reduced obesity would certainly be a much more efficient way to achieve the stated policy goal of reducing obesity.

Of course, “fat taxes,” even when framed as weight-loss tax credits, seem pretty loathsome. Why is . . . unclear.

We tax soda instead, even though that is less effective, for instance because soda drinkers may substitute into other sugary beverages.  We are unwilling to humiliate the obese by taxing them directly, and so our chosen policies do less to help…the obese.  (That’s assuming that attempting to shift their consumption behavior helps them at all, which is debatable.)  As Robin Hanson has told us many times, politics isn’t about policy…

Opportunity!  That is from Justin Wolfers.

Jeff Kaufman writes:

Buses are much safer than cars, by about a factor of 67 [1] but they’re not very popular. If you look at situations where people who can afford private transit take mass transit instead, speed is the main factor (ex: airplanes, subways). So we should look at ways to make buses faster so more people will ride them, even if this means making them somewhat more dangerous.

Here are some ideas, roughly in order from “we should definitely do this” to “this is crazy, but it would probably still reduce deaths overall when you take into account that more people would ride the bus”:

  • Don’t require buses to stop and open their doors at railroad crossings.
  • Allow the driver to start while someone is still at the front paying.
  • Allow buses to drive 25mph on the shoulder of the highway in traffic jams where the main lanes are averaging below 10mph.
  • Higher speed limits for buses. Lets say 15mph over.
  • Leave (city) bus doors open, allow people to get on and off any time at their own risk.

Other ideas?

Excellent recognition of tradeoffs. Pharmaceuticals should also be more dangerous.

Hat tip: Slate Star Codex.

That is the subject of the new JPE paper by Charles I. Jones, here is the abstract:

Some technologies save lives—new vaccines, new surgical techniques, safer highways. Others threaten lives—pollution, nuclear accidents, global warming, and the rapid global transmission of disease. How is growth theory altered when technologies involve life and death instead of just higher consumption? This paper shows that taking life into account has first-order consequences. Under standard preferences, the value of life may rise faster than consumption, leading society to value safety over consumption growth. As a result, the optimal rate of consumption growth may be substantially lower than what is feasible, in some cases falling all the way to zero.

It is a well-known stylized fact that the share of health care in gdp is generally rising…

Which is better?  A society with quite patient, very long-lived individuals with a static standard of living, or a society of people who die at eighty but manage to double living standards every generation?

Which would we choose?

Addendum: Here is an earlier, “less gated” version of the paper.

Brookings has a good memo on four ways occupational licensing reduces both income and geographic mobility. Here is point 1:

Since state licensing laws vary widely, a license earned in one state may not be honored in another. In South Carolina, only 12 percent of the workforce is licensed, versus 33 percent in Iowa. In Iowa, it takes 16 months of education to become a cosmetologist, but just half that long in New York. This licensing patchwork might explain why those working in licensed professions are much less likely to move, especially across state lines:

The graph, is from the excellent White House report on occupational licensing. The first blue column says that workers in heavily licensed occupations are nearly 15% less likely to move between states than those in less licensed occupations–this is true even after controlling for a number of other variables that might differ across occupations and also influence mobility such as citizenship, sex, number of children, and education.

The orange column provides another test. An occupational license makes it difficult to move across states but not within a state. If workers in licensed occupations had lower rates of mobility for some other reason than the license then we would expect that workers in heavily licensed occupations would also have lower rates of within state mobility. The orange bars show that workers in heavily licensed occupations do have slightly lower rates of within state mobility but not by nearly enough to explain the dramatically lower rates of between state mobility.

Lower rates of worker mobility mean that workers are misallocated across the states in a similar way that price controls or discrimination misallocate resources and reduce total wealth. Lower rates of workforce mobility also increase the persistence of unemployment.

To its credit, the Federal government is investing in efforts to make licenses more portable including encouraging “cross-State licensing reciprocity agreements to accept each other’s licenses.” Cross-state reciprocity agreements sound like an excellent idea.

Yesterday, I pointed out that generic drug prices are falling. So what accounts for the small number of large price increases in the generic drug market? It’s a combination of market shenanigans, supply shocks, and FDA delay.

The markets where price increases have been large tend to be relatively small. Daraprim, for example, is only prescribed some 8-12 thousand times per year in the United States. The small size of these markets is no accident. Keep in mind that whatever one may think of Shkreli, he did show a kind of entrepreneurial genius in scouring the universe of drugs in the United States to select one where monopoly power could be so effectively exploited. Shkreli found a market where 1) the total size of the market was low so there wasn’t much competition but 2) the drug treated a serious illness and 3) there wasn’t a good substitute so the value of the drug to the small number of patients was very high.

In addition, Shkreli knew that he had at least a 3-4 year window of opportunity to exploit monopoly power. To compete with Daraprim a competitor would have to submit an Abbreviated New Drug Applications (ANDA) to the FDA. Despite the name, Abbreviated, it costs at least five million dollars to go through the process and right now there is a backlog of nearly 3,000 ANDAs at the FDA’s Office of Generic Drugs. In recent years, it has taken 3- 4 years to get a generic drug approved. The cost is too high and the delay too long.

(I am focusing on the standard route to market entry and ignoring the possibility of importation or compounding which I discussed earlier. I’m also ignoring that Daraprim is unusual in that it was approved in 1953 before the current FDA system of safety and efficacy trials, and the FDA is being absurdly cagey about whether they would allow a simple ANDA for Daraprim. I may write about that in a future post– see here for a related case.)

So what’s the good news? In 2012 Congress passed the Generic Drug User Fee Act (GDUFA). Modeled after the very succesful PDUFA, the act earmarks fees paid by generic drug manufacturers to the FDA’s Office of Generic Drugs. As a result of those fees, the FDA has hired more reviewers and they are rapidly reducing the backlog. That’s the first piece of good news.

A second piece of good news is that FDA delay isn’t the only cause of the backlog. Another cause of the ANDA backlog was an unexpected increase in the number of ANDAs. I would have been much more worried if the number of ANDAs had decreased. Despite new user fees and some increase in regulation the increase in submissions is evidence that the US generic market is competitive, vibrant, and profitable.

The generic drug market in the United States has been very successful. We are constantly told, for example, that US pharmaceutical prices are the highest in the world and that is true for patented drugs but generic drug prices in the US are among the lowest in the developed world and most prescriptions are of generics.

We can address the price hiccups in the generic market by opening up to more world suppliers, speeding up the ANDA process and keeping costs of entry low. Overall, however, we shouldn’t let the price hiccups detract attention from the fact that the generic drug market is competitive, vibrant and thriving and we want to keep it that way.