America does pretty well at public health

Michael S. Sparer and Anne-Laure Beaussier has a new and interesting piece on this topic, here is part of the abstract:

First, the United States outperforms its European peers on several public health metrics. Second, the United States spends a comparable proportion of its health dollar on prevention. Third, these results are due partly to a federalism twist (while all three nations delegate significant responsibility for public health to local governments, federal officials are more engaged in the United States) and partly to the American version of public health moralism. We also consider the renewed interest in population health, noting why, against expectations, this trend might grow more quickly in the United States than in its European counterparts.

I also learned (or relearned) from this paper the following:

1. For per capita prevention, the U.S. is a clear first in the world.  (I wonder, by the way, to what extent this contributes to higher health care costs in the United States, since preventive care also can drive doctor and hospital visits.)

2. The UK and France made a deliberate decision to switch away from public health to curative medicine, after the end of World War II, when they were building out their universal coverage systems.

3. The American history with public health programs is a pretty good one, with advances coming from the anti-smoking campaign, lower speed limits, anti-drunk driving initiatives, fluoridated water, and mandatory vaccination programs.

4. The British fare poorly on various public health metrics.

5. “The US system of public health fares rather well compared to other Western nations.”  On net, our population is not as anti-science as it may seem, at least not if we look at final policy results, as compared to some of our peer countries.

All in all, an interesting read.


'For per capita prevention, the U.S. is a clear first in the world.'

Why, just looks at how the U.S. leads the world in public health programs intended to prevent firearm death and injury. Stop laughing, Megan McCardle is quite capable of writing such a sentence.

And from the article, terms like 'European peers' or 'European counterparts' appear, though only the UK and France are actually compared. Just anecdotal experience, but a neighbor returned from working at a German car company in South Carolina, and she was appalled at how Americans seemingly knew nothing about how to take care of their health. Going to work sick, for example, was for her idiocy. (Yes, I know, the American car industry is doing so much better than the German one because Americans don't slack off like Germans do, right?) But more concretely, she could not believe how people with health problems would just go to a drugstore to buy something that was supposed to help with problem, without ever going to a doctor. In part because it would cost too much, in part because they simply did not have time, and in part because doctors are not as easily available as in this part of Germany. She thought that it was a striking failure how Americans were not taught how to take care of their health starting in school, giving an entirely different perspective on preventive care.

The UK and NHS tend to stand out in European statistics too, but mostly because compared to Nordic or German speaking countries, they are generally outliers on the bottom of the scale (the picture with the NHS is a bit more complex, but with Brexit, NHS is facing a growing problem concerning a lack of staff).

Leading to a certain suspicion that the UK and France were chosen in a way that was less than random - 'including tobacco use and dangerous alcohol consumption.' Basically, if one were to pick two larger European countries that stand out in either area, it just so happens one would ever so coincidentally end up with the UK and France.

But give the authors some credit for their first note - 'It is difficult to note with certainty overall spending on prevention and public health, given uncertainties about what to include in the estimate. For example, garbage collection is generally not counted, though it surely is a public health necessity.' What is notable is how poorly the U.S. does in terms of dealing with rats (as anyone who has visited DC can attest). Though strangely enough, this top ten list just happens to include the capitals of America's European counterparts as being the only two non-American cities not in the top ten -

I think we need to focus more on the question of why Steven Pinker was on Jeffery Epstein’s plane

Was he really? I hadn't heard that.

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That was Falsedearieme. Real dearieme has no interest in libelling Mr Pinker.

Most of the shooters are in democratic controlled areas. How many NRA members ever shoot anybody? Poverty, ignorance and violence are the fruits of socialism and the welfare state.

That gun activist from Texas is in trouble for sexually assaulting a teen aged girl. He's also hiding out from the law overseas. The right needs to purge its ranks of pedophiles and other criminal elements instead of nominating them for high office.

Well, the U.S. at least managed to drive away one dirty rat to Germany. And you really ought to avail yourself of Germany's health care system to get some treatment for your unhealthy obsession with TC.

"Leading to a certain suspicion that the UK and France were chosen in a way that was less than random - 'including tobacco use and dangerous alcohol consumption.' Basically, if one were to pick two larger European countries that stand out in either area, it just so happens one would ever so coincidentally end up with the UK and France. "

Alcohol consumption fares pretty average.

Leading to a certain suspicion that you have an obsession with snarky remarks....

'Alcohol consumption fares pretty average.'

Not precisely - the UK has a notable problem with binge drinking. 'Boozy Brits are second only to the plastered Portuguese when it comes to a European table of binge drinkers.

And British men and women came second and third, respectively, for over indulgence out of 21 countries.

The Portuguese topped both tables, with the inebriated Netherlands also ahead of the UK for women.

The researchers also discovered that British men drink three times as much as the average European woman.

It's the first study of its kind to compare the drinking habits of Europeans by looking at what they drink - and how often.'

And do note how the article even talks about averages, though not exactly in a fashion designed to support the idea that the UK is just average when it comes to drinking.

'Leading to a certain suspicion that you have an obsession with snarky remarks....'

Or facts, though these days, it seems pretty hard for some to tell the difference. Or maybe you could talk to someone from the UK who has also travelled in continental Europe? They are quite aware of how the UK stands out in this area compared to France or Germany. Actually, maybe if someone from the UK is too hard to find, you could find someone from France or Germany who has travelled to the UK. Binge drinking is one of those things that tends to distort averages - such as the public health problems associated with alcohol.

Odd to pick a tabloid with no comparative data tables to link. Most results finds UK not consistently particularly far outlier in various data measures.

Well, it seemed more concisely related to the point about the UK and binge drinking, but if you wish to read the actual work, here is the link -

Is France in the same ballpark?

According to the data in your article, the France is on average on smoking, sub-average on binge drinking. UK is sub-average on smoking and over-average on binge drinking.

To sum it up: I don't see anything abnormal in choice of these 2 countries to represent some normal country in EU.

That said, the study numbers seem strange. Czech men have slightly higher consumption than the UK, half the binge-drinking, yet only 25% of them consume alcohol more than once a week compared to 38% in the UK. That doesn't make any sense (I'd guess the 25% is just waaay too low).

Nah. As a person who spends a lot of time in France. Nah.

In all fairness, the article does a fairly good job explaining that America's public health programs starting more than a century ago were truly extraordinary in their impact at improving health in the U.S. There was a time when the U.S. was truly a world leading nation in many ways - American baby boomers still have nostalgic memories of that past, along with a seemingly increasing desperation to say nothing has declined on their watch.

Besides, Americans who can compare their experiences within the U.S. and outside of it are fairly rare, making it much easier for most Americans to continue to trust their feelings about American superiority in such areas.

"...along with a seemingly increasing desperation to say nothing has declined on their watch." At least when it come the THEM... They don't care for the great unwashed and hoi palloi...

Are you actually saying there was a decline from the past, rather having been passed by countries like Germany?

"American baby boomers still have nostalgic memories of that past, along with a seemingly increasing desperation to say nothing has declined on their watch."

Are you actually saying there was a decline from the past, rather having been passed by countries like Germany?

Keep in mind the US population is younger than Western European ones, which all else being equal should yield better public health.

That said, having grown up in France and spent the last 18 years in the US, anyone who claims the US’ incredibly expensive and inefficient health care can match France’s (apart from ultra-high-end procedures that are statistically irrelevant) is simply delusional. One thing that is seldom mentioned is that waiting times to see a physician or have something like a MRI done are much worse in the US in France, where they are usually same-day. The situation is a bit different in the UK where the NHS is operated on a much lower budget, and thus you get equivalent care, but with no frills and longer waits.

'is simply delusional'

Yes. But most Americans, having no grounds for comparison, reject the idea that their health care system is a mess that would not be tolerated in a country like France or the UK. They simply reject anything that disturbs their belief in the superiority of the U. S. in health care.

This post is about public health, not health care

Chances that this paper turns out to be counterintuitive-result-hacking?

It appears that, mainly, this paper is being misinterpreted here.

Tyler's post (somewhat) and the comments (more so) take it as a defense of the US healthcare system. However, the claim of the paper is actually something like "The US healthcare system is horribly inefficient, but contrary to many claims, a lack of public health focus is not a major driver of this problem."

Actually, if anything, the paper mainly seems to be a historical overview.

Yes, it's also a rather qualitative work.

I wish that he had chosen to title it similarly. Empirical metrics have long supported the fact that the U.S. spends much more and produces the same or worse health outcomes when compared to Europe.

I don't think there's any misinterpretation or misrepresentation involved. They're very clearly talking about public health.

"Efforts to explain this (dismal) cross-national performance often focus on the subordinate status of public health; presumably the key to a higher performing US health system (and better health outcomes) would be to spend a higher percentage of the health care dollar on prevention and public health (and a lower percentage on specialty and acute care). Moreover, the subordinate status of public health in America is presumably rooted in health care federalism: the decentralized American system arguably fares poorly compared to more centralized systems like those found in many European peers."

It is precisely the two notions laid out above that they seek to debunk, at least partially. Nowhere is any overall superiority of healthcare outcomes posited, nor are claims as to overall efficiency made.

Tyler doesn't claim overall superiority of the American healthcare system, but I do think the post creates a more positive picture than the paper does. The paper is more like "the public health track record in all three countries is a mixed bag, with the U.S. not notably worse", while the post creates the impression that America is better at public health than the comparators.

That's why I take Tyler as "somewhat" portraying this as a defense of the U.S. healthcare system.

Meanwhile, many commenters (whether supportive or critical) have clearly not clicked through to look at any of it, but are just running headlong into the typical healthcare debates.

Studies to date may have included too few people to detect slight overall mortality benefits associated with screening, two doctors and a health care journalist argue in The BMJ. It’s also possible that any reduction in cancer deaths due to screening may be offset by fatalities connected to harmful effects of the tests themselves or of unnecessary treatments.
more on
what is really needed is to know what is right for individual patients. Statistical medicine causes massive expense, stress for patients and staff, difficulty in getting treatment for people who really are ill, and even traffic congestion and consequent pollution around hospitals.

I’m just here asking questions about what Steven Pinker was doing on Jeffery Epstein’s plane?

Would you please pretend to be some other poster?

If you are so confident in your view of Mr Pinker why don't you invent your own pseudonym?

Plus being a Brit, I’m more a Jimmy Saville man myself.

You're safe libelling Saville; he's dead.

What a joke!

I follow MR just to see what the KOCH Bros pay for. In this case it’s pure drivel.

At the end of the day it comes down to life expectancies and the USA despite being the most expensive place in the world for health care doesn’t rate in the top twenty for life expectancy

Life expectancy in eight R-T-W states falls closer to Russia and North Korea than to California. Russia and North Korea don’t even make the top 100. Of the twenty-seven Right-To-Work states, not one has a life expectancy better than California. A study of R-T-W states perhaps has merit.

Well, they likely come out way ahead in economic freedom, and probably beat California hands down. And really, what metric is more valuable in the U.S. these days?

This is driven almost entirely by premature birth rates. That’s the cause of the high US infant mortality rate. Which is the cause of the life expectancy value differences.

Easy to see how it breaks down just by looking at the stats.

US rate: ~12%
France: < 7%

Differences in state rate within US is mostly demographics.

White US rate: ~7%
African American US rate: 14.5%

Causes mostly attributed to obesity, age (under 17 and over 40) and smoking while pregnant.

What that has to do with state union laws is an exercise left to the reader.

“Sure” can probably add some value to this discussion if he checks the blog today.

I'm guessing that the confusing threading used here after the revamp is why this comment appears in response to 'economic freedom.'

"Well, they likely come out way ahead in economic freedom, and probably beat California hands down."

Works for me!

Blacks and Hispanics have shorter life expectancies, and tend to concentrate in RTW states, which have lower barriers to entry for employment.

That's my hypothesis, any way.

But most Americans are from Northern Europe or Africa, while countries with the highest life expectancy are in Southern Europe and East Asia.

Actually, Mediterranean is prolly a more apt description than "Southern Europe".

The only drivel is your coming from your drooling mouth about the KOCH Bros who had nothing to do with the study.

Yet Chuck Kotlarz's comment, inspired by that 'drivel,' is quite interesting, even if it does lack a link to check the basic factual assertions.

And eyeballing Alabama compared to Russia, it seems that Chuck Kotlarz is correct.

We can hopefully all agree to ignore whatever numbers North Korea provides, while also agreeing to take the Russian numbers with a certain grain of salt.

And for fun, here is the latest index of economic freedom rankings from the Cato institute -

California - 48

Alabama - 18

Shame how people in California are condemned to an additional half decade of living economic misery compared to Alabama, but those are the breaks, right?

See my reply above.

Attributing demographic results to politics is just lazy.

What’s the preferred policy anyways, locking up pregnant women who are obese, smoke, and do drugs? No thanks.

Whats your supposed causal mechanism between state union laws and obesity, smoking, and drug use among pregnant women?

'Attributing demographic results to politics is just lazy.'

Well, attribution might be lazy, but Chuck Kotlarz's comment is actually factually true, using a single comparison, as is the difference in the Cato ranking of economic freedom.

Since I did not bother to check all of the twenty-seven Right-To-Work states, you are welcome to - I doubt that your demographic explanation is anywhere near as solid as you seem to believe.

'Whats your supposed causal mechanism between state union laws and obesity, smoking, and drug use among pregnant women?'

I am not the one making the assertion, merely the one observing that his data is actually correct, while pointing out that the economic freedom index from the Cato Institute provides another perspective. At least in the one case I actually looked at - along with providing the links to allow one to look at the data.

Utah is RTW and it is 9th in the nation as far as life expectancy. So yeah, demographics has to play a role.

Fair enough, and a difference of a half year is not that notable.

But that demographics plays a role among a group noted for their healthy lifestyle without actually managing to place them above California is interesting. Of course, other demographic features are in play too. For example, Asian Americans seem to have a 1 and 1/2 year shorter life span in Utah.

Ah, I meant averaged total when talking about 'above California' - whites seem to have 3 month shorter life expectancy California, which just might reflect the benefits of following various tenets of Mormonism.

Sure, I bet there are all kinds of variables playing a role here. It's just silly in my opinion to discard one or another without a full study of how they correlate and impact certain variables.

Nothing to do with Asians, with the highest lifespans, being well represented in California vs African descendants, with the shortest lifespans, being well represented Alabama.

I just used one example, because to be honest, I was skeptical of the claim (mainly because Russian life expectancy was a joke after the collapse of the Soviet Union). I'm sure that all of us Americans can pretty much agree that Alabama tends to come out at the bottom of most rankings, even when using a southern state like Virginia.

As noted in the replay to Hmmm, you are welcome to look at the other 26 states to see if they meet your objection.

Lots of people make lots of claims here - checking is always a good idea when one is unsure.

I agree, so let’s check.

Let’s take Alabama vs California as you did.

We know the largest determinant of life expectancy comparisons here is infant mortality.

The determinant in infant mortality is preterm birth rate.

We know African Americans have over double (7 vs 14.5%) the rate of preterm births. Then we can make a direct comparison of infant mortality by state.

California percentage Black : 6.5%
Alabama percentage black : 26.7%

California infant mortality rate: 4.8 per 1000
Alabama infant mortality rate: 9.1 per 1000

I take it I don’t need to explain the math behind life expectancy and how large of an impact infant mortality has on the differences.

You left out the economic freedom ranking aspect.

Which just might have some bearing on this, from the wikipedia article that performs the necessary demographic breakdown -

Life Expectancy, White (in years)

California - 79.8

Alabama - 76.0

There’s still a difference, accounting for demographics.

Point taken.

I would think it’s caused by differences in smoking, opioid abuse, alcohol and obesity.

If you think it can be explained by union regulations or that unionization is a causal factor upstream, then I think we’ve reached the end of the discussion. I don’t know how to verify that one way or the other.

I have no explanation, it was just an interesting observation from Chuck Kotlarz that actually turns out to be accurate when checked.

I doubt that the original commenter is providing any explanatory basis regardless of how one looks at the data, but the data that the comment prompted was accurate. A state like Alabama has a life expectancy closer to that of Russia than that of California, which struck me as implausible enough to check.

Basically, it was just another confirmation that the U.S. is a really large country with a fair amount of variation.

We know infant mortality affects avg lifespan, but we can't tell if Alabama's better freedom ranking makes their life expectancy rank better or worse than it would have been otherwise.

As you note, infant mortality can dramatically impact life expectancy. The infant mortality rate of R-T-W states runs about 20% higher than non-R-T-W states. If R-T-W states can address this, you may end up saving tens, hundreds of thousands of lives, maybe millions.

I'm unaware of a link comparing Right-To-Work states to Russia and North Korea. A comparison of states appears in slide nine of the “Spirit Level Slides”, a PowerPoint file that can be downloaded at the link:

Life expectancy came from the link clockwork_prior refers to:

One must read the entire article to understand what the authors mean by "public health". No, it's not the incidence and curative rates for disease, public health are the things the public sector does to improve health. In the U.S., that is mostly accomplished via "public health morality": moral suasion to reduce drunk driving, obesity, smoking, STDs, drug abuse, etc. In other words, advertising campaigns to alter harmful individual human behavior. Beyond individual human behavior, the authors allude to efforts at the national and state level to reduce pollution and other toxins of industry and to encourage the use of "clean" energy rather than fossil fuels. And the authors end the piece by alluding to the "integrated delivery systems" and reimbursement tied to outcomes not just the quantity of care, two initiatives that were part of Obamacare. Of course, the current administration is unraveling these initiatives, while rescinding rules designed to reduce pollution and the emission of toxins and increase the use of "clean" energy, vastly increasing the number of uninsured and reducing or eliminating funding for efforts to alter harmful individual human behavior. It's as if the authors' clock stopped at noon on January 20, 2017.

I will point out something that was likely in an early draft of the article but only appears between the lines of the article. The authors mention that many chronic conditions are the product of harmful individual human behavior, such as smoking, drinking alcohol, drug abuse, etc., which "public health morality" is designed to alter. The authors do not mention the long-standing American public health policy of excluding pre-existing conditions from private health insurance coverage, but it's hanging over the paragraph like the grim reaper. Of course, the current administration is unraveling the structure that made it possible to require private insurers to cover pre-existing conditions. I suppose an economist would see the public health benefit from excluding coverage for pre-existing conditions (i.e., it discourages harmful individual human behavior), but what sane economist wants to be viewed as the partner of the grim reaper.

There is no such thing as insurance for pre-existing conditions. Medical insurance is also not allowed to price by risk. There are distortions all over the place.

We should be asking why one of the largest and most sophisticated markets on the planet can only think of employer-based insurance or government transfer payments to fund medical care.

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3. The American history with public health programs is a pretty good one, with advances coming from the ... anti-drunk driving initiatives....

The pseudo-obsession with drunk driving, along with sex in America, is truly remarkable. It's almost as though the only possible reason for a traffic accident is impairment by alcohol. Totally disregarded, because no statistics are kept, are accidents that are caused by German shepherds running about in the passenger compartments of cars, people getting in head-on collisions after dribbling ketchup down the front of their Redskins jersey while eating Big Macs as they drive and, of course, rear-enders as a result of cell phone calls to the neighbor's wife.

Leaving aside the morality, you do know that alcohol has a number of empirically proven factors that impair driving ability, right?

Which might just explain why in a large number of countries, the amount of alcohol that is allowed (generally using BAC) for drivers has been lowered significantly.

This is not a secret, by the way - we learned this in the MSF course available in the mid-80s.

And if you prefer a humorous send up, here is Dr. Johnny Fever (with a DMCA evading twist degrading the quality) -

The BAC limits are artificially low. To generate revenue. Pretty much most things are just as dangerous: eating, having a conversation, a lot of medicines, your phone. Amazing any of us make it through the week.

'The BAC limits are artificially low. To generate revenue.'

Then I bet you hate Hungary's laws, which for decades have not allowed any measurable alcohol at all in a driver's blood.

I was told that the law dates back to the Soviet occupation era - it seem fairly certain that the communists were not all that interested in generating revenue, though.

Yes, we should emulate the Soviets.

>lower speed limits

Dear God man.... you think this was a "Public Health Initiative"?

It was an attempt to save gas, and to raise money. That is all.

You could have gone with airbags or seat belt laws if you wanted to have any prayer of crediting The Glorious State with saving the lives of the idiot peasantry.

How about Trump's groundbreaking diplomacy with North Korea? How many American lives did that save? Better add that to the list....

'It was an attempt to save gas, and to raise money.'

So, if it reduced federal and state gas excise taxes through increasing fuel efficiency, what was the raising money angle? Speeding tickets would be a drop in the bucket by comparison.

And in which case, you would probably consider the speed limits in school zones to be a revenue enhancing scheme too.

This is pretty good, hits the obvious points that nonetheless will startle many.

One of the bugaboos here is proportion of GDP -- people spend absolute dollars, not proportions of GDP. and absolute dollars have diminishing marginal returns. Some PPP adjustment might make sense, but if we shouldn't expect health care to be a constant proportion of GDP at different income levels (note this adjustment highlights the US choosing to spend more at the less-efficient margins).

Sorry, last sentence should be:

Some PPP adjustment might make sense, but we shouldn't expect health care to be a constant proportion of GDP at different income levels (note this adjustment highlights the US choosing to spend more at the less-efficient margins).

Pretty remarkable, even libertarians seem to be on board with mandatory vaccines. You couldn’t make up a more perfectly anti libertarian system.

Mandatory chemical intervention in children, shaming of parental choice, government created captive monopoly markets, blanket preemptive liability waivers, fear mongering and propaganda, government bureaucracies elevated and empowered with human cost benefit decisions... all in the name of the greater good.

But but but its a medical miracle; so it’s okay, seems to be the refrain.

What other massive government testing and intervention programs ought to be justified by their ends?

Eugenics based sterilization of the infirm and impure?
Secret aerial testing of pathogens over population centers?
Mandatory minimum incomes and universal health care?
Seat belt and helmet laws?

Where do we draw the line?

Even for you, this comment is pretty stupid.

You are equating some form of anarchism with libertarianism.

The concept of herd immunity is pretty obviously a clear form of externality.

The social cost of non vaccination is large, whereas the private cost is low with a high variance.

You did not answer my question. Which was how do libertarians reconcile themselves with the nearly Stalinesque structure of the vaccine system?

Apparently there are some social goods for which they are willing to accept what amounts to a caricature of state-planning and state-corporatism, and fully surrender their choice, autonomy, or status as party to a bilateral contract.

The concept of herd immunity, for what it is worth, is taking a beating. And the private cost includes death and a variety of major adverse reactions, albeit statistically low in the aggregate. But I suspect you actually know very little about that.

In any case, the efficacy of vaccines not the question here. Unless efficacy is justification for abandoning core principles of government. Which it seems to be.

Don't feel bad, you are not alone. Liberals who refuse to eat GMOs, pay extra for organics, think fracking is toxic, and believe drug companies are the only industry more sociopathic than banking give vaccines a pass. And conservatives who want to abolish the FDA, claim the government wants to take their guns with black helicopters, say that climate change is a scientific conspiracy, and refuse to be told how to buy health insurance also give vaccines a complete pass. Libertarians as well.

THAT is fascinating. And to my mind, a little suspicious.

But who knows, maybe vaccines are indeed the one unmitigated unimpeachable incorruptible island of permanently-settled science. The Lake Woebegone of public policy, where all the bureaucrats are above average, central planning and government-enforced medical interventions are enlightened, and drug companies ignore their government-granted monopolies and liability protection work selflessly towards the greater good just because it's so darned important.

Libertarianism is the belief in personal freedom, as long as you are not harming others. However, not getting vaccinated harms others (since the effectiveness of vaccines depends on everyone being vaccinated, which prevents the spread of disease). Support of mandatory vaccination is therefore not inconsistent with libertarianism.

Many critics of libertarianism ignore the distinction between "limited government" and "no government" and assume that libertarians should be against any form of government intervention. Your comment appears to be in this vein, hence Hmmm's point that you are confusing anarchism and libertarianism.

Your over-the-top language also doesn't help your case. Statements like the "nearly Stalinesque structure of the vaccine system" are just absurd. Nobody is being forcibly vaccinated. Rather being vaccinated is a prerequisite before using a public service (public schools, which happen to be a context where an unvaccinated child will be a risk to others). Plus, nearly all states allow religious/philosophical exemptions to this policy.

Well, Libertarians suffer a bit from the no true scotsman problem, where a lot of anti-regulation and anti-tax activists and don't-tell-me-what-to-do types hide behind libertarianism to preach a form of market anarchy.

I said "nearly" Stalinesque, and was referring more to the central planning and government infallibility than the violence. No, they do not vaccinate at gunpoint, but quarantines and prison for parents is raised from time to time. And the exemption system is currently being systematically dismantled; many states having drastically narrowed or removed exemptions of late.

The system, if you take a moment to study it, is truly exceptional in the design features that wouldn't last a minute in any other endeavor, except perhaps war-making.

Nevertheless, the vaccine system, despite a mountain of red flags and structural incentives to fuel the nightmares of liberals and conservatives alike, is granted a sacred status that really can only be understood as a religion.

You do have several unexamined premises, like that the diseases are spread by the unvaccinated, rather than the recently-vaccinated, which in fact there is reasonable question about.

Oh well, I am not interested in debating vaccines any more than debating religion. What I am interested in exploring is how vaccines became the sole infallible unimpeachable facet of public policy and economic activity. You must agree, vaccine enjoy an extraordinary exemption, in era where everything is broken, every system and motive is suspect, and everything is up for debate, and even basic facts and history are on the table - vaccine are the shining city on the hill.

Vaccines do not have an extraordinary exemption from criticism. There is a significant movement opposing vaccines, even though the evidence of their benefit is overwhelming.

'that you are confusing anarchism and libertarianism'

Far too many people make this mistake, to be honest.

However, if any commenter here was to use 'anarcho-syndicalism' in opposition to libertarianism, it means that the person probably is also aware of Kropotkin's critique of those who do not understand the importance of mutual aid in terms of Darwinian theory.

However, my memory is a touch different in regards to this - 'Nobody is being forcibly vaccinated.' That was true back in Fairfax County, VA in the 1960s/early 70s, at least in being not precisely 'forcibly' - you were not allowed into the public school system without proving you were vaccinated (I'm fairly sure that the occasional Christian Scientist was exempted).

I also remember getting several free vaccinations in elementary school - the 'gun' vaccine device being a big step up in my roughly 3rd grade opinion. The U.S. was truly an exemplary model of public health programs, at least in my childhood.

These days, not so much - and part of the reason is not merely the tax cutting corporate right, but the anti-science left.

No, not anti-science left, the anti-corporate-science left. The left looks at "science" (in this sort of context) and sees conflicts of interest, revolving doors, outright fraud, a replicability crisis, and a system of incentives around careerism, grant funding, and profiteering etc that has corrupted the practice of science. Except with vaccines.

The left looks at "science" and sees the tobacco industry; sees the fracking industry and the pesticide companies ; sees the serially-pathological drug companies.

The right, meanwhile, is willing to believe that thousands of climate scientists. 99+% or whatever, are engaged in a coordinated mass conspiracy of lies and corruption. EXCEPT with vaccines.

Yet, somehow, conservatives and liberals alike agree that the scientists' peers next door in the infectious disease labs are pure as driven snow.

Libertarians, meanwhile, are fully willing to submit - with the bodies of their children - to the cost-benefit calculations of bureaucrats at the CDC, and entrust in these bureaucracies transparency, humility, and wisdom, and embark on a nationwide medical experiment, under a system that does not incorporate any elements of market feedback mechanisms, and in fact actively overrides market mechanisms.

Vaccines have performed an alchemy where it combines the worst features of the government, regulatory, and corporate systems from all perspectives (right, left, libertarian), and has combined them into a system that is then granted universal infallibility. That's remarkable.

Occam's razor: everyone's fine with vaccinating because it so obviously works and has so little downside. But you keep on with your thing, it's adorable.

What's adorable is to see people cling to their religions.

What's not simple at all, is how vaccines achieved the status of infallibility. Particularly in an age when everything is challenged and dragged into controversy. One would expect that this alone -given the universal free lunch that vaccines are, self-evident, unmitigated - this ought to be cause for celebration and consideration.

Why can't any other human endeavor that requires imposing mass behavior standards and monopoly markets achieve this status?

Again, Occam: because those other endeavors aren't as obviously effective and lacking downside.

Again, it's pretty damn remarkable that a medical achievement managed to marry empowering governments to creating private monopolies to force people to inject themselves, and what's more, it has managed to to not just survive, but thrive and expand its list of wonderful unimpeachable character and infallible results for over 50 years.

That is hardly simple at all sir. That is unprecedented in the history of mankind.

'for over 50 years'

More like over two centuries, considering that Edward Jenner came up with the word vaccination in 1796.

Or maybe over 125 years, in terms of rabies and Louis Pasteur and Émile Roux in 1885.

Again, precisely. It solved a problem before they even knew how. It emerged when the dominant science theory was the vapors.

So many bedrock ideas of science - not just medicine but physics, geology you name it - have fallen by the wayside during vaccination's uninterrupted reign.

The systematic problems with institutions, government, and corruption. Bah. Vaccination is immune to all of it.

It truly is a miracle.

So, that Pasteur guy - never heard of him either? He didn't believe in the vapors, by the way.

Oddly enough, you still probably believe his ideas concerning hand washing having something to do with micro-organisms that cause disease, even though so many bedrock ideas of science - not just medicine but physics, geology you name it - have fallen by the wayside during his germ theory's uninterrupted reign.

It gets worse! People still unquestioningly believe in gravity and Newton's Laws even though he came up with them 350 years ago when people still believed in ghosts. Heck, Newton was a blinkered alchemist, how could his theories possibly be correct?

Really weird windmill you are tilting at. Something is accepted by everyone because it's so obviously useful and true and lacking in downsides relative to its efficacy, and you call conspiracy.

+1. Excellent.

"Downsides relative to its efficacy." We'll see about that. Eventually, that will be easier to determine.

You have, like clockwork has also (even though he pretends not too), keep lumping polio in with HPV, and the dozen other vaccines on the list. as if the smallpox vaccine justifies the flu vaccine, and the polio vaccine justifies the HPV. And as if any of them justify the way we built the economic and incentives system for delivery.

My concern is not about vaccines per se, but about the system. It is rife with red flags and perverse incentives that only work if you accept the core premise of cheating death without cost - along with a massive amount of faith in the FDA and the drug companies.

'keep lumping polio in with HPV'

Well, to the extent that all represent different facets of using vaccination as a concept, sure. But you still seem to be avoiding the whole TB/smallpox aspects of vaccination too. I'm guessing we can agree, as of today, that the chickenpox vaccine is basically a waste of money whose benefits for those purchasing it are minimal (unlike you, empirical data in any direction is likely to cause me to change my opinion, though).

Vaccination lumps vaccines together. It is only when detailing specifics - links really help in this regard - that one can have a reasonable discussion. Not that you apparently can even cite the sorts of actual problems involving actual vaccines (by name) which support your argument in any sense at all.

Actually, it is pretty sad that the people you are arguing against have to provide you the information to support your position. Which just might be a hint that the people who find the concept of vaccination useful are even more aware of various flaws than you.

'how vaccines achieved the status of infallibility'

Who is claiming infalllibility? Vaccines come with a risk, obviously.

'given the universal free lunch'

Vaccines are not a free lunch, they are an attempt to prevent various diseases from occurring. That individuals may suffer side effects is not precisely a secret, but the same applies to giving an infant antibiotics. Of course, you are also welcome to talk about all the harm that antibiotics have caused since their discovery - this comment section is always reliably entertaining.

In a few years, we may not be talking about vaccines at all. In case you haven't noticed, many professionals are soiling themselves in panic over the impending resistance crisis.

No worries, super antibiotics will save the day

'In case you haven't noticed, many professionals are soiling themselves in panic over the impending resistance crisis.'

So, you just casually skipped over the term 'multidrug resistant TB'? Basically, in German maternity wards where Russian visitors can be expected (much of this region, actually), infants are vaccinated against TB within a couple of days.

'No worries, super antibiotics will save the day'

Not if we use them as stupidly as we use the current antibiotics. And for all I mock both Prof. Cowen and Prof. Tabarrok, on this subject both of them favor various restrictions and concepts in the attempt to keep current antibiotics from becoming more ineffective, which is unreservedly to their credit.

Stop baiting him, Prior

He's a nong.

Well, in all fairness, this has not been baiting, though I agree that it has become an utter waste of time.

This is the first time meeting such a believer - very depressing. And I do know German parents who did not vaccinate their children - none of them were like this.

"Not if we use them as stupidly"

What evidence do you have that we won't use everything stupidly - especially a government-mandated monopoly with a liability umbrella?

"Against stupidity the very gods themselves contend in vain." - Friedrich Schiller

'the anti-corporate-science left'

Then stick to things like Gardasil (which according to Harald zur Hausen, the German Nobel Prize winner makes serious compromises concerning effectiveness so as to increase profits - sorry, no link, he was being interviewed in German on SWR a decade or more ago).

'Except with vaccines'

You do know that many people commenting here are not Americans, right? That the U.S. is a mess in this area too is no surprise. Here is an older example that clearly demonstrates what you are concerned about - 'Anthrax vaccine shipments from BioPort have been suspended by the FDA since 1998 because of questions about the facility's quality control, forcing the Pentagon to dramatically reduce its program to vaccinate all 2.4 million U.S. soldiers and reservists against anthrax. Now the lack of the vaccine threatens to become a scandal, as the U.S. is sending thousands of soldiers overseas and calling up reserves, and as the public is clamoring for access to protection from the deadly bacterium.

After three years of getting bailed out by the Defense Department, BioPort could be poised to make a fortune -- as its CEO Fuad El-Hibri did working with the British seller of anthrax vaccine, Porton International, during the Gulf War a decade ago. But only if the FDA approves the company's renovated plant, as expected, sometime in the next week. The decision could open the door for BioPort to market the drug to a worried public, as new anthrax scares are reported daily.

The story of the troubled U.S. anthrax-vaccine program is a tangled saga of science, politics, private-sector deal-making and national security. There have been persistent questions about the vaccine's safety and effectiveness.'

'Vaccines have performed an alchemy where it combines the worst features of the government, regulatory, and corporate systems from all perspectives'

We clearly do not live in the same world. The one I live in has actually managed to eradicate smallpox and is close to eradicating polio - without relying on any such alchemy at all.

Precisely. The vaccine industry is increasingly like the Trump Presidency, its advocates must hand-wave and step around a larger and larger pile of concerns, scandals, etc, and rely on invoking platitudes, myths, and anecdotes to justify the whole pile. As if the eradication of polio (whether due to vaccines or changes in behavior or both) justifies HPV vaccines, and whatever else is coming down the pipeline.

I did misspeak on one point. There is on constituency who ought to be thrilled about vaccines (besides the bureaucrats and drug companies). That's the technology utopians. They seem happiest when concocting a new technological fix to repair the damage of the previous one. No amount of collateral damage, corruption. or unintended consequences takes them off their enthusiasm.

'The vaccine industry is increasingly like the Trump Presidency'

You do know that the world is not the U.S., right? The German vaccine industry (which is now required to indemnify those people who suffer vaccination side effects) is not like the Trump Presidency.

'its advocates must hand-wave and step around a larger and larger pile of concerns, scandals'

Not in Germany, but then, Trump isn't president here either.

'rely on invoking platitudes, myths, and anecdotes to justify the whole pile'

Or empirical data, but really, who cares about that these days, right?

'As if the eradication of polio (whether due to vaccines or changes in behavior or both) justifies HPV vaccines'

I talked about Gardasil, which if memory serves of that radio interview, only covered 2 of the 4 HPV varieties, and thus only offered 85% protection against HPV, representing the two varieties that the drug company could in some fashion claim ownership of. That was one of the points that most outraged the Nobel Prize winner, by the way. He was a passionate advocate of the benefits for women in terms of cancer prevention, and completely scornful of the makers of Gardasil for not offering it. Has it occurred to you that maybe this subject is not as black and white as you seem to wish to make it?

'That's the technology utopians.'

Yeah, nothing says technology utopia like cowpox.

'They seem happiest when concocting a new technological fix to repair the damage of the previous one.'

Do you have the noticeable imprint from a smallpox vaccination? And if you don't, ever wondered why you don't?

'No amount of collateral damage, corruption. or unintended consequences takes them off their enthusiasm.'

Don't worry, depending on the vagaries of fate concerning biological warfare during your lifetime, you just might just get to experience smallpox personally without having to worry about having been vaccinated for it. At least for a few days, that is.

I am not in Germany. If I start talking about the US Congress, will you rebut me by talking about the British Parliament?

Once again, you start talking about HPV and chickenpox, but always come back to smallpox and polio. You're as guilty as the rest on this.

'If I start talking about the US Congress, will you rebut me by talking about the British Parliament?'

Nope - in major part because as an American citizen, I am quite familiar with Congress. However, you do know that vaccination is not restricted to the U.S., right?

'Once again, you start talking about HPV and chickenpox, but always come back to smallpox and polio.'

Gardasil - less effective than possible due to corporate profit concerns. Chickenpox vaccine - apparently unbelievably overpriced, with reasonable questions about efficacy in a way that HPV vaccination does not share in terms of preventing cancer.

Smallpox - a disease that no longer exists, thus proving just how worthless vaccination is, apparently.

But don't worry, this quote seems perfect for this entire, and surprisingly illuminating, exchange -

'Ripper: Water, that's what I'm getting at, water. Mandrake, water is the source of all life. Seven-tenths of this earth's surface is water. Why, do you realize that seventy percent of you is water?
Mandrake: Uh, uh, Good Lord!
Ripper: And as human beings, you and I need fresh, pure water to replenish our precious bodily fluids.
Mandrake: Yes.
Ripper: Are you beginning to understand?
Mandrake: Yes.
Ripper: Mandrake. Mandrake, have you never wondered why I drink only distilled water, or rain water, and only pure-grain alcohol?
Mandrake: Well, it did occur to me, Jack, yes.
Ripper: Have you ever heard of a thing called fluoridation. Fluoridation of water?
Mandrake: Uh? Yes, I-I have heard of that, Jack, yes. Yes.'

You're a weird duck clock. An odd mix of discussion and troll.

'The concept of herd immunity, for what it is worth, is taking a beating.'

Well, if you mean that this empirical public health concept is taking a beating as people do not immunize their children, that is correct.

If you mean that the concept is not supported by empirical data, you are thoroughly wrong.

'and a variety of major adverse reactions, albeit statistically low in the aggregate'

One can use the German method to handle this problem - all adverse reactions to immunization are covered by the health care system, over the victim's lifetime. All adverse reactions to not being immunized, however, are the responsibility of those who chose not to have their children vaccinated. Multidrug-resistant tuberculosis of a 2 year old? - that is the parent's problem to pay for, not the health care system.

And yes, Germany is close enough to Russia that multidrug-resistant tuberculosis is considered a serious health care threat that can best be handled by vaccination - you are welcome to read about it here - This solution seems to work fairly well, actually, and did a good job stopping one of the major reasons for anti-vaxx hysteria in Germany.

And just in case you are not actually familiar with TB, here is the WHO fact sheet, leading off with this - Tuberculosis (TB) is one of the top 10 causes of death worldwide.

Like I said, there's no point in debating the efficacy or long term and indirect consequences of vaccines. I've done my homework. You've done yours. It'll be an annoying waste of time.

What i want to discuss is the question of: are vaccines indeed that perfect, that all our usual concerns about public policy systems and economic incentives - whether liberal, conservative, or libertarian - can be set aside without a second thought. That the existence of any number of red flags which would enrage and engage us in any other endeavor, can be disregarded here. That in this one case, we can set aside our distrust of [name your boogeyman here].

That's truly extraordinary. And, no, I don't trust it.

'can be set aside without a second thought'

Smallpox comes to mind as something we don't give a second thought to - oh wait, smallpox no longer kills people, does it?

'That the existence of any number of red flags which would enrage and engage us in any other endeavor, can be disregarded here'

Tuberculosis comes to mind - what number of red flags bothers you about one of the ten leading causes of death, the vast number of those deaths being preventable by a vaccine?

You would be on a lot firmer ground if you ridiculed a vaccine for something like chickenpox, as that herpes virus does not have the same potential for mass death that both smallpox and TB have demonstrated throughout human history.

'And, no, I don't trust it.'

The number of non-victims of polio since the 1950s don't care about what you trust. Especially since the U.S. has basically been polio free since 1994 - probably why people don't trust vaccines to eradicate diseases, right?

Where did I ridicule any particular disease?

But yes, the fact that the vaccine advocacy fails to differentiate between the diseases on the list - regarding their severity, the nature of the risks, the effectiveness of the vaccines, or who is at risk - is one of the red flags.

Polio, for what it's worth, started to go away about the time towns started to treat raw sewage more effectively, and people were taught to wash their hands after pooping. You know, public health programs. Probably a coincidence.

'is one of the red flags'

Well, one of your flags. I (possibly mistakenly of course) just assume people are intelligent enough to make a distinction between something like TB and chickenpox.

'vaccine advocacy'

What is vaccine advocacy? Is it something like helmet advocacy for motorcycle riders? Because to be honest, as a motorcycle rider for more than three decades, I advocate helmet wearing for all riders, even if a corporation profits from manufacturing them.

'started to go away about the time towns started to treat raw sewage more effectively'

Not a coincidence, obviously. And the eradication of smallpox also occurred alongside a broad improvement in public health programs. Oddly, that was not just 'probably' a coincidence, it basically had nothing to do with smallpox's eradication.

And as a question, considering that multidrug resistant TB is spreading, what is your public health program proposal? That WHO wants a more effective vaccine for adults is probably all too predictable in your eyes, but considering that TB has a long track record as the most deadly disease in terms of total human deaths, a few billion people are waiting for the anti-corporate-science left to provide an effective public health program to keep them from being infected from a variety of TB that is about as easily treated as TB was in 1918, before the availability of antibiotics.

You are mistaken that people make that distinction. The government does not in its promotion of vaccines. The list of mandatory vaccines does not make a distinction. The laws around exemptions do not make a distinction. The press coverage of outbreaks do not make a distinction. And the fear mongering by talking heads, PR flacks, and internet trolls do not make a distinction.

I cannot count the times I have talked about chickenpox or HPV, and had polio thrown back in my face. You've done it several times yourself: invoking polio and chickenpox like a holy incantation.

Polio and smallpox

'You are mistaken that people make that distinction.'

Not where I live, but as noted in the very first comment, the U.S. is different from other places.

'The government does not in its promotion of vaccines.'

The American government. The British government does not need to, as health care is free to anyone who suffers side effects from vaccination. In Germany, the vaccine manufacturers indemnify such cases.

'The laws around exemptions do not make a distinction.'

You might find this hard to believe, but in Germany, it is not possible to mandate vaccinations for anyone. That's right, there is no need for 'exemptions' because there are no laws requiring vaccination before attending school. Sounds like the sort of place you had never imagined could ever exist, actually. But then, Germans cannot imagine that the American government forces children to be vaccinated before they can attend school.

'chickenpox or HPV'

Is there some reason you refuse to use the more accurate term Gardasil when referring to corporate profit making creating a situation where the vaccine was less effective than possible?

Though upon checking (something you seem incapable of), I see that my memory may have been faulty - 'All three available HPV vaccines include the two most virulent strains: “Cervarix” by Glaxo-SmithKline only works against these two.' So, it is Cervarix that deserves the most scorn these days, though as the article talks about Gardasil 9, it may have been that a decade ago, Gardasil was no more effective than Cervarix.

'like a holy incantation'

And the fact that smallpow was eradicated seems like the sort of reality you wish to exorcise.

We'll see how you feel about helmets, when the government tells you that you must buy from one monopoly maker, and you can't sue him if it is faulty, and that you most by the single design the government specifies, even if a subset of the population is harmed by wearing it, and even though no one can tell you which subset will be harmed.

And in the end, helmets are a lousy analogy, because in the end, as you well know, for the majority of vaccines, you are not the beneficiary. The beneficiary may be infants or the elderly, or may be those who practice unprotected sex and don't get pap smears, or etc.

'even if a subset of the population is harmed by wearing it'

Believe it or not, there was a very detailed study decades ago concerning motorcycle accidents in California called the Hurt Report. And though this has been immensely entertaining, I will just go with memory, where the study determined that out of something like 1,000 accidents involving a rider with a helmet, in 3 cases the helmet seemed to lead to more injury, not less.

If you wish to not wear a helmet because you just might experience more injury at those odds, please be my guest.

'The beneficiary may be infants or the elderly'

One of which I already was, and the other I hope to be - you seem to have surprisingly strange perspectives, to be honest. Are you sure you are not actually a lapsed libertarian or Rand follower?

(And as a note - pap smears are to detect cancer, not prevent them. 'The Papanicolaou test (abbreviated as Pap test, also known as Pap smear, cervical smear, cervical screening or smear test) is a method of cervical screening used to detect potentially pre-cancerous and cancerous processes in the cervix (opening of the uterus or womb). Abnormal findings are often followed up by more sensitive diagnostic procedures, and, if warranted, interventions that aim to prevent progression to cervical cancer. The test was invented by, and named for, doctor Aurel Babeș and doctor Georgios Papanikolaou.'

McMike is a leftist, I doubt he was ever inclined towards libertarianism which polls around what, 3% ?

But no political group has a monopoly on idiocy.

For every McMike there’s a an Alt-Right whackjob ranting about pedophile conspiracies and tweeting excerpts from QAnon.

"Polio, for what it's worth, started to go away about the time towns started to treat raw sewage more effectively, and people were taught to wash their hands after pooping. You know, public health programs. Probably a coincidence."

I thought polio incidence started increasing exactly because people had less exposure to feces in their youth. Polio was rather rare in antiquity because of the exposure to feces throughout childhood.

Does anyone else notice the irony? For a relatively free market blog, the examples in the paper of how the US outperforms its OECD peers (actually France and the UK) are examples where the government intrudes upon individual choice. The article goes into detail on the differences in morality, but what I think is ironic is that the examples given where the US does more are examples where individual choice is more readily interfered with in the US.

Also, the paper has no data or empirical analysis at all. The only quantitative comparison of spending on public health is a reference to an OECD study. The US spends more per capita and a larger percentage of health spending on public health than elsewhere. But that is a dubious metric. The US system is so wasteful that these measures could simply be due to inefficiency in the US system and have nothing to do with any priority on public health.

If it ok to discourage smoking through taxes and higher health insurance premiums because smoking causes lung cancer, why is it not acceptable to discourage male homosexuality because the practices engaged in cause AIDS? Why should not health insurance premiums be higher for people who engage in certain sexual behaviors?

This may surprise you, but a lot of those 'behaviors' are enjoyed by women, who tend to fit the definition of 'receptive partner' amazingly well. Of course, their partners, most of whom do not have sex with men, equally enjoy the insertive role.

And since we are actually talking about public health programs, the failure of the U.S. (even with the possible morality edge noted in the paper) in terms of AIDS in comparison to European countries is notable - '“Since the start of the epidemic,” one of them says, “more than 27,000 people have died of AIDS in Germany.”

Wait, that sounds triumphantly low for a country of 80 million people. I pull out my phone and check the Centers for Disease Control and Prevention (CDC) website, which tells me that, in the United States, 636,000 people have died since the epidemic began. That’s 23 times higher than Germany, for a country with four times the population.

This makes no sense. Germany has big cities, it has gay men and sex workers and drug users, it has all the same temptations for them to be uncareful that the United States does. How could so many fewer people have died?

Maybe it’s a fluke. I visit the Public Health England website and it says 21,000 people have died of AIDS there in total. If the rates were the same as the United States, it would be 128,000.

The further down the Google-hole I go, the more mind-boggling the numbers get. Since the beginning of the epidemic, AIDS has claimed more people in New York City than in Spain, Italy, the Netherlands, and Switzerland combined.'

AIDS is not a "public health" issue. Its incidence is restricted to discrete high-risk groups engaging in certain behaviors.

If we didn't spend a cent on HIV/AIDS going forward, the incidence would probably drop to zero over time. It's basically incurable, until we figure out how to rehabilitate entire immune systems.

The real driver of for homosexual spread of HIV was the dual nature of some switches. Being both top and bottom meant that individuals were both the most likely to infect their partner (top) and to be infected by their partner (bottom). For all manner of STIs, men are vastly less likely to catch them per sex act due to biology. However, ejaculate is a bodily fluid and thus allows for direct passage of large amounts of fluid. The chain from man -> woman -> man (all with anal sex) is nowhere near as frequently transmissive on the second exchange than the first. Having people who both receive and ejaculate makes transmission far more effective.

The other thing was that, prior to the 90s, gay relationship were rarely viewed by participants as monogamous (e.g. a 1980s study found the rate of non-monogamy to be 100% in their sample); these days younger gay men are much more likely to endorse serial monogamy. This means that even if you are non-monogamous, you have to hide things and less likely to have repeated sexual contacts closely spaced in time.

Lastly, the US has had a far more active drug scene than Europe. Gay men in the 60s, 70s, and 80s reported far higher injection drug use rates than the general population. Just about the riskiest thing you can do to pass on HIV is to use dirty IV needles.

Of course riskier things exist - clotting factor replacement with untested blood or just being born to an untreated HIV+ mother. Which is why in Africa in many places by the biggest form of transmission is vertical.

HIV certainly hit harder because of massive increases in the homosexual intercourse rates of the 60s - 80s and harder still due to the confounding of IV drug use with the gay sex scene of that era. But today, HIV is sustained in poor places through prostitution and childbirth.

How do you propose to do that? It isn't something we can tax. Do you want to install panopticon cameras in every bedroom? Moreover you are wrong on your premise: homosexuality is not the problem; promiscuous sex of any kind is what spreads STDs.

Anal sex is much more likely to spread AIDS than vaginal sex. Michael Fumento documented this long ago in his 1990 book "The Myth of Heterosexual AIDs".

We ask people if they smoke and adjust health insurance premiums accordingly. Health insurance premiums could also vary based on self-reported sexual behavior, and lying could be punished as fraud.

> lower speed limits

"Speed Kills!" is a common cry, but is not particularly valid by itself. If one crashes at a higher speed, it is indeed more deadly, but the phrase completely ignores how the "if" occurred.

What's more dangerous than speed? Greater speed differential -- the difference in speeds between the lowest and fastest vehicles. Studies have shown that as speed limits are increased, the faster drivers do not go any faster, but the slower drivers do. This moves the peak of the bell bell curve higher, while making the distance from 1 SD below to 1 SD above narrower. The result is much fewer overall vehicle-to-vehicle crashes, while single-vehicle crashes increase only a little or not at all.

No matter what the speed limit is, you're far less likely to have a vehicle-to-vehicle crash if you go with the flow of traffic.

One item to read:

Durr... "bell curve," not "bell bell curve."

Control-f "metrics" yields five instances, none of them particularly informative. This article is fluff.

Why all the focus on European countries? Particularly, France and the UK. If you are looking at a model for excellent health care, Japan seems to be best case.

As dan1111 already noted, this paper is not about health care.

He is correct (though being charitable) to note that 'the claim of the paper is actually something like "The US healthcare system is horribly inefficient, but contrary to many claims, a lack of public health focus is not a major driver of this problem."'

Article states the obvious (Americans are fat, Europeans smoke more) without putting a lot of perspective on the various metrics.

The metrics the US fares poorly in (obesity, gun violence, opiod use) are much more costly, both in terms of health care system burden and life expectancy than the metrics that France/UK do a worse job managing.

Many of the US accomplishments are decades old. The current US health system discourages consumers from seeking preventive care (inconvenient access to primary care providers, high administrative burden when dealing with payers, long check-in to check-out times because you have fill out a million paper forms just for getting a check-up for a minor health problem).

As many others have mentioned, the UK and France are likely in the stone ages regarding technology health care practice/coordination (I heard a recent electronic health records implementation in the UK was extremely difficult because one of the foremost UK hospitals basically didn't have computers and printers). I believe the Nordics and Baltics are relatively advanced (Denmark has a national patient registry that all providers submit data to).

"Preventive care" is a fairy tale. It's checkups for people who are already sick or genetically pre-disposed.

"Preventive care" is diet, exercise, no smoking or drug use, and low alcohol consumption, if any.

I don't recall ever spending any significant time filling out forms on a visit to the doctor except maybe on a first visit to a new provider. Most wasted time in doctors' offices is spent waiting.

Some "public health initiatives" may give negative returns. For example: (a) almost certainly government diet propaganda for the last couple of generations, (b) very possibly propaganda in favour of mass screening for prostate cancer, breast cancer and maybe others, (c) government attempts (certainly in the UK) to strong-arm asymptomatic patients onto various pills that are unsuitable - putting women and the elderly onto statins, for example. No doubt there are other cases.

Once you get past the obvious sewers, water supply, and vaccinations, "public health" sounds awfully like a lobby looking for a livelihood. It's a pretty shaky edifice to build on the sole substantial foundation of successful anti-smoking campaigns.

Sewers and water supply are obvious low-hanging fruit but not very romantic. Idealistic people don't relish the idea of going to Haiti or Liberia to build sewage treatment plants or laying pipe for potable water.

"...the United States spends more than nearly all Organisation of Economic Co-operation and Development nations on prevention, both on a per-capita basis and as a percentage of overall health spending..." What is so shocking about this, since the US spends MORE on healthcare than any other nation as a % pf GDP...?

A first glance, why is this surprising? We would expect in most patient populations for the sickest patients to get the most preventative care expenditures. After all secondary and tertiary prevention are expected to cost more than primary prevention. The US has a variety of demographics that make our population sicker.

Secondly, public bureaucracies are good at self-enlargement. The US has one of the longest and most entrenched such bureaucracies while health care providers are still not quite to that level. I wholly expected doctors or nurses in non-preventative medicine to crowd out spending in prevention.

Lastly, I have no idea why we are using the units of measure specified here. Health care responds to PPP. Percentage wise, I expect the US naturally come out on top because being rich, we spend the lowest fraction of income on "overhead" like basic staple foods and have more discretionary funds for things like healthcare and moral signalling.

Can you lend your expertise upthread?

I’m relying on google for causes of infant mortality and differences in life expectancy.

Seems like you could weigh in.

Also the anti-vaccine insanity.

Yes, if that is typical of the sort of people who are on the left scale of American politics, I have a lot more sympathy for those who have to deal with it than before.

Though entertaining in its way, it is also more than faintly disturbing.

The data gets kinda wonky. More liberals than conservatives believe that vaccines are unsafe. Actual vaccination rates are not massively different, but the interesting thing is where those vaccination lapses are occurring. Conservative places with low vaccination rates tend to be places in the back country of Idaho - far from doctors and where following vaccine schedules may actually represent a large outlay of time and money. Liberal places with low vaccination rates tend to be some of the wealthiest liberal enclaves and some of the poorest areas dominated by ethnic minorities (the Tuskegee "experiment" still being a driving force today).

In my experience, conservatives who are not vaccinated are far more often lacking in access or knowledge. White or Hispanic liberals who are not vaccinated are far less likely to lack access or knowledge (African American liberals are more likely to cite Tuskegee to me; I have literally never met an Asian American family that has rejected vaccination).

The fact that Alabama has much better vaccination rates than California is not surprising to me. Californian liberals can typically afford to make all manner of silly choices and offset the consequences. Places like Alabama cannot and so they do not (these, however makes them far more susceptible to things that they can afford, like obesity).

Not actually reading the thread due to time concerns, I will say that infant mortality statistics are worthless for international comparison. Using the OECD data we find that the United States has the highest rates of neonatal death in the world.

Yet we also have the best neonatal hospitals in the world by the account of every neonatalogist I have ever met.

The circle is squared by the fact that we have strong selection effects on who is born. In France and most other OECD countries there are fewer sick kids brought to term. There are also reporting defects for what constitutes a "live birth" (e.g. does anencephaly count?). We also have more children born to poor mothers, to mothers with poor social support (e.g. no contact with dad, in poor neighborhoods), and to unhealthy mothers (e.g. we have one of the higher rates of gestational diabetes in the world).

To some degree this also applies to places in the US. Higher abortion, genetic testing & ultrasound rates means fewer sick kids born. More kids born to wealthy parents helps your numbers.

Everyone always think that life-expectancy-at-birth is this magical health statistic, but it is far more sensitive to who gets born (e.g. those with Edward's syndrome) in the first place.

It’s interesting that NOBODY has mentioned “harm-reduction” at all...especially as some consider it the libertarian hallmark of public health

Not according to the leftists. We are held to standards of perfection we can never meet.

How does that square with this:
Using data on 25 major American cities for the period 1900-1940, we explore the effects of municipal-level public health efforts that were viewed as critical in the fight against food- and water-borne diseases. In addition to studying interventions such as treating sewage and setting strict bacteriological standards for milk, which have received little attention in the literature, we provide new evidence on the effects of water filtration and chlorination, extending the work of previous scholars. Contrary to the consensus view, we find that none of the interventions under study contributed substantially to the observed declines in total and infant mortality.

Health seems to be driven more by some mysterious factor.

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