Category: Medicine

The chess diet

Robert Sapolsky, who studies stress in primates at Stanford University, says a chess player can burn up to 6,000 calories a day while playing in a tournament, three times what an average person consumes in a day. Based on breathing rates (which triple during competition), blood pressure (which elevates) and muscle contractions before, during and after major tournaments, Sapolsky suggests that grandmasters’ stress responses to chess are on par with what elite athletes experience.

“Grandmasters sustain elevated blood pressure for hours in the range found in competitive marathon runners,” Sapolsky says.

It all combines to produce an average weight loss of 2 pounds a day, or about 10-12 pounds over the course of a 10-day tournament in which each grandmaster might play five or six times. The effect can be off-putting to the players themselves, even if it’s expected. Caruana, whose base weight is 135 pounds, drops to 120 to 125 pounds. “Sometimes I’ve weighed myself after tournaments and I’ve seen the scale drop below 120,” he says, “and that’s when I get mildly scared.”

And this:

He has even managed to optimize … sitting. That’s right. Carlsen claims that many chess players crane their necks too far forward, which can lead to a 30 percent loss of lung capacity, according to studies in the Journal of Physical Therapy Science. And, according to Keith Overland, former president of the American Chiropractic Association, leaning 30 degrees forward increases stress on the neck by nearly 60 pounds, which in turn requires the back and neck muscles to work harder, ultimately resulting in headaches, irregular breathing and reduced oxygen to the brain.

Here is the full ESPN article, via multiple MR readers.

Free Will and the Brain

Tyler and I have been arguing about free will for decades. One of the strongest arguments against free-will is an empirical argument due to physiologist Benjamin Libet. Libet famously found that the brain seems to signal a decision to act before the conscious mind makes an intention to act. Brain scans can see a finger tap coming 500 ms before the tap but the conscious decision seems to be made nly 150 ms before the tap. Libet’s results, however, are now being reinterpreted:

The Atlantic: To decide when to tap their fingers, the participants simply acted whenever the moment struck them. Those spontaneous moments, Schurger reasoned, must have coincided with the haphazard ebb and flow of the participants’ brain activity. They would have been more likely to tap their fingers when their motor system happened to be closer to a threshold for movement initiation.

This would not imply, as Libet had thought, that people’s brains “decide” to move their fingers before they know it. Hardly. Rather, it would mean that the noisy activity in people’s brains sometimes happens to tip the scale if there’s nothing else to base a choice on, saving us from endless indecision when faced with an arbitrary task. The Bereitschaftspotential would be the rising part of the brain fluctuations that tend to coincide with the decisions. This is a highly specific situation, not a general case for all, or even many, choices.

…In a new study under review for publication in the Proceedings of the National Academy of Sciences, Schurger and two Princeton researchers repeated a version of Libet’s experiment. To avoid unintentionally cherry-picking brain noise, they included a control condition in which people didn’t move at all. An artificial-intelligence classifier allowed them to find at what point brain activity in the two conditions diverged. If Libet was right, that should have happened at 500 milliseconds before the movement. But the algorithm couldn’t tell any difference until about only 150 milliseconds before the movement, the time people reported making decisions in Libet’s original experiment.

In other words, people’s subjective experience of a decision—what Libet’s study seemed to suggest was just an illusion—appeared to match the actual moment their brains showed them making a decision.

The Atlantic piece with more background is here. A scientific piece summarizing some of the new experiments is here. Of course, the philosophical puzzles remain. Tyler and I will continue to argue.

*Never Enough: the neuroscience and experience of addiction*

That is the new and fascinating book by Judith Grisel, unlike most neuroscientists on these topics she has been addicted to many of the drugs she writes about, or at least has tried them “for real,” furthermore her book integrates her personal and scientific knowledge in a consistently interesting manner.

Here is one bit from early on:

The very definition of an addictive drug is one that stimulates the mesolimbic pathway, but there are three general axioms in psychopharmacology that also apply to all drugs:

1. All drugs act by changing the rate of what is already going on.

2. All drugs have side effects.

3. The brain adapts to all drugs that affect it by counteracting the drug’s effects.

And a tiny bit from the middle:

Excessive use of alcohol now results in about 3.3 million deaths around the world each year.  In Russia and its former satellite states, one in five male deaths is caused by drinking.  And in the United States during the period 2006 and 2010, excessive alcohol use was responsible for close to 90,000 deaths a year…

And finally:

…primates given ecstasy twice a day for four days (eight total doses) show reduction in the number of serotonergic neurons seven years later.

Definitely recommended, this will make my list for the year’s best non-fiction.

Maybe pet health care is not seeing as much cost inflation as we thought

Nationwide’s pet health insurance division has partnered with Purdue University researchers to track trends in pet insurance payouts. The researchers track a “basket” of the most commonly-utilized procedures to see how the typical veterinary visit has changed in price over time. According to their research, these ordinary expenses declined by 6 percent from January 2009 to December 2017 after adjusting for inflation.

This decrease is corroborated by less reliable sources, such as the American Pet Products Association (APPA) annual consumer spending surveys. For virtually every year tracked (accessible via web archive), cat and dog owners reported spending less money on average routine and surgical visits. The data is jumpier than the Nationwide and Purdue rigorous analysis of 30 million insurance claims but confirms an interesting – and counterintuitive – trend.  In a system where consumers and patients’ “representatives” have enough skin in the game, healthcare prices behave like they would in most other markets.

That is from Ross Marchand, “Why cats pay a lower price for CAT scans.”  Here is earlier work by Einav, Finkelstein, and Gupta about pet health care being about as inefficient as human health care.  I don’t consider this a settled issue, but it is interesting to hear a revision on what had been the most common take.

Do Extreme Rituals Have Functional Benefits?

To show their devotion to Murugan, the Hindu God of War, devotees in South India and Sri Lanka (all males) are pierced with large hooks and then hung on a festival float, as if they were toys on a nightmarish baby mobile. It’s an amazing and horrifying display not unlike Christian devotees in the Philippines who are nailed to crosses.

But what are the effects of these practices on those who undergo them? Surprisingly, positive. In, Effects of Extreme Ritual Practices on Psychophysiological Well-Being, a group of anthropologists, biologists and religious studies scholars compared measures of physiological, psychological and social well being in a small group of devotees compared to a matched sample. The group performing the ritual had no long lasting health harms but did appear to benefit psychologically through feelings of euphoria and greater self-regard and socially through higher status.

Despite their potential risks, extreme rituals in many contexts are paradoxically associated with health and healing (Jilek 1982; Ward 1984). Our findings suggest that within those contexts, such rituals may indeed convey certain psychological benefits to their performers. Our physiological measurements show that the kavadi is very stressful and high in energetic demands (fig. 2C, 2D). But the ostensibly dangerous ordeal had no detectable persistent harmful effects on participants, who in fact showed signs of improvement in their perceived health and quality of life. We suggest that the effects of ritual participation on psychological well-being occur through two distinct but mutually compatible pathways: a bottom-up process triggered by neurological responses to the ordeal and a top-down process that relies on communicative elements of ritual performance (Hobson et al. 2017).

Specifically, the bottom-up pathway involves physical aspects of ritual performance related to emotional regulation. Ritual is a common behavioral response to stress (Lang et al. 2015; Sosis 2007), and anthropological evidence shows that in many cultures dysphoric rituals involving intense and prolonged exertion and/or altered states of consciousness are considered as efficient ways of dealing with various illnesses (Jilek 1982). In our study, those who suffered from chronic illnesses engaged in more painful forms of participation by enduring more piercings. Notably, higher levels of pain during the ritual were associated with improvements in self-assessed health post-ritual. Although the pain was relatively short-lived, there is evidence that the social and individual effects of participation can be long-lasting (Tewari et al. 2012; Whitehouse and Lanman 2014).

The sensory, physiological, and emotional hyperarousal involved in strenuous ordeals can produce feelings of euphoria and alleviation from pain and anxiety (Fischer et al. 2014; Xygalatas 2008), and there is evidence of a neurochemical basis for these effects via endocrine alterations in neurotransmitters such as endorphins (Boecker et al. 2008; Lang et al. 2017) or endocannabinoids (Fuss et al. 2015). These endocrine effects are amplified when performed collectively, as shown by studies of communal chanting, dancing, and other common aspects of ritual (Tarr et al. 2015). While it is uncertain how long-lasting these effects are, such euphoric experiences may become self-referential for future well-being assessment.

At the same time, a top-down pathway involves social-symbolic aspects of ritual. Cultural expectations and beliefs in the healing power of the ritual may act as a placebo (McClenon 1997), buffering stress-induced pressures on the immune system (Rabin 1999). In addition, social factors can interact with and amplify the low-level effects of physiological arousal (Konvalinka et al. 2011). Performed collectively, these rituals can provide additional comfort through forging communal bonds, providing a sense of community and belonging, and building social networks of support (Dunbar and Shultz 2010; Xygalatas et al. 2013). The Thaipusam is the most important collective event in the life of this community, and higher investments in this ritual are ostensibly perceived by other members as signs of allegiance to the group, consequently enhancing participants’ reputation (Watson-Jones and Legare 2016) and elevating their social status (Bulbulia 2004; Power 2017a). Multiple lines of research suggest that individuals are strongly motivated to engage in status-seeking efforts (Cheng, Tracy, and Henrich 2010; Willard and Legare 2017) and that there is a strong positive relationship between social rank and subjective well-being (Anderson et al. 2012; Barkow et al. 1975). Indeed, we found that individuals of lower socioeconomic status were more motivated to invest in the painful activities that can function as costly signals of commitment. Recent evidence from a field study in India shows that those who partake in these rituals indeed reap the cooperative benefits that result from increased status (Power 2017b).

In addition, the cost of participation can have important self-signaling functions. On the one hand, it can boost performers’ perceived fitness and self-esteem, which positively affects mental health (Barkow et al. 1975). On the other hand, through a process of effort justification, such costs can strengthen one’s attachment to the group and sense of belonging (Festinger 1962; Sosis 2003). This role of costly rituals in generating positive subjective states (Bastian et al. 2014b; Fischer et al. 2014; Wood 2016) and facilitating social bonding (Bastian, Jetten, and Ferris 2014a; Whitehouse and Lanman 2014) may offer insights into the functions of painful religious practices.

The mind has an amazing ability to turn what would be torture under some scenarios into something else.

Hat tip: Kevin Lewis.

Alexey Guzey on progress in the life sciences

I already linked to this piece, but wanted to recommend it again.  I don’t agree with all of the points, but it has many excellent arguments, here is one excerpt from the opening section:

I think that the perception of stagnation in science – and in biology specifically – is basically fake news, driven by technological hedonic treadmill and nostalgia. We rapidly adapt to technological advances – however big they are – and we always idealize the past – however terrible it was.

I mean – we can just go to Wikipedia’s 2018 in science (a) and see how much progress we made last year:

  • first bionic hand with a sense of touch that can be worn outside a laboratory
  • development of a new 3D bioprinting technique, which allows the more accurate printing of soft tissue organs, such as lungs
  • a method through which the human innate immune system may possibly be trained to more efficiently respond to diseases and infections
  • a new form of biomaterial based delivery system for therapeutic drugs, which only release their cargo under certain physiological conditions, thereby potentially reducing drug side-effects in patients
  • an announcement of human clinical trials, that will encompass the use of CRISPR technology to modify the T cells of patients with multiple myeloma, sarcoma and melanoma cancers, to allow the cells to more effectively combat the cancers, the first of their kind trials in the US
  • a blood test (or liquid biopsy) that can detect eight common cancer tumors early. The new test, based on cancer-related DNA and proteins found in the blood, produced 70% positive results in the tumor-types studied in 1005 patients
  • a method of turning skin cells into stem cells, with the use of CRISPR
  • the creation of two monkey clones for the first time
  • a paper which presents possible evidence that naked mole-rats do not face increased mortality risk due to aging

Doesn’t seem like much? Here’s the kicker: this is not 2018. This is January 2018.

Are Health Administrators To Blame?

The graph at right made the twitter rounds a few days ago (1.3k RTs and 2.7k likes for Noah). The graph looked off to me immediately. Between approximately 1992 and 1994 the number of administrators went up by a factor of 4? (Or, if something goes from a 500% growth since 1970 to a 2000% growth rate since 1970, is that a factor of 3? Confusing! Anyway, a big jump.) Big jumps are often a sign that definitions, not reality, have changed. Indeed, what is an administrator?

There’s another problem with this type of graph which shows not absolute numbers but percent growth since 1970. Everything in this graph depends on getting one number, the number of administrators in 1970, exactly correct! But the first number is the one that is the farthest in the past, often the hardest to find and the most suspect. But if that first number is underestimated then every other number in the chart is overestimated.

People send me this kind of thing all the time. “See,” they say, “Why are the Prices So D*mn High is wrong! It isn’t Baumol!”–and I am always reluctant to follow-up because tracking down the underlying data, figuring out what it means, if there are mistakes etc. is a huge time sink. It was the excellent Conversable Economist who go the ball rolling on the latest iteration of this graph, however, and he cites the graph to noted health economist Uwe Reinhardt’s last book, Priced Out so I thought it could be worthwhile to go deeper.

Unfortunately, Reinhardt simply calls this a “famous graph” and it’s clear that he just found it on the internet like everyone else! Oh dear. Following up further, I did find the original Woolhandler-Himmelstein analysis written in 1991 and taking the data up to 1987. WH cite the Statistical Abstract of the United States  (Table 64-2, 109th edition). You can find the SA 109th edition here but it doesn’t have the data. At least, I couldn’t find it. Ok, several hours wasted.

Finally, however, I did find a number for health administrators in an earlier edition of the SA. In the 1980 edition in Table 165, Employed Persons in Selected Health Occupations, there is a number for “Health administrators,” which says 118 thousand in 1972. Aha! Now things are beginning to make sense because from that same table there were at least 3.5 million workers (physicians, nurses, technicians and others) in health occupations and 118 thousand administrators is clearly far too low. Indeed, in a later paper Woolhandler, Campbell and Himmelstein estimate that in 1969, 18.2% of health care workers were in administration which would imply a figure of 639 thousand health administrators circa 1970, a much more plausible number.

The Woolhandler, Campbell and Himmelstein piece also finds that between 1989 and 1994 the share of health care administrators as a percent of the health care workforce increased from 25.5% to….wait for it….25.7%. In other words, no big jump and inconsistent with the huge jump seen in the graph.

It was at this point that I found Kevin Drum’s excellent analysis. Drum was also suspicious of the graph and after a lot of work he concludes that the graph exaggerates by at least a factor of 3 and probably more. Drum estimates an increase in administrators of 831%; using my initial number and Drum’s end number, I estimate an increase of 682%. All numbers to be taken with a grain of salt. Is that a big increase? Compared to what? Drum gives his best takeaway of the data as this graph, administration costs as a percent of health care costs :

I agree with Drum–this way of presenting the data looks plausible, sensible and much less sensationalist than the original graph. Note that there has been an increase in administrative costs. Why? Here’s Drum’s bottom line:

Bottom line: the health care system has grown tremendously over the past 50 years, but that’s mostly not because we have a lot more doctors. It’s because we have MRI techs and ultrasound specialists and more kinds of nurses and more kinds of pills and enormous proton beams to cure cancer. (Those proton beams are massively expensive and require large staffs, but that doesn’t mean you need any more oncologists per patient.) To manage all this new stuff, we need bigger admin and support staffs. As a result, admin and support have grown about 50-100 percent on a relative basis. That’s the real number.

I believe the original graph uses a number for administrators that is too low in 1970 and includes what I suspect was a change in definitions around 1992 (project the 1970 to 1990 line forward or the 1994 to 2009 line backward and you will get a more accurate graph.) More generally, the graph is misleading because it suggests that “administrators” are to blame for high health care costs and if only we could focus on the “real producers” of medicine, the physicians, costs would be much lower. Blaming administrators for high prices is a lot like blaming “the middlemen.” It’s easy to say and easy to tweet but blaming the middlemen reflects a naive perspective on how goods and services are actually produced in a modern economy.

Administrative costs in the United States are high compared to other countries like Canada. (Helland and I discuss this in Why are the Prices So D*mn High.) We might even be able to lower administrative costs by moving to a single-payer, universal system. But there is no free lunch and there is no returning to an administrative free Eden.

What should I ask Ben Westhoff?

I will be doing a Conversation with him, no associated public event, here is from his home page:

Ben Westhoff is an award-winning investigative journalist who writes about culture, drugs, and poverty. His books are taught around the country and have been translated into languages all over the world.

His new book Fentanyl, Inc.: How Rogue Chemists Are Creating the Deadliest Wave of the Opioid Epidemic releases September 3, 2019 in the U.S. (Grove Atlantic) and October 10, 2019 in the UK, Austrailia, and New Zealand (Scribe). Here’s more information.

His previous book Original Gangstas: Tupac Shakur, Dr. Dre, Eazy-E, Ice Cube, and the Birth of West Coast Rap has received raves from Rolling Stone and People, a starred review in Kirkus, a five-star Amazon rating, and made numerous year-end best lists. More info can be found here.

…his 2011 book on southern hip-hop, Dirty South: OutKast, Lil Wayne, Soulja Boy, and the Southern Rappers Who Reinvented Hip-Hop was a Library Journal best seller.

Here is my review of his excellent forthcoming Fentanyl, Inc.  He also has a well-acclaimed book on New York City bars and dives.  All of his work is fascinating.

So what should I ask him?

Patient Empowerment and the Collective Action Problem

In an insightful paper with human interest but also public policy implications Jasmin Barman-Aksözen writes:

My parents and I searched throughout my entire childhood for an explanation of why I frequently had unbearable burning pain after spending even short periods of time outdoors on a sunny day. This pain was incapacitating and often left me in agony for days, during which I was unable to go to school, to sleep, to tolerate even weak light exposure, or the body heat of my parents as they tried to comfort me. Not a single pain killer provided any relief, and the only option for me was to wait alone in a darkened and cooled room until the pain sub-sided. Of course, we tried everything that physicians recommended; still, not even high sun protection factor sunscreens helped prevent the symptoms despite the fact that they were obviously caused by sunlight. It must have been hard for my parents to see me in such a painful state without being able to alleviate or prevent it. What’s more, the worst thing was that classmates, teachers, and even physicians did not believe me when I told them about the symptoms; I even brought photographs showing myself with swollen and burnt hands and face. Yet, this didn’t stop some from making fun of me when I wore long clothing, hats, or used an umbrella on sunny days to protect myself from the sun’s rays. Eventually, after I was sent to see a psychologist for my “made-up symptoms,” I could no longer tolerate the derision and being treated with such condescension, and decided to stop sharing my experiences with healthcare professionals altogether.

Finally, a full 26 years after the first symptoms, Dr Google provided the answer! In April 2006, I found myself yet again unable to sleep because, despite all precautionary measures taken, I had burnt myself in the strong sunlight of spring. I entered the combination of my symptoms in the Google search mask and, surprisingly, there was a new link in Wikipedia with an expression I had not encountered before “Erythropoietic Protoporphyria.”

The made-for-tv aspect continues as Barman-Aksözen earns a PhD, moves to Switzerland to join the world’s leading lab studying these issues and, yes, develops the first effective treatment!

Afamelanotide was approved for the treatment of adult EPP patients in the European Union (EU) at the end of 2014.

But now is where reality and public policy step back in.

In April 2019, most EPP patients in Europe, however, still do not have access to the only treatment for their condition and are still unnecessarily suffering from fre-quent excruciating pain, social isolation, and impaired life choices. What went wrong? Before a newly approved medicine reaches patients, most European countries per-form a Health Technology Assessment (HTA) to evaluate the benefits in relation to the costs of the new product in order to support decisions on whether it should be reimbursed by the respective national health systems.

Getting the drug approved is only the first step. Now they have to get the medical authorities to pay for it and that means they have to show the drug is not only effective but cost effective given the disability. Barman-Aksözen goes on to describe her efforts to get the drug approved for actual use. She doesn’t put it this way but essentially she has to solve the collective action problem and form a lobbying group to make the case that patients with her disease, EPP, face a serious disability. It’s easy to measure death, however, but hard to measure the “disability weight” on say blindness. The WHO says blindness has a disability weight of .195 today, but in 2004 they gave it a weight of 0.594. Hmmm. One study of Afamelanotide suggests it has a cost of £373,000 per DALY averted, which is high, even though the article recommends adoption. Many meetings ensue in which the case for and against Afamelanotide is made. The process is slow. Years go by. Much depends on seemingly minor choices in how to present the data.

I was reminded of Mancur Olson’s discussion in the Rise and Decline of Nations:

Distributional coalitions make decisions more slowly than the individuals and firms which they comprise [and] tend to have crowded agendas and bargaining tables…The accumulation of distributional coalitions increases the complexity of regulation, the role of government, and the complexity of understandings, and changes the direction of social evolution.

In other words, socializing health care means socializing decisions about how to allocate health care. A difficult tradeoff.

Addendum: The FDA has yet to approve Afamelanotide.

Hat tip: Joe P.

Scotland Trainspotting fact of the day

Last year there were 1,187 drug-related deaths in Scotland, a record, and a staggering increase of 27 percent from the year before. Overdoses are more common in Scotland, by some measures, than even in the United States.

And:

Scotland wasn’t always the “sick man of Europe.”

Until around 1950, life expectancy there was on par with most of Western Europe, or better. But after World War II, things in Scotland improved more slowly than in any other Western European country.

If you would like an anecdote:

Mr. Nugent had been using the drug on and off since he was 19, but overdosed the first time he shot up again. He has overdosed three more times since last year.

“I’ve nearly died four times,” said Mr. Nugent, who turns 43 this month. “It’s getting harder for me to recover as I get older.”

Here is the full NYT story by Allison McCann.

Mortality Change Among Less Educated Americans

The bottom of the educational distribution is doing very very poorly:

Changing mortality rates among less educated Americans are difficult to interpret because the least educated groups (e.g. dropouts) become smaller and more negatively selected over time. New partial identification methods let us calculate mortality changes at constant education percentiles from 1992–2015. We find that middle-age mortality increases among non-Hispanic whites are driven almost entirely by changes in the bottom 10% of the education distribution. Drivers of mortality change differ substantially across groups. Deaths of despair explain a large share of mortality change among young non-Hispanic whites, but a small share among older whites and almost none among non-Hispanic blacks.

That is from Paul Novosad and Charlie Rafkin.

Falling prices for generic pharmaceuticals

We find the chained direct-out-of-pocket CPI for generic prescription drugs declines by about 50% between 2007 and 2016, while the total CPI [what the dispensing pharmacy receives, the difference being generated by co-pay rates] falls by nearly 80% over the same time period. The smaller decline in the direct out-of-pocket CPI than in the total CPI is due in part to consumers’ increasingly moving away from fixed copayment benefit plans to pure coinsurance or a mixed package of coinsurance and copayments. While consumers are experiencing more cost sharing that in fact shifts more of the drug cost burden on to them, on balance in the US consumers have experienced substantial price declines for generic drugs.

That is from a new NBER working paper by Richard G. Frank, Andrew Hicks, and Ernst R. Berndt.

Air Pollution Kills

In recent years I have substantially increased my estimate of the deadly nature of air pollution. It’s not that I had a contrary opinion earlier but the number and range of studies showing surprisingly large effects has raised this issue in relative importance in my mind. I would not have guessed, for example, that the introduction of EZ Pass could reduce pollution near toll booths enough to reduce the number of premature and low birth weight babies. I also find the following result hard to believe yet also hard to dismiss given the the accumulating body of evidence. Diane Alexander and Hannes Schwandt find that Volkswagen’s cheating diesel cars increased the number of low birth weight babies and asthma rates. Here are some details:

In 2008, a new generation of supposedly clean diesel passenger cars was introduced to the U.S. market.These new diesel cars were marketed to environmentally conscious consumers, with advertising emphasizing the power and mileage typical for diesel engines in combination with unprecedented low emissions levels. Clean diesel cars won the Green Car of the Year Award in 2009 and 2010 and quickly gained market share. By 2015, over 600,000 cars with clean diesel technology were sold in the United States. In the fall of 2015, however, it was discovered that these cars covertly activated equipment during emissions tests that reduced emissions below official thresholds, and then reversed course after testing. In street use, a single “clean diesel” car could pollute as much nitrogen oxide as 150 equivalent gasoline cars.Hereafter, we refer to cars with “clean diesel” technology as cheating diesel cars.

We exploit the dispersion of these cheating diesel cars across the United States as a natural experiment to measure the effect of car pollution on infant and child health. This natural experiment provides several unique features. First, it is typically difficult to infer causal effects from observed correlations of health and car pollution, as wealthier individuals tend to sort into less-polluted areas and drive newer, less-polluting cars. The fast roll-out of cheating diesel cars provides us with plausibly exogenous variation in car pollution exposure across the entire socio-economic spectrum of the United States. Second, it is well established that people avoid known pollution, which can mute estimated impacts of air pollution on health (Neidell, 2009). Moderate pollution increases stemming from cheating diesel cars, a source unknown to the population, are less likely to induce avoidance behaviors, allowing us to cleanly estimate the full impact of pollution. Third, air pollution comes from a multitude of sources, making it difficult to identify contributions from cars, and it is measured coarsely with pollution monitors stationed only in a minority of U.S. counties. This implies low statistical power and potential attenuation bias for correlational studies of pollution (Lleras-Muney, 2010). We use the universe of car registrations to track how cheating diesel cars spread across the country and link these data to detailed information on each birth conceived between 2007 and 2015. This setting provides rich and spatially detailed variation in car pollution.

We find that counties with increasing shares of cheating diesel cars experienced large increases both in air pollution and in the share of infants born with poor birth outcomes. We show that for each additional cheating diesel car per 1,000 cars—approximately equivalent to a 10 percent cheating-induced increase in car exhaust—there is a 2.0 percent increase in air quality indices for fine particulate matter (PM2:5) and a 1.9 percent increase in the rate of low birth weight. We find similar effects on larger particulates (PM10; 2.2 percent) and ozone (1.3 percent), as well as reductions in average birth weight (-6.2 grams) and gestation length (-0.016 weeks). Effects are observed across the entire socio-economic spectrum, and are particularly pronounced among advantaged groups, such as non-Hispanic white mothers with a college degree. Effects on pollution and health outcomes are approximately linear and not affected by baseline pollution levels. Overall, we estimate that the 607,781 cheating diesel cars sold from 2008 to 2015 led to an additional 38,611 infants born with low birth weight. Finally, we also find an 8.0 percent increase in asthma emergency department (ED) visits among young children for each additional cheating diesel car per 1,000 cars in a subsample of five states.

Another surprising result is that on a global scale air pollution reduces life expectancy more than smoking. In part, because a single individual can’t quit air pollution.

Globally, the AQLI reveals that particulate pollution reduces average life expectancy by 1.8 years, making it the greatest global threat to human health. By comparison, first-hand cigarette smoke leads to a reduction in global average life expectancy of about 1.6 years. Other risks to human health have even smaller effects: alcohol and drugs reduce life expectancy by 11 months; unsafe water and sanitation take off 7 months; and HIV/AIDS, 4 months. Conflict and terrorism take off 22 days. So, the impact of particulate pollution on life expectancy is comparable to that of smoking, twice that of alcohol and drug use, three times that of unsafe water, five times that of HIV/AIDS, and more than 25 times that of conflict and terrorism.

Which of these claims is false?

The Democratic-controlled House just voted to abolish the “Cadillac tax” on employer-supplied health plans.

The Independent Payments Advisory Board no longer exists, having been abolished with support from both parties.

In the public option for Democratic-controlled Washington State, reimbursement rates were set at up to 160 percent of Medicare levels.

Single-payer health care will save America a great amount of money.

*The Body: A Guide for Occupants*

That is the title of the new Bill Bryson book, and it delivers in all the ways you would expect a Bryson book to do.  Here is one sample paragraph:

Before penicillin, the closest thing to a wonder drug that existed was Salvarsan, developed by the German immunologist Paul Ehrlich in 1910, but Salvarsan was effective against only a few things, principally syphilis, and had a lot of drawbacks.  For a start, it was made from arsenic, so was toxic, and treatment consisted in injecting roughly a pint of solution into the patient’s arm once a week for fifty weeks or more.  If it wasn’t administered exactly right, fluid could seep into muscle, causing painful and sometimes serious side effects, including the need for amputation.  Doctors who could administer it safely became celebrated.  Ironically, one of the most highly regarded was Alexander Fleming.

By the way:

…the average grave is visited for only about fifteen years…

You can pre-order the book here, I would be interested to read more about Bryson’s work, writing, and research habits.