Category: Medicine
Does Costco Cause Cancer?
In December 2025, researchers led by Yazan Alwadi at Harvard’s T.H. Chan School of Public Health published a paper in Environmental Health that claimed to find that cancer incidence increased for people living closer to nuclear power plants in Massachusetts. In March, the same researchers published an expanded nationwide study claiming a similar result—this time looking at cancer mortality rates, rather than incidence—in Nature Communications. This was followed by a paper in the Journal of Exposure Science & Environmental Epidemiology that looked at associations of lung, breast, and colon cancers. Most recently, a study of total mortality, not just cancer, was published in the European journal Environmental Epidemiology.
The problem? Using the same methods pretty much everything causes cancer. An amazing takedown from Deric Tilson and Adam Stein:
For instance, living near a private four-year university is associated with a 15-fold increase in cancer mortality when compared to living near a nuclear power plant.
Costco has the largest effect of all the locations we have tested. Over 2.2 million cancer deaths can be attributed to Costco; that’s more than 20% of all cancer deaths between 2000 and 2018. Hot dogs, bulk spices, and reasonably priced clothes come with a cost.
What went wrong?
[The authors] chose nuclear power plants because a story could be built around that framework. When the researchers got positive results across our nation’s nuclear power plants, they didn’t check what their shiny new methodology would do using other landmarks. This is their pitfall: by taking the easy way out—getting results and making up a story around those results without double-checking their method—the authors could have no idea that what they were actually capturing was the methodology itself.
…The attributable number of deaths from this methodology is probably zero, but the attributable number of bad papers is at least four.
Do the elderly prefer robotic care?
The Japanese elderly, to be clear:
Population aging and shortages of long-term care workers have increased interest in care-giving robots and information and communication technology (ICT). This paper provides novel large-scale evidence on older individuals’ perceptions of such technologies, drawing on a custom-designed internet survey of 4,314 Japanese individuals aged 55 to 75. Respondents choose between two otherwise identical nursing homes: one in which all care is provided by human caregivers, and one in which robots and ICT are used to provide a substantial share of care in one randomly assigned domain (communication, monitoring, or mobility assistance), while other care remains human-provided. A majority of respondents (65 percent) prefer nursing homes where robots and ICT are used. Acceptance differs substantially across care domains: It is highest for mobility assistance, intermediate for monitoring, and lowest for communication. The average willingness to pay (WTP) for a nursing home where robots and ICT provide a substantial share of care is sizable, at 8 percent above the typical nursing home fee. Prior awareness of caregiving robots is positively associated with both acceptance and WTP, pointing to the potential role of information in shaping older individuals’ preferences. Acceptance and WTP are also strongly associated with sentiments toward robots and ICT expressed in attitude questions, providing support for the internal consistency of survey responses. A back-of-the-envelope calculation offers suggestive evidence that the benefits of introducing robots and ICT can be much larger than the costs, in particular for mobility-aid robots.
From a recent paper by Bertrand Achou, et.al.
Did the ACA reduce mortality?
Many of us brought up related points at the time, but basically we were booed off the reservation:
While recent research has provided evidence that the Medicaid expansions of the Affordable Care Act (ACA) reduced mortality, there is no evidence on the effect of the Affordable Care Act (ACA) net of the Medicaid expansions on mortality. This is an important gap in knowledge because the ACA significantly increased health insurance coverage in non-expansion states. In this article, we exploit the large increase in health insurance coverage brought forth by the ACA to examine the effect of the ACA and Medicaid expansions on mortality. Unlike prior studies that relied solely on geographic variation in Medicaid expansions to estimate the net effect of the expansion, we use a novel empirical approach that allows us to investigate the effect of the ACA net of Medicaid expansion on mortality, the incremental effect of the Medicaid expansion, and the overall effect of the ACA including Medicaid expansion. We use longitudinal data from the NHIS Linked Mortality Files (LMF) and a nationally representative sample of 40 to 58-year-olds combined with a difference-in-differences and a difference-in-differences-in-differences research design to obtain estimates of the effect of the ACA on mortality. We find no evidence that the Medicaid expansions had a beneficial effect on mortality but do find that the ACA net of Medicaid expansion reduced mortality.
That is from a new NBER working paper by
Is there now a better trend in youth mental health?
A key U.S. government report on mental health, substance use and addiction showed continued improvements in several metrics, especially among young people.
There was some uncertainty about the future of the National Survey on Drug Use and Health last year, when the entire 17-member team responsible for it was laid off by the Trump administration. But the Substance Abuse and Mental Health Services Administration released the latest report Monday, with data that lets researchers look at trends from 2021 to 2025.
Fewer adolescents aged 12 to 17 reported using tobacco, alcohol, marijuana and binge drinking in the previous month, the survey found.
And in the past year, fewer in that age group reported:
— illicit drug and marijuana use
— starting drinking alcohol, vaping or marijuana
— substance, alcohol or drug use disorders
Adolescents also saw declining trends for major depressive episodes and fewer reported serious thoughts of suicide, making a suicide plan and attempting suicide.
Here is the link, via Chris Ferguson.
No Doing, No Learning
A regulation that raises gasoline prices makes people angry but when regulation prevents an industry from ever existing, most people never learn what they lost.
Consider nuclear power. Overnight construction costs for early U.S. demonstration reactors fell 81 percent between 1954 and 1968. For reactors begun between 1967 and 1972, costs rose 187 percent. The 1971 Calvert Cliffs decision and then the reaction to Three Mile Island in 1979 accelerated the cost increases and slowed construction even more.
What might have happened had the earlier learning and deployment trends continued? Peter Lang’s 2017 paper in Energies estimates that nuclear power would have cost about one-tenth as much by 2015. The additional generation could have avoided as many as 9.5 million premature deaths.
The number is staggering even if quartered. Millions of deaths. Yet, the graveyard was both invisible and silent.
(Furthermore, climate change would not be a problem today had nuclear power not been handicapped.)
The nuclear story you probably know but Niko McCarty has an excellent new Works in Progress piece on an invisible graveyard of technology that I knew almost nothing about.
In the 1980s, officials decided to regulate engineered microbes under the Toxic Substances Control Act, a law written for industrial chemicals. Microbes swap genes all the time, but EPA treats them as “new” whenever DNA is introduced from another genus. As a result, even a marker gene used simply to identify successfully edited cells can trigger review if it remains in the organism. McCarty reports that researchers filed more than 240 applications between 1987 and 2018: “Only a few were ever approved for widespread use.”
What have we lost? We can’t know for sure but among the plausible losses McCarty discusses are engineered bacteria that detect buried explosives, microbes that extract rare-earth metals and improved plastic-digesting enzymes. Similarly, Chernia et al. write:
Promising many societal benefits, emergent products of biotechnology involve releasing genetically modified microbes (GMMs) into the environment. However, regulatory challenges limit their use. So far, GMMs have mainly been tested in agriculture and environmental cleanup, with few approved for commercial purposes. Current government regulations inadequately address modern genetic engineering and limit the potential of gut therapeutics, skin products, self-repairing materials, ocean pollution treatment, anti-corrosion coatings, etc.
And those are just some of the plausible first-stage losses. Perhaps even more importantly, we learn by doing. Thus, no doing, no learning. The first approved product is rarely the safest or the best but when we fail to approve the first we don’t get the much better 5th. Forty years of that process could have taken us well beyond the applications McCarty describes. We must build to build better.
Nuclear power at least left us enough reactors to get some idea of what we lost. With microbes, I needed McCarty to tell me there was something missing even though I study these issues for a living. And note one reason new microbe loss was invisible. No vote was ever taken. No debate was ever had. Officials in the 1980s reasoned that genomes are made of chemicals and chemicals are covered, and that doctrine has governed the field ever since despite being overly broad and excessively costly.
How many other gaps in our technology have explanations buried in the Federal Register?
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Here is a video version of this post. Which do you like better?
Could our preoccupation with mental health be part of the problem?
Could our preoccupation with mental health be part of the problem?
In some ways, encouraging people to think and talk more about their mental health is a good thing. There is now less stigma around mental illness, and more people who can benefit from professional help are getting it. But there is also reason to believe that efforts to bring attention to mental health struggles are inadvertently making us more vulnerable to psychological distress.
Start with our expanding conception of mental illness. The more fixated we are on mental health, the more sensitive we become to anything that might qualify as a symptom and the more we use clinical language to describe normal emotional experiences like grief, burnout and loneliness. This broadening of what we think counts as a disorder — known as concept creep — encourages us to pathologize ordinary life and see ourselves as mentally unhealthy.
Here is more from Clay Routledge at the NYT.
The demand for human enhancement technologies
When a new technology promises large private benefits but may impose social costs that markets do not price, demand need not reveal how citizens want it governed. We examine this using a nationally representative U.S. survey experiment (N=5,556) on human enhancement technologies (HET). The experiment randomizes benefit domain, mechanism, heritability, purpose, and risk across vignettes; for each respondent’s assigned vignette, we elicit stated adoption, preferred regulation, and ethical and societal concerns. Overall, about 53% would adopt. Framing the technology as enhancing rather than restorative lowers adoption by about five percentage points, as much as a severe side-effect profile. About 28% would not adopt at any benefit. This refusal is driven overwhelmingly by the enhancing framing rather than by risk, consistent with a non-compensatory constraint for a substantial subgroup. Most who would adopt still favor strict regulation, and most who would never adopt do not wish to forbid others from doing so. Productivity enhancement generates the most ethical concern of any attribute but attracts the least regulation, and respondents favor subsidizing rather than taxing its adoption, consistent with a concern about access rather than safety. Private demand is therefore an unreliable guide to the governance citizens want, and the divergence we document provides a basis for regulators seeking to align the direction of technical change with societal values and priorities.
That is from a new NBER working paper by . And I will repeat this segment: “Productivity enhancement generates the most ethical concern of any attribute…” Do note of course that the last sentence of the authors is completely unwarranted, and is a classic example of underidentified political bias in academic reasoning.
Talk Therapy is Speech
IJ: On Wednesday, the United States District Court for the District of Columbia struck down a D.C. law that barred therapists from other jurisdictions from doing online teletherapy visits with clients in D.C. The decision comes nearly six years after Virginia-based counselor Elizabeth Brokamp teamed up with the Institute for Justice (IJ) to file a lawsuit arguing the law violated the First Amendment.
“This decision is a victory for anyone who speaks for a living,” said IJ Deputy Director of Litigation Robert McNamara. “Elizabeth’s victory here confirms that the First Amendment protects useful speech, including counseling, and that licensing boards can’t censor speech simply because someone doesn’t have their permission to talk.”
Congrats to the IJ! Now, we need to get rid of all the other bans on patients hiring physicians from other states. As I wrote last year:
During the pandemic, many restrictions on telemedicine were lifted, making it far easier for physicians to treat patients across state lines. That window has largely closed. Today, unless a doctor is separately licensed in a patient’s state—or the states have a formal agreement—remote care is often illegal. So if you live in Virginia and want a second opinion from a Mayo Clinic physician in Florida, you may have to fly to Florida, unless that Florida physician happens to hold a Virginia license.
The standard framing says this is a problem of physician licensing. That leads directly to calls for interstate compacts or federalizing medical licensure. Mutual recognition is good. Driver’s licenses are issued by states but are valid in every state. No one complains that Florida’s regime endangers Virginians. But mutual recognition or federal licensing is not the only solution nor the only way to think about this issue.
The real issue isn’t who licenses doctors. It’s that patients are forbidden from choosing a licensed doctor in another state. We can keep state-level licensing, but free the patient. Let any American consult any physician licensed in any state. That’s competitive federalism—no compacts, no federal agency, just patient choice.
Hat tip: Joel Selanikio.
The economic effects of GLP-1s
We estimate the causal impacts of GLP-1 treatment on labor market outcomes using linked Danish administrative data and a matched stacked difference-in-differences design. We compare patients who initiate GLP-1 treatment during the first two years of Semaglutide availability to observably similar patients who initiate four years later. We find that GLP-1 treatment reduces long-term sickness leave by 17.3%. We estimate total fiscal benefits of GLP-1 initiation of approximately 1.3–1.5% of annual labor income per employed individual. We do not detect statistically significant or economically meaningful impacts on income, labor force participation, or employment over four years.
That is from a new NBER working paper by
The Trump Administration’s Threat to Scientific Research
In The Nationalization of American Science I warned that the Trump administration’s rewriting of the seemingly mundane Regulation for Federal Financial Assistance was a tremendous threat to America’s historically successful decentralized system of science funding. Many others are now sounding the alarm.
It’s not surprising that organizations like the AAAS oppose the rule, albeit with unusually strongly worded dissents:
This latest move is a brazen power grab by the Director of the Office of Management and Budget to buck the will of Congress and the American people and will make future discoveries less likely. If this rule becomes final, Americans’ hopes for future cures, national security and economic strength will rely on the scientific sensibilities of the nation’s chief bureaucrat. Alzheimer’s disease will not be cured by a budget analyst from either political party.
But we are now seeing strong pushback from independent thinkers such as:
Grayson Logue writing at The Dispatch:
A sweeping new rule proposed by the Trump administration could remake how that money is awarded and give the president and his political appointees discretion to cancel funding or target recipients for virtually any reason—with little opportunity for recourse.
White House officials argue the new rule is necessary to assert more accountability over federal grantmaking, but observers fear the shift will expand opportunities for politicization, abuse, and even corruption for an administration that has already demonstrated a penchant for using the levers of the federal government to punish partisan enemies and reward ideological allies.
if I was trying to ruin American leadership in scientific research this is pretty much the kind of rule I would write…One of the genuine difficulties with observing the second Trump term is that the assault on state capacity and impartiality has been so multipronged that it is difficult to keep track of everything going on. But these proposed rule changes are monumental and catastrophic.
and Noah Smith:
MAGA’s attack on science is even worse than it looks…despite science’s overwhelming popularity and public trust, Trump and his administration are launching an unprecedented and devastating attack on American science — cutting funding, and forcing science projects to undergo ideological review by government commissars.
It may be that the Trump administration has pushed too far, but my real worry is that we are losing an equilibrium. Science was never completely independent of politics, of course, but even at the worst of times, funding was decentralized and the culture-war material that dominated the headlines was never more than a tiny fraction of the whole. Like an independent judiciary, independent science has been an American virtue. COVID policy, gender policy, and now the Trump administration’s weaponization of these mistakes may have destroyed that equilibrium.
As I wrote in my original post, we are adopting the loser policies of authoritarian nations but those policies are the norm elsewhere for a reason. Centralized control of science is the default because it serves the people in power of whatever party. Decentralization is the fragile exception—a historically unusual achievement that is easier to destroy than rebuild.
Addendum: And here is Andrew Gelman.
Progress against dementia
Mr Stallard has been working for a decade to corroborate this revelation. His findings have, if anything, become even more striking. Last year he and some colleagues published research in the Journal of the American Medical Association showing that, whereas 40 years ago three in every ten Americans aged 85-89 had dementia, by 2024 just one in ten had it (see chart 1). What is more, America is not the only beneficiary of this trend. Between 1988 and 2015 the share of older people being diagnosed with dementia fell by 13% a decade across six countries in North America and Europe, according to a study of almost 50,000 people by Frank Wolters of the Erasmus Medical Centre in Rotterdam, and colleagues.
Some smaller studies have also found big declines. Data from the Framingham Heart Study, which has tracked three generations in an American town, show an average drop in new dementia cases of 20% per decade over almost 40 years between the late 1970s and early 2010s. Those who were entering their dotage when Daft Punk’s “Get Lucky” was topping the charts (2013) were 44% less likely to have dementia than those who were doing so when Sting was urging Roxanne to switch off her red light (1978).
Whereas most earlier studies had simply pooled elderly people and then applied a statistical adjustment for age, Mr Stallard looked at narrow bands of ages to compare different cohorts of people over 50 years. By examining the changes between each successive cohort, he calculates that dementia rates have been declining by 2.5-3% for each calendar-year cohort.
Here is more from Jonathan Rosenthal at The Economist. You can think of this as the new instantiation of the Flynn Effect…
Single-payer health care systems are looking worse all the time
That is the theme of my latest Free Press piece, here is one excerpt from it:
Government-run systems often (not always) do a perfectly fine job setting a broken arm or administering a long-standing, well-known medication. They do much less well when it comes to developing, financing, and delivering a new immunological approach to fighting cancer, personalized to your individual genome at a cost of hundreds of thousands of dollars. In our rapidly arriving biomedical future, innovation capacity will matter above all else. And though they may not see it today, the people with the most life ahead of them will reap nearly all of the benefits of a dynamic system, or suffer the consequences of a paralytic one.
Thirty years ago, it was often debated whether the Canadian or British healthcare systems were better than what we have in the U.S. After all, they offered a kind of guaranteed access to health services. The details could differ, but often the healthcare had no upfront price or only a low user fee. In America, in contrast, healthcare was more expensive, there were many millions of uninsured people, and dealing with sometimes rapacious insurers and hospitals could involve significant emotional trauma.
But over time the British and Canadian systems look worse and worse. The queues and rationing have increased, as giving healthcare away for free makes it hard to satisfy demands in a timely manner. In Canada, for instance, the median wait time has risen from 9.3 weeks in the early 1990s to 28.6 weeks today. In the British National Health Service, only 65.3 percent of patients start treatment within 18 weeks.
Worse yet, both of those systems are undercapitalized. In Britain, healthcare is badly understaffed and underfunded. Yet the country already has high taxes, high debt, and slow economic growth, so it is not clear where the new money will come from to recapitalize the system.
And this sentence:
This entire dynamic will be intensified as the pace of medical innovation picks up.
Your life may depend on it.
Will future biomedical advances be low marginal cost?
Most pharmaceuticals involve high upfront costs, to discover and test the drug, and very low marginal costs. Another pill can be printed almost for free.
That cost structure favors health systems, such as that of Britain, that try to pay lower for services. They can end up getting a relatively good deal from price discrimination. After all, they can be served at low marginal cost, at least for those ttreatments.
Now imagine a biomedical future where many more treatments are based on the sequencing of your individual genome, and then the development of specific treatments personalized to you. Obviously it will depend on developments, but very likely those remedies will have relatively high marginal costs.
In that setting the British approach to health care procurement and pricing will work less well. It is the well-capitalized, “overspending” systems, such as the United States, that will have an easier time making the adjustment.
“The rising relative advantage of well-capitalized health care systems” is a neglected trend, because it makes a lot of earlier elite pronouncements about health care economics look a bit off.
GLP-1 drugs and marriage
GLP-1 medications generate large weight loss and may also alter social and economic outcomes. Using the Understanding America Study, I compare women starting GLP-1s for weight loss with matched women who would like to start a GLP-1 but have not. Single women’s marriage/cohabitation rates rise by 29 percentage points and employment among baseline non-employed women rises 27 percentage points after six or more quarters. Existing partnerships do not dissolve, and already-employed women show no upward job mobility. The pattern suggests that part of the female obesity penalty operates at new-match formation rather than only through health or incumbent productivity.
Here is the paper by Rebecca Diamond. And here is a thread on the paper. And not everyone believes the size of these estimates. I do not find them so crazy? Here is Steven’s dialogue with GPT.
Two Roads to Fast Clinical Trials, and the US Takes Neither
The HHS (FDA, NIH, ARPA-H and related agencies) is moving to speed clinical trials in what they are calling Operation TrialBlazer (kudos on the pun). The motivator, of course, is China:
China has made biotechnology a strategic national priority, systematically expanding its clinical research infrastructure with government backing, streamlined regulatory pathways, and sustained investment. In 2021, China’s global share of Phase 1 trials surpassed the United States’ share for the first time, a milestone that would have seemed unlikely just a decade earlier. And in 2024, China surpassed the United States in the total number of clinical trials registered, with over 7,100 registered, representing 39% of global trials…. For certain cutting edge modalities, including cell and gene therapy, radioligand therapy, and stem cell therapy, China uses investigator-initiated trials to provide additional flexibility, though with some tradeoffs around oversight and quality control. This means that drugs can move into human testing if a researcher has an interest and funding. In the U.S., comparable trials might wait years to start.
I am also pleased to see that they mention Australia, another advanced democracy, as a leader in clinical trial regulation:
Australia’s Clinical Trial Notification System allows trials to begin in fewer than 70 days after a final protocol is submitted, with regulatory approval granted in as little as 21 to 28 days and sites activated within 6 to 12 weeks.
Keep those comparisons in mind. Operation TrialBlazer proposes some good reforms such as CMC clarification. CMC is Chemistry, Manufacturing, and Controls–and it deals with the basics of manufacturing a drug. The FDA, however, is very risk averse and companies know that so they have often gone overboard in CMC: for example, proving stability of a formula at 6+ months when the trial is to last only a few weeks or documenting their full commercial manufacturing process before they even know if the drug works and knowing full-well that the process will be changed many times before a drug actually gets to market. In short, a lot of cost for very little benefit. The FDA is now clarifying that this kind of thing is not necessary. Good, that is low-hanging fruit. There are other good ideas as well.
But note what they are not proposing. Despite using China and Australia as exemplars they are not going down either path. Where China is fastest is in cell therapy, gene therapy, radioligand, and stem cell work and in these areas, China lets trials proceed on an investigator-initiated basis: as the TrialBlazer document puts it, a drug can move into humans “if a researcher has an interest and funding.” China then combines this open (or lax) front end (for these products) with an all-of-government industrial policy to accelerate winners.
The US is declining to go down that path. Ok, not my call, but I get it. But they are also declining to follow Australia. In Australia there is also no government prospective regulatory evaluation of most early-phase clinical trials. Under the Clinical Trial Notification (CTN) scheme, the sponsor submits their protocol package to a Human Research Ethics Committee (HRECs)–Australia’s IRBs–and once the ethics committee approves, the sponsor notifies the regulator, the Therapeutic Goods Administration (TGA), and pays a fee. The TGA does not read and clear the package before the trial starts. The roughly 21-to-28-day “approval” and sub-70-day start figures in the document are fast precisely because the regulatory step is not an evaluation. The government regulator stays out of the front end for most clinical trials, although in direct contrast with China it does step in for the highest risk biologicals. China has decided, high-risk, high-reward.
Australia does certify the certifiers, the HRECs. Europe uses a similar system for medical device approval. It’s a system proposed by former medical officer at the FDA Henry Miller and one I have long supported for the US. China is more laissez-faire.
The US architecture in contrast rests on the “gold standard” FDA reviews and the “FDA will retain full regulatory authority and decision-making.” In short, all of the TrialBlazer reforms are about making the gatekeeper faster, cheaper to prepare for, and less uncertain. None of it is about getting rid of the gatekeeper.
Addendum: Full disclosure, I did some consulting with ARPA-H on related work. See also my previous post on the a radical deregulatory approach, Montana’s SB535 and a Potential Biotech Renaissance in America