Category: Medicine
Carrying opioids in legal imports?
The U.S. opioid crisis is now driven by fentanyl, a powerful synthetic opioid that currently accounts for 90% of all opioid deaths. Fentanyl is smuggled from abroad, with little evidence on how this happens. We show that a substantial amount of fentanyl smuggling occurs via legal trade flows, with a positive relationship between state-level imports and drug overdoses that accounts for 15,000-20,000 deaths per year. This relationship is not explained by geographic differences in “deaths of despair,” general demand for opioids, or job losses from import competition. Our results suggest that fentanyl smuggling via imports is pervasive and a key determinant of opioid problems
That is from a new NBER working paper by Timothy J. Moore, William W. Olney, and Benjamin Hansen. One core lesson seems to be that interdiction is largely a futile endeavor.
*Saints, Scholars, and Schizophrenics*
The author of this excellent book is Nancy Scheper-Hughes, and the subtitle is Mental Illness in Rural Ireland. One of the most interesting themes of this book is how life in rural Ireland became so “de-eroticized,” to use her word. Here is one bit:
Marriage in rural Ireland is, I suggest, inhibited by anomie, expressed in a lack of sexual vitality; familistic loyalties that exaggerate latent brother-sister incestuous inclinations; an emotional climate fearful of intimacy and mistrustful of love; and an excessive preoccupation with sexual purity and pollution, fostered by an ascetic Catholic tradition. That these impediments to marriage and to an uninhibited expression of sexuality also contribute to the high rates of mental illness among middle-aged bachelor farmers is implicit in the following interpretations and verified in the life history materials and psychological tests of these men.
And:
In the preceding pages I have drawn a rather grim portrait of Irish country life, one that differs markedly from previous ethnographic studies. Village social life and institutions are, I contend, in a state of disintegration, and villagers are suffering from anomie, of which the most visible sign is the spiraling schizophrenia. Traditional culture has become unadaptive, and the newly emerging cultural forms as yet lack integration. The sexes are locked into isolation and mutual hostility. Deaths and emigrations surpass marriages and births.
Recommended. This seminal book, republished and revised in 2001, but originally from the 1970s, would be much harder to write and publish today.
England is underrated, a continuing series
The UK has said it will refrain from regulating the British artificial intelligence sector, even as the EU, US and China push forward with new measures. The UK’s first minister for AI and intellectual property, Viscount Jonathan Camrose, said at a Financial Times conference on Thursday that there would be no UK law on AI “in the short term” because the government was concerned that heavy-handed regulation could curb industry growth.
Here is more from the FT. And also from the FT: “UK approves Crispr gene editing therapy in global first.“
The Amazing Vernon Smith
You can find Vernon Smith hard at work at his computer by 7:30 each morning, cranking out 10 solid hours of writing and researching every day.
His job is incredibly demanding — he is currently on the faculty of both the business and law schools at Chapman University. But the hard work pays off: Smith’s research is consistently ranked as the most-cited work produced at the school — a testament to his ongoing academic influence and success. He manages his job and research work while also coauthoring books and traveling around the country to deliver lectures.
It’s a remarkable level of productivity, made all the more remarkable by one simple fact: Vernon Smith is 96 years old.
Smith, who was awarded the Nobel Prize in Economic Sciences at the tender age of 75, says he feels the same passion as he did then, and even as he did when he embarked on his career more than seven decades ago.
That’s from the AARP on SuperAgers. In addition to all that, Vernon “is one of 1,600 participants in the University of California, Irvine’s 90+ Study, a research project examining both successful aging and dementia in people age 90 and older.”
Vernon was always one of our sharpest and most productive colleagues. He remains an inspiration.
Pharmaceutical Price Controls and the Marshmallow Test
The pharmaceutical market is in turmoil. On the one hand we have what looks like a golden age of medicine with millions of lives saved by COVID vaccines, a leap in mRNA technology, excellent new obesity and blood sugar drugs, breakthroughs in cancer treatments and more. On the other hand, the Inflation Reduction Act includes the most extensive price controls on pharmaceuticals we have ever seen in the United States.
In Washington-speak the “Inflation Reduction Act” requires HHS to “negotiate” drug prices for Medicare Part D and Part B to establish a maximum “fair” price. In reality there is no negotiation–firms who refuse to negotiate are hit with huge taxes. The “negotiation,” if you want to call it that, is “your money or your life” and fairness has little to do with it. The IRA also requires very costly inflation rebates, i.e. a price control/tax. In essence, the IRA is a taking; for drugs with a large Medicare market it is similar to abrogating patents to 9 years for small molecule drugs and 13 years for biologics. For the included drugs there will be a significant reduction in revenues. Moreover, we don’t yet know whether the plan will be extended to more and more drugs. There is significant uncertainty affecting the entire market. What will be situation in 10 years? Will the US be like Europe?
Reduced revenues mean less R&D. The value of extending life is very high and so in my view medical R&D is underprovided. Thus, price controls are taking us in the wrong direction.
The positive effects of price controls are immediate and easy to see: Prices are reduced.
The negative effects of price controls take time and are harder to see. Namely:
- Fewer drugs for Medicare market.
- Less research on post-approval indications and confirmatory trials.
- Reduced incentive for generics to enter quickly.
- Most importantly: Less R&D spending leading to fewer new drugs, a reduced pharmaceutical armory, lower life expectancy and higher morbidity. By one calculation, ~135 fewer new drugs through to 2039 (see also here and here and here and here).
- Fewer new drugs means more spending on physicians and hospitals so in the long run price controls may not even save money! (Most prescriptions are for generics. Drugs fall greatly in price when they go generic but physicians and hospitals never go generic!)
Price controls are a classic example of political myopia. Price controls, like rent controls and deficit financing, have modest benefits now and big future costs and thus they are supported by politicians who want to be elected now. Unfortunately, current citizens don’t forecast the future well and future citizens don’t have a vote so it’s easy to create big future costs without engaging an opposition.
The emergence of groundbreaking pharmaceuticals and the increasing implementation of price controls are probably related trends. Everyone wants the great new pharmaceuticals without paying for them. We need to think more long-term–we have much more to gain from a continuing flow of new pharmaceuticals than from lower prices on the last generation. Don’t forget that children who fail the marshmallow test do less well later in life. Well, our government is failing the marshmallow test, big time.
Pharmaceutical price controls driven by myopia and the failure to delay gratification are greatly harming future patients.
Are dementia rates falling?
A study published in 2020, which drew together multiple pieces of research to track the health of almost 50,000 over-65s, showed the incidence rate of new cases of dementia in Europe and North America had dropped 13 per cent per decade over the past 25 years — a decline that was consistent across all the studies.
For Albert Hofman, who chairs the department of epidemiology at the Harvard TH Chan School of Public Health, the research points to one conclusion: “The absolute risk [of developing dementia] is lower now” than it was 30 years ago. Now, there are early signs that the same phenomenon may be emerging in Japan, a striking development in one of the world’s most aged populations, suggesting that the downward trend is becoming more widespread…
While emphasising that the reasons for the reduction in incidence are not yet fully understood, Hofman believes better cardiovascular health is likely to be a significant factor given the proven links between the two.
Here is more from Sarah Neville at the FT. Maybe that is where the Flynn effect has been hiding!
Covid vaccines and mortality
The global COVID-19 vaccination campaign is the largest public health campaign in history, with over 2 billion people fully vaccinated within the first 8 months. Nevertheless, the impact of this campaign on all-cause mortality is not well understood. Leveraging the staggered rollout of vaccines, we find that the vaccination campaign across 141 countries averted 2.4 million excess deaths, valued at $6.5 trillion. We also find that an equitable counterfactual distribution of vaccines, with vaccination in each country proportional to its population, would have saved roughly 670,000 more lives. However, this distribution approach would have reduced the total value of averted deaths by $1.8 trillion due to redistribution of vaccines from high-income to low-income countries.
That is from a new NBER working paper by Virat Agrawal, Neeraj Sood, and Christopher M. Whaley.
The culture (polity?) that is Dutch
Several people with autism and intellectual disabilities have been legally euthanized in the Netherlands in recent years because they said they could not lead normal lives, researchers have found.
The cases included five people younger than 30 who cited autism as either the only reason or a major contributing factor for euthanasia, setting an uneasy precedent that some experts say stretches the limits of what the law originally intended.
In 2002, the Netherlands became the first country to allow doctors to kill patients at their request if they met strict requirements, including having an incurable illness causing “unbearable” physical or mental suffering.
Between 2012 and 2021, nearly 60,000 people were killed at their own request, according to the Dutch government’s euthanasia review committee. To show how the rules are being applied and interpreted, the committee has released documents related to more than 900 of those people, most of whom were older and had conditions including cancer, Parkinson’s and ALS.
Here is the full story.
A Genius Award for Airborne Transmission
One of the strangest aspects of the pandemic was the early insistence by the WHO and the CDC that COVID was not airborne. “FACT: #COVID19 is NOT airborne.” the WHO tweeted on March 28, 2020, accompanied by a large graphic (at right). Even at that time, there was plenty of evidence that COVID was airborne. So why was the WHO so insistent that it wasn’t?
Ironically, some of the resistance to airborne transmission can be traced back to a significant achievement in epidemiology. Namely, John Snow’s groundbreaking arguments that cholera was spread through water and food, not bad air (miasma). Snow’s theory took time to be accepted but when the story of germ theory’s eventual triumph came to be told, the bad air proponents were painted as outdated and ignorant. This sentiment was so pervasive among physicians and health officials that anyone suggesting airborne transmission of disease was vaguely suspect and tainted. Hence, the WHOs and CDCs readiness to label airborne transmission as dangerous, unscientific “misinformation” promulgated on social media (see the graphic). In reality, of course, the two theories were not at odds as one could easily accept that some germs were airborne. Indeed, there were experts in the physics of aerosols who said just that but these experts were siloed in departments of physics and engineering and not in medicine, epidemiology and public health.
As a result of this siloing, we lost time and lives by telling people that they were fine if they kept to the 6ft “rule” and washed their hands, when what we should have been telling them was open the windows, clean the air with UVC, and get outside. Windows not windex.
Linsey Marr at Virginia Tech was one of the aerosol experts who took a prominent role in publicly opposing the WHO guidance and making the case for aerosol transmission (Jose-Luis Jimenez was another important example). Thus, it’s nice to see that Marr is among this year’s MacArthur “genius” award winners. A good interview with Marr is here.
It didn’t take a genius to understand airborne transmission but it took courage to put one’s reputation on the line and go against what seemed like the scientific consensus. Marr’s award is thus an award to a scientist for speaking publicly in a time of crisis. I hope it encourages others, both to speak up when necessary but also to listen.
Addendum: I didn’t take part in the aerosol debates but my wife, who has done research in aerosols and germs, told me early on that “of course COVID is airborne!” Wisely, I chose to take the word of my wife over that of the WHO and CDC.
“Does Paid Sick Leave Facilitate Reproductive Choice?”
I might give the paper a slightly different title, but:
Unlike most advanced countries, the U.S. does not have a federal paid sick leave (PSL) policy; however, multiple states have adopted PSL mandates. PSL can facilitate healthcare use among women of child−bearing ages, including use of family planning services such as contraception, in−vitro fertilization, or abortion services. Use of these services, in turn, can increase or decrease birth rates. We combine administrative and survey data with difference-in-differences methods to shed light on these possibilities. Our findings indicate that state PSL mandates reduce birth rates, potentially through increased use of contraception but not changes in abortion services. We offer suggestive evidence of heterogeneity in birth rate effects by age, education, and race. Our findings imply that PSL policies may help women balance family and work responsibilities, and facilitate their reproductive choices.
That is a new NBER working paper by Johanna Catherine, Maclean, Ioana Popovici, and Christopher J. Ruhm.
They are solving for the equilibrium
The Affordable Care Act of 2010 limited the profits of health insurers to between 15% and 20% of collected premiums, depending on the size of the health plan. But it imposed no restrictions on what physicians or other intermediaries can earn. The law created an incentive for insurers to buy clinics, pharmacies and the like, and to steer customers to them rather than rival providers. The strategy channels revenue from the profit-capped insurance business to uncapped subsidiaries, which in theory could let insurers keep more of the premiums paid by patients.
According to Irving Levin Associates, a research firm, between 2013 and August 2023 the nine health-care giants spent around $325bn on over 130 mergers and acquisitions.
Here is more from The Economist.
The Effect of Organizations on Physician Prescribing Opioids
Here is one of the more important IO papers in recent times:
In theory, there are several reasons why physician organizational form might affect the price, quantity, and quality of physician services. In this paper, we examine the effect of three aspects of physician organizational form on opioid prescribing: the number of physicians in the physician’s group (if any); the physician’s integration with or employment by a hospital or hospital system; and the average age of the other physicians in the physician’s group. We present three key findings. First, all else held constant, group physicians prescribe far fewer opioids, and prescribe them more appropriately, than do solo physicians. Second, although physicians who are employed by a hospital or practice in a hospital-owned group prescribe fewer opioids than do independent physicians, there is evidence that this difference may be due to differences in the other characteristics of physicians who are hospital-integrated rather than a causal effect. Third, we find substantial peer effects on opioid prescribing. Physicians in groups with a higher average age (excluding the physician him- or herself) prescribe more intensively and are more likely to write inappropriate opioid prescriptions than physicians in younger groups – holding constant the physician’s own age and other characteristics of his or her group.
That is from a new NBER working paper by M. Kate Bundorf, Daniel Kessler, and Sahil Lalwani.
What is an Emergency? The Case for Rapid Malaria Vaccination
Compare two otherwise similar towns. In Town A there have always been 1000 deaths every month from disease X. In contrast, Town B has been free of disease X for as long as anyone can remember until very recently when disease X suddenly started to kill 1000 people per month. A vaccine for disease X is developed. Which town should receive expedited vaccinations?
From a utilitarian perspective, both towns present equally compelling cases for immediate vaccination (1). Vaccination will avert 1,000 deaths per month in either location. The ethical imperative is thus to act swiftly in both instances. Lives are lives. However, given human psychology and societal norms, Town B is more likely to be perceived as facing an “emergency,” whereas Town A’s situation may be erroneously dismissed as less dire because deaths are the status quo.
A case in point. The WHO just approved a malaria vaccine for use in children, the R21/Matrix-M vaccine. Great! There are still some 247 million malaria cases globally every year causing 619,000 deaths including 476 thousand deaths of children under the age of 5. That’s not 1000 deaths a month but more than 1000 deaths of children every day. The WHO, however, is planning on rolling out the vaccine next year.
Adrian Hill, one of the key scientists behind the vaccine is dismayed by the lack of urgency:
“Why would you allow children to die instead of distributing the vaccine? There’s no sensible answer to that — of course you wouldn’t,” Hill told the Financial Times. The SII said it “already” had capacity to produce 100mn doses annually.
…“There’s plenty of vaccine, let’s get it out there this year. We’ve done our best to answer huge amounts of questions, none of which a mother with a child at risk of malaria would be interested in.”
Hill is correct: the case for urgency is strong. More than a thousand children are dying daily and the Serum Institute already has 20 million doses on ice and is capable of producing 100 million doses a year. Why not treat this as an emergency?! Implicitly, however, people think that the case for urgency in Africa is weak because “what will another few months matter?” The benefits of vaccination in Africa are treated as small because they are measured relative to the total deaths that have already occurred. In contrast, vaccination for say COVID in the developed world (Town B) ended the emergency and restored normality thus saving a large percent of the deaths that might have occurred. But the percentages are irrelevant. This is a base rate fallacy, albeit the opposite of the one usually considered. Lives are lives, irrespective of the historical context.
Hill, director of the university’s Jenner Institute, compared the timeframe with the swift rollout of the first Covid vaccines, which were distributed “within weeks” of approval.
“We’d like to see the same importance given to the malaria vaccine for children in Africa. We don’t want them sitting in a fridge in India,” he said. “We don’t think this would be fair to rural African countries if they were not provided with the same rapidity of review and supply.”
The term “emergency” inherently embodies the conundrum I highlight. Emergency is defined as an unexpected set of events or the resulting state that calls for immediate action. When formulating a response to an emergency, however, the focus should not be on whether the events were unexpected but on the resulting state. The resulting state is what is important. The resulting state is the end that legitimizes the means. The unexpected draws our attention–our emotional systems, like our visual systems, alert on change and movement–but what matters is not what draws our attention but the situational reality.
Lives are lives and we should act with all justifiable speed to save lives. The WHO should accelerate malaria vaccination for children in Africa.
(1) You might argue that in Town B the 1000 deaths are more unusual and thus more disruptive but you might also argue that Town A has undergone the deaths for so much longer that the case for speed as matter of justice is even greater. These are quibbles.
Cost-benefit analysis of marijuana legalization
We analyze the effects of legalizing recreational marijuana on state economic and social outcomes (2000–20) using difference-in-differences estimation robust to staggered timing and heterogeneity of treatment. We find moderate economic gains and accompanied by some social costs. Post-legalization, average state income grew by 3 percent, house prices by 6 percent, and population by 2 percent. However, substance use disorders, chronic homelessness, and arrests increased by 17, 35, and 13 percent, respectively. Although some of our estimates are noisy, our findings suggest that the economic benefits of legalization are broadly distributed, while the social costs may be more concentrated among individuals who use marijuana heavily. States that legalized early experienced similar social costs but larger economic gains, implying a potential first-mover advantage.
That is from a new paper by Jason Brown, Elior Cohen, and R. Alison Felix, via the excellent Kevin Lewis.
The “Deaths of Despair” narrative is somewhat wrong
Matt Yglesias does an excellent job laying out the case against the “deaths of despair” narrative and putting it bluntly.
Over the past few years, Anne Case and Angus Deaton have unleashed upon the world a powerful meme that seems to link together America’s troublingly bad life expectancy outcomes with a number of salient social and political trends like the unexpected rise of Donald Trump.
Their “deaths of despair” narrative linking declining life expectancy to populist-right politics and to profound social and economic decay has proven to be extremely powerful. But their analysis suffers from fundamental statistical flaws that critics have been pointing out for years and that Case and Deaton just keep blustering through as if the objections don’t matter. Beyond that, they are operating within the confines of a construct — “despair” — that has little evidentiary basis.
…Novosad, Rafkin, and Asher have provided a compelling analysis of a very concentrated problem of worsening health outcomes for the worst-off Americans. Case and Deaton, by contrast, have delivered a very misleading portrait of worsening health outcomes for the majority of Americans that (because they mistakenly think it’s a majority) they attribute to broad economic forces that exist internationally but which for some reason only cause “despair” in the United States.
…The point is that we face a set of discrete public health challenges that we need to think about both as policy matters and in terms of politics and public opinion. But there is no “despair” construct driving any of this, and the linkage to big picture political trends is simply that Republicans are more hostile to regulation. Case and Deaton, meanwhile, have sent us on the equivalent of a years-long wild goose chase away from well-known ideas like “smoking is unhealthy” or “it would be good to find a way to get fewer people to use heroin.”
I tend to agree with Matt but I would offer a few cautions. Case and Deaton have been too broad in identifying the at-risk population. Identifying more carefully the at-risk group(s) is important so that we can target different problems with different solutions. Indeed, part of what makes the very important opioid crisis so bedeviling is precisely that it is not limited to “despairing” populations but cuts across many groups.
I wouldn’t, however, throw out despair as an organizing principle. The evidence on “despair” goes beyond death to include a host of co-morbidities such as mental stress, marriage rates, labor force participation rates and other measures of well being. Regardless of the precise population to which these problems attach they are co-morbidities and I suspect not by accident. Education is a proxy for the underlying problem but likely not causal. Matt’s cheeky suggestion to promote ideas like “smoking is unhealthy” illustrates part of the issue. Education and information will not solve that problem. Smokers know that smoking is unhealthy but they do it anyway–perhaps because it’s one of the few easily available pleasures if you are unmarried, out of work and stressed.
Nevertheless, do read the whole thing.