Category: Medicine

Why we feel overloaded, and can it be fixed?

The real source of our frustration is signaling with "face time." 

People — and not only at work — get insulted if they are dealt with in peremptory fashion, even when the issue at hand can be resolved quickly.  Imagine a visiting professor comes to give a seminar, but you can’t find time for lunch.  Lunch would have been chit-chat anyway, but now the professor feels you don’t value his research  — or him — very much.  Can you imagine such vanity?  And if others perceive your time as important, they want it all the more.

What are some possible solutions to this problem?  After all, a day has only twenty-four hours and your face has (one hopes) only one side.

1. Pretend that some other privilege you offer (hand kisses? birthday cards?) is extremely costly to you.  Offer this other privilege in lieu of large amounts of time.

2. Pretend to be busier than you are.  Let people believe — perhaps truthfully — that everyone else receives even less time.

3. Pretend your time is unimportant.  (NB: This may involve dressing down.)  The hope is that no one will feel slighted if they don’t get much time.  Who feels slighted not to be given free thumb tacks?  But there exists another equilibrium, in which the neglected person feels all the more insulted.  After all, you are not giving away even your crummy low-value time.

4. Tell people you are autistic, or that you have Asperger’s syndrome.

I await your suggestions in the comments.

Don’t put your faith in a central Tamiflu stockpile

Countries around the world are stockpiling Tamiflu, in anticipation of a possible avian flu pandemic.  This is better than doing nothing, but Tamiflu is unlikely to protect most of us, should a pandemic arrive.  Here are a few reasons why:

1. Tamiflu must be taken within the first two days of symptoms.  Your chance of getting some Tamiflu that quickly, in a pandemic, will not be great (of course you could buy some on your own).

2. Tamiflu, if taken preventively, can prevent you from getting sick in the first place.  But you would need two tablets each day.  Only essential medical personnel, and select  politicians, are likely to receive such treatments.

3. You show up at the emergency room with avian flu, and then they have to decide where you stand on the priority list.  Will the hospital fear a lawsuit?  How long will this take?  Will it require federal or regulatory clearance?

4. Given the crush of the infected, will you be afraid to show up at the emergency room in the first place?  Maybe you just have the common cold.  See point #1.

5. Many Tamiflu supplies will be exhausted on false alarms, such as colds and other flus.

6. A Tamiflu stockpile is only good for a few years.  If avian flu does not come soon, do you expect the stockpile to be replenished?  Or would avian flu become the new "swine flu", never to be uttered by politicians again?  The avian flu threat will likely be with us for at least ten years, in the form of a bird "flu reservoir" for possible mutation.

7. There is some chance that the virus will develop Tamiflu immunity over time, especially if Tamiflu is applied indiscriminately at the early stages of a pandemic.

8. Let’s say the virus arrives first in California.  Will Tamiflu supplies all be sent that way at first?  Will they ever later be shipped back to Kansas?  How much of the stockpile — an inevitable political football — will be available at any point in time?

Did I mention that the U.S. won’t be getting any more new Tamiflu for at least two years?  Right now we only have 4.3 million courses.

Comments are open.  Yes we should buy more Tamiflu, but we need to think harder about what else to do as well.

Should we confiscate Tamiflu property rights?

Tamiflu can combat avian flu, but the Swiss company Roche can’t get us more Tamiflu for well over a year.  They won’t (can’t?) set up a U.S. manufacturing plant for almost two years.  (Face it, in a pinch neither the Swiss nor anyone else will export much Tamiflu, no matter what the previous agreement.)  Roche holds a patent on Tamiflu but India will go ahead and produce a generic version; Taiwan has been making similar noises.  What should we do?  Here is one argument for producing generic tamiflu.  Andrew Sullivan concurs.

I suggest a different approach.  Let’s offer Roche a large prize for speeding up the construction of the U.S. plant.  This can include legal and regulatory waivers (Bush already has suggested this idea).  We also make it clear upfront that if a pandemic comes, the U.S. government will purchase Tamiflu doses at a relatively high price.  This latter round of payments can be made upfront, with a refund to the government if no pandemic arrives.  Ex post, the government distributes the doses for free, with medical workers and key individuals in the supply chain (food, transportation, Typepad) given priority.

Note how avian flu differs from AIDS.  AIDS is a relatively slow acting condition and the possibility of disease hangs around for decades.  Avian flu, if it becomes a pandemic, will likely come and go in a few waves of a few months each, spread out over a year or two.  That makes the case for abrogating property rights weaker.  The key question is not price but whether you have a stockpile at all.

We should not focus on avian flu to the exclusion of other emergencies, including bioterrorism.  Avian flu is just one possible pandemic of many.  If we confiscate property rights this time around, there won’t be a Tamiflu, or its equivalent, next time.  We also need to stop taxing our vaccine-producing infrastructure through liability law.

Respecting Tamiflu property rights would supply an international public good as well.  Many other countries will confiscate Tamiflu property rights.  If the U.S. holds the line, we are subsidizing global R&D and doing a greater service for the world than our critics are willing to admit.

Addendum: The worthier-than-ever Daniel Drezner notes that no country is well prepared for avian flu.  Comments, by the way, are open, please stick to the subject at hand.

Prediction markets for the flu

In many asset markets the very phenomenon of market trading appears to increase volatility. Richard Roll did some empirical studies of exogenously determined market closings (occasionally various exchanges have closed for brief periods for purely technical reasons, such as catching up on paperwork or upgrading systems). Price volatility was higher across periods when markets where open than when markets where shut. In essence you draw inferences from watching other people trade, other people draw inferences from your inferences, and so on. The “dialogue” embedded in the market makes the price bounce around, even when it hones in on a better mean forecast.

Note further that most meta-rational people should not trade (economists refer to no-trade theorems). When you trade, you should always ask why you think you know more than the person you are trading with. Not every trader in the market as a whole can meta-rationally conclude that she knows more than the other traders. Yes you might trade for liquidity to put your kids through college, but I suspect that most trading in prediction markets is or would be opinion-based. It is especially prone to hubris and irrationality, which again contributes to volatility.

Here is the paradox. We need volume for the price to tell of much about market conditions. But volume is based on irrationality to large extent. Most people — the uninformed — should simply park their money about forget about active trading. And the remaining informed cannot so easily trade against each other.

Prediction markets may be least well-suited for predicting terrorist attacks. Tracking an excessively volatile price could create worry and perhaps sometimes panic. What will happen each time the market price spikes for a nuclear bomb going off in a major American city?

The very virtue of prediction markets now becomes their cost. If you hear rumors, in the absence of prediction markets, you can ignore them and pretend they are not true. With asset markets, however, your forecast moves into equality with that of the market, otherwise you would trade. It is precisely this “forcing quality” that makes prediction markets so useful, but also so potent. Price movements are materially and psychologically harder to ignore. The very feature of prediction markets that mobilizes information also mobilizes coordinated social reactions to the embodied information, and not always for the better.

So the prediction market skeptics have a valid point in some contexts, but this does not detract from the benefits of prediction markets more generally.

I welcome the Ubermensch

There is a great scene in the movie Gattaca of a piano recital.  (As I remember it).  As we listen to the beautiful and complex music the camera slowly pans in on the pianist’s fast-moving fingers until we see why the music is so amazing, the pianist has six fingers on each hand.  Was the music written for the pianist or was the pianist written for the music?  Even though Gattaca is often understood as a dystopia the movie is great at showing the promise of genetic engineering.

In India, genetic mutation has done what we are close to doing with genetic engineering.  Devender Harne has six fingers on each hand and six toes on one foot and seven on the other.  He says the extra fingers let him work faster than other children. 

Sixfingers

If you think the photo has been Photoshopped, it hasn’t.  See here for the full story and video.  Thanks to J-Walk Blog for the link.

Department of Yikes

Two teams of federal and university scientists announced today that they had resurrected the 1918 influenza virus, the cause of one of history’s most deadly epidemics, and had found that unlike the viruses that caused more recent flu pandemics of 1957 and 1968, the 1918 virus was actually a bird flu that jumped directly to humans.

The work, being published in the journals Nature and Science, involved getting the complete genetic sequence of the 1918 virus, using techniques of molecular biology to synthesize it, and then using it to infect mice and human lung cells in a specially equipped, secure lab at the Centers for Disease Control and Prevention in Atlanta.

The findings, the scientists say, reveal a small number of genetic changes that may explain why the virus was so lethal. The work also confirms the legitimacy of worries about the bird flu viruses that are now emerging in Asia.

The new studies find that today’s bird flu viruses share some of the crucial genetic changes that occurred in the 1918 flu. The scientists suspect that with the 1918 flu, changes in just 25 to 30 out of about 4,400 amino acids in the viral proteins turned the virus into a killer. The bird flus, known as H5N1 viruses, have a few, but not all of those changes.

Here is the full story, which contains many other points of interest, including whether the sequencing should have been done in the first place.  In case you forgot, 1918 was the flu pandemic which killed 50 to 100 million people, and don’t think we are so much better protected in 2005.  Today I started writing my piece on what we should do about avian flu.

A Bush plan for avian flu

President Bush said today that he was working to prepare the United States for a possibly deadly outbreak of avian flu. He said he had weighed whether to quarantine parts of the country and also whether to employ the military for the difficult task of enforcing such a quarantine.

"It’s one thing to shut down your airplanes, it’s another thing to prevent people from coming in to get exposed to the avian flu," he said. Doing so, Mr. Bush said, might even involve using "a military that’s able to plan and move."

The president had already raised, in the wake of Hurricanes Katrina and Rita, the delicate question of giving the military a larger role in responding to domestic disasters. His comment today appeared to presage a concerted push to change laws that limit military activities in domestic affairs.

Mr. Bush said he knew that some governors, all of them commanders of their states’ National Guards, resented being told by Washington how to use their Guard forces.

"But Congress needs to take a look at circumstances that may need to vest the capacity of the president to move beyond that debate," Mr. Bush said. One such circumstance, he suggested, would be an avian flu outbreak. He said a president needed every available tool "to be able to deal with something this significant."

Here is the full story.  Here is the text of his remarks, with commentary from Glenn Reynolds.

I am hoping to write a longer piece on what we should do, but frankly Bush’s idea had not crossed my mind.  For a start, quarantines don’t usually work, especially in a large, diverse, and mobile country.  The Army would if anything spread the flu.  A list of better ideas would include well-functioning public health care systems at the micro-level, early warning protocols, and good decentralized, robust plans for communication and possibly vaccine or drug distribution.  Might the postal service be more important than the Army here?  How about the police department, and the training of people in the local emergency room?

Stockpiling Tamiflu is worthwhile in expected value terms, but many strains of avian flu are developing resistance; we should not put all our eggs in this basket.  We also should stockpile high-quality masks and antibiotics for secondary infections (often more dangerous than the flu itself), and more importantly have a good plan for distribution and dealing with extraordinary excess demand and possibly panic.  Let’s not ignore obvious questions like: "if the emergency room is jammed with contagious flu patients, where will other (non-flu) emergencies go?" 

A good plan should also make us less vulnerable to terrorist attacks, storms, and other large-scale disasters.  Robustness and some degree of redundancy are key.  You can’t centrally plan every facet of disaster response in advance; you need good institutions which are capable of improvising on the fly.  In the meantime, let’s have betting markets in whether a pandemic is headed our way; that would provide useful information.

Addendum: It is Bird Flu Awareness Week in the blogosphere, Silviu has the appropriate links.

The FDA Tragedy

Writing in the WSJ (Oct. 3), whose editors ought to know better, Cynthia Crossen says:

Only 70 years ago, American companies could legally sell poison in a
medicine bottle.

Obviously, no drug maker would knowingly kill its customers — the
free market would punish that kind of bad business. But a company
that inadvertently sold a drug resulting in multiple deaths faced no
legal penalties.

In 1937, however, the consequences of Americans’ unfettered right to
buy and sell medicine became disastrously clear. An antibacterial
syrup called Elixir Sulfanilamide killed at least 75 people, some of
them young children who had been suffering from nothing more serious
than a sore throat.

What a load of rot.  Here is a letter I sent to the WSJ:

Where did
Crossen get the bizarre idea that poisoining was not illegal 70 years ago?  It’s true that there was no federal law
against drug fraud but there was no federal law against rape either –
this did not mean that only 70 years ago rape was legal.  In fact, 
Massengil, the company that sold Elixir Sulfanilamide, was successfully
sued and punished under the common law of tort.

Dramatic, easy to see, tragedies like those caused by Elixir
Sulfanilamide and Thalidomide encouraged the naive to demand an
expansion of the FDA’s powers.  The less easily seen tragedy has been drug delay, fewer new drugs, and higher prices.  Careful observers
– see FDAReview.org for some evidence – estimate that the costs of the latter tragedy
far exceed the former.  The FDA has put the nail in the coffin of more
than just the "pain and beauty boys."

Opportunity cost

Visits to hospital emergency rooms in Boston plummeted during the city’s most nail-biting sports moments, according to a group of local doctors.

The team found that visits went down to as little as 80% of the average for the key Boston Red Sox games that attracted the most TV viewers. But ER visits rose above the average for games that had fewer viewers.

Is it safer to be watching TV, or do people with emergencies simply wait?  Here is the link.

Human-to-human transmission of avian flu in Indonesia?

There appear to be increasing clusters of human cases of avian flu in Indonesia.  Check out the Avian flu blog (scroll down just a tiny bit) for an account.  Recombinomics offers a technical discussion of the cases.

The best case option is that avian flu, at least in Indonesia, has become more efficient in jumping from birds to humans.

The most likely option is that weak human-to-human transmission has been going on in Indonesia, and possibly Vietnam, for some months.  Fortunately this still could end up being a false alarm.  Note also that options one and two could both be true at the same time.

The worst option is…well, the best case option is scary enough.  Indonesian families commonly live with either doves or chickens or both.

The Vioxx Hex

It’s a real thrill when the editorial page of the Washington Post starts to sound like, well, me (e.g. here and here).

Politicians and regulators should be asking themselves whether a system of
massive cash awards to people who may or may not have been adversely affected by
Vioxx is a logical, fair or efficient way to run a drug regulatory system. They
should also be asking whether juries that scorn medical evidence are the right
judges of what information should or should not have been on a prescription
label. After all, Vioxx was produced and sold legally. The drug was approved by
the Food and Drug Administration, and its label did warn of coronary side
effects. It is possible, even probable, that Merck was negligent in its decision
to ignore early warnings of the cardiovascular risks of Vioxx. But the company
has already paid a price for that negligence, in the losses it has suffered
after abruptly taking Vioxx off the market. Fair compensation for the injured
needn’t entail disproportionate financial punishment as well.

In the long term, using the courts to "send a message" to Merck isn’t going
to help consumers. If the result is an even more cautious FDA approval system
and a more cautious pharmaceutical industry, that will keep innovative drugs off
the market for much longer. More people will die waiting for new treatments. The
cost of producing new drugs will rise dramatically. Already, there are whole
areas of medicine — women’s health during pregnancy, for example — that are
made so risky by liability issues that companies may stop doing research in
them.

The first principle of reforming this system should be that a company that
follows the FDA’s rather extensive guidelines should be protected from punitive,
if not compensatory, damages.

Good news, sort of

DHHS Secretary Leavitt…has warned of the risk of "typhoid
and cholera" as a result of contaminated water, while others have
talked generally of mosquito-borne disease and the hazards caused by
dead people and animals. It is time to separate the real risks from the
phantom risks.

Diarrheal disease from contaminated water is a concern, but not cholera
and probably not typhoid. In order to get these diseases the water has
to be contaminated with the organisms that cause those diseases,
neither of which is endemic in that region. What is more likely is
gastroenteritis or hepatitis A from enteric viruses or bacteria.

Similarly the presence of dead animals and people is not a health
hazard. Dead animals decompose naturally in the environment. Unless
they were infected with a contagious organism before death, they will
not themselves become the source of disease. The persistent concern in
mass disasters over unburied bodies is an urban myth. Mass disasters
like floods rarely cause epidemic disease and to suggest otherwise
results in misplaced concern and potential diversion of resources from
more important issues.

The true danger?

The biggest health hazards may well be those we would classify under
"injury." Heat-related illness might be at the top of the list here. As
body core temperatures rise above 105 degrees F., mortality increases
quickly. The high heat and humidity of the area, coupled with
dehydration are a significant health hazard that requires intervention
by providing fluids and cooler shelters. The many sources of physical
injury, whether from feral animals (snakes, alligators, etc.), sharp
metal debris, falls and injuries in an environment where the hazards
are numerous and not easily visible can result in substantial
accumulated morbidity and even mortality. The only remedy is removal of
people to a safer environment, which should be the top priority.

That is from a very smart public health scientist.  Shouldn’t our HHS people know such things?  Isn’t this about, umm…health and human services…?  Read more here.

No Pain Relief for Tort Sufferers

James Hamilton takes a look at one of the key studies on Vioxx and heart attacks.  He is not greatly impressed.

I took a look at one of the studies on which the decision was
justified, written by Dr. David Graham and co-authors and published in Lancet
in February. This study looked at 8,143 Kaiser Permanente patients who
had suffered a heart attack and had also at some point taken a
nonsteroidal anti-inflammatory drug (NSAID), of which Vioxx (rofecoxib)
is one. Of these patients, 68 were taking rofecoxib while 4,658 were
receiving no medication at the time of their heart attack, a ratio of
(68/4658) = 1.46%. For comparison, the study looked at 31,496 other
patients who had also at some point taken an NSAID, matched for
characteristics like age and gender with the first group, but who
didn’t have a heart attack. The ratio of rofecoxib users to those with
no current medication was slightly lower (1.05%) in this second group,
which one might summarize as a (1.46/1.05) = 1.39-fold increase risk of
heart attack from taking rofecoxib compared to no NSAID. Is that
statistically significant, in other words, can you rule out that you’d
see a difference of that size just by chance? Yes, the study claimed,
but just barely.

On the other hand, this was not a controlled experiment, in which
you give the rofecoxib randomly to some patients and not others in
order to see what happens. Rather, something about either these
patients or their doctors led some of them to be using rofecoxib and
others not. Dr. Graham and co-authors looked at a variety of indicators
that suggested that the rofecoxib patients already had slightly
elevated risk factors for coronary heart disease. Once they controlled
for these with a logistic regression, their study found an elevated
risk factor of heart attack for rofecoxib takers of 1.34, which was not
statistically significantly distinguishable from 1.0.

The strongest evidence from this study was a claimed dose-effect
relation. Of these 68 rofecoxib-using heart-attack patients, 10 of them
were taking doses above 25 mg per day. Only 8 patients in the much
larger control group were taking so high a dose, implying an elevated
risk factor of 5 to 1 for high-dose patients. Again observable risk
factors could explain some of this, with the conditional logistic
regression analysis bringing the implied drug-induced risk down to 3 to
1. According to the study, this elevated risk factor was still
statistically significant, even though the inference is based on the
experience of just 10 patients.

The obvious question here is whether in fact the authors were able
to observe all the relevant risk factors. The study openly acknowledged
that it did not, missing such important information as smoking and
family history of myocardial infarction.

…[E]ven if
there actually is an elevated risk of the magnitude the studies suggest
but can’t prove, the question is whether I might want to accept a 1 in 4,000 risk of dying from a heart attack in order to get the only medication timt makes my pain bearable and a mobile life livable.  And if I say no to the Vioxx, I may end up taking something that is less effective for my pain but has risks of its own.

…. How did we arrive at a
system in which 12 random Texans are assigned responsibility for
evaluating the scientific merits of statistical evidence of this type,
weighing the costs and benefits, and potentially sending a productive blue-chip American company into bankruptcy protection?

See also my op-ed Bringing the Consumer Revolution to the FDA.

The fear of death

Robin Hanson writes:

Humans clearly have trouble thinking about death.  This trouble is often invoked to explain behavior like delays in writing wills or buying life insurance, or interest in odd medical and religious beliefs.  But the problem is far worse than most people imagine.  Fear of death makes us spend fifteen percent of our wealth on medicine, from which we get little or no health benefit, while we neglect things like exercise, which offer large health benefits.

Here is the (short) paper.  Here is another paper on the same topic, here is Robin’s interpretative take on the authors:

When the salience of death is increased, such as by standing next to a Mortuary, we tend to want to reward heros more and punish prostitutes more.  We tend to favor more those who praise our religion and nation and those who criticize others.  We become more reluctant to disrespect items like flags or crucifixes.  We think we are better drivers, and that others agree with us more.  We try harder to divert attention from our less popular features and group identifications.  We believe more in the supernatural.  People with high self-esteem are mostly immune to these effects.

My take: Bryan Caplan and I have an ongoing debate.  He holds the traditional economist’s view that people are usually more rational with more important or more decisive choices.  I see important exceptions to this principle.  Many critical choices cause people to freeze up, become more dogmatic, distract their attention, or engage in greater self-deception.   But I am not as skeptical as Robin is about the benefits of health care expenditures.

Addendum: Try this NBER paper on denial of death.

Just how bad is U.S. health care?

Malcolm Gladwell delivers a lengthy polemic.  He favors some form of national health insurance, but is this the correct conclusion?  A few observations:

1. He is correct that "too much insurance" is not the problem.  Health savings accounts are not the answer.

2. Many of the current uninsured are linked to immigration, or voluntarily uninsured.  This is not pure institutional failure.

3. Gladwell downplays moral hazard, arguing that the fully insured wealthy do not forgo their golf games for superfluous doctor visits.  But the real problem comes from the other side: doctors overbill or perform unnecessary procedures.

4. The U.S. health care system probably is the world’s best for some class of people, namely the well-off and I don’t mean just the super-rich.  Trying to extend those benefits — however this might be accomplished — is a better approach than nationalizing the sector.

5. Much of our excess spending is to make people feel they have done everything they can for themselves or their relatives.  It is partly voluntary in nature.  Socialized systems don’t allow many of these options to reach the menu in the first place.  We need to think long and hard about the right answer here; it is not useful to simply call these expenditures wasteful.

6. The whole debate is emphatically not about "a few simple questions," as Gladwell suggests at the end.

7. No one has a good plan for socializing American medical care or insurance.

8. Much European health comes from diet, walking, and tighter social networks of friends.  Don’t expect European healthcare policies to produce the same level of well-being in the United States.

Thanks to Mark LaRochelle for the pointer.