Category: Medicine

1. Daniel Kehlmann, Measuring the World.  A best-seller and critical rave in Germany, but it is dull.  Did it succeed because Germans are overreacting to a "normal" (read: non-Nazi) novel about their history?

2. Mating in Captivity: Reconciling the Erotic and the Domestic, by Esther Perel.  This is the most dangerous book I read this year.  The main thesis is you keep your sex life alive through anger/arousel and distance, not intimacy.  Here is a review. 

3. Kathryn Davis, The Thin Place: A Novel.  She is a consistently intriguing writer who finally wrote her breakthrough book; one of the best-reviewed novels of 2006.

4. Alice Munro, The View from Castle Rock: Stories.  I’ll put her with early Pynchon, Coetzee, Rushdie, Saramago, Sebald, and Pamuk.  A wonderful collection, but read this "roots approach" last, not first.  You might start here instead, be ready for lots of Ontario.  A big dose of her is the easiest way to make Philip Roth look overrated.

5. Javier Marias, Your Face Tomorrow: Fever and Spear.  Spain’s best-known current writer, but ignored by Anglos.  Here is a good article on him.  The English-language translation is first-rate, but the story doesn’t click with me.

6. Pessimism: Philosophy, Ethic, Spirit, by Joshua Foa Dienstag, interesting from beginning to end: "Freedom for the pessimists is not merely a status but an
experience that a time-bound person can aspire to through a certain
approach to life.  As I will elaborate later, the pessimists have
tended to see this approach exemplified in questing figures like
Columbus or Don Quixote."

Kieran Healy writes:

This reminds me of one of my favorite books, encountered during research for Last Best Gifts: Ed Brassard’s Body For Sale: An Inside Look At Medical Research, Drug Testing, And Organ Transplants And How You Can Profit From Them.
This is a how-to guide for selling the renewable and non-renewable bits
of yourself and also for getting accepted into paying clinical trials
of all kinds.

We can’t just bargain down the prices of pharmaceutical drugs without adverse consequences.  It is hard to measure the effects here, but yesterday I came across this piece of serious empirical work:

EU countries closely regulate pharmaceutical prices whereas the U.S. does not.  This paper shows how price constraints affect the profitability, stock returns, and R&D spending of EU and U.S. firms.  Compared to EU firms, U.S. firms are more profitable, earn higher stock returns, and spend more on research and development (R&D).  Some differences have increased over time.  In 1986, EU pharmaceutical R&D exceeded U.S. R&D by about 24 percent, but by 2004, EU R&D trailed U.S. R&D by about 15 percent.  During these 19 years, U.S. R&D spending grew at a real annual compound rate of 8.8 percent, while EU R&D spending grew at a real 5.4 percent rate.  Results show that EU consumers enjoyed much lower pharmaceutical price inflation, however, at a cost of 46 fewer new medicines introduced by EU firms and 1680 fewer EU research jobs.

Here is the paper.  Here is a non-gated copy.  Here is my column on medical R&D.  Here is a previous installment in the series "Scream this from the rooftops."

From Mark Kleiman, via Matt Yglesias:

Since the Veterans Administration, since its reform under Bill Clinton,
now has the best medical-records system going and produces high-quality
health care at a reasonable cost, could we move a baby step toward
national health insurance by allowing non-veterans to buy into the VA
system at a price equal to whatever the VA figures is its marginal
cost?

I find this idea appealing: this is a market test of whether the federal government could take better care of most of us.  (In case you are wondering, I wouldn’t buy in.)  In any case, a reform like this could deflect the pressure for trying a related idea on a non-experimental basis.  But if you think more government involvement in health care is desirable, well, this change should suffice to get us where we need to go.  And if you don’t think the VA could handle the extra demand, for whatever reasons, let’s set up a copycat institution.  If you are too worried about adverse selection, read Alex’s earlier post.

In an important editorial the Washington Post advocates giving points in the current organ allocation system to people who have previously signed their organ donor cards.  I have long argued for such a system (see Entrepreneurial Economics and here) and am an advisor to Lifesharers an organization that is implementing a similar system privately.

The decision to pledge organs could be linked to the chance of
receiving one: People who check the box on the driver’s-license
application when they are healthy would, if they later fell sick, get
extra points in the system used to assign their position on the
transplant waiting list (other factors include how long you have waited
and how well an available organ would match your blood type and immune
system).

Thanks to Dave Undis for the pointer.

The practice of modern medicine is surprisingly primitive.  My doctor only recently started to provide printed prescriptions instead of the usual scrawl.  Incorrectly filled prescriptions can be serious and computer printed prescriptions are an obvious response yet even today only one in four physicians use some form of electronic health records and only one in ten really use electronic records to follow a patient’s entire history.  My credit card company knows far more about my shopping history than my physician knows about my medical history.

Medicine is primitive in another way.  The number of treatment regimes supported only by tradition and authority is very high.  Here’s a recent example:

For the past 30 years or so, doctors have routinely given pregnant
women intravenous infusions of magnesium sulfate to halt contractions
that can lead to premature labor.

…[a] team reviewed 23 clinical trials worldwide involving 2,000 women who
had received the drug to quell contractions. They found that it did not
reduce preterm labor and that more babies died when their mothers took
the drug than in a control group where the mothers had not been given
it.

…Grimes and Nanda estimate that about 120,000 American women receive mag
sulfate each year for premature contractions, and they say some
evidence suggests it may be associated with 1,900 to 4,800 fetal deaths
annually in the United States.

This would be a shocker except for the fact that stories like this are common – by some accounts a majority of medical procedures are not supported by serious scientific evidence.  Indeed, what are we to make of a profession where evidence-based medicine is only a recent and still far from accepted movement?

Why is medicine so primitive?  One reason is that medicine is the largest area of the economy still dominated by artisanal production.  I will be blunt: We need assembly line medicine, medicine that is routinized, marked and measured. As I have argued before I would much prefer to be diagnosed by a computerized expert system than by a physician. The HMOs, Kaiser in particular, have done good work on measuring the effectiveness of different procedures but much more needs to be done to bring medicine into the twentieth century let alone the twenty first.   

Here is my column on that topic.  Excerpt:

In real terms, spending on American biomedical research has doubled
since 1994.  By 2003, spending was up to $94.3 billion (there is no
comparable number for Europe), with 57 percent of that coming from
private industry.  The National Institutes of Health‘s current annual research budget is $28 billion.  All European Union
governments, in contrast, spent $3.7 billion in 2000, and since that
time, Europe has not narrowed the research and development gap.  America
spends more on research and development over all and on drugs in
particular, even though the United States has a smaller population than
the core European Union countries.  From 1989 to 2002, four times as
much money was invested in private biotechnology companies in America
than in Europe.

Dr. Thomas Boehm of Jerini, a biomedical
research company in Berlin, titled his article in The Journal of
Medical Marketing in 2005 “How Can We Explain the American Dominance in
Biomedical Research and Development?” (ostina.org/downloads/pdfs/bridgesvol7_BoehmArticle.pdf)
Dr. Boehm argues that the research environment in the United States,
compared with Europe, is wealthier, more competitive, more meritocratic
and more tolerant of waste and chaos.  He argues that these features
lead to more medical discoveries.  About 400,000 European researchers
are living in the United States, usually for superior financial
compensation and research facilities.

This innovation-rich environment stems from the money spent on
American health care and also from the richer and more competitive
American universities.  The American government could use its size, or
use the law, to bargain down health care prices, as many European
governments have done.  In the short run, this would save money but in
the longer run it would cost lives.

Medical innovations improve
health and life expectancy in all wealthy countries, not just in the
United States.  That is one reason American citizens do not live longer. 
Furthermore, the lucrative United States health care market enhances
research and development abroad and not just at home.

In other words, the case for national health insurance is far from clear.  In terms of other reforms, one key question is how much waste could be reformed while keeping incentives for innovation intact.  I am optimistic about the prospects for change, but this does mean that eliminating "waste" can have negative secondary consequences.

The argument has another angle, explored only briefly.  The National Institutes of Health is one of the best governmental programs we have in the United States.  Part of its success stems from its relative autonomy.  It is harder to find worthwhile governmental R&D initiatives when Congress is pulling the strings on the specific allocations.  We should do more along the lines of NIH, and lack of autonomy is one big reason why R&D programs such as synfuels did not turn out well.

And no, I don’t think the U.S. system is close to ideal:

American health care has many problems.  Health insurance is linked too
tightly to employment, and too many people cannot afford insurance.
Insurance companies put too much energy into avoiding payments.
Personal medical records are kept on paper rather than in accessible
electronic fashion.  Emergency rooms are not always well suited to serve
as last-resort health care for the poor.  Most fundamentally, the lack
of good measures of health care quality makes it hard to identify and
eliminate waste.

What do you think of this?  Consumer sovereignty anyone?

Several U.S. fertility clinics admit they’ve helped couples deliberately select defective embryos.  According to a new survey report, "Some prospective parents have sought [preimplantation genetic diagnosis] to select an embryo for the presence of a particular disease or disability, such as deafness, in order that the child would share that characteristic with the parents.  Three percent of IVF-PGD clinics report having provided PGD to couples who seek to use PGD in this manner."  Since 1) the United States has more than 400 fertility clinics, 2) more than two-thirds that answered the survey offer PGD, and 3) some clinics that have done it may not have admitted it, the best guess is that at least eight U.S. clinics have done it.  Old fear: designer babies.  New fear: deformer babies.

Of course Nick Bostrom will push us one step further and ask why the status quo bias?  Aren’t we all "deformed" compared to the Uebermensch of the future?

Life expectancy for an Asian female living in Bergen County, New Jersey: 91 years.

Here is the source, via Jason Kottke.  Yes, lifestyle and attitude matter.  This is one indication that the American health care system isn’t as bad as it is sometimes made out to be.

Addendum: From a different direction, here is Levitt and Dubner on paying doctors to wash their hands.

I am looking for metrics as to which countries — that is which medical systems — have contributed the most to medical innovation.  That can range from pharmaceuticals to pacemakers to well…please let me know what you know.  Thanks in advance for the help.

Addendum: Speaking of medical innovation, here is a new piece on neuroeconomics, from The New Yorker.

The first clinic for internet addiction opened up in China last year, but now internet-addicted teens can take advantage of an improved facility, the Shanghai Sunshine Community Youth Affairs Center, an actual halfway house set up to soothe and detox the internet-riddled souls of young Chinese addicts.

According to the BBC, "internet addiction is reaching epidemic proportions in China". Internet addiction, like most of the so-called addictions, is usually diagnosed as a compulsion which requires intervention.

That is from Alina Stefanescu.