Category: Medicine

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.

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.

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.

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.

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.

Guns, Germs, and Steel emphasized the role that germs played in the clash of civilizations of the early modern period, say up to about 1700.  I was surprised to learn from John M. Barry’s excellent book The Great Influenza that germs continued to have a disproprtionate influence on the civilizations well into the twentieth century and perhaps even today.

The great influenza of 1918 probably killed 100 million people, about five percent of the entire world’s population.  An even higher percentage of young people died and most shockingly all of this occured in about 12 weeks.   Death was not evenly distributed:

The Western world suffered the least, not because its medicine was so advanced but because urbanization had exposed its population to influenza viruses so immune systems were not naked to it.  In the United States, roughly 0.65 percent of the total population died, with roughly double that percentage of young adults killed.  Of developed countries, Italy suffered the worst, losing approximately 1 percent of its total population….

The virus simply ravaged the less developed world.  In Mexico the most conservative estimate of the death toll was 2.3 percent of the entire population, and other reasonable estimates put the death toll over 4 percent.  That means between 5 and 9 percent of all young adults died.

In even more remote areas the death toll was much higher. One doctor visiting Inuit in Alaska found everyone dead in 3 villages and 7 other villages with a death toll of 85%.  We don’t know how many people died in India and China but the rates were certainly higher than in the more urban United States. 

By the way, an enterprising researcher should be able to make use of the 1918 influenza in Mexico (and elsewhere as well) as a shock to population that likely had important reverbations throughout the economy and society for decades.

Addendum: Bill Johnson at UVA points me to, Is the 1918 Influenza Pandemic Over? (NBER), a very recent paper by Douglas Almond.  From the abstract:

In the 1960-1980 Decennial U.S. Census data, cohorts in utero during the height of the Pandemic typically display reduced educational attainment, increased rates of physical disability, lower income, lower socioeconomic status, as well as accelerated adult mortality compared with other birth cohorts. In addition, persons born in states with more severe exposure to the Pandemic experienced worse outcomes than those born in states with less severe Pandemic exposures. These results demonstrate that investments aimed at improving fetal health can have substantial long-term effects on subsequent health and economic outcomes.

Now consider, if the effects in the United States are large then in Mexico, not to mention India and China (where data will be much harder to gather), the effects could have been devastating on a macro scale.

No good news here:

1. Human cases appear to be developing in Kazhakstan.

2. There is probably (weak) human-to-human transmission in Indonesia.

3. Birds are spreading the flu to other birds in Europe, and probably later to Australia and North America as well.

4. Casualties continue in Vietnam.

5. The Chinese government is not being forthright about the possibility — admittedly speculative — of rampant bird flu (for birds and humans) on its territory.

6. Bird flu is now entrenched in bird populations throughout Southeast Asia for at least the next six to eight years, giving the virus more time to mutate and possibly become a pandemic.

Your chance of dying from avian flu is much greater than your chance of dying from terrorism.  Yet the Bush Administration is still doing virtually nothing.

For documentation, and further updates, check in regularly on avianflu.typepad.com, the avian flu blog which I run with Silviu Dochia.

Addendum: Do not get too hopeful about recent vaccine reports.

…[there are] striking variations in what Medicare pays for care in different states, or even neighboring Zip codes. In 2001, the typical Medicare patient in Los Angeles cost the government $3,152 more than a comparable patient in the District. A patient in Miami cost $3,615 more than one in Baltimore.

Those disparities cannot be explained by differences in local prices or rates of illness, said John E. Wennberg, a Dartmouth physician and an expert on geographical variations in medical care. Rather, higher spending is related to the number of specialists, hospital beds and technology available. "If you have twice as many docs in a community," said Wennberg, "you end up with twice as many office visits."

Yet most high-spending states rank near the bottom in quality of care, Medicare data show. Louisiana ranked 50th in quality yet first in Medicare spending in 2001, the most recent year available. New Hampshire was first in quality but 47th in spending.

Andrew Samwick has more, including the original links.

When you live in a small village, or hunter-gatherer society, everyone knows that a weird person is weird.  You stick out like a sore thumb.  But when I fly to, say, Dubai, hardly anyone knows I am weird.  Perhaps I dress differently, talk differently, and spend too much time reading books, but to them I appear weird in any case.  The proverbial "Aunt Millie from Peoria" also would come across as strange.  The differences in weirdness are blurred, and the truly weird can pass for simply being "foreign."

I recall my time in Yemen: all the women wore veils, and all the men carried daggers and chewed qat.  Just don’t ask me who the weirdos were.

This suggests that airplanes lower the costs of being weird.  Of course, with enough globalization — especially mass market images — this relationship can cut the other way.  Perhaps the people in Dubai are wondering why I don’t act more like Tom Cruise.  Alternatively, we might send them some more Johnny Depp movies.

Does this mean that weird men are more likely to have foreign wives?

I went to the doctor yesterday.  I told him that to avoid altitude sickness in Peru I wanted a prescription for Diamox.  He used to be surprised when I self-diagnosed but he knows me now.  He wrote the prescription and I was done in less than four minutes.  I like my doctor but this visit took an hour of my time and probably cost the insurance company at least $100, my deductible was $25.  No big deal for me but a non-trivial expense for someone without insurance.

Why aren’t more pharmaceuticals available over the counter?  In other words, why must we pay the priestly caste known as physicians for the right to treat ourselves?  "Safety," we are told (second only to "for the children" as an excuse for giving up liberty).  But, as Sam Peltzman pointed out long ago, safety runs both ways.  Not getting a pharmaceutical because it’s too expensive and time consuming to go through a doctor has adverse safety consequences and there is no evidence that the costs of potential mistreatment outweigh the costs of undertreatment.  (In anycase, politics not safety is often the reason for restrictions on OTC drugs e.g. the morning after pill.)

In fact, there are many countries where prescriptions are not required for legal medicines and they appear to do just fine.  Writing in Reason, Kerry Howley points out (online version, the print version is longer and I am quoted) that in this respect if no other Myanmar is a bastion of rationality and liberty compared to the United States.

Last year, while living in the Southeast Asian nation of Myanmar,
my phones were tapped, my journals were read, my work was censored, and
for the first time in my life, I was given the authority to care for my
own body.

There is no prescription drug system in Myanmar, but there are plenty of illnesses waiting to befall an effete Western immune system.  My expatriate colleagues and I were free to treat our ailments as we saw fit.
We staved off food poisoning and bouts of malaria with frequent trips to
the local pharmacy, consulting doctors when necessary, but ultimately
responsible for our own medical decisions. We formed doctor-patient
relationships that were partnerships rather than paternalistic
hierarchies, and each of us lived to tell the story.

Coming back to the States in the midst of hand-wringing about direct-to-consumer advertising, the restriction of life-saving cholesterol drugs, a wrenching process to make the morning-after-pill readily available, and now a push to put Sudafed behind the counter, it’s increasingly hard to understand why Americans cede crucial health decisions to the bureaucratic dithering of the FDA. In an age of empowerment through information, it is mind-boggling that patients are still willing to be silent spectators while their doctors call the shots.

People itching for a solution to seasonal allergies could get help from self-hypnosis, a team of Swiss researchers suggests. The study finds that simply focusing one’s thoughts on allergen-free environments can reduce symptoms of hay fever by one-third.

Beware my posts on the sciences; I like to report results which confirm my priors.  Here is the full story.