Category: Medicine

Ms. Brown would get her results in just 20 minutes, thanks to one of
two new tests that AIDS workers say have revolutionized testing for
H.I.V…

On Thursday, the Food and Drug Administration’s Blood Products Advisory
Committee heard testimony on whether to recommend over-the-counter
sales of the rapid test for home use. The agency approved a home
testing kit in 1996, but users have to mail a blood sample to a
laboratory and wait for results by telephone.

Proponents say
rapid testing in the home will reduce the stigma and other obstacles
that prevent many people, including one in four of the nearly one
million Americans who are infected with H.I.V., from getting tested and
starting treatment. Research shows that people who learn they are
infected are less likely to infect others.

Here are the details, note that test is an easy oral swab.  I am not much worried about immediate suicides ("The most emotional responses come from negatives," says the article).  But what are the further ramifications?

1. The test is in the hands of the individual, and the kit presumably does not issue a credible AIDS-free certificate.  So perhaps we return to a greater reliance on trusting the word of the individual — "don’t worry, I tested negative a few weeks ago."  Formal certificates of health might become less expected.

2. Will lovers-to-be ask for an on-the-site test?  There is a stigma attached to asking a partner about his or her status.  It suggests you often sleep with people whose health status you are unsure about; the alternative impression is "of course I’ve never done this before, and I bet you haven’t either.  I’m not used to asking.  HIV, what’s that?"  And how much fun is it to watch a potential partner waiting for the results?  Do you bring little consolation cards in case the test turns out badly?  The resulting unwillingness to pry may further increase the reliance on verbal assurances.  Again, the presence or lack of a certificate — however dated — may provide a clearer focal point and thus greater information and clarity.

3. How often should you test yourself?  Given the signaling point from #2, what should you tell your next partner?  That you test yourself every year?  Every month?  Every day?  Which frequency would you find most reassuring in a potential partner?  Keep in mind the probability of a lie or false result. 

You can spin this one either way.  You might assume that someone who self-tests every day has dangerous habits.  Alternatively, you might assume (at least in pure theory) that the previous partners have been monitoring the test results, and that you don’t need to.  "Hey, if two hundred people have slept with you in the last year, a few of them must have checked you out."  Don’t you usually find the presence of other "customers" reassuring?

4. Say you test yourself after every new partner.  You have a better sense of who infected you, which in turn identifies a greater number of infected agents in advance and also deters self-recognized infectors.  Therefore people will test themselves less often than is socially optimal.  The main benefits from testing may accrue to others, not to yourself.

Hmm…it’s not so simple after all.  But I still believe this test is likely a positive development.  Comments are open…

p.s. We thank Robin Hanson for his guest blogging!

Organic cigarettes.  Henry Sicignano, American Spirit’s vice president of marketing, explains his purpose succintly:

"Our company’s greatest challenge – also
our greatest opportunity – is to expose smokers to our chemical-free,
all-natural tobacco products…"

I also liked this classic bit of statistical illusion:

With a market share of less than 1 percent
of the total U.S. cigarette business, Santa Fe is undaunted by the
behemoths that are their competition. "Natural American Spirit
cigarettes are the fastest growing brand in the United States,"
Sicignano reports.

(Groups which are small are often the fastest growing, also the fastest declining.)

Simplicity in action, from Kevin Drum:

…any healthcare proposal that’s designed to appeal more to healthy people than to sick people is fundamentally flawed. After all, the whole point of healthcare is to take care of sick people.

Read more here.  I am eagerly awaiting Arnold Kling’s excellent health care book from Cato; I will let you know when it is out.

Here is a brief excerpt from the piece I am writing on avian flu:

…these policy recommendations go against the U.S. national character. They will not strike an intuitive chord of approval from all quarters. America typically responds to challenges by refusing to admit it can fail. We have a “can-do” mentality. We built the first atomic bomb, we put a man on the moon, we revitalized the American economy in the 1980s and 1990s, and so on. This trait is admirable and it has been responsible for much of our national greatness. Nonetheless it may hinder our progress in fighting avian flu. We tend to seek out options which offer some option, however unlikely, of apparent invulnerability. Our approach should be different. We should be admitting that at this point we cannot stop a terrible event but we can only make it somewhat less bad.

For an example of our national tendency, consider the response to Hurricane Katrina. It was immediately decided that we should rebuild New Orleans as much as possible. I am not questioning whether this is a wise decision; maybe yes, maybe no. The point is we made this decision for reasons of emotion and temperament, rather than wisdom. We refused to admit that a major American city would be wiped out by a mere act of nature. So we engaged in a large macro response, designed to overturn or reverse the initial calamity altogether. This way we do not have to admit defeat, at least not yet. We seek to control problems when we cannot. All human beings have this tendency, but it is perhaps strongest in the United States, due to our long record of exceptional achievement.

Such a tendency could influence avian flu policy in damaging ways. For instance systematic stockpiles, centrally directed, and military-directed quarantines both give the impression that we can control the course of the pandemic. We would be making a highly symbolic and visual stand of “We won’t just let this happen.” Nonetheless these are not the most effective measures. Preparing emergency rooms or instructing people to wash their hands is, in effect, admitting that the disease would spread and kill people. It is a partial admission of “defeat.” Yet we might need some national modesty to address the problem in a relatively effective manner.

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.

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.

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.

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.

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.

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.

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.

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.