Category: Medicine
They Got the Lead Out of Turmeric!
Last year in Get the Lead Out of Turmeric! I reported that adulteration of turmeric was a major source of lead exposure among residents of rural Bangladesh. Well there is good news: the lead is gone! 
Wudan Yan at UnDark reports the remarkable story of academic research quickly being translated into political action that improves lives.
The story begins (more or less) with PhD student Jenna Forsyth:
Jenna Forsyth knew nothing about the practice of adding lead chromate to turmeric in 2014, when she started her Ph.D. in environment and resources at Stanford University. Excited to continue her masters research on water and sanitation, she sought out working with Stephen Luby, a world expert on the subject. When she arrived, Luby instead pointed Forsyth to a conundrum he was encountering in his work in Bangladesh: In a rural part of the country, pregnant women and children had high levels of lead in their blood. There were none of the usual suspects of lead exposure. There were no nearby battery recycling plants and families didn’t paint their homes. How could this be?
After eliminating dozens of explanations, Forsyth eventually hit on turmeric contamination. But Forsyth and the team didn’t just analyze turmeric in the lab, they hit the ground in Bangladesh:
They visited mills, and sometimes found sacks of the pigment on-site. They sampled dust from the polishing machine and from the floors of the mill. If there was about one part of lead to chromium, it was a dead giveaway that the adulterant was being used. From interviews, they also understood the motive: Brighter roots led to more profit, and adulterating with a consistently bright paint agent could disguise poorer-quality roots. The findings from this study were published in 2019.
Then they took their results to the Bangladesh Food Safety Authority:
The team held a meeting with the Bangladesh Food Safety Authority. The agency’s chairman at the time, Syeda Sarwar Jahan, was immediately concerned. She decided to spearhead a massive public information campaign.
…Local and international news outlets disseminated the findings from Forsyth’s new studies to create public awareness. The researchers met with businesses to make them aware of the risks of lead in turmeric. BFSA posted notices in the nation’s largest wholesale spice market, Shyambazar. The flyers warned people of the dangers of lead and that anyone caught selling turmeric adulterated with lead would be subject to legal action.
Authorities also raided Shyambazar using a machine called an X-ray fluorescence analyzer which can quickly detect lead in spices. Nearly 2,000 pounds of turmeric was seized in the raid and two wholesalers were fined 800,000 taka, more than $9,000 USD.
…In late 2019, as part of the intervention against lead chromate use in turmeric, the Bangladesh Food Safety Authority printed and distributed an estimated 50,000 copies of green flyers, that they shared with traders and plastered around the market. Be skeptical of fingers that appear too bright and yellow, it advised, and if the yellow dusting from turmeric doesn’t come off easily, it’s likely you’ve been played.
Getting rid of the lead isn’t just a cosmetic change. Lead can be so bad, especially for children, that removing it from spices improves lives at very low cost. Kate Porterfield writing at the EA Forum reports:
Despite being a preliminary assessment, this cost-effectiveness analysis (CEA) of this intervention in Bangladesh presents an exceptionally encouraging outlook, with a cost per DALY-equivalent averted estimated at just under US$1. It is crucial not to overlook the profound significance of this outcome: US$1 represents a small investment for the equivalent of an additional year of life in optimal health.
Early results from Pure Earth’s Rapid Market Assessment project find that between 6 and 12 countries may have similar problems with contaminated spices. Large parts of northern India (also highly populated) are similarly affected. Other lead salts are also highly colored, in reds and oranges, and found in other products. Programs to halt intentional contamination of spices and other foodstuffs are enormously impactful, and ought to be a first response in the fight against lead poisoning globally.
Finally, other significant sources of lead exposure (including leaded pottery and aluminum cookware, paint, medicines etc) require a similar regulatory response, and are likely to show cost benefit ratios that are also very strong.
Bangladesh has done it. It is time for Northern India to also eliminate lead from spices.
Big congratulations to Forsyth and the other Stanford researchers who documented the problem and who cared enough to follow up with a plan to work with charities and governments in Bangladesh to solve the problem. Big congratulations also to Givewell who supported the project.
The impacts of Covid-19 absences on workers
In the Journal of Public Economics, by Gopi Shah Goda and Evan J. Soltas:
We show that Covid-19 illnesses and related work absences persistently reduce labor supply. Using an event study, we estimate that workers with week-long Covid-19 absences are 7 percentage points less likely to be in the labor force one year later compared to otherwise-similar workers who do not miss a week of work for health reasons. Our estimates suggest Covid-19 absences have reduced the U.S. labor force by approximately 500,000 people (0.2 percent of adults) and imply an average labor supply loss per Covid-19 absence equivalent to $9,000 in forgone earnings, about 90 percent of which reflects losses beyond the initial absence week.
Here is the full article.
Excess All-Cause Mortality in China After Ending the Zero COVID Policy
In this cohort study across all regions in mainland China, an estimated 1.87 million excess deaths occurred among individuals 30 years and older during the first 2 months after the end of China’s zero COVID policy. Excess deaths predominantly occurred among older individuals and were observed across all provinces in mainland China, with the exception of Tibet.
So what is the proper sarcastic headline here? “I guess that flu was worse than we thought!”? Or “How is it that China ran out of ivermectin?” Here is the new JAMA piece, via Rich Dewey.
To be clear, I never thought Zero Covid was a sustainable policy for China. The real criminal negligence lies with CCP leadership, which turned down opportunities to pursue joint mRNA vaccine production — with the West of course — earlier on.
Compensating Kidney Donors
LA Times: Never in the field of public legislation has so much been lost by so many to one law, as Churchill might’ve put it. The National Organ Transplant Act of 1984 created the framework for the organ transplant system in the United States, and nearly 40 years later, the law is responsible for millions of needless deaths and trillions of wasted dollars. The Transplant Act requires modification, immediately.
We’ve got skin in this game. We both donated our kidneys to strangers. Ned donated to someone who turned out to be a young mother of two children in 2015, which started a chain that helped an additional two recipients. And Matt donated at Walter Reed in 2021, after which his kidney went to a Seattleite, kicking off a chain that helped seven more recipients, the last of whom was back at Walter Reed.
…The National Organ Transplant Act prohibits compensating kidney donors, which is strange in that in American society, it’s common to pay for plasma, bone marrow, hair, sperm, eggs and even surrogate pregnancies. We already pay to create and sustain life.
…Compensation models have been proposed in the past. A National Institutes of Health study listed some of the possibilities, including direct payment, indirect payment, “in kind” payment (free health insurance, for example) or expanded reimbursements. After much review, we come down strongly in support of indirect payment, specifically, a $100,000 refundable federal tax credit. The tax credit would be uniformly applied over a period of 10 years, in the amount of $10,000 a year for those who qualify and then become donors.
This kind of compensation is certainly not a quick-cash scheme that would incentivize an act of desperation. Nor does it commoditize human body parts. Going forward, kidney donation might become partly opportunistic rather than mostly altruistic, as it is now. But would it be exploitative? Not at all.
Long-time readers will know that I have argued for the greater use of incentives in organ donation both for live donors and cadaveric donors. Pecuniary compensation is one possibility but so are no-give, no-take laws that give those who previously signed their organ donor cards priority should they one day need an organ.
Market depletion and the income of doctors
Rural regions rule the doctor rankings: Alaska, Wyoming and Nebraska join the Dakotas in the top five states for physician pay, confounding the intuition hammered into our souls by more than a decade of covering economics. None of those are high-earning states overall, with the evergreen exception of Alaska. They’re also not high-cost: North and South Dakota rank 41st and 45th, respectively, in cost of living among the states and D.C.; only Alaska costs more than average, according to the Bureau of Economic Analysis.
Of course the highest-paid lawyers do not live in the Dakotas. Do note this:
Rural America has about 20 percent of the U.S. population but about 10 percent of its doctors, according to our analysis of Census Bureau data. So the talented young physicians willing to hang their shingles in North Dakota don’t have to worry about rivals undercutting their prices. They can charge more for everything, from appendectomies to vasectomies.
Here is more from Andrew Van Dam.
Diego on gas station drugs
From my email:
The average gas station is now packed to the brim with drugs. This place had a Whip-it stand near the checkout, that I imagine is for recreational nitrous oxide users rather than whipped cream enjoyers, as well as a massive selection of kratom. ‘Whippets’ can cause irreversible brain damage and kratom has opiate-like effects, binding to the same receptors as morphine. There were also 3 stands near the checkout dedicated to weed-adjacent things including a mix of gummies, vapes, and flower bud containers. Unsure exactly what the weed-adjacent stuff was, some of it was Delta-8. Seems like a lot of these weed derivatives stemmed from the 2018 farm bill. The kratom proliferation has been insane. One of the main kratom brands, Botanic Tonics, sells super-popular small blue vials under the name ‘Feel Free’ that merely say ‘Plant-based herbal supplement’ on the front. Despite the FDA recently seizing $3M of kratom from Botanic Tonics as well as endless stories of addiction on the subreddit r/Quittingfeelfree, Botanic Tonics is an official sponsor of UT Austin and Florida State University and gives out free vials to students.
I do not personally have data on this question, but I thought this content was worth passing along.
AOC Gets on the Anti-FDA Bandwagon
At least when it comes to suncreen. As long-time readers will know, I have been complaining about FDA over-regulation of sunscreen for a decade! Maybe now that AOC is on the case things will change.
AOC’s sunscreen video is pretty good. One point she doesn’t stress is that requiring Americans to use more oily, less natural-feeling sunscreen can cause less use and thus more skin cancer. Even more important is the general issue of reciprocity or polycentric authority:
My rule is very simple. I don’t think the FDA is better than the EMA so if any drug or device is approved in Europe it ought to be available for purchase in the United States with a label saying “Approved by the EMA. Not approved by the FDA.” (By the way, we do have reciprocity type agreements with Canada and New Zealand for food so this would not be unprecedented.)
US sunscreens are far behind the rest of the world and our regulations aren’t necessarily making our sunscreens better or safer — but it doesn’t have to be this way! pic.twitter.com/vaZXpZ2a7S
— Rep. Alexandria Ocasio-Cortez (@RepAOC) August 11, 2023
The Impact of Vaccines and Behavior on U.S. Cumulative Deaths from COVID-19
It is hard to think of a topic area where the Republican Party, the right-wing, and (many by no means all) MR commentators are so far off base. Here are some new results from Andrew Atkeson:
…I find that vaccines saved 748,600 lives through June 2023. That is, without vaccines, cumulative mortality from COVID-19 would have been closer to 1.91 million over this time period. In answering the second question, I find that behavioral efforts to slow the transmission of the virus before vaccines became widely administered were critical to this positive impact of vaccines on cumulative mortality. For example, with a complete relaxation of these mitigation efforts, vaccines would have come too late to have saved a significant number of lives. Earlier deployment of vaccines would have saved many lives. I find that marginal changes in the strength of the behavioral response to COVID-19 deaths within the range of those responses estimated with the model have a significantly impact on cumulative COVID-19 mortality over this time period.
Here is the full paper. By the way, in case you are wondering I did write some columns arguing we should reopen the schools (and I strongly encouraged my own institution, GMU, to reopen in the fall of 2020, when asked for advice. Mercatus reopened once our landlord allowed us to.). But I am glad that for instance normal NBA games with full crowds were not up and running in the usual manner in November of 2020.
Health Alert: Your Survival Odds May Increase When Surgeons Take a Break!
Another bit from my review in the WSJ of Random Acts of Medicine by Jena and Worsham:
The authors do not always endear themselves to their colleagues. In one intriguing study spanning a decade and involving 200,000 patients, a surprising revelation emerged. Patients who happened to have a heart attack during a week when hot-shot cardiac surgeons were away at national conferences were found more likely to survive. It sounds like a joke—stay away from hospitals because that’s where lots of people die—but the statistics are solid. The heart surgeons most likely to attend the national meetings also tend to be the go-getters, eager to cut and demonstrate their prowess in the operating theater. When these surgeons are away, mortality rates decrease by about 12.5%, a decrease “similar in magnitude to some of the best treatments we have available for heart attacks.” (Emphasis in the original). The president of the American Heart Association breezily dismissed the study’s findings, saying, “there’s nothing in this study that we see that would lead us to recommend a change in clinical practice.” Such dismissal in the face of significant evidence feels akin to malpractice.
There is now widespread recognition that too much medical care can be wasteful, but less recognition that it can also be harmful. Unfortunately, nearly all stakeholders, including patients, doctors, pharmaceutical firms and hospitals, are incentivized to spend and do more. Only insurance companies bear the burden of saying no. Given the inherent bias in our information sources toward positivity, it’s crucial to remain vigilant about instances where medical care has exceeded reasonable boundaries.
Left Digit Bias in Medicine
From my review in the WSJ of Random Acts of Medicine by Jena and Worsham:
You have probably heard of left-digit bias—the idea that $7.99 seems cheaper than $8, even though $8 is only negligibly different than $8.01. Left-digit bias is widely observed in pricing but the effect is more general. A car with 39,990 miles on the odometer, for instance, sells for more than a car with 40,005 miles (so be smart and buy the car with 40,005 miles). Could left-digit bias show up in medicine?
People who end up in the emergency room complaining of chest pains a few weeks before their 40th birthday are very similar to people who end up in the emergency room with chest pains a few weeks after their 40th birthday. But on a chart, the former are 39 years old and the latter are 40.
The big 40 is a heuristic among physicians for potential heart attack. Looking at more than five million patient records, the economist Stephen Coussens found that patients who were slightly over the age of 40 were almost 10% more likely to be tested for a heart attack than those just under 40. The difference shows up as a discontinuity, a jump up in the probability of being tested as patients cross their
40th birthday.
Messrs. Jena and Worsham show that similar discontinuities appear throughout medicine. Heart-attack patients just under the age of 80, for instance, are more likely to be given coronary artery bypass surgery than those just over 80. Kidneys from patients who die at age 69, just short of their 70th birthday, are more likely to be used for transplant than kidneys from patients just over 70, even though by all objective measures the kidneys are equally viable and valuable. Perhaps most tellingly, “children” just under the age of 18 are less likely to be prescribed opioids than “adults” slightly over the age of 18, even though these groups are statistically indistinguishable.
The point of these studies isn’t to titter or sigh at the peculiarities of human reasoning but to use these natural experiments to estimate the effect of medical procedures. If the only reason that near-18 and 18-year-olds are prescribed opioids differently is the semantics of “child” and “adult,” then we can use the discontinuity in prescriptions as a natural experiment—it’s as if prescribing around the age of 18 were randomly assigned. The authors find, for example, that compared to the just-under-18s, the just-over-18s were 12.6% more likely to later be diagnosed for an opioid-related adverse event such as an overdose. The greater rate of overdose is valuable information—but imagine the difficulty of trying to convince an Institutional Review Board that it would be ethical to randomly prescribe opioids to young people.
The Amy Finkelstein and Liran Einav health care plan
I am away from my review copy, so I am pleased that Matt Yglesias has offered ($) a good “standing on one foot” summary of the plan, as outlined in the new book We’ve Got You Covered: Rebooting American Health Care, by Amy Finkelstein and Liran Einav:
They call for:
- A universal basic insurance system, covering both catastrophic and routine care but at a bare bones/no frills level of service.
- A global budget, set by Congress, to determine how much money the basic plan has to spend on meeting the public’s basic needs, paired with expert panels to decide which services to cover.
- An additive system of private top-up insurance that people could (and they anticipate mostly would) buy into to secure access to shorter wait times and more creature comforts.
The book offers a “think it through using first principles” approach, so perhaps the authors will be frustrated by my invocation of a “how has politics been going lately?” kind of response. Nonetheless I see that Obamacare cost the Democrats dearly in more than one election, it had to be defanged (the mandate) to survive, it was supposed to be the new comprehensive framework that actually could pass (it did), and the most influential Americans just love their employer-provided private health insurance.
Whether you think those facts are good or bad, I take them as my starting point for health care reform. This book does not.
I observe also that Obamacare passed, and American life expectancy fell. I do not blame Obamacare for that, but I do notice it. As a result, I have grown increasingly interested in “how can we boost biomedical scientific progress?” and increasingly less interested in “how can we reform health insurance coverage again?” All the more because we seem to be living in a biomedical progress of science golden age.
One of the Democratic Party frustrations with conservatives during the ACA debates was witnessing them tolerate or even support Romney’s Massachusetts plan, but oppose Obamacare. That I can understand. One of the conservative frustrations with ACA was the fear that it would just be the first step in a never-ending, upward-ratcheting series of efforts to spend ever more on health insurance coverage, which has positive but only marginal implications for health itself. After all, where exactly do the moral arguments for spending more on health insurance coverage stop?
Is there a politically feasible version of the Finkelstein and Einav plan that can spend less or the same? Is there a politically feasible version of the plan period? How much trust will there be in the promise that if I give up my private health insurance coverage, it will be replaced by something better? How much trust should there be?
But again, the authors here have a very different perspective on the sector and how to do health care policy.
Australia fact of the day
Health officials have “virtually” eliminated HIV transmission in parts of Sydney that were once the centre of the Australian Aids epidemic, raising hopes of conquering a disease that has killed more than 40mn people.
HIV diagnoses in inner Sydney plunged 88 per cent from the 2008-12 average to just 11 cases last year, a decline on a scale never before recorded in a former Aids hotspot.
The results add to evidence that existing prevention strategies, including testing and pre-exposure drugs, are highly effective when implemented correctly.
“Rapid progress towards ending Aids is possible. If trends continue, several countries in several global regions will reach the [UN] goal of a 90 per cent HIV incidence reduction by 2030,” researchers said.
Here is the full FT story. As I have been saying people, you are living in a new age of biomedical miracles.
Mental health and European economics departments
We study the mental health of graduate students and faculty at 14 Economics departments in Europe. Using clinically validated surveys sent out in the fall of 2021, we find that 34.7% of graduate students experience moderate to severe symptoms of depression or anxiety and 17.3% report suicidal or self-harm ideation in a two-week period. Only 19.2% of students with significant symptoms are in treatment. 15.8% of faculty members experience moderate to severe depression or anxiety symptoms, with prevalence higher among nontenure track (42.9%) and tenure track (31.4%) faculty than tenured (9.6%) faculty. We estimate that the COVID-19 pandemic accounts for about 74% of the higher prevalence of depression symptoms and 30% of the higher prevalence of anxiety symptoms in our European sample relative to a 2017 U.S. sample of economics graduate students. We also document issues in the work environment, including a high incidence of sexual harassment, and make recommendations for improvement.
That is from a new paper by Elisa Macchi, Clara Sievert, Valentin Bolotnyy, and Paul Barreira.
How the NSF Moved Faster than the NIH During COVID-19
The NSF is a much smaller organization than the NIH but during the pandemic it moved more quickly. Why? Maxwell Tabarrok explains:
The NSF relied on its special congressional authority to skip peer review to bootstrap its pandemic-related granting. Two pre-existing programs which use this authority enabled the NSF’s speedy response. The RAPID (Rapid Response Research) and EAGER (EArly-concept Grants for Exploratory Research) programs focus on “proposals having a severe urgency,” and “exploratory work in its early stages on untested, but potentially transformative, research ideas,” respectively. Both turn applications around quickly: while typical federal science grants take 9-12 months of review, RAPID and EAGER grants usually provide funding to researchers in less than a month.
…The NSF funded valuable research through its RAPID grants program, including the development of the first COVID-19 test to get FDA approval, the Johns Hopkins COVID-19 data dashboard, and both inhaled and micro-needle patch vaccines, the latter of which is currently being scaled up for use in HPV vaccines. These examples don’t conclusively show that the NSF avoided sacrificing quality control for speed, but they suggest that the NSF’s internal team of reviewers funded multiple effective projects that benefited from faster turnarounds. The benefits of speeding up these big successes when they were urgently needed outweighed the hypothetical costs of approving some below-average projects.
In crises generally, the success of a science funder is determined by its biggest wins, not by the average quality of the projects it approves. Science’s impact on the pandemic was dominated by a single technology: the mRNA vaccine. The next most important contributions, likely testing or pharmaceutical treatments, were less important than the vaccine, and the average COVID-19 research project may have had minimal impact. External peer review slows down the funding of all projects to make sure that low-quality research is not funded. This kind of bottom-end quality control is less important in a crisis environment. At crisis-response margins, it’s probably better for science funding agencies to anchor less on quality control and instead take more shots on goal.
The NIH, to be fair, also responded more rapidly than usual and it used some special “shark-tank” like programs to do so which also worked well.
Read the whole thing for more recommendations.
Against human-AI collaboration
From a new NBER working paper by Nikhil Agarwal, Alex Moehring, Pranav Rajpurkar, and Tobias Salz:
Radiologists do not fully capitalize on the potential gains from AI assistance because of large deviations from the benchmark Bayesian model with correct belief updating. The observed errors in belief updating can be explained by radiologists’ partially underweighting the AI’s information relative to their own and not accounting for the correlation between their own information and AI predictions. In light of these biases, we design a collaborative system between radiologists and AI. Our results demonstrate that, unless the documented mistakes can be corrected, the optimal solution involves assigning cases either to humans or to AI, but rarely to a human assisted by AI.
I am more optimistic in my views, noting there may well be contexts such as radiology where the collaborations fail. I collaborate with Google’s AI all the time, and I am pretty sure that joint effort does better than either myself or “Google with no human” unaided. Still, this is a cautionary note of some import, as many humans are not good enough to work well with AIs.