Category: Medicine
Pollution and Macro Inequality
Combining 36 years of satellite derived PM2.5 concentrations with individual-level administrative data provided by the U.S. Census Bureau and Internal Revenue Service (IRS), we provide new evidence on the important role that disparities in air pollution exposure play in shaping broader patterns of economic opportunity and inequality in the United States. We first document that early-life exposure to particulate matter is one of the top five predictors of upward mobility in the United States. Second, we exploit regulation-induced reductions in pollution exposure from the 1990 Clean Air Act Amendments to produce new age-specific estimates of pollution-earnings relationship. Combined with individual-level measures of pollution exposure during early childhood, we calculate that disparities in air pollution can account for 17-26 percent of the Black-White earnings gap, 5-27 percent of the Hispanic-White earnings gap, and 6-20 percent of the average neighborhood-earnings effect (Chetty and Hendren, 2018; Chetty, Hendren, and Katz, 2016). Collectively, our findings indicate that environmental inequality is an important contributor to observed patterns of racial economic disparities, income inequality and economic opportunity in the United States.
That’s Colmer, Voorheis and Williams summarizing Air Pollution and Economic Opportunity in the United States. The authors also estimate that
…a 1 μg/m3reduction in prenatal PM2.5 exposure is associated with a $1,105 increase in later-life W-2 earnings and…a 1 μg/m3 reduction in prenatal PM2.5 exposure is associated with a 1.29 percentile rank point increase in upward mobility…We estimate pollution-earnings relationships for each age of exposure from birth to age 12 and show that the relationship between pollution exposure and earnings is stable up to age 4 and then diminishes quickly. We do not estimate a meaningful relationship between particulate matter exposure and later-life earnings from age 8 onward.
These estimate are big but given the substantial number of micro-estimates of the effect of pollution on IQ and cognition that Tyler and I have discussed before (see also this video) substantial effects at the macro level are almost inevitable.
OTC Prescriptions Save on Medical Costs
The excellent Joel Selanikio writes on medical disruption from the rise of self-care:
I’ve been asked many times whether I think that AI will replace doctors. Never once have I been asked if I thought that OTC drugs could replace doctors. But that’s exactly what they have done: every time a drug switches from prescription to OTC, the total number of doctor visits drops.
In fact, a 2012 study by Booz concluded that
“if OTC medicines did not exist, an additional 56,000 medical practitioners would need to work full-time to accommodate the increase in office visits by consumers seeking prescriptions for self-treatable conditions.”
Fifty-six thousand doctors that we don’t need because of OTC drugs; that’s almost 6% of the practicing doctors in America. Think of the effect on healthcare costs.
Selanikio gives more examples of how AI plus super-computers, i.e. cell phones, can lead to better, at-home diagnosis and fewer physician hours (and more here). More generally, due to the Baumol effect the only way to save on medical care costs is by using less labor and more capital–this is rarely recognized.
Irresponsible Gain of Function Research
Scientists at Boston University have grafted the new Omicron spike protein onto the old SARS-Cov-2 virus creating a new and deadlier version of Omicron.
bioRXiv: The recently identified, globally predominant SARS-CoV-2 Omicron variant (BA.1) is highly transmissible, even in fully vaccinated individuals, and causes attenuated disease compared with other major viral variants recognized to date1-7. The Omicron spike (S) protein, with an unusually large number of mutations, is considered the major driver of these phenotypes3,8. We generated chimeric recombinant SARS-CoV-2 encoding the S gene of Omicron in the backbone of an ancestral SARS-CoV-2 isolate and compared this virus with the naturally circulating Omicron variant. The Omicron S-bearing virus robustly escapes vaccine-induced humoral immunity, mainly due to mutations in the receptor49 binding motif (RBM), yet unlike naturally occurring Omicron, efficiently replicates in cell lines and primary-like distal lung cells. In K18-hACE2 mice, while Omicron causes mild, non-fatal infection, the Omicron S-carrying virus inflicts severe disease with a mortality rate of 80%. This indicates that while the vaccine escape of Omicron is defined by mutations in S, major determinants of viral pathogenicity reside outside of S.
Some of the headlines (here, here, here and here) aren’t making clear that the newly created chimeric virus is deadlier than Omicron (in mice) but less deadly than the ancestral strain. Nevertheless, in my view, this is gain of function research that should have come under extra scrutiny. The authors, however, did not go through P3CO review, a rule requiring agencies under HHS to review grant applications for any research on “a credible source of a potential future human pandemic.” More specifically:
The HHS Framework for Guiding Funding Decisions about Proposed Research Involving Enhanced Potential Pandemic Pathogens (HHS P3CO Framework)(link is external) was established in 2017 to guide funding decisions on proposed research that is reasonably anticipated to create, transfer or use potential pandemic pathogens resulting from the enhancement of a pathogen’s transmissibility and/or virulence in humans, called ePPP research.
I think this research qualifies. Frankly, the authors of the study were irresponsible. Boston University also failed terribly in its oversight. I also put some blame on Anthony Fauci for evading and obfuscating earlier gain of function research in a way that suggested very little falls under this category. (Rand Paul was right about this). Note, I am not taking a position on whether this research should have passed P3CO review but it should have been subject to review. I am also well aware that BSL-3 labs are heavily regulated, greatly increasing the cost of useful research. Overregulation is a real cost than can make us less safe and secure.
Nevertheless, if there is even a 5% chance that the SARS-CoV-II pandemic started with a lab leak–and don’t trust anyone who tells you the probability is less than 5%–then we need more care and scrutiny of research on potential pandemic pathogens. Furthermore, the United States must lead if we are to have any influence at all on what happens elsewhere in the world.
Why so much drug use in the United States?
That is a question from a loyal reader, and he does not mean pharmaceuticals rather illegal drugs. I can see a few hypotheses:
1. Americans consume more of almost everything. Including health care. We are simply a nation of consumption, for longstanding cultural reasons and supported by our higher wealth and our ability to save through human capital and rising asset prices, thus enabling more spending. So we are going to spend more on illegal drugs too. In fact illegal behavior with the prescription drugs themselves is one of the fastest-growing drug problems in the United States.
1b. Americans also take way more legal prescription drugs than their counterparts in other countries. Under one estimate, Americans consume 80 percent of the world’s painkillers.
2. Corporate interests, including Big Pharma, are in America relatively strong, including politically strong, and relatively prominent in advertising. Some of those companies have worked hard to accustom you to the idea that you ought to “take something.”
3. America has borders with Mexico and the Caribbean, which makes it harder to keep out illegal drugs.
4. Price! (Duh) Somewhere recently I saw price estimates for cocaine in various countries (might anyone recall the link?). It was cheaper in the United States than elsewhere. We are a large market, have economies of scale, and are great at retail and marketing. Many other things are cheaper here to, which in turn brings us back to #1.
5. Compared to say Germany or Denmark, there are fewer people “looking out for you.” Americans are more likely to move away from family and friends, and more likely to live “in the middle of nowhere.” We are lonelier, maybe not at the median but on the left hand side of the distribution. Our demand for therapists is pretty high too.
6. Student life can be more competitive in the United States than in Canada or Europe, and that may induce many Americans teens to use amphetamines, which are more popular in America.
7. America is in general a high-variance country, due to large market size, ethnic diversity, relatively open and competitive markets, and the looseness of many of its social norms. A higher-variance country will have many more people clustered in the unsatisfactory behavior patterns.
7b. Along related lines, American teens are more frequent users of illegal drugs than are European teens. But American teens also have amongst the lowest rates of smoking and drinking. So some of us are very disciplined, others much less so, again reflecting the high variance of both inputs and outcomes.
8. Americans are keener to try new products, relative to most of the rest of the world. Along these lines, we have relatively big problems with the newer opioids and synthetic drugs. Heroin historically has often been a bigger problem in Europe, and that is hardly a new drug. In era of new drugs, as we currently are living in, this will nudge the balance toward Americans doing drugs more.
9. American teens have more disposal income to spend, compared say to European teens. This may come from either jobs or from parental allowances. Furthermore, the European youth, especially in Italy, are more likely to live at home for many more years. That probably limits illegal drug use. Americans are more likely to go away for college to “a campus,” and “a dorm,” a horrible institution if you think about it for too long.
What else?
Telemedicine is Dying
Bloomberg: Prior to the Covid era, telehealth accounted for less than 1% of outpatient care, according to the Kaiser Family Foundation. Telehealth services have since surged, at their peak accounting for 40% of outpatient visits for mental health and substance use.
Unfortunately, as I warned last year telemedicine is being wound back as regulations which were lifted for the pandemic emergency are put back into place.
Telemedicine exploded in popularity after COVID-19 hit, but limits are returning for care delivered across state lines.
…Over the past year, nearly 40 states and Washington, D.C., have ended emergency declarations that made it easier for doctors to use video visits to see patients in another state, according to the Alliance for Connected Care, which advocates for telemedicine use.
…To state medical boards, the patient’s location during a telemedicine visit is where the appointment takes place. One of MacDonald’s hospitals, Massachusetts General, requires doctors to be licensed in the patient’s state for virtual visits.
I know people who have had to travel over the Virginia/Maryland border just to find a wifi spot to have a telemedicine appointment with their MD physician. Ridiculous.
….telemedicine innovations pioneered during the pandemic should remain as options. No one doubts that some medical services are better performed in-person nor that requiring in-person visits limits some types of fraud and abuse. Nevertheless, the goal should be to ensure quality by regulating the provider of medical services not regulating how they perform their services. Communications technology is improving at a record pace. We have moved from telephones to Facetime and soon will have even more sophisticated virtual presence technology that can be integrated with next generation Apple watches and Fitbits that gather medical information. We want medical care to build on the progress in other industries and not be bound to 19th and 20th century technology.
USA (Sweden) fact of the day
Middle-age mortality increases among non-Hispanic Whites from 1992 to 2018 are driven almost entirely by the bottom 10 percent of the education distribution.
Here is the newly published paper, by Paul Novosad, Charlie Rafkin and Sam Asher (AEA gate). In another new paper, by Randi Hjalmarsson and Matthew J. Lindquist, being sentence to extra time in a Swedish prison is good for your health.
From the comments, more on health care
Again this comment is from Sure:
From the comments, on single payer
Single payer’s magic has historically worked via just a few channels:
1. Some amount of monopsony allows the government to bid down medical services below market rates.
2. Political imperatives lead to lower training burdens, lower staffing ratios, and lower certainty in diagnosis and treatment.
3. Obfuscation of possible alternatives diminishes demand for costlier care.Option 1 means that you pay health professionals worse. There is some utility in this even. But it has some long run consequences that are only now being discovered. First, you see the exit of the most skilled people from medical careers. Second, the physicians unionize (or equivalent) and become political actors. Third, with everyone trying this and some semblance of open borders, it becomes ever harder to keep people in the places you need them (which rarely match the places where the sort of folks who can become Western physicians want to live). At some point you can no longer suppress wages below their natural clearing rate and it becomes ever harder to import foreign talent when other places (e.g. the US) offer a more lucrative immigration option.
US physicians are overtrained. But it also means that as things need ever more understanding to manage, we can deal better with things like CAR-T therapy and the like. And it is not like foreign docs are unaware of these things. As status is the important thing for most educated professionals, there will be continuous pressure towards increasing the prestige of the job at that comes with more training. As much as the government wants to have the minimally trained folks doing as much as possible, single payer countries are starting to see ever more pressure for their physicians, nurses, and the rest to match educational qualifications of the rest of the world.
Tying into all of this is the fact that the alternatives are quite visible. Everyone in the US these days can see an alternative where the masses do not have to pay out of pocket and theoretically fund health care by taxing someone else. But the flip side is also true. Wealthy Britons know that their American friends need not live with chronic pain for years for surgeries the NHS eventually will perform. They know that their American friends get screened more frequently and actually get treatment that cures diseases which are merely managed in Britain. They may still support the tradeoffs that come from single payer, but the days when these sorts of comparisons are no longer discussed are long gone.
Frankly I am always amazed at how much gets attributed to single payer. We know that, at most, only 25% of life expectancy outcomes are due to healthcare. We know that all of the correlates of single payer (e.g. percent of health expenditures paid by government) and health correlates (e.g. life expectancy) get vastly less favorable when you drop the US from the analysis as an outlier. We know that the UK has habitually adopted US practices a decade or so later, once the cost falls into the range where the UK can afford it.
But going forward, I think the old metrics that showed large advantages for single payer are going to continue to slide. Unions (formal or otherwise) are going to militate for higher pay. Governments are going to have to deal with one side of the political spectrum going into hoc to the health employees and the other polarizing to the folks in the disfavored region(s) who are lower priority for healthcare and pay more in taxes for the “giveaways”. And all of it is going to run into the trouble that the developing world is going to have fewer kids and hence fewer physicians while the relative advantage of immigrating is going to continue to fall.
Single payer was overwhelmingly built on the post-World Wars consensus and environment. It operates as a monopsony. What on earth would make us think that it would be stable into the future?
That is from “Sure.”
TC again: There is a natural tendency on the internet to think that all universal coverage systems are single payer, but they are not. There is also a natural tendency to contrast single payer systems with freer market alternatives, but that is also an option not a necessity. You also can contrast single payer systems with mixed systems where both the government and the private sector have a major role, such as in Switzerland.
I’ll say it again: single payer systems just don’t have the resources or the capitalization to do well in the future, or for that matter the present. Populations are aging, Covid-related costs (including burdens on labor supply) have been a problem, income inequality pulls away medical personnel from government jobs, and health care costs have been rising around the world. Citizens will tolerate only so much taxation, plus mobility issues may bite. So the single payer systems just don’t have enough money to get the job done. That stance is conceptually distinct from thinking health care should be put on a much bigger market footing. But at the very least it will require a larger private sector role for the financing.
The evolution of single payer health insurance
This is one of the big underreported stories these days, namely that single payer systems are working far less well than they used to, including during the pandemic but not only. Eventually the blame will shift and will be put on something like “austerity,” whereas the deeper understanding was that those systems were bound to end up understaffed and undercapitalized all along. In any case, here is the latest from Sweden, circa summer 2022:
In 2000, around 100,000 Swedes had private health insurance. Today, there are seven times as many, in a country of 10 million people. In 60% of cases, the insurance is paid for by the employer. According to the Swedish insurers’ organization Svensk Försäkring, the rate can vary from 300 to 600 crowns on average per month. For those dealing with health problems, the advantages are quicker consultations and avoiding long waiting lines.
And that is from Le Monde, not the Heritage Foundation. The Canadian, British, and New Zealand systems are all in crisis too. But that narrative is not exactly tailor-made for today’s media environment…
Markets in everything
That John is on his feet at all is impressive—and probably foolish—considering that only eight months prior, he was five feet eight and a half. Back in September, he paid $75,000 for the agonizing privilege of having his legs surgically lengthened. That entailed having both his femurs broken, and adjustable metal nails inserted down their centers. Each nail is made of titanium, which is both flexible and sturdy, like bone, and about the size of a piccolo. The nails were extended one millimeter every day for about 90 days via a magnetic remote control. Once the broken bones heal, ta-da: a newer, taller John.
Here is the full story. Oh and this:
With a procedure like this, there are, of course, some caveats. All the height gain obviously comes from your legs, so your proportions can look a little weird, especially when you’re naked. Also, the recovery can be long and taxing. When we meet, the bones in John’s legs are not yet fully healed, and a small section of his right femur is still a little soft, like al dente spaghetti; the smallest stumble could snap a bone in two. And it’s especially dangerous since he’s a big guy, over 200 pounds.
Then there’s the pain, which is relentless, ambient. The extension of the nails in his legs stretched the nerves and tissue around the bones—especially the thick, meaty muscles like the hamstrings—to an almost excruciating degree. He couldn’t walk for months. “They fill you with enough painkillers that it’s bearable,” John explains, but his biggest fear was becoming addicted to the drugs, so he weaned himself off the regimen earlier than he should have.
File under: “The costs of lookism.” The technique is originally a Soviet one. Via Anecdotal.
Covid-19 and labor supply
We show that Covid-19 illnesses persistently reduce labor supply. Using an event study, we estimate that workers with week-long Covid-19 work 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 illnesses have reduced the U.S. labor force by approximately 500,000 people (0.2 percent of adults) and imply an average forgone earnings per Covid-19 absence of at least $9,000, about 90 percent of which reflects lost labor supply beyond the initial absence week.
That is from a new NBER working paper, by Gopi Shah Goda and Evan J. Soltas, of relevance both to Long Covid and our current human capital crisis.
Plastic Might Be Making You Fat
WashPost: An emerging view among scientists is that one major overlooked component in obesity is almost certainly our environment — in particular, the pervasive presence within it of chemicals which, even at very low doses, act to disturb the normal functioning of human metabolism, upsetting the body’s ability to regulate its intake and expenditure of energy.
Some of these chemicals, known as “obesogens,” directly boost the production of specific cell types and fatty tissues associated with obesity. Unfortunately, these chemicals are used in many of the most basic products of modern life including plastic packaging, clothes and furniture, cosmetics, food additives, herbicides and pesticides.
Ten years ago the idea of chemically induced obesity was something of a fringe hypothesis, but not anymore.
“Obesogens are certainly a contributing factor to the obesity epidemic,” is what Bruce Blumberg, an expert on obesity and endocrine-disrupting chemicals from the University of California, Irvine, told me by email. “The difficulty is determining what fraction of obesity is related to chemical exposure.”
An important piece of evidence is something I pointed to in my post The Animals are Also Getting Fat namely, cats and dogs are getting fatter and so are rats and so (very importantly) are control mice fed a very standard diet. I hadn’t realized there is also some experimental evidence.
In particular, consequences of chemical exposure may not appear during the lifetime of an exposed organism but can be passed down through so-called epigenetic mechanisms to offspring even several generations away. A typical example is tributyltin or TBT, a chemical used in wood preservatives, among other things. In experiments exposing mice to low and supposedly safe levels of TBT, Blumberg and his colleagues found significantly increased fat accumulation in the next three generations.
Overall, I find the chemical story plausible–people in the past, even rich people, just didn’t get fat so easily–but my skepticism rises whenever I hear the word epigenetics.
An Update on Nasal Vaccines
Nasal vaccines are more likely to stop infection than vaccines injected into muscle because they stimulate mucosal immunity in the nose and respiratory system, the first line of attack, and they are likely to increase uptake especially among people with trypanophobia. Hence my longstanding call for an Operation Warp Speed for nasal vaccines. We haven’t got OWS 2.0 in the United States but nasal vaccines have recently been approved in China and India.
The Chinese vaccine is developed by CanSino and is the same as its injected vaccine but packaged in an aerosol taken with a nebulizer. It has been approved in China as a booster. Another advantage is that the Chinese nasal vaccine it’s one-fifth the dose of the injected version. India has also just approved a nasal vaccine on an emergency use basis. The Indian vaccine was developed by Bharat Biotech in a partnership with Washington University St. Louis.
Nasal vaccines as boosters seem like an especially promising approach as administration is much easier.
Mandated vaccine boosters for the AEA meetings?
Yes, the new AEA regulations will mandate vaccine boosters for attendance at the New Orleans meetings. Not just two jabs but yes boosters, at least one of them.
Like the N-95 (or stronger) mask mandate, this seems off base and possibly harmful to public health as well. Here are a few points:
1. The regulations valorize “booster with an older strain,” and count “infection with a recent strain” for nothing. In fact, the latter is considerably more valuable, most of all to estimate a person’s public safety impact on others. So the regulations simply target the wrong variable.
1b. People who are boosted might even be less likely to have caught the newer strains (presumably the boosters are at least somewhat useful). Thus they are potentially more dangerous to others, not less, being on average immunologically more naive. Ideally you want a batch of attendees who just had Covid two or three months ago.
2. More than three-quarters of Americans have not had a booster to date. Very likely the percentage of potential AEA attendees with boosters stands at a considerably higher level. Still, this is a fairly exclusionary policy, and pretty far from what most Americans consider to be an acceptable regulation.
2b. To be clear, I had my booster right away, even though I expected it would make me sick for two days (it did). I am far from being anti-booster. I am glad I had my booster, but I also understand full well the distinction between “getting a booster at the time was the right decision,” and “we should mandate booster shots today.” They are very different! Don’t just positively mood affiliate with boosters. Think through the actual policies.
3. Blacks are a relatively undervaccinated group, and probably they are less boosted as well. The same may or may not be true for black potential AEA attendees, but it is certainly possible. After all the talk of DEI, and I for one would like to see more inclusion, why are we making inclusion harder? And for no good medical reason.
3b. How about potential attendees from Africa, Latin America, and other regions where boosters are harder to come by? What are their rates of being boosted? Do they all have to fly to America a few days earlier, line up boosters, and hope the ill effects wear off by the time of the meetings? Why are we doing this to them?
3c. Will the same booster requirements be applied to hotel staff and contractors? Somehow I think not. Maybe that is a sign the boosters are not so important for conference well-being after all?
4. Many people are in a position, right now, where they should not boost. Let’s say you had Covid a few months ago, and are wondering if you should get a booster now or soon. I looked into this recently, and found the weight of opinion was that you should wait at least six months for your immune system to process the recent infection. That did not seem to be “settled science,” but rather a series of judgments, admittedly with uncertainty. So now let’s take those people who were not boosted, had a new strain of Covid recently, and want to go to the AEA meetings. (The first two of three there cover a lot of people.) They have to get boosted. And in expected value terms, boosting is bad for them. Did this argument even occur to the decision-makers at the AEA?
5. The AEA mentions nothing about religious or other exceptions to the policy. Maybe there are “under the table” exceptions, but really? Why not spell out the actual policy here, and if there are no exceptions come right out and tell us. And explain why so few other institutions have chosen the “no exceptions” path, and why the AEA should be different. (As a side note, it is not so easy to process exceptions for the subset of the 13,000 possible attendees who want them. Does the AEA have this capacity?)
Again, this is simply a poorly thought out policy, whether for N-95 masks or for boosters. I hope the AEA will discard it as soon as possible. Or how about a simple, open poll of membership, simple yes or not on the current proposal?
U.S.A. facts of the day
In 2021, the average American could expect to live until the age of 76, federal health researchers reported on Wednesday. The figure represents a loss of almost three years since 2019, when Americans could expect to live, on average, nearly 79 years.
The reduction has been particularly steep among Native Americans and Alaska Natives, the National Center for Health Statistics reported. Average life expectancy in those groups was shortened by four years in 2020 alone.
The cumulative decline since the pandemic started, more than six and a half years on average, has brought life expectancy to 65 among Native Americans and Alaska Natives — on par with the figure for all Americans in 1944.
Here is more from the NYT. Do note that Native Americans are generally considered to have done OK in terms of their vaccination rates.