Category: Medicine

Ratio of <= 40 to >= 50 scientists funded by the NIH

The dotted line at the top is the Jones-implied ratio of productivity of <= 40 year olds to >= 50 year-olds, as drawn from Figure 1 in this source.

For the construction of this data source I am indebted to PseudoMontaigne.  Does it not imply that NIH funding is vastly over-allocated according to the criterion of seniority?  Or might this be the rise of the lab system, where the older people are the PIs, and they in turn dole this money out to younger researchers?  More middlemen, so to speak.  Opinions?

My Conversation with Rebecca Kukla

She is a philosopher at Georgetown, here is the audio and transcript, I thought it was excellent and lively throughout.  Here is part of the summary:

In her conversation with Tyler, Kukla speaks about the impossibility of speaking as a woman, curse words, gender representation and “guru culture” in philosophy departments, what she learned while living in Bogota and Johannesburg, what’s interesting in the works of Hegel, Foucault, and Rousseau, why boxing is good for the mind, how she finds good food, whether polyamory can scale, and much more.

Here is one bit:

KUKLA: What’s interesting in Hegel? Okay. You ask hard questions. This is why you’re good at your job, right?

I think Hegel’s fascinating. I think the main idea in Hegel that is fascinating is that any cultural moment, or set of ideas, or set of practices is always internally contradictory in ways it doesn’t notice, that there are tensions built into it. What happens, over time, is that those tensions bubble up to the surface, and in the course of trying to resolve themselves, they create something newer and better and smarter that incorporates both of the original sides.

That was a much more Hegelian way of putting it than I wanted it to come out, basically — the idea that going out and looking for consistency in the world is hopeless. Instead, what we should do is figure out how the contradictions in the world are themselves productive, and push history forward, and push ideas forward, is what I take to be the key interesting Hegelian idea.

COWEN: Michel Foucault. How well has it held up?

KUKLA: Oh, you’re asking me about people I mostly love.

COWEN: But empirically, a lot of doubt has been cast upon it, right?

KUKLA: On the details of his empirical genealogical stories, you mean?

COWEN: Yes.

KUKLA: Yes, but I think that the basic Foucauldian picture, which is — let’s reduce Foucault to just two little bits here. One basic piece of the Foucauldian picture is that power is not a unify-unilateral, top-down thing. Power expresses itself in all of the little micro interactions that go on between people and between people and their environments all the time.

Power isn’t about a big set of rules that’s imposed on people. Power is about all of the little things that we do with one another as we move through the world. All of those add up to structures of power, rather than being imposed top-down. I think that has been, at least for me and for many other people, an incredibly fertile, productive way of starting to think about social phenomenon.

The other bit of the Foucauldian picture that I think is incredibly important is the idea that a lot of this happens at the level of concrete, fleshy bodies and material spaces. Power isn’t sets of abstract rules. Power is the way that we are trained up when we are little kids — to hold our legs in a certain way, or to hold our face in a certain way, or to wear certain kinds of clothing. Power is the way that schools are built with desks in rows that enforces a certain direction of the gaze, and so on.

I could go on and on, but the way that the materiality of our bodies and our habits and our environments is where power gets a hold, and where our social patterns and norms are grounded, rather than in some kinds of high-level principles or laws, is also, I think, very fertile.

That’s independent of the details of his genealogical stories. Because, yeah, he does seem to have played fairly fast and loose with actual historical details in a lot of cases.

Here is another segment:

COWEN: Let me start with a very simple question about feminism. What would be a rhetorical disadvantage that many women are at that even, say, educated or so-called progressive men would be unlikely to see?

KUKLA: A rhetorical disadvantage that we’re at — that’s a fascinating question. I think that there is almost no correct way for a woman to use her voice and hold her body to project the proper kind of expertise and authority in a conversation.

I think that there’s massive — I don’t even want to call it a double bind because it’s a multidimensional bind — where if we sound too feminine, sounding feminine in this culture is coded as frivolous and unserious. If we sound too unfeminine, then we sound like we are violating gender norms or like we are unpleasant or trying to be like a man.

I think that almost any way in which we position ourselves — if we try to be polite and make nice, then we come off as weak. If we don’t make nice, then we’re held to a higher standard for our appropriate behavior than men are. I think there’s almost no way we can position ourselves so that we sound as experts. So oftentimes, the content of our words matters less than our embodied presentation as a woman.

Definitely recommended.

Department of Unintended Consequences, American health care edition

In 2010, the federal agency that oversees Medicare, the Centers for Medicare and Medicaid Services, established the Hospital Readmissions Reduction Program under the Affordable Care Act. Two years later, the program began imposing financial penalties on hospitals with high rates of readmission within 30 days of a hospitalization for pneumonia, heart attack or heart failure, a chronic condition in which the heart has difficulty pumping blood to the body.

At first, the reduction program seemed like the win-win that policymakers had hoped for. Readmission rates declined nationwide for target conditions. Medicare saved an estimated $10 billion because of the reduction in hospital admissions. Based on those results, many policymakers have called for expanding the program.

But a deeper look at the Hospital Readmissions Reduction Program reveals a few troubling trends. First, since the policy has been in place, patients returning to a hospital are more likely to be cared for in emergency rooms and observation units. This has raised concern that some hospitals may be avoiding readmissions, even for patients who would benefit most from inpatient care.

Second, safety-net hospitals with limited resources have been disproportionately punished by the program because they tend to care for more low-income patients who are at much higher risk of readmission. Financially penalizing these resource-poor hospitals may impede their ability to deliver good care.

Finally, and most concerning, there is growing evidence that while readmission rates are falling, death rates may be rising.

In a new study of approximately eight million Medicare patients hospitalized between 2005 and 2015 that we conducted with other colleagues, we found that the Hospital Readmissions Reduction Program was associated with an increase in deaths within 30 days of discharge among patients hospitalized for heart failure or pneumonia, though not for a heart attack.

That is by Rishi K. WadheraKaren E. Joynt Maddox and Robert W. Yeh in The New York Times.

Rational self-medication

We develop a theory of rational self-medication. The idea is that forward-looking individuals, lacking access to better treatment options, attempt to manage the symptoms of mental and physical pain outside of formal medical care. They use substances that relieve symptoms in the short run but that may be harmful in the long run. For example, heavy drinking could alleviate current symptoms of depression but could also exacerbate future depression or lead to alcoholism. Rational self-medication suggests that, when presented with a safer, more effective treatment, individuals will substitute towards it. To investigate, we use forty years of longitudinal data from the Framingham Heart Study and leverage the exogenous introduction of selective serotonin reuptake inhibitors (SSRIs). We demonstrate an economically meaningful reduction in heavy alcohol consumption for men when SSRIs became available. Additionally, we show that addiction to alcohol inhibits substitution. Our results suggest a role for rational self-medication in understanding the origin of substance abuse. Furthermore, our work suggests that punitive policies targeting substance abuse may backfire, leading to substitution towards even more harmful substances to self-medicate. In contrast, policies promoting medical innovation that provide safer treatment options could obviate the need to self-medicate with dangerous or addictive substances.

That is a new NBER working paper by Michael E. Darden and Nicholas W. Papageorgge.

A social credit system for scientists?

Researchers in China who commit scientific misconduct could soon be prevented from getting a bank loan, running a company or applying for a public-service job. The government has announced an extensive punishment system that could have significant consequences for offenders — far beyond their academic careers.

Under the new policy, dozens of government agencies will have the power to hand out penalties to those caught committing major scientific misconduct, a role previously performed by the science ministry or universities. Errant researchers could also face punishments that have nothing to do with research, such as restrictions on jobs outside academia, as well as existing misconduct penalties, such as losing grants and awards.

“Almost all aspects of daily life for the guilty scientists could be affected,” says Chen Bikun, who studies scientific evaluation systems at Nanjing University of Science and Technology.

The policy, announced last month, is an extension of the country’s controversial ‘social credit system’, where failure to comply with the rules of one government agency can mean facing restrictions or penalties from other agencies.

The punishment overhaul is the government’s latest measure to crack down on misconduct. But the nature and extent of the policy has surprised many researchers. “I have never seen such a comprehensive list of penalties for research misconduct elsewhere in the world,” says Chien Chou, a scientific integrity education researcher at Chiao Tung University in Taiwan.

By David Cyranoski in Nature, via Michelle Dawson.

The second cohort of Emergent Ventures winners

Here is the list of the second set of winners, in the order the grants were made, noting that the descriptions are mine not theirs:

Kelly Smith has a for-profit project to further extend a parent-run charter school system in Arizona, using Uber-like coordinating apps and “minimalist” OER methods.

Andrew L. Roberts, Northwestern University, a small grant to further his work on how sports relates to politics.

Stefan de Villiers, high school student, to create podcasts on the decisions of other high school students and how/why they become successful.

Brian Burns is working (with Samo Burja) on the history of mathematics and career networks, with special attention to the blossoming of innovation in 18th century Göttingen: “The secret to producing flourishing mathematical and scientific traditions may lie in a careful study of institutions. I will undertake this investigation and in the process uncover lost mathematical knowledge.”  Gauss, Riemann, and Hilbert!

Can Olcer is one of the two entrepreneurs behind Kosmos School, a K-12 school that exists only in virtual reality, a for-profit enterprise with an emphasis on science education.

Anonymous, working on a board game for ten years, aimed at teaching basic economics, including supply and demand and the core ideas of Ronald Coase.  The grant is for marketing the game.

Sophie Sandor is a 23-year-old Scottish film-maker making films with “noticeable themes [of] rational optimism, ambition and a rejection of the victimhood notion that millennials are prone to.”  She is also interested in making documentaries in the education space.

Nicholas Dunk has a for-profit to bring voice recognition/machine transcription to the daily tasks of doctors.  The goal is to solve paperwork problems, free up doctor time, encourage better record-keeping, and improve accuracy, all toward the end of higher quality and less expensive health care.

Lama Al Rajih, a young Saudi CS student, building Therma, among other projects, she received a travel grant to visit potential mentors.

I am very excited by this new cohort.  Here is a list of the first round of winners, and here is the underlying rationale for Emergent Ventures.  You can apply here.

Cohort effects and life expectancy and many other facts about the history of American medicine

The cohort reaching age 55 around 1982 (born around 1927) has significantly higher mortality than the cohort 10 years younger. That higher mortality continues through the cohort passing through that age range in the mid-1990s, roughly, when the cohort born in 1933 reaches age 65. That same cohort also has higher mortality when they are 65-74 and 75-84. The story is not one of selection – a handful of less healthy people who die and leave behind healthier stock. Rather, it seems that an entire generation was rendered vulnerable by being born during and just before the Great Depression (Lleras-Muney and Moreau, 2018).

That is from a new NBER history of health care paper by Maryaline Catillon, David Cutler, and Thomas Getzen.  This piece is interesting on virtually every page.  For instance, on the rise of American science:

Of the 18 Nobel Prizes in Physiology or Medicine awarded 1901-1920, none went to US researchers. Over the next two decades, four out of twenty-four did, then for the rest of the century, more than half.

Then:

…our analysis of Massachusetts data does not support a large impact of medical care supply on mortality in the pre-antibiotic era.

Using the best data I’ve seen to date, apart from RCTs, the authors conclude from their statistical work:

…there is little evidence that access to medical care plays a role in mortality over the entire 1965-2015 period, but it appears to have had an effect during recent years.

That is from p.33

Death rates from influenza/pneumonia and cancer seem most responsive to access to medical care.  And I had not known this:

The period from 1935 to 1950 saw the most…decline in infant and child mortality of any time period since 1900.  It is unclear how much of this change would have happened without antibiotics, but blood banking and advances in surgical techniques were among the host of distinct and incremental improvements that added to life expectancy while the health share of GDP increased only slightly.

Recommended.

What should I ask Larissa MacFarquhar?

I will be doing a Conversations with Tyler with her, no associated public event.  Here is her New Yorker bio:

Larissa MacFarquhar has been a staff writer at The New Yorker since 1998. Her Profile subjects have included John Ashbery, Barack Obama, Noam Chomsky, Hilary Mantel, Derek Parfit, David Chang, and Aaron Swartz, among many others. She is the author of “Strangers Drowning: Impossible Idealism, Drastic Choices, and the Urge to Help” (Penguin Press, 2015). Before joining the magazine, she was a senior editor at Lingua Franca and an advisory editor at The Paris Review, and wrote for ArtforumThe NationThe New Republic, the New York Times Book ReviewSlate, and other publications. She has received two Front Page Awards from the Newswomen’s Club of New York and the Academy Johnson & Johnson Excellence in Media Award. Her writing has appeared in “The Best American Political Writing” (2007 and 2009) and “The Best Food Writing” (2008). She is an Emerson Fellow at New America.

She also wrote famous profiles of Richard Posner and Paul Krugman.

So what should I ask her?

The Political Economy of Lobotomies in the United States

The actual title starts with: “Gordon Tullock Meets Phineas Gage:”, and here is the abstract:

In the late 1940s, the United States experienced a “lobotomy boom” where the use of the lobotomy expanded exponentially. We engage in a comparative institutional analysis, following the framework developed by Tullock (2005), to explain why the lobotomy gained popularity and widespread use despite widespread scientific consensus it was ineffective. We argue that government provision and funding for public mental hospitals and asylums expanded and prolonged the use of the lobotomy. We support this claim by noting the lobotomy had virtually disappeared from private mental hospitals and asylums before the boom and was less used beforehand. This paper provides a more robust explanation for the lobotomy boom in the US and expands on the literate examining the relationship between state funding and scientific inquiry.

That is from Raymond March and Vincent Geloso, via the excellent Kevin Lewis.

China possible fact of the day

A Chinese researcher claims that he helped make the world’s first genetically edited babies — twin girls born this month whose DNA he said he altered with a powerful new tool capable of rewriting the very blueprint of life.

If true, it would be a profound leap of science and ethics.

A U.S. scientist said he took part in the work in China, but this kind of gene editing is banned in the United States because the DNA changes can pass to future generations and it risks harming other genes.

Here is the full story.  Here is further background.

A Time to Fast

Over one hundred years ago researchers demonstrated that calorie restriction in rats increased lifespan, sometimes by as much as 50%. Since that time, the finding has been replicated and extended to primates. A few humans have taken up the diet but for most of us easy access to delicious food trumps willpower. A new paper in Science reviews the literature on calorie restriction and also offers some evidence that less restrictive regimes such as intermittent fasting may have similar effects.

First on calorie restriction. As noted, we have data on mice and primates showing increased lifespan and we also have data on humans showing the same physiological improvements as seen in other species:

In humans, short-term trials such as the multicenter CALERIE (Comprehensive Assessment of Long-Term Effects of Reducing Intake of Energy) study (2629), the observational studies of centenarians residing in Okinawa who have been exposed to CR for most of their lives (30), and observations of the members of the Calorie Restriction Society (CRONies) who self-impose CR (31) have shown the occurrence of many of the same physiological, metabolic, and molecular benefits typically associated with long-lived animals on CR. These studies support the observation that long-term CR preserves a more youthful functionality by improving several markers of health, including decreases in body weight, metabolic rate, and oxidative damage (14); lower incidence of cardiovascular disease (31) and cancer; and decreased activity of the insulin-Akt-FOXO signaling pathway (32, 33).

Although these findings clearly indicate that a reduction of caloric intake could be an effective intervention to improve health and prevent disease during aging in humans, there are several obstacles [including safety concerns and lack of data in older popualtions] and…The current “obesogenic” social environment makes it difficult for individuals to adhere to strict dietary regimens and lifestyle modifications for long periods of time. Thus, there is interest in alternative feeding regimens that may recapitulate at least some of the beneficial effects of CR by controlling feeding-fasting patterns with little or no reduction in caloric intake.

So what else works? Three regimes have shown promise. 1) Time Restricted Feeding (TRF), i.e. limiting eating time to a 4-12 period during the day and preferably earlier in the day, 2) Intermittent Fasting (IF)–say a 24-hour period of 1/4 calorie consumption once or twice a week and 3) a Fasting Mimicking Diet (FMD) in which calories are restricted to 30% of normal with a higher proportion coming from fat and doing this for five days periodically, i.e. once a month to once very couple of months. The diagram presents the main results and evidence.

 

How is Obamacare doing?

Yes, it is more popular, but how is it doing?:

Obamacare has continued to devastate the individual health insurance market:

  • In March of 2016, there were 20.2 million people covered in the individual health insurance market according to a hard count of state insurance department filings done by Mark Farrah and Associates.
  • In March of 2017 that count was down to 17.7 million.
  • In March of 2018 the count was 15.7 million–a 22% drop in two years.

This means 4.5 million people lost their individual health insurance in just two years.

Hardest hit are the 40% of middle class individual market consumers who are not eligible for a subsidy.

  • In March of 2016 there were 7,520,939 people covered in the off-exchange individual health insurance market where subsidies are not available.

  • In March of 2017 5,361,451 were covered.

  • In March of 2018 4,004,522 were covered–a 47% drop in two years.

And, the Obamacare subsidies paid to consumers are hardly sustainable.

According to the CBO, the average Medicaid outlay for a non-disabled adult is $4,230–a program that virtually has no premiums and co-pays. But because the risk pool is so bad and therefore expensive in the Obamacare exchanges, the average subsidy cost for taxpayers is $6,300–and that doesn’t include what the consumer pays in premiums and out-of-pocket expenses for Obamacare coverage.

Why has the Obamacare individual market melted-down in these last two years? Because its premiums and deductibles are sky high–for all but the lowest income participants.

In Northern Virginia, for example, the cheapest 2019 Obamacare individual market Silver plan for a family of four (mom and dad age-40) making a subsidy eligible $65,000 a year costs $4,514. That plan has a $6,500 deductible meaning the family would have to spend $11,014 on eligible health care costs before collecting other than nominal first dollar benefits.

That same family, but making too much for a subsidy, as 40% of families do, and a typical family in the affluent Virginia 10th, would have to spend $19,484 in premiums plus a $6,500 deductible, for a total of $25,984 in eligible costs before they would collect any meaningful benefits.

That is from Robert Laszewski, with additional interesting points at the link.  Do see my earlier post on what does and does not make sense in Obamacare — the risk pool for the individual market simply isn’t big or robust enough.

Depression and religion in adolescence

Depression is the leading cause of illness and disability in adolescence. Many studies show a correlation between religiosity and mental health, yet the question remains whether the relationship is causal. We exploit within-school variation in adolescents’ peers to deal with selection into religiosity. We find robust effects of religiosity on depression that are stronger for the most depressed. These effects are not driven by the school social context; depression spreads among close friends rather than through broader peer groups that affect religiosity. Exploration of mechanisms suggests that religiosity buffers against stressors in ways that school activities and friendships do not.

That is the abstract of a new paper by Jane Cooley Fruehwirth, Sriya Iyer, and Anwen Zhang, forthcoming in the JPE.  I find this to be one of the most underemphasized benefits of religion, perhaps because religious people themselves do not wish to come off as overly neurotic.  And the effect seems to be large:

…a one standard deviation increase in religiosity decreases the probability of being depressed by 11 percent.  By comparison, increasing mother’s education from no high school degree to a high school degree or more only decreases the probability of being depressed by about 5 percent.

And for the most depressed individuals, religiosity seems to be more effective than cognitive-based therapy “one of the most recommended forms of treatment.”

What should I ask Rebecca Kukla?

I will be doing a Conversation with her, here is her home page:

Professor of Philosophy and Senior Research Scholar in the Kennedy Institute of Ethics at Georgetown University

Also: amateur powerlifter and boxer and certified sommelier

I live in the middle of Washington, DC, with my 13-year-old son Eli and my two Portal-themed cats, Chell and Cube. My research focuses on social epistemology, philosophy of medicine, and philosophy of language. 

This interview is an excellent entry point into her thought and life, here is an excerpt from the introduction:

[Rebecca] talks about traveling the world with her nomadic parents, her father who was a holocaust survivor and philosopher, hearing the Dream argument in lieu of bedtime stories, chaotic exposure to religion, getting a job at and apartment at the age of 14, the queerness of Toronto, meeting John Waters and Cronenberg, her brother who is the world’s first openly transgender ordained rabbi, getting into ballet, combating an eating disorder, the importance of chosen family, co-authoring an article with her dad, developing an interest in philosophy of mathematics, the affordability of college in Canada, taking care of a disabled, dramatically uninsured loved one, going to University of Pitt for grad school, dealing with aggravated depression, working with Brandom, McDowell, the continental/analytic distinction, history of philosophy, how feminism and women—such as Tamara Horowitz, Annette Baier, and Jennifer Whiting–were treated at Pitt, coping with harassment from a member of the department, impostor syndrome, Dan Dennett and ‘freeedom’, her sweet first gig (in Vermont), dining with Bernie Sanders, spending a bad couple of years in Oregon, having a child, September 11th, securing tenure and becoming discontent at Carleton University, toying with the idea of becoming a wine importer, taking a sabbatical at Georgetown University which rekindled her love of philosophy, working on the pragmatics of language with Mark Lance, Mass Hysteria and the culture of pregnancy, how parenting informs her philosophy, moving to South Florida and the quirkiness of Tampa, getting an MA in Geography, science, philosophy and urban spaces, boxing, starting a group for people pursuing non-monogamous relationships, developing a course on Bojack Horseman, her current beau, Die Antwoord, Kendrick, Trump, and what she would do if she were queen of the world…

And from the interview itself:

I suspect that I’m basically unmentorable. I am self-destructively independent and stubborn, and deeply resentful of any attempt to control or patronize me, even when that’s not really a fair assessment of what is going on.

So what should I ask her?

Maybe We Won’t All Die in a Pandemic

The high frequency of modern travel has led to concerns about a devastating pandemic since a lethal pathogen strain could spread worldwide quickly. Many historical pandemics have arisen following pathogen evolution to a more virulent form. However, some pathogen strains invoke immune responses that provide partial cross-immunity against infection with related strains. Here, we consider a mathematical model of successive outbreaks of two strains: a low virulence strain outbreak followed by a high virulence strain outbreak. Under these circumstances, we investigate the impacts of varying travel rates and cross-immunity on the probability that a major epidemic of the high virulence strain occurs, and the size of that outbreak. Frequent travel between subpopulations can lead to widespread immunity to the high virulence strain, driven by exposure to the low virulence strain. As a result, major epidemics of the high virulence strain are less likely, and can potentially be smaller, with more connected subpopulations. Cross-immunity may be a factor contributing to the absence of a global pandemic as severe as the 1918 influenza pandemic in the century since.

From a new paper in bioRxiv, the biological preprint service analagous to arXiv.

Hat tip: Paul Kedrosky.