Category: Medicine

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.

Kenyan hospital markets in everything

The Kenyatta National Hospital is east Africa’s biggest medical institution, home to more than a dozen donor-funded projects with international partners — a “Center of Excellence,” says the U.S. Centers for Disease Control and Prevention.

The hospital’s website proudly proclaims its motto — “We Listen … We Care” — along with photos of smiling doctors, a vaccination campaign and staffers holding aloft a gold trophy at an awards ceremony.

But there are no pictures of Robert Wanyonyi, shot and paralyzed in a robbery more than a year ago. Kenyatta will not allow him to leave the hospital because he cannot pay his bill of nearly 4 million Kenyan shillings ($39,570). He is trapped in his fourth-floor bed, unable to go to India, where he believes doctors might help him…

The hospitals often illegally detain patients long after they should be medically discharged, using armed guards, locked doors and even chains to hold those who have not settled their accounts. Mothers and babies are sometimes separated. Even death does not guarantee release: Kenyan hospitals and morgues are holding hundreds of bodies until families can pay their loved ones’ bills, government officials say.

Dozens of doctors, nurses, health experts, patients and administrators told The Associated Press of imprisonments in hospitals in at least 30 other countries, including Nigeria and the Democratic Republic of the Congo, China and Thailand, Lithuania and Bulgaria, and others in Latin America and the Middle East.

Here is the full story by Maria Cheng, via Daniel Lippman.

Interview with Chad Syverson

Interesting and substantive throughout, here is one bit:

Syverson: In general, we think companies that do a better job of meeting the needs of their consumers at a low price are going to gain market share, and those that don’t, shrink and eventually go out of business. The null hypothesis seems to be that health care is so hopelessly messed up that there is virtually no responsiveness of demand to quality, however you would like to measure it. The claim is that people don’t observe quality very well — and even if they do, they might not trade off quality and price like we think people do with consumer products, because there is often a third-party payer, so people don’t care about price. Also, there is a lot of government intervention in the health care market, and governments can have priorities that aren’t necessarily about moving market activity in an efficient direction.

Amitabh Chandra, Amy Finkelstein, Adam Sacarny, and I looked at whether demand responds to performance differences using Medicare dataOffsite. We looked at a number of different ailments, including heart attacks, congestive heart failure, pneumonia, and hip and knee replacements. In every case, you see two patterns. One is that hospitals that are better at treating those ailments treat more patients with those ailments. Now, the causation can go either way with that. However, we also see that being good at treating an ailment today makes the hospital big tomorrow.

Second, responsiveness to quality is larger in instances where patients have more scope for choice. When you’re admitted through the emergency department, there’s still a positive correlation between performance and demand, but it’s even stronger when you’re not admitted through the emergency department — in other words, when you had a greater ability to choose. Half of the people on Medicare in our data do not go to the hospital nearest to where they live when they are having a heart attack. They go to one farther away, and systematically the one they go to is better at treating heart attacks than the one nearer to their house.

What we don’t know is the mechanism that drives that response. We don’t know whether the patients choose a hospital because they have previously heard something from their doctor, or the ambulance drivers are making the choice, or the patient’s family tells the ambulance driv­ers where to go. Probably all of those things are important.

It’s heartening that the market seems to be respon­sive to performance differences. But, in addition, these performance differences are coordinated with produc­tivity — not just outcomes but outcomes per unit input. The reallocation of demand across hospitals is making them more efficient overall. It turns out that’s kind of by chance. Patients don’t go to hospitals that get the same survival rate with fewer inputs. They’re not going for productivity per se; they’re going for performance. But performance is correlated with productivity.

All of this is not to say that the health care market is fine and we have nothing to worry about. It just says that the mechanisms here aren’t fundamentally different than they are in other markets that we think “work better.”

Here is the full interview, via Patrick Collison.

The new CEA report on socialism is better than critics are claiming

That is the topic of my latest Bloomberg column, here is one excerpt:

More to the point, by far the longest section in the report covers a specific health-care bill, introduced in both the Senate and House and supported by 141 members of Congress, that has become a centerpiece of debate in the Democratic Party. It is hardly irrelevant.

The legislation would eliminate cost sharing, prevent private insurance plans from competing, and prevent private markets from supplementing government coverage (outside of, say, cosmetic surgery). The House version would even prohibit health-care providers from earning profits. These provisions are far more extreme than what is found in most Western European health-care systems. The analogies with traditional socialism are indeed apt — the bill is much worse than anything the Trump administration has proposed to date.

Many of the criticisms of the report have been directed at the section on health-care economics. The critics tend to proclaim their own moderate views and favorably compare some of the Western European health-care systems to that of the U.S. The goal is apparently to smash the report for associating those well-functioning health-care systems with Lenin and Mao. Yet I haven’t seen any of the report’s critics acknowledge the extreme nature of the current Democratic proposal, or that it might need rebuttal, and that such a rebuttal is inevitably going to sound somewhat over the top.

And:

The report also commits the now-unpardonable and immediately punished sin of supporting a doctrine of “false equivalence” — namely, that these days many Democratic ideas are as unacceptable as those associated with Trump.

There are further points at the link, controversial throughout.  Here is the report itself.

The Big Push Failed

In 2004, Jeff Sachs and co-authors revived an old theory to explain Africa’s failure to develop, the poverty trap, and an old solution, the big push.

Our explanation is that tropical Africa, even the well-governed parts, is stuck in a poverty trap, too poor to achieve robust, high levels of economic growth and, in many places, simply too poor to grow at all. More policy or governance reform, by itself, will not be sufficient to over-come this trap. Specifically, Africa’s extreme poverty leads to low national saving rates, which in turn lead to low or negative economic growth rates. Low domestic saving is not offset by large inflows of private foreign capital, for example foreign direct investment, because Africa’s poor infrastructure and weak human capital discourage such inflows. With very low domestic saving and low rates of market-based foreign capital inflows, there is little in Africa’s current dynamics that promotes an escape from poverty. Something new is needed.

We argue that what is needed is a “big push” in public investments to produce a rapid “step” increase in Africa’s underlying productivity, both rural and urban.

Note also the mosquito bed nets being used for other purposes, AT.

As the title of the blog might suggest, I was skeptical. But even if a big push wasn’t exactly the right idea, I’m all in favor of Big Ideas and Sachs pursued his Big Idea with tremendous skill and media savvy. Pilot programs were soon up and running and then quickly expanded into full programs. In June 2010, the Millennium Villages Project released its first public evaluation and that is when things started to fall apart.

The initial MVP evaluation claimed great success but simply compared some development indicators before and after in the treated villages without comparing to trends elsewhere. In 2010 such a study was completely out of step with contemporary practices in impact evaluation. Red flag! Clemens and Demombynes showed that comparing to trends elsewhere significantly moderated the impact. A second MVP paper was published in the Lancet but then was quickly retracted when Bump, Clemens, Demombynes and Haddad demonstrated that it had  significant errors. Clemens and Demombynes wrote a summary piece on the controversy then in an astounding and under-reported scandal the MVP tried to stifle Clemens and Demombynes. The MVP, with Jeff Sachs at the head, also sicced their lawyers on Nina Munk and her book, The Idealist: Jeffrey Sachs and the Quest to End Poverty. More red flags.

Yet, despite all of this controversy and bad behavior, the MVP project continued to move ahead and in 2012, the UK Department for International Development (DFID) funded US $11 million into an MVP in Northern Ghana that ran until December 2016. Under the auspices of the DFID, we now finally have the first in-depth, independent evaluation of one MVP project and it doesn’t look great. The project did some good but the big push failed and the good that was done could have been done at lower cost.

Overall, the MVP in northern Ghana did not achieve the overall MDG target to reduce extreme poverty and hunger at the local level. Where there are attributable changes to the MDG targets, these tended to be the more limited changes than those that will fundamentally improve people’s health, educational and other outcomes. For instance, the project did increase attendance at primary school (Goal 2) but did not go beyond this MDG and improve the learning outcomes of children; the project did increase the proportion of births attended by professionals and women said to be using contraceptive methods (MDG indicators), but it is not possible to assess the effect on maternal health (Goal 5); and the project did increase the number of toilets (a target under Goal 7), but not beyond this MDG in terms of hygiene and sanitation practices. There are, however, exceptions. The project had a remarkable impact on stunting, which is a long-term health indicator and a predictor of socioeconomic outcomes in adulthood.

So the MVP had some good effects on some indicators:

But is this impact sufficient given the size of the investment? And, by doing everything together, is there a synergistic effect that offers greater value for money than would arise through implementing individual sector-based interventions? In our cost-effectiveness analysis, we demonstrate that the project has so far not yielded sufficiently positive results, and what has been achieved could have been attained at a substantially lower cost (even when we take account of investments made for future usage). As such, the project seems to have fallen short of producing a synergistic effect; and the impact is not large enough for the project to be regarded as cost-effective, even when each sector is assessed independently of the others. Of course, in the longer run, the MVP may produce welfare gains. Importantly the investments in improving the health care service may enhance health outcomes later on; or other considerable investments in infrastructure (roads, health and school facilities) may have an impact on future outcomes. 

Perhaps then, the most concerning findings are the early indications that the MVP approach will be difficult to be sustained by district institutions and at the community level; and there are signs that any gains made under the project are already being undermined.

Addendum: Andrew Gelman and co-authors, including Jeff Sachs, offer a broadly similar although less negative in tone evaluation of the entire MVP project.

Marijuana in Canada

Dispensaries selling various strains of marijuana and high-potency extracts, called budder and shatter, have opened on main streets. Regular pop-up markets like the one in Hamilton have sprouted, to the point vendors can attend five a week in the Toronto area.

Cannabis lounges have expanded, offering not just a place to smoke and take hits, but classes on growing cannabis at home and making cannabis creams. Cannabis-infused catering has gone so mainstream that the national association of food service businesses, Restaurants Canada, is hosting a seminar on it. Cannabis tour companies have opened, as have cannabis “bud-and-breakfasts.”

Universities and colleges across the country have introduced courses on cannabis business, investing, retail and cultivation.

Newspapers, which have hired full-time cannabis reporters, have published cannabis sections, filled with editorial ads by government-licensed producers advertising lines of cannabis-infused beverages, coffee and dog chew toys they are developing for when such products become legal.

…Ms. Roach see cannabis becoming almost like corn in its derivative form, threaded through everyday Canadian consumer products. Although people eat a minimal amount of corn each day, she said, “there’s corn syrup in everything.”

That is from Catherine Porter at the NYT.  I increasingly believe that decriminalization will prove a more stable solution than outright legalization.

America does pretty well at public health

Michael S. Sparer and Anne-Laure Beaussier has a new and interesting piece on this topic, here is part of the abstract:

First, the United States outperforms its European peers on several public health metrics. Second, the United States spends a comparable proportion of its health dollar on prevention. Third, these results are due partly to a federalism twist (while all three nations delegate significant responsibility for public health to local governments, federal officials are more engaged in the United States) and partly to the American version of public health moralism. We also consider the renewed interest in population health, noting why, against expectations, this trend might grow more quickly in the United States than in its European counterparts.

I also learned (or relearned) from this paper the following:

1. For per capita prevention, the U.S. is a clear first in the world.  (I wonder, by the way, to what extent this contributes to higher health care costs in the United States, since preventive care also can drive doctor and hospital visits.)

2. The UK and France made a deliberate decision to switch away from public health to curative medicine, after the end of World War II, when they were building out their universal coverage systems.

3. The American history with public health programs is a pretty good one, with advances coming from the anti-smoking campaign, lower speed limits, anti-drunk driving initiatives, fluoridated water, and mandatory vaccination programs.

4. The British fare poorly on various public health metrics.

5. “The US system of public health fares rather well compared to other Western nations.”  On net, our population is not as anti-science as it may seem, at least not if we look at final policy results, as compared to some of our peer countries.

All in all, an interesting read.

The crack culture that is Long Island, vending machine markets in everything

Suffolk County locals in New York’s Long Island are on alert in the wake of the appearance of three potential crack pipe vending machines, with authorities trying to find out who planted them.

The town of Brookhaven received complaints about the machines last weekend and two have been removed. One of the machines that was removed was partially destroyed by the community, according to WABC-TV.

The station reported that the machines featured the words “Sketch Pens” and were mounted in cement into the ground. It would dispense a small glass tube and a filter for $2 in the form of eight quarters.

The dispensers were initially reported to officials as merely pen dispensers as it was the first week of school in the community.

Here is the full story, via David C. and John C., more information here.

*Sick: A Memoir*, by Porochista Khakpour

I very much enjoyed this book, which is simultaneously an account of having Lyme disease (and not knowing for a long time), a tale of multiple substance abuses, a look into the mindset of somebody not at all like me, a second-generation Iranian-American memoir, and (unintended) the strongest case for social conservatism I have read in some time.  Here is one excerpt, another application of the intersectionality concept:

It is no coincidence then that doctors and patients and the entire Lyme community report — anecdotally, of course, as there is still a frustrating scarcity of good data on anything Lyme-related — that women suffer the most from Lyme.  They tend to advance into chronic and late-stage forms of the illness most because often it’s checked for last, as doctors often treat them as psychiatric cases first.  the nebulous symptoms plus the fracturing of articulacy and cognitive fog can cause any Lyme patient to simply appear mentally ill and mentally ill only.  This is why we hear that young women — again anecdotally — are dying of Lyme the fastest.  This is also why we hear that chronic illness is a woman’s burden.  Women simply aren’t allowed to be physically sick until they are mentally sick, too, and then it is by some miracle or accident that the two can be separated for proper diagnosis.  In the end, every Lyme patient has some psychiatric diagnosis, too, if anything because of the hell it takes getting to a diagnosis.

And this bit:

I am a sick girl.  I know sickness.  I live with it.  In some ways, I keep myself sick.

You can order the book here.

Hysteria Was Not Treated With Vibrators

You know the story about the male Victorian physicians who unwittingly produced orgasms in their female clients by treating them for “hysteria” with newly-invented, labor-saving, mechanical vibrators? It’s little more than an urban legend albeit one transmitted through academic books and articles. Hallie Lieberman and Eric Schatzberg, the authors of a shocking new paper, A Failure of Academic Quality Control: The Technology of Orgasm, don’t quite use the word fraud but they come close.

Since its publication in 1999, The Technology of Orgasm by Rachel Maines has become one of the most widely cited works on the history of sex and technology (Maines, 1999). This slim book covers a lot of ground, but Maines’ core argument is quite simple. She argues that Victorian physicians routinely treated female hysteria patients by stimulating them to orgasm using electromechanical vibrators. The vibrator was, according to Maines, a labor-saving technology that replaced the well-established medical practice of clitoral massage for hysteria. She states that physicians did not perceive either the vibrator or manual massage as sexual, because neither method involved vaginal penetration.

This argument has been repeated in dozens of scholarly works and cited with approval in many more. A few scholars have challenged various parts of the book. Yet no scholars have contested her central argument, at least not in the peer-reviewed literature. Her argument even spread to popular culture, appearing in a Broadway play, a feature-length film, several documentaries, and many mainstream books and articles. This once controversial idea has now become an accepted fact.

But there’s only one problem with Maines’ argument: we could find no evidence that physicians ever used electromechanical vibrators to induce orgasms in female patients as a medical treatment. We examined every source that Maines cites in support of her core claim. None of these sources actually do so. We also discuss other evidence from this era that contradicts key aspects of Maines’ argument. This evidence shows that vibrators were indeed used penetratively, and that manual massage of female genitals was never a routine medical treatment for hysteria.

… the 19-year success of Technology of Orgasm points to a fundamental failure of academic quality control. This failure occurred at every stage, starting with the assessment of the work at the Johns Hopkins University Press. But most glaring is the fact that not a single scholarly publication has pointed out the empirical flaws in the book’s core claims in the 19 years since its release.

Wow. Read the whole thing.

Hat tip: Chris Martin on twitter.

Government Medical Research Spending Favors Women

It is commonly believed that medical research spending is biased against women. Here are some representative headlines: Why Medical Research Often Ignores Women (Boston University Today), Gender Equality in Medical Research Long Overdue, Study Finds (Fortune), A Male Bias Reigns in Medical Research (IFL Science). Largely on the basis of claims like this the NIH set up a committee to collect data on medical research funding and gender and they discovered there was a disparity. Government funded medical research favors women.

The Report on the Advisory Committee on Research on Women’s Health used the following criteria to allocate funding by gender:

All funding for projects that focus primarily on women, such as the Nurses’ Health Study, the Mammography Quality Standards Act, and the Women’s Health Initiative, should be attributed to women. For research, studies, services, or projects that include both men and women, recommended methods to calculate the proportion of funds spent on women’s health are as follow:

a. If target or accrual enrollment data are available, multiply the expenditure by the proportion of female subjects included in the program. For example, if 50 percent of the subjects enrolled in a trial, study, service, or treatment program are women, then 50 percent of the funds spent for that program should be counted as for women’s health. On the other hand, for diseases, disorders, or conditions without enrollment data, expenditures can be calculated based on the relative prevalence of that condition in women.

b. Where both males and females are included, as may be the case for many basic science research projects, multiply the expenditure by 50 percent.

On the basis of these criteria the report finds that in almost every category there is more female-focused NIH funding than male-focused NIH spending with the totals more than two to one in favor of females ($4.5 billion to $1.5 billion). Now personally I don’t regard this as a terrible “bias” as most spending ($25.7 billion) is for human beings and I don’t see any special reason why spending on women and men should be equal. It does show, however, that the common wisdom is incorrect. The Boston University Today piece I linked to earlier, for example, motivated its claim of bias in funding with the story of a female doctor who died of lung cancer. The NIH data, however, show a large difference in favor of women–$180 million of NIH lung cancer funding was focused on women while just $318 thousand was focused on men ($135 million wasn’t gender focused).

What about clinical trials? Well for NIH-funded clinical trials the results favor women:

Enrollment of women in all NIH-funded clinical  research in FY 15 and FY 16 was 50 percent or greater. Enrollment of women in clinical  research was highest in the intramural research program at 68 percent for both FY 15 and FY 16.

In the most clinically-relevant phase III trials:

NIH-defined Phase III Clinical Trials are a subset of NIH Clinical Research studies. The proportion of female participants enrolled in NIH-defined Phase III Clinical Trial was 67 percent in in FY 15 and 66 percent in FY 2016.

Historically, one of the reasons that men have often been more prevalent in early stage clinical trials (trials which are not always meant to treat a disease) is that after the thalidomide disaster the FDA issued a guidance document which stated that women of child-bearing age should be excluded from Phase 1 and early Phase 2 research, unless the studies were testing a drug for a life-threatening illness. That guidance is no longer in effect but the point is that interpreting these results requires some subtlety.

The NIH funds more clinical trials than any other entity but overall more clinical trials are conducted by industry. FDA data indicate that in the United States overall (the country where by far the most people are enrolled in clinical trials) the ratios are close to equal, 49% female to 51% male, although across the world there are fewer women than men in clinical trials, 43% women to 57% men for the world as whole with bigger biases outside the United States.

It would be surprising if industry research was biased against women because women are bigger consumers of health care than men. The Centers for Medicare and Medicaid Services, find, for example, that:

Per capita health spending for females was $8,315 in 2012, approximately 23 percent more than for males, $6,788

Also:

Research indicates that women visit the doctor more frequently, especially as they have children, and tend to seek out more preventive care. The National Center for Health Statistics found that women made 30% more visits to physicians’ offices than men between 1995 and 2011.

Nor is it the case that physicians ignore women. In one study of time use of family physicians and thousands of patients:

After controlling for visit and patients characteristics, visits by women had a higher percent of time spent on physical examination, structuring the intervention, patient questions, screening, and emotional counseling.

Of course, you can always find some differences by gender. The study I just cited, for example, found that “More eligible men than women received exercise, diet, and substance abuse counseling.” One often quoted 2008 study found that women in an ER waited 65 minutes to men’s average of 49 minutes to receive a pain killer. Citing that study in 2013 the New York Times decried that:

women were still 13 to 25 percent less likely than men to receive high-strength “opioid” pain medication.

Today, of course, that same study might be cited as a bias against men as twice as many men as women are dying of opioid abuse. I don’t know what the “correct” numbers are which is why I am reluctant to describe differences in the treatment of something as complex as pain to bias.

Overall, spending on medical research and medical care looks to be favorable to women especially so given that men die younger than women.

Hat tip: Discussants on twitter.

Addendum: I expect lots of pushback and motte and baileying on this post. Andrew Kadar wrote an excellent piece on The Sex-Bias Myth in Medicine in The Atlantic in 1994 but great memes resist data. Also, school summer vacation is not a remnant from when America was rural and children were needed on the farm.

Olympic gold medals and longevity

Perhaps it is better to win the silver, to which other life outcomes might this apply?:

This paper compares mortality between Gold and Silver medalists in Olympic Track and Field to study how achievement influences health. Contrary to conventional wisdom, winners die over one year earlier than losers. I find strong evidence of differences in earnings and occupational choices as a mechanism. Losers pursued higher-paying occupations than winners according to individual Census records. I find no evidence consistent with selection or risk-taking. How people respond to success or failure in pivotal life events may produce long-lasting consequences for health.

That is from Adam Leive, via the excellent Kevin Lewis.