Category: Medicine
My Conversation with Mark Zuckerberg and Patrick Collison
@patrickc, CEO of Stripe, and @tylercowen, economist at George Mason University, sit down with our CEO, Mark Zuckerberg to discuss how to accelerate progress.
Video, audio, and transcript here, part of Mark’s personal challenge for the year, an excellent event all around. This will also end up as part of CWT.
Genes and health insurance coverage
We provide the first investigation into whether and how much genes explain having health insurance coverage or not and possible mechanisms for genetic variation. Using a twin-design that compares identical and non-identical twins from a national sample of US twins from the National Survey of Midlife Development in the United States, we find that genetic effects explain over 40% of the variation in whether a person has any health coverage versus not, and nearly 50% of the variation in whether individuals younger than 65 have private coverage versus whether they have no coverage at all. Nearly one third of the genetic variation in being uninsured versus having private coverage is explained by employment industry, self-employment status, and income, and together with education, they explain over 40% of the genetic influence. Marital status, number of children, and available measures of health status, risk preferences, and prevention effort do not appear to be important channels for genetic effects. That genes have meaningful effects on the insurance status suggests an important source of heterogeneity in insurance take up.
That is from a paper by George L. Wehby and Dan Shane. Via the excellent Kevin Lewis. We do need to know more, but one possibility is that the adverse selection model of health insurance is much overrated, and advantageous selection into health insurance is a live possibility.
Learning about the Roots of Progress from the History of Smallpox Eradication
The excellent Jason Crawford at the Roots of Progress has a long-form read on the history of smallpox eradication. It’s an important and insightful piece especially because Jason is interested not just in what happened but why it happened when and where it did and what the lessons are for today:
In 1720, inoculation had been a folk practice in many parts of the world for hundreds of years, but smallpox was still endemic almost everywhere. The disease had existed for at least 1,400 and probably over 3,000 years. Just over 250 years later—it was gone.
Why did it take so long, and how did it then happen so fast? Why wasn’t inoculation practiced more widely in China, India, or the Middle East, when it had been known there for centuries? Why, when it reached the West, did it spread faster and wider than ever before—enough to significantly reduce and ultimately eliminate the disease?
The same questions apply to many other technologies. China famously had the compass, gunpowder, and cast iron all before the West, but it was Europe that charted the oceans, blasted tunnels through mountains, and created the Industrial Revolution. In smallpox we see the same pattern. [Why?]
- The idea of progress. In Europe by 1700 there was a widespread belief, the legacy of Bacon, that useful knowledge could be discovered that would lead to improvements in life. People were on the lookout for such knowledge and improvements and were eager to discover and communicate them. Those who advocated for inoculation in 1720s England did so in part on the grounds of a general idea of progress in medicine, and they pointed to recent advances, such as using Cinchona bark (quinine) to treat malaria, as evidence that such progress was possible. The idea of medical progress drove the Suttons to make incremental improvements to inoculation, Watson to run his clinical trial, and Jenner to perfect his vaccine.
- Secularism/humanism. To believe in progress requires believing in human agency and caring about human life (in this world, not the next). Although England learned about inoculation from the Ottoman Empire, it was reported that Muslims there avoided the practice because it interfered with divine providence—the same argument Reverend Massey used. In that sermon, Massey said in his conclusion, “Let them Inoculate, and be Inoculated, whose Hope is only in, and for this Life!” A primary concern with salvation of the immortal soul precludes concerns of the flesh. Fortunately, Christianity had by then absorbed enough of the Enlightenment that other moral leaders, such as Cotton Mather, could give a humanistic opinion on inoculation.
- Communication. In China, variolation may have been introduced as early as the 10th century AD, but it was a secret rite until the 16th century, when it became more publicly documented. In contrast, in 18th-century Europe, part of the Baconian program was the dissemination of useful knowledge, and there were networks and institutions expressly for that purpose. The Royal Society acted as an information hub, taking in interesting reports and broadcasting the most important ones. Prestige and acclaim came to those who announced useful discoveries, so the mechanism of social credit broke secrets open, rather than burying them. Similar communication networks spread the knowledge of cowpox to from Fewster to Jenner, and gave Jenner a channel to broadcast his vaccination experiments.
- Science. I’m not sure how inoculation was viewed globally, but it was controversial in the West, so it was probably controversial elsewhere as well. The West, however, had the scientific method. We didn’t just argue, we got the data, and the case was ultimately proved by the numbers. If people didn’t believe it at first, they had to a century later, when the effects of vaccination showed up in national mortality statistics. The method of meticulous, systematic observation and record-keeping also helped the Suttons improve inoculation methods, Haygarth discover his Rules of Prevention, and Fewster and Jenner learn the effects of cowpox. The germ theory, developed several decades after Jenner, could only have helped, putting to rest “miasma” theories and dispelling any idea that one could prevent contagious diseases through diet and fresh air.
- Capitalism. Inoculation was a business, which motivated inoculators to make their services widely available. The practice required little skill, and it was not licensed, so there was plenty of competition, which drove down prices and sent inoculators searching for new markets. The Suttons applied good business sense to inoculation, opening multiple houses and then an international franchise. They provided their services to both rich and poor by charging higher prices for better room and board during the multiple weeks of quarantine: everyone got the same medical procedure, but the rich paid more for comfort and convenience, an excellent example of price differentiation without compromising the quality of health care. Business means advertising, and advertising at its best is a form of education, helping people throughout the countryside learn about the benefits of inoculation and how easy and painless it could be.
- The momentum of progress. The Industrial Revolution was a massive feedback loop: progress begets progress; science, technology, infrastructure, and surplus all reinforce each other. By the 20th century, it’s clear how much progress against smallpox depended on previous progress, both specific technologies and the general environment. Think of Leslie Collier, in a lab at the Lister Institute, performing a series of experiments to determine the best means of preserving vaccines—and how the solution he found, freeze-drying, was an advanced technology, only developed decades before, which itself depended on the science of chemistry and on technologies such as refrigeration. Or consider the WHO eradication effort: electronic communication networks let doctors be alerted of new cases almost immediately; airplanes and motor vehicles got them and their supplies to the site of an epidemic, often within hours; mass manufacturing allowed cheap production at scale of needles and vaccines; refrigeration and freeze-drying allowed vaccines to be preserved for storage and transport; and all of it was guided by the science of infectious diseases—which itself was by that time supported by advanced techniques from X-ray crystallography to electron microscopes.
Read the whole thing and follow the roots of progress.
On fentanyl, from the comments
Eliminate Journal Formatting on First Submission!
Many years ago I was incredulous when my wife told me she had to format a paper to meet a journal’s guidelines before it was accepted! Who could favor such a dumb policy? In economics, the rule is you make your paper look good but you don’t have to fulfill all the journal’s guidelines until after the paper is accepted.
In The high resource impact of reformatting requirements for scientific papers Jian et al. calculate the cost of reformatting–it’s $1.1 billion dollars annually! True, the authors simply surveyed 203 authors for the time it took to reformat and then multiplied that by an hourly wage and then multiplied that by all article submissions so, at best, this is a back of the envelope calculation. What is beyond doubt, however, is that reformatting typically takes several tedious hours for a high-wage professional.
Our data show that nearly 91% of authors spend greater than four hours and 65% spend over eight hours on reformatting adjustments before publication…Among the time-consuming processes involved are adjusting manuscript structure (e.g. altering abstract formats), changing figure formats, and complying with word counts that vary significantly depending on the journal. Beyond revising the manuscript itself, authors often have to adjust to specific journal and publisher online requirements (such as re-inputting data for all authors’ email, office addresses, and disclosures). Most authors reported spending “a great deal” of time on this reformatting task. Reformatting for these types of requirements reportedly caused three month or more delay in the publication of nearly one fifth of articles and one to three month delays for over a third of articles.
And for what? Most papers will be rejected so the reformatting serves no purpose.
What frustrates me about this inanity is that, as far as I can tell, almost no one benefits! We simple seem stuck in an inefficient equilibrium. What hope is there to deregulate zoning or pass a carbon tax–where benefits exceed costs but you can understand why the process is difficult because some people gain from the inefficiency–when we can’t even fix wasteful journal formatting policy? Can Elsevier or other publishing heavyweight not unilaterally move us to the Pareto frontier! Pick up those $1.1 billion bills! Come on humanity, just do it!
Addendum: Economics is good on the reformatting score but n.b. “A prior survey-based research study on biomedical journal publications times noted a median time of first submission to acceptance of five months but this seemingly included all delays in the publication process (including review time and changes to improving scientific content).” Five months would be unheard of speed in economics where you are lucky if you get referee comments in five months!
Air Pollution Reduces IQ, a Lot
The number and quality of studies showing that air pollution has very substantial effects on health continues to increase. Patrick Collison reviews some of the most recent studies on air pollution and cognition. I’m going to post the whole thing so everything that follows is Patrick’s.
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Air pollution is a very big deal. Its adverse effects on numerous health outcomes and general mortality are widely documented. However, our understanding of its cognitive costs is more recent and those costs are almost certainly still significantly under-emphasized. For example, cognitive effects are not mentioned in most EPA materials.
World Bank data indicate that 3.7 billion people, about half the world’s population, are exposed to more than 50 µg/m³ of PM2.5 on an annual basis, 5x the unit of measure for most of the findings below.
- Substantial declines in short-term cognitive performance after short-term exposure to moderate (median 27.0 µg/m³) PM2.5 pollution: “The results from the MMSE test showed a statistically robust decline in cognitive function after exposure to both the candle burning and outdoor commuting compared to ambient indoor conditions. The similarity in the results between the two experiments suggests that PM exposure is the cause of the short-term cognitive decline observed in both.” […] “The mean average [test scores] for pre and post exposure to the candle burning were 48 ± 16 and 40 ± 17, respectively.” – Shehab & Pope 2019.
- Chess players make more mistakes on polluted days: “We find that an increase of 10 µg/m³ raises the probability of making an error by 1.5 percentage points, and increases the magnitude of the errors by 9.4%. The impact of pollution is exacerbated by time pressure. When players approach the time control of games, an increase of 10 µg/m³, corresponding to about one standard deviation, increases the probability of making a meaningful error by 3.2 percentage points, and errors being 17.3% larger.” – Künn et al 2019.
- A 3.26x (albeit with very wide CI) increase in Alzheimer’s incidence for each 10 µg/m³ increase in long-term PM2.5 exposure? “Short- and long-term PM2.5 exposure was associated with increased risks of stroke (short-term odds ratio 1.01 [per µg/m³ increase in PM2.5 concentrations], 95% CI 1.01-1.02; long-term 1.14, 95% CI 1.08-1.21) and mortality (short-term 1.02, 95% CI 1.01-1.04; long-term 1.15, 95% CI 1.07-1.24) of stroke. Long-term PM2.5 exposure was associated with increased risks of dementia (1.16, 95% CI 1.07-1.26), Alzheimer’s disease (3.26, 95% 0.84-12.74), ASD (1.68, 95% CI 1.20-2.34), and Parkinson’s disease (1.34, 95% CI 1.04-1.73).” – Fu et al 2019. Similar effects are seen in Bishop et al 2018: “We find that a 1 µg/m³ increase in decadal PM2.5 increases the probability of a dementia diagnosis by 1.68 percentage points.”
- A study of 20,000 elderly women concluded that “the effect of a 10 µg/m³ increment in long-term [PM2.5 and PM10] exposure is cognitively equivalent to aging by approximately 2 years”. – Weuve et al 2013.
- “Utilizing variations in transitory and cumulative air pollution exposures for the same individuals over time in China, we provide evidence that polluted air may impede cognitive ability as people become older, especially for less educated men. Cutting annual mean concentration of particulate matter smaller than 10 µm (PM10) in China to the Environmental Protection Agency’s standard (50 µg/m³) would move people from the median to the 63rd percentile (verbal test scores) and the 58th percentile (math test scores), respectively.” – Zhang et al 2018.
- “Exposure to CO2 and VOCs at levels found in conventional office buildings was associated with lower cognitive scores than those associated with levels of these compounds found in a Green building.” – Allen et al 2016. The effect seems to kick in at around 1,000 ppm of CO2.
Alex again. Here’s one more. Heissel et al. (2019):
“We compare within-student achievement for students transitioning between schools near highways, where one school has had greater levels of pollution because it is downwind of a highway. Students who move from an elementary/middle school that feeds into a “downwind” middle/high school in the same zip code experience decreases in test scores, more behavioral incidents, and more absences, relative to when they transition to an upwind school”
Relatively poor countries with extensive air pollution–such as India–are not simply choosing to trade higher GDP for worse health; air pollution is so bad that countries with even moderate air pollution are getting lower GDP and worse heath.
Addendum: Patrick has added a few more.
Opioid deaths are not mainly about prescription opioids
A recent study of opioid-related deaths in Massachusetts underlines this crucial point, finding that prescription analgesics were detected without heroin or fentanyl in less than 17 percent of the cases. Furthermore, decedents had prescriptions for the opioids that showed up in toxicology tests just 1.3 percent of the time.
Alexander Walley, an associate professor of medicine at Boston University, and five other researchers looked at nearly 3,000 opioid-related deaths with complete toxicology reports from 2013 through 2015. “In Massachusetts, prescribed opioids do not appear to be the major proximal cause of opioid-related overdose deaths,” Walley et al. write in the journal Public Health Reports. “Prescription opioids were detected in postmortem toxicology reports of fewer than half of the decedents; when opioids were prescribed at the time of death, they were commonly not detected in postmortem toxicology reports….The major proximal contributors to opioid-related overdose deaths in Massachusetts during the study period were illicitly made fentanyl and heroin.”
The study confirms that the link between opioid prescriptions and opioid-related deaths is far less straightforward than it is usually portrayed. “Commonly the medication that people are prescribed is not the one that’s present when they die,” Walley told Pain News Network. “And vice versa: The people who died with a prescription opioid like oxycodone in their toxicology screen often don’t have a prescription for it.”
That is by Jacob Sullum at Reason, via Arnold Kling.
Mortality sentences to ponder paging Ross Douthat too
This paper uses complete death certificate data from the Mortality Multiple Cause Files with American Community Survey data to examine age-specific mortality rates for married and non-married people from 2007 to 2017. The overall rise in White mortality is limited almost exclusively to those who are not married, for men and women…
That is from Philip N. Cohen, via Arnold Kling.
USA fact of the day
More than a third of Ph.D. students have sought help for anxiety or depression caused by Ph.D. study, according to results of a global survey of 6,300 students from Nature.
Thirty-six percent is a very large share, considering that many students who suffer don’t reach out for help. Still, the figure parallels those found by other studies on the topic. A 2018 study of mostly Ph.D. students, for instance, found that 39 percent of respondents scored in the moderate-to-severe depression range. That’s compared to 6 percent of the general population measured with the same scale.
And this:
Twenty-one percent of respondents said they’d been bullied in their programs. Of those, 48 percent said their supervisor was the perpetrator.
Here is the full story from Colleen Flaherty at Inside Higher Ed.
Model this dopamine fast
“We’re addicted to dopamine,” said James Sinka, who of the three fellows is the most exuberant about their new practice. “And because we’re getting so much of it all the time, we end up just wanting more and more, so activities that used to be pleasurable now aren’t. Frequent stimulation of dopamine gets the brain’s baseline higher.”
There is a growing dopamine-avoidance community in town and the concept has quickly captivated the media.
Dr. Cameron Sepah is a start-up investor, professor at UCSF Medical School and dopamine faster. He uses the fasting as a technique in clinical practice with his clients, especially, he said, tech workers and venture capitalists.
The name — dopamine fasting — is a bit of a misnomer. It’s more of a stimulation fast. But the name works well enough, Dr. Sepah said.
The purpose is so that subsequent pleasures are all the more potent and meaningful.
“Any kind of fasting exists on a spectrum,” Mr. Sinka said as he slowly moved through sun salutations, careful not to get his heart racing too much, already worried he was talking too much that morning.
Here is more from Nellie Bowles at the NYT.
Can we spend another $52 trillion without raising middle class taxes?
The question seems like a joke, right? Yet because so much of our elite media class wants Elizabeth Warren to win, they are contorting themselves into every possible direction to make this one sound coherent. It is not a question of whether total nominal expenditures on health care go up or down, but rather of thinking through incidence and opportunity cost and where the real burdens of the plan will fall. Those are the core themes of my Bloomberg column, here is one excerpt:
Another part of the plan is to pay lower prices — 70% lower — for branded prescription drugs. That is supposed to save about $1.7 trillion, but again focus on which opportunities are lost. Lower drug prices will mean fewer new drugs are developed. There is good evidence that pharmaceuticals are among the most cost-effective ways of saving human lives, so the resulting higher mortality and illness might be especially severe.
And the close:
Warren’s proposals, when all is said and done, are best viewed not as a way of paying for her program but as a series of admissions about just how expensive it would be. Whether or not you call those taxes, they are very real burdens — and many of them will end up falling on the middle class.
By the way, here is a good NYT summary of Warren’s financing plan. Here is a good Maxim Jacobs tweet:
It’s really hard to pick out which part of her plan is most insane?: – Lowering brand drug pricing by 70%? – CMS paying specialists less money – Taxing unrealized capital gains – Claim hiring more IRS agents will raise $2.3 trillion – “Not one penny in middle-class tax increases”
Here is more from Peter Suderman.
The Global Kidney Exchange Programme
In my WSJ review of Al Roth’s excellent book Who Gets What—and Why I wrote about Roth’s proposal to extend the idea of kidney swaps globally:
It’s often the case that a living donor is willing to give a kidney to a loved one, but the loved one can’t accept it because of immunity mismatch. But if a pair of such mismatched donors could be found (call them A and A´ and B and B´), then perhaps a match could be found by a crisscross pairing: Donor A could give to recipient B´ and donor B could give to recipient A´, thus solving the mismatch problem and saving lives.
…Today such multi-way exchanges are becoming common….Mr. Roth, however, wants to go further….why not open U.S. transplants to the world? Imagine that A and A´ are Nigerian while B and B´ are American. Nigeria has virtually no transplant surgery or dialysis available, so in Nigeria patient A’ will die for certain. But if we offered a free transplant to him, and received a kidney for an American patient in return, two lives would be saved.
The plan sounds noble but expensive. Yet remember, Mr. Roth says, “removing an American patient from dialysis saves Medicare a quarter of a million dollars. That’s more than enough to finance two kidney transplants.” So offering a free transplant to the Nigerian patient can save money and lives.
It’s hard to think of a better example of gains from trade (or a better PR coup for the U.S. on the world stage).
Recently, Rees et al., (including Roth) announced the first such global kidney exchange:
We report the 1‐year experience of an initial Filipino pair, whose recipient was transplanted in the United states with an American donor’s kidney at no cost to him. The Filipino donor donated to an American in the United States through a kidney exchange chain. Follow‐up care and medications in the Philippines were supported by funds from the United States. We show that the logistical obstacles in this approach, although considerable, are surmountable.
Naturally, some people aren’t happy because of “ethical” objections. Minerva, Savulescu and Peter Singer write in defense of the program:
Lurking behind all the arguments against the GKE is the assumption that people who are poor are incapable of autonomous choices. So, if they appear to choose to act in ways that benefit not only themselves, but people in HICs, they must have been coerced, exploited, or commodified.
…Poverty does not necessarily make a person unable to choose to donate a kidney to a loved one, nor does it make someone incapable of weighing the pros and cons of an option like that offered by the GKE. Poverty does narrow down the options available to people, and often forces them to settle for an option that is not as good as a wealthy person would choose. That, however, is irrelevant to the ethics of the GKE if that programme provides a better option to patients in LMICs who need a kidney than any other option currently available to them.
…It would be tragic if such misguided objections were to prevent the GKE from realising its potential to reduce suffering and save the lives of rich and poor patients alike.
Hat tip: Frank McCormick.
The Prescription Escalator
Ask anyone and they will tell you that their prescription costs are rising. But generic drug prices are falling (also here) and generics are 80-90 percent of all prescriptions. Moreover, although branded drugs are expensive total out-of-pocket costs for the population as a whole are flat or even decreasing as Michael Mandel points out:
[A] May 2019 research report from the Agency for Healthcare Research and Quality reported that average out-of-pocket spending for prescribed medications, among persons who obtained at least one prescribed medication, declined from $327 in 2009 to $238 by 2016, a decrease of 27 percent. Data from the Bureau of Labor Statistics Consumer Expenditure Survey shows that average household spending on prescription drugs fell by 11% between 2013 and 2018.
Moreover, OECD data shows that average out- of-pocket spending on prescribed medicines in the United States ($143 per capita in 2017) is actually lower than countries such as Canada ($144), Korea ($156), Norway ($178), and Switzerland ($215).
So are people simply mistaken about what they are experiencing? Not quite. Mandel uses the metaphor of the prescription escalator to explain the apparent paradox:
It turns out that an escalator is the appropriate model for prescription drug costs for individuals. As people get older, they unwillingly ride the prescription escalator, with their average spending on prescription drugs rising by about 5-6% per year. This figure assumes no change in the underlying price of drugs. Rather, people fill more prescriptions as they age.
In other words, every individual experiences an increase in prescription costs as they age even though for the population as a whole prescription prices are flat or falling–a form of Simpson’s paradox. The driver of higher costs is usage not price. People aged 65-74 have on average 25 (!) prescriptions to fill, more than two and half times as many as people aged 25-34 (about 9 per year).
Understanding the prescription escalator is important because regulating drug prices–aside from being a bad idea–won’t solve the perceived problem.
…even if drug reform efforts were successful and there were no more increases in drug costs, every individual would still face a 5.6% increase each year in drug spending as they got older. That would total 30% after five years, and 70% after ten years, across the board.These are enormous increases.
Indeed, the prescription escalator is a sign of success. If drugs weren’t successful we wouldn’t buy more of them when we were older and sicker and costs wouldn’t rise.
Opioids and labor market participation
The onset of the opioid crisis coincided with the beginning of nearly 15 years of declining labor force participation in the US. Furthermore, the areas most affected by the crisis have generally experienced the worst deteriorations in labor market conditions. Despite these time series and cross-sectional correlations, there is little agreement on the causal effect of opioids on labor market outcomes. I provide new evidence on this question by leveraging a natural experiment which sharply decreased the supply of hydrocodone, one of the most commonly prescribed opioids in the US. I identify the causal impact of this decrease by exploiting pre-existing variation in the extent to which different types of opioids were prescribed across geographies to compare areas more and less exposed to the treatment over time. I find that areas with larger reductions in opioid prescribing experienced relative improvements in employment-to-population ratios, driven primarily by an increase in labor force participation. The regression estimates indicate that a 10 percent decrease in hydrocodone prescriptions increased the employment-to-population ratio by about 0.7 percent. These findings suggest that policies which reduce opioid misuse may also have positive spillovers on the labor market.
That is from a job market paper by David Beheshti at the University of Texas at Austin.
The Causal Effect of Cannabis on Cognition
Does smoking lots of pot make you dumb or do dumb people smoke lots of pot? Mostly, the latter. Ross et al. (2019) write:
Although many researchers have concluded that cannabis causes impairment in cognition, there are alternative explanations. First, poor cognitive functioning is a risk factor for substance use. Specifically, EF measured in childhood predicts later substance use and substance use disorders (SUDs; Ridenour et al., 2009). Thus, studies need to control for prior cognitive functioning (Meier et al., 2012). Second, poor cognitive functioning and cannabis use may also be related, not because one causes the other, but because they share common risk factors, like lower SES (Rogeberg, 2013). Lynskey and Hall (2000) proposed that early use is likely to occur in a social context characterized by affiliations with substance using peers, poor school attendance, and precocious adoption of adult roles including dropping out of school; such an effect on educational participation may also influence later cognitive functioning.
Indeed–twin studies which control for genetics and family environment–do not find that cannabis reduces cognition:
Lyons et al. (2004) examined MZ twins discordant for use 20 years after regular use, and found a significant difference between twins on only one of 50+ measures of cognition. Second, Jackson et al. (2014) found no evidence for a dose-dependent relationship or significant differences in cognition among MZ twins discordant for cannabis use. Similarly, Meier et al. (2017) found no evidence for differences in cognition among a combined sample of MZ and DZ twins discordant for cannabis dependence or use frequency. Thus, quasi-experimental, co-twin control designs have yielded little evidence that cannabis causes poorer cognition.
Ross et al. run a similar study but testing also for executive function skills–the ability to plan, focus, control impulses and so forth which are skills related to IQ but distinct–and they conclude:
Families with greater cannabis use showed poorer general cognitive ability. Yet within families, twins with higher use rarely had lower cognitive scores. Overall, there was little evidence for causal effect of cannabis on cognition.
Hat tip: The excellent Kevin Lewis.
That is from a commentator named Sure.