Results for “antibiotic” 59 found
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.
*A Tangled Tree: A Radical New History of Life*
That is the new and excellent book by David Quammen, here is one summary excerpt:
We are not precisely who we thought we were. We are composite creatures, and our ancestry seems to arise from a dark zone of the living world, a group of creatures about which science, until recent decades, was ignorant. Evolution is tricker, far more intricate, than we had realized. The tree of life is more tangled. Genes don’t move just vertically. they can also pass laterally across species boundaries, across wider gaps, even between different kingdoms of life, and some have come sideways into our own lineage — the primate lineage — from unsuspected, nonprimate sources. It’s the genetic equivalent of a blood transfusion or (different metaphor, preferred by some scientists) an infection that transforms identity. “Infective heredity.” I’ll say more about that in its place.
My favorite part of the book is the section, starting on p.244, on bacteria that are resistant to antibiotics that have not yet been invented. Overall this is likely to prove the best popular science book of the year, you can buy it here. Here are various reviews of the book.
The Good Wife
Steffanie Strathdee, [is] the associate dean of global health science at the University of California, San Diego. In 2016, she helped revive her husband from a coma with a combination of phage therapy and antibiotics after he’d come back from Egypt with an untreatable bacterial infection, and she’s since become a kind of phage activist, helping others, like the Smiths, coordinate their own phage hunts.
That’s just a sidenote in an article on phages, viruses that kill bacteria. Seems like there’s a movie there.
Phages were long used in the Soviet Union to treat bacterial infections but are only now being studied in the West as bacteria evolve resistance to antibiotics.
Addendum: Dallas Weaver makes excellent points in the comments.
My Conversation with Atul Gawande
Here is the podcast and transcript (no video), Atul was in top form. We covered the marginal value of health care, the progress of AI in medicine, whether we should fear genetic engineering, whether the checklist method applies to marriage (maybe so!), whether FDA regulation is too tough, whether surgical procedures should be more tightly regulated, Michael Crichton and Stevie Wonder, wearables, what makes him weep, Knausgaard and Ferrante, why surgeons leave sponges in patients, how he has been so successful, his own performance as a medical patient, and much more.
Here is one excerpt:
COWEN: A lot of critics have charged that to get a new drug through the FDA, it takes too many years and too much money, and that somehow the process should be liberalized. Do you agree or disagree?
GAWANDE: I generally disagree. It’s a trade-off in values at some basic level. In the 1950s, we had no real FDA, and you had the opportunity to put out, to innovate in all kinds of ways, and that innovation capability gave us modern cardiac surgery and gave us steroids and antibiotics, but it also gave us frontal lobotomies, and it gave us the Tuskegee experiment and a variety of other things.
The process that we have regulation around both the ethics of what we’re doing and that we have some safety process along the way is totally appropriate. I think a lot of lessons about when the HIV community became involved in the FDA process to drive approaches that smoothed and sped up the decision-making process, and also got the public enough involved to be able to say . . . That community said, “Look, there are places where we’re willing to take greater risks for the sake of speed.”
People are trying to treat the FDA process as a technical issue. When what it is, is it’s an issue about what are the risks we are genuinely willing to take, and what are the risks that we’re not?
And:
COWEN: The idea of nudge.
GAWANDE: I think overrated.
COWEN: Why?
GAWANDE: I think that there are important insights in nudge units and in that research capacity, but when you step back and say, “What are the biggest problems in clinical behavior and delivery of healthcare?” the nudges are focused on small solutions that have not demonstrated capacity for major scale.
The kind of nudge capability is something we’ve built into the stuff we’ve done, whether it’s checklists or coaching, but it’s been only one. We’ve had to add other tools. You could not get to massive reductions in deaths in surgery or childbirth or massive improvements in end-of-life outcomes based on just those behavioral science insights alone. We’ve had to move to organizational insights and to piece together multiple kinds of layers of understanding in order to drive high-volume change in healthcare delivery.
Definitely recommended, this was one of my favorite “episodes.”
What I’ve been reading
1. Harold James, The German Slump: Politics and Economics 1924-1936. Not economic history in the post-cliometrics sense, but a history of economic issues, very high quality, full of good information on just about every page.
2. William Rosen, Miracle Cure: The Creation of Antibiotics and the Birth of Modern Medicine. A good book on exactly what the title promises, my favorite sentence was this: “Before penicillin, three-quarters of all prescriptions were still compounded by pharmacists using physician-supplied recipes and instructions, with only a quarter ordered directly from a drug catalog. Twelve years later, nine-tenths of all prescribed medicines were for branded products.”
3. Justin Yifu Lin and Celestin Monga, Beating the Odds: Jump-Starting Developing Countries. An instructive look at how countries have to start growing before the right institutional framework is in place, and how they can get around that. Haven’t you wondered how China racked up so many years of stellar growth with such a bad “Doing Business” ranking from the World Bank? One of the better books on developing economies in the last few years.
4. Joan C. Williams, White Working Class: Overcoming Class Cluelessness in America. An intelligent and indeed reasonable basic approach to answering questions about class, including “Why don’t they push their kids harder to succeed?” and “Why don’t the people who benefit most from government help seem to appreciate it?” I am not the intended audience, but still this was better than I was expecting.
Rick Wartzman, The End of Loyalty: The Rise and Fall of Good Jobs in America, is a densely-written but nonetheless useful history of how America moved from paternalistic big businesses to lower-benefit jobs.
Arnold Kling, The Three Languages of Politics: Talking Across the Political Divides. This short book, revised, improved, and expanded, is so good it is wasted on almost all of you. Here are various pieces of background information.
Tuesday assorted links
1. Amazon is now a major force in literary translation.
2. New paper on minimum wage hikes in San Francisco.
3. Johnson and Koyama paper on state capacity.
4. Monique (Alex’s wife) in the NYT, more on Komodo dragon blood.
5. “Curious heifers marched after beaver, rancher calls event a very Canadian moment”
Monday assorted links
Komodo Dragon Blood!
The Economist covers some important new research out of George Mason University on the search for new antibiotics:
MYTHOLOGY is rich with tales of dragons and the magical properties their innards possess. One of the most valuable bits was their blood. Supposedly capable of curing respiratory and digestive disorders, it was widely sought. A new study has provided a factual twist on these fictional medicines. Barney Bishop and Monique van Hoek, at George Mason University in Virginia, report in The Journal of Proteome Research that the blood of the Komodo dragon, the largest living lizard on the planet, is loaded with compounds that could be used as antibiotics.
Komodo dragons, which are native to parts of Indonesia, ambush large animals like water buffalo and deer with a bite to the throat. If their prey does not fall immediately, the dragons rarely continue the fight. Instead, they back away and let the mix of mild venom and dozens of pathogenic bacteria found in their saliva finish the job. They track their prey until it succumbs, whereupon they can feast without a struggle. Intriguingly, though, Komodo dragons appear to be resistant to bites inflicted by other dragons.
Most animals—not just Komodo dragons—carry simple proteins known as antimicrobial peptides (AMPs) as general-purpose weapons against infection. But if the AMPs of Komodo dragons are potent enough to let them shrug off otherwise-fatal bites from their fellow animals, they are probably especially robust. And that could make them a promising source of chemicals upon which to base new antibiotics.
Prizes are flourishing
Stumped for solutions to hundreds of industrial and technical problems, businesses and governments alike are turning the search for innovative ideas into prize-worthy puzzles that capitalize on the ingenuity of the crowd.
At a time when the pace of innovation seems to be slowing, prize sponsors hope that today’s hackers and makers can step into the breach and jump-start progress in a way that today’s research institutions—with their many constituencies and restraints—are struggling to do.
Improve smartphone voice recognition? There’s a $10,000 prize for that. Design a delivery drone? $50,000. Extend the human lifespan? Venture capitalist Dr. Joon Yun offers the $1 million Palo Alto Longevity Prizes. Diagnose antibiotic resistance? That’s worth $20 million. And if anyone can profitably repurpose the carbon emissions involved in global warming, there are prizes totaling $55 million in the offing.
“You name it, there is a prize for it,” said Karim Lakhani at the Harvard Business School’s Crowd Innovation Lab, who has helped run 650 innovation contests in the past six years.
In addition, crowdsourcing companies such as InnoCentive Inc., NineSigma, and Kaggle have posted hundreds of these lucrative research contests on behalf of corporate and government clients, offering cash prizes up to $1 million for practical problems in industrial chemistry, remote sensing, plant genetics and dozens of other technical disciplines. Among them, the three companies can draw on the expertise of two million freelance researchers who have registered for access to the prize challenges.
All told, more than 30,000 significant prizes are awarded every year worth $2 billion and growing, according to McKinsey & Co. The total value of purses from the 219 largest prizes has tripled in the past 10 years. Not only are there more prizes than ever, but nearly 80% of all the major new prizes announced since 1991 are designed to spur specific innovations.
Yet here is a cautionary note:
To be sure, there is little evidence that crowdsourcing competitions have significantly altered the innovation landscape yet. “Prizes are important, but they are not the ultimate incentive for innovation” said Luciano Kay, a research fellow at the University of California at Santa Barbara who studies incentive prizes. “They are not big enough to change how industry works in general.”
Here is the full Robert Lee Hotz WSJ article. Here are previous MR posts on prizes. Here is an MRU video on prizes. Here is my 2007 talk at Google on prizes as a means of funding innovation.
For the pointer I thank Ray Lopez.
Private versus Public Health Care in India
In an important paper in the latest AER, Das, Holla, Mohpal and the excellent Karthik Muralidharan compare private and public health care in India. (I once asked, “Is any economist doing more important work with greater potential for real improvement in the lives of millions than Karthik Muralidharan?” See previous posts on Karthik’s work for the answer.)
The AER paper examines health care in villages in Madhya Pradesh, one of the poorer states in India (GDP per capita of $1,500 PPP). In India, primary health care is ostensibly available for free from public health clinics and hospitals manned by professionally trained nurses and physicians. As with teachers at public schools, however, it’s very common for doctors at public clinics to be absent on any given day (40% were absent on a given day in 2010) and public clinics are not highly regarded. As a result, some 70% percent of primary care visits nationally–and an even higher percentage in Madhya Pradesh–are to private, fee-charging health-care providers. Most of the private providers do not have a license or medical degree although they may have some health-care training.
The authors sent trained actors, “standardized patients” to public and private clinics to evaluate provider effort and accuracy in response to the presentation of textbook symptoms of common illnesses (angina, asthma, and dysentery in a child at home). Standardized patients are used to train medical students in the United States and in India and the Indian SPs were trained by professionals including medical doctors, and a medical anthropologist familiar with local forms of presenting illnesses and symptoms.
The first result is that the provision of health care is uniformly and distressingly poor. Overall, only 2.6% of patients received a correct treatment (and nothing unnecessary or harmful). The private providers, however, exert much more effort than do the public providers. The private providers, for example, perform more items on a standard checklist and they spend more time with patients. But the private providers are no better than the public providers at giving a correct treatment. Why not?
Private providers exert more effort but are less knowledgeable. Loosely we might say that Quality=Effort*Knowledge. Private providers put in more effort but have less knowledge and public providers have more knowledge but put in less effort leading to similar quality levels overall.
There is one big difference, however, between the public and private regimes, the private regime is much less socially costly. Since costs are lower and the quality level is the same, the private system is much more productive. The authors note:
…our estimates suggest that the public health care system in India spends at least four times more per patient interaction but does not deliver better outcomes than the private sector
(FYI, this also holds true for public and private schooling in India and around the world. Private schooling is usually somewhat better or about as good as public schooling but much less costly so the productivity of private schooling is much higher.)
To focus on the issue of market incentives rather than knowledge the authors do a second set of remarkable tests. Indian doctors often work in a public and a private practice. Thus, the authors send standardized patients to the same doctors but in one case the patient is treated under the public regime and in other under the private, market regime. Once knowledge is controlled for the results are very clear, private, markets dominate the public regime.
…treatments provided in the private practice strictly dominate those provided in the public practice of the same doctor. The rate of correct treatment is 42 percent higher (16 percentage points on a base of 37 percent), the rate of providing a clinically non-indicated palliative treatment is 20 percent lower (12.7 percentage points on a base of 64 percent), and the rate of antibiotic provision is 28 percent lower (13.9 percentage points on a base of 49 percent) in the private practice relative to the public practice of the same doctor.
The bottom line is that the private market for health care is much bigger and less expensive than the public health regime in rural India and once we control for knowledge it’s of higher quality. These results have important implications for reform. In particular, much more effort should go into improving the knowledge of the private sector.
….the marginal returns to better training and credentialing may be higher for private health care providers who have stronger incentives for exerting effort. Current policy thinking often points in the opposite direction, with a focus on hiring, training, and capacity building in the public sector on one hand (without much attention to their incentives for effort), and considerable resistance to training and providing legitimacy to unqualified private providers on the other.
Cuba’s glum economic forecast
That is my latest Bloomberg column, here is one excerpt:
One way to approach Cuba’s economic fate is to consider the Caribbean region as a whole. For the most part, it has seen mediocre results since the financial crisis of 2008. Economic problems have plagued Puerto Rico, Trinidad, Jamaica, Haiti and Barbados, with only Jamaica seeing a real turnaround.
The core problems of the region include high debt, weak commodity prices, lack of economies of scale and an inability to upgrade tourist facilities to compete with the U.S., Mexico and further-flung locales. Cuba cannot service its foreign debt, and losing most of its support from Venezuela has been a massive fiscal problem.
Perhaps the country most like Cuba in the Caribbean, in terms of history, heritage and ethnic composition, is the Dominican Republic. Currently, it has a nominal gross domestic product of somewhat over $6,000 per capita, depending which source you prefer. That’s far from the bottom tier of developing economies, but it’s hardly a shining star. And Cuba will take a long time to attract a comparable level of multinational investment, or to develop its tourist facilities to a comparable level of sophistication. Well-functioning electricity and air conditioning cannot be taken for granted in Cuba, especially after the major decline in energy supplies from Venezuela.
The most optimistic forecast for Cuba is that, after a few decades of struggle and reorientation, it will end up at the income level of the Dominican Republic.
If you are wondering, the World Bank measures Cuban GDP at over $6,000 per capita, but that is based on a planned economy and an unrealistic exchange rate. In reality, Cuba probably is richer than Nicaragua, where GDP per capital is approximately $2,000, but we don’t know by how much. Cuba does have relatively high levels of health care and education, but we’ve learned from post-Soviet reform experiences that it is easy for a nation to lose those advantages. There are already shortages of many basic health care items, including medical technology and antibiotics.
There is much more at the link.
Why Is Turkey Cheaper When Demand Is Higher?
When you do your Thanksgiving shopping this week, you will encounter two vastly different options for the centerpiece: an expensive heritage, organic, antibiotic-free, freshly killed turkey; or a relatively cheap, mass-produced, rock-solid-frozen bird. The frozen birds are a pretty attractive deal — especially because this time of year, they are unusually cheap. According to government data, frozen whole-turkey prices drop significantly every November; over the last decade, retail prices have fallen an average of 9 percent between October and November.
That trend seems to defy Econ 101. Think back to those simple supply-and-demand curves from introductory micro, and you’ll probably remember that when the demand curve shifts outward, prices should rise. That’s why Major League Baseball tickets get most expensive during the World Series — games that (theoretically, anyway) many more people want to see. Similarly, airline tickets spike around Christmas.
That’s Catherine Rampell but don’t read the whole thing. Argue about it! Happy Thanksgiving.
Why isn’t there more telemedicine?
Austin Frakt tells us:
The biggest hurdle may be state medical boards. Idaho’s medical licensing board punished a doctor for prescribing an antibiotic over the phone, fining her $10,000 and forbidding her from providing telemedicine. State laws that restrict telemedicine — for instance, requiring that patients and doctors have established in-person relationships — have drawn lawsuits charging that they illegally restrict competition. Georgia’s state medical board requires a face-to-face encounter before telemedicine can be delivered, while Ohio’s does not.
A study by Julia Adler-Milstein, an assistant professor at the School of Information and the School of Public Health, University of Michigan, found that such state laws and medical board requirements influence the extent of telemedicine use by hospitals. While 70 percent or more hospitals in Maine, South Dakota, Arkansas and Alaska use telemedicine, only 13 percent in Utah and none in Rhode Island do, for instance.
In a passionate commentary on the establishment’s hesitancy to embrace telemedicine, David Asch, a University of Pennsylvania physician, pointed out that the inconvenience of face-to-face care limits its use, but arbitrarily and invisibly. The costs of waiting and travel time and those borne by rural populations with poor access to in-person care don’t appear on the books. “The innovation that telemedicine promises is not just doing the same thing remotely,” Dr. Asch wrote, “but awakening us to the many things that we thought required face-to-face contact but actually do not.”
Here is the full NYT account.
Saturday assorted links
1. Parrot testimony. And a cat from Hamilton, New Zealand steals underwear. And the polity that is Selma markets in everything horse underwear. And “Simply getting hold of so many stage-ready sheep was an exceptionally difficult bit of opera casting…” (NYT).
2. “Proper crumbing takes some practice, but the purpose is obvious.”
3. How frictionless is Bitcoin?
4. Nudging against antibiotic use (NYT).
5. Stanford’s Jon Levin answers economics questions on Quora.
When can median income consumers afford the very best?
A random Econ ? that pops into my head: are there any goods that a US median income maker can buy that are the best available?
I can think of quite a few:
iPhones and Kindle
mineral water (Gerolsteiner)
most vaccines and antibiotics
writing paper
books
movies
basketballs and many other sporting goods
rutabagas
Coca-Cola, Mexican or otherwise
Google and Facebook
Raffi himself cites “razor blade” on Twitter.
What else?
