Results for “antibiotic”
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The Great Stagnation in medicine

by  Tyler Cowen in

Here is one bit from a very good Robert Gordon essay (which I will cover again in a while):

…if one starts down the road of comparing changes in life expectancy, the yearly rate of increase in life expectancy at birth during 1900–50, resulting in substantial part from the inventions of the Second Industrial Revolution, was 0.72 percent per year, the 0.24 percent annual rate during 1950–95.

James Le Fanu, in his 2000 history of modern medicine, lists definitive moments of modern medicine.  In the 1940s there are six such moments, seven moments in the 1950s, six moments in the 1960s, a moment in 1970 and 1971 each, and from 1973-1998, a twenty-five year period, there are only seven moments in total.

For his "Dates of the discovery and sources of the more important antibiotics," the list starts in 1929-1940 with penicillin and ends in…1963, with Gentamicin.

Ezra has a very good post on penicillin.  Megan has a very good post and piece on the drying up of the pharmaceutical pipeline.  Andrew Jack has a very good and scary piece on the withering of pharmaceuticals innovation in the UK.

As Le Fanu writes: "Currently most medical researchers would concede that progress has slowed in recent years…"

As an aside, this has a number of political economy implications for health care reform, none of them cheery.  In both Washington and in the blogosphere, we're very focused on insurance and coverage issues, but is not the innovation pipeline more important?  Does it receive one-tenth the discussion?  One-fiftieth?  Does a slow pipeline mean that health care policy is doomed to be unpopular?

Quick quiz: is health care a growing or a shrinking part of the U.S. economy?

*The Emperor of all Maladies*

by  Tyler Cowen in

The author is Siddhartha Mukherjee and the subtitle is A Biography of Cancer.  This is not a typical excerpt, but it works as an excerpt for this blog:

In 1942, when Merck had shipped out its first batch of penicillin — a mere five and a half grams of the drug — that amount had represented half of the entire stock of the antibiotic in America.  A decade later, penicillin was being mass-produced so effectively that its price had sunk to four cents for a dose, one-eighth the cost of a half gallon of milk.

This book deserves its rave reviews; it is one of the best non-fiction works of the year.

Related to this topic, here is an update on Christopher Hitchens.

Paul Langley asks about consumer surplus

by  Tyler Cowen in

What non-subsidized common products and services do you think have the highest average consumer surplus? Cell phones? Shampoo? Antibiotics? Just wondering.

Obviously it depends what margin you are at; for many people antibiotics or pharmaceuticals mean the difference for life or death but right now they do not for me.  And surely we cannot answer with "all food" or "all water."  For average value, I'll go with antibiotics, but a separate question is about median value.

I'm not sure cell phones have a positive marginal utility for a lot of people.  I would be happy with an email-only iPhone and I know people — close to us all right now — who don't even own a cell phone.

How about a toothbrush?  Eyeglasses?  The median adult wears them.  Often it's a car, though in the longer run you can adjust by moving to a walkable city.  A properly functioning toilet and waste disposal system?  Television?  Painkillers?

I thank the lunch group for a useful conversation on this topic.

*Steak*, by Mark Schatzker

by  Tyler Cowen in

Roughly 98 percent of cattle do live to see the day the truck from the packing plant pulls up because antibiotics are mixed in with the feed to keep livers and guts from failing.  A certain number are fated to die, however.  Feedlot nutritionists, Williams explained, actually want to see a small percentage get sick, as "that way, they know they're pushing the feed to the edge."  The ones that aren't dying are getting fat fast."

That is from the new and notable book Steak: One Man's Search for the World's Tastiest Piece of Beef.  This book is interesting and substantive on virtually every page and it is one of the best food books I have read in some time.

If you are wondering, the best steaks I have had were (in no order):

1. Kobe Beef in Kobe, Japan.

2. Dry-aged, in Hermosillo, Mexico.

3. Southern Brazil, in small towns outside of Curitiba.

It is rare that I end up eating steak in the United States; I just don't see a good reason to do it.  I also think a lot of steak in B.A. is overrated, as does Schatzker.

Assorted links

by  Tyler Cowen in

1. Doubts on cash for clunkers.

2. Stanley Lebergott passes away at 93.

3. Lobbying strategy: give us money or we will kill the gorilla.

4. How many people are killed by cows?  "…All but one of the victims died from head or chest injuries; the last
died after a cow knocked him down and a syringe in his pocket injected
him with an antibiotic meant for the cow. In at least one case the
animal attacked from behind, when the person wasn’t looking. Older men
with arthritis and hearing aids have the highest risk of being injured
by livestock, the report says, probably because they don’t hear the
animals charging and can’t move fast enough to get out of the way."

Is there a silver lining for Mexico?

by  Tyler Cowen in

To be sure, tourism to Mexico is devastated and the country will suffer many economic problems (yes, real business cycle theory still is relevant these days).  But is there any upside?

I hesitate to speak too soon but I'm actually somewhat impressed by how the Mexican government, at least at the national level, has responded.  There have been many failures of Mexican health care systems at local levels but keep a few things in mind: a) some of the problems lie with citizens who won't go see doctors, or who won't go see non-shaman doctors, b) too many Mexicans self-administer antibiotics, and c) when there is so much air pollution it is harder to discover flu cases, especially in the midst of flu season there.  Nonetheless Mexican reporting systems seem to have discovered an unusual flu fairly promptly.

Once the national government discovered what is going on, they acted decisively and without undue panic.  There has been very little denial, a common feature in the early stages of health crises (how long was it until the U.S. government acknowledged AIDS?).  No one is treating the Mexican federal government like a banana republic or a basket case or thinking that the Canadian government would have done so much better. 

Am I wrong?  Could this episode in the longer run bring Mexico closer to the community of developed nations?  Might Mexicans now be more likely to self-identify with a government that is at least partially competent?

Time will tell.

Worse than Viruses

by  Alex Tabarrok in

Public computer surfaces are reservoirs for methicillin-resistant staphylococci.

The role of computer keyboards used by students of a metropolitan
university as reservoirs of antibiotic-resistant staphylococci was
determined. Putative methicillin (oxacillin)-resistant staphylococci
isolates were identified from keyboard swabs following a combination of
biochemical and genetic analyses. Of 24 keyboards surveyed, 17 were
contaminated with staphylococci that grew in the presence of oxacillin
(2 mg l-1). Methicillin (oxacillin)-resistant Staphylococcus aureus (MRSA), –S. epidermidis (MRSE) and –S. hominis
(MRSH) were present on two, five and two keyboards, respectively, while
all three staphylococci co-contaminated one keyboard. Furthermore,
these were found to be part of a greater community of
oxacillin-resistant bacteria. Combined with the broad user base common
to public computers, the presence of antibiotic-resistant staphylococci
on keyboard surfaces might impact the transmission and prevalence of
pathogens throughout the community.

Thanks to Monique van Hoek for the pointer.

Brad DeLong’s health care plan is outed

by  Tyler Cowen in

It is described as utopian, read it here, excerpt:

20% Deductible/Out of Pocket Cap: The IRS snarfs
20% of your family economic income and uses it to pay your family
health bills. If your expenses in a year are less than 15% of your
family economic income, the balance is returned to you with your tax
refund check (or stuffed into your IRA).

Single-Payer for the Rest: All family health bills
greater than 20% of your family economic income are paid by the federal
government out of the 5% not returned (and perhaps, someday general
revenues). The main point, after all, is insurance: if you fall
seriously sick, you want right then and there to be treated whether or
not your wallet biopsy is positive.

Sin Taxes: on Tobacco, Gorgonzola, Three-Liter Bottles of
Liquid High-Fructose Corn Syrup, Tanning Clinics (Melanoma), et cetera:
Sin taxes (and, perhaps, someday general revenues) pay for an army of
barefoot doctors and nurses and mobile treatment vans roaming the
country and knocking on doors: Let me examine your prostate. Mind if I
check your refrigerator and tell you how to eat healthier? Have you
exercised today? I’m a Pilates instructor, and we could do a session
now? Are you up on your immunizations? Anybody here have a fever and
need antibiotics? Come on out to the van and I’ll clean your teeth."
The idea is to make the preventive care cheaper-than-free, to insure
that nothing with a high long-run benefit/cost ratio gets left undone
because people would rather get a bigger check the next April to use to
buy an HDTV.

A Lot of Serious Research on Best Public-Health, Chronic-Disease, and Hospital Practices

That’s it. No deduction for employer-paid health expenses. No insurance companies.

There is plenty of further rationale given, do read the whole post.  But I have to say, those rubber gloves have me worried… 

A Bush plan for avian flu

by  Tyler Cowen in

President Bush said today that he was working to prepare the United States for a possibly deadly outbreak of avian flu. He said he had weighed whether to quarantine parts of the country and also whether to employ the military for the difficult task of enforcing such a quarantine.

"It’s one thing to shut down your airplanes, it’s another thing to prevent people from coming in to get exposed to the avian flu," he said. Doing so, Mr. Bush said, might even involve using "a military that’s able to plan and move."

The president had already raised, in the wake of Hurricanes Katrina and Rita, the delicate question of giving the military a larger role in responding to domestic disasters. His comment today appeared to presage a concerted push to change laws that limit military activities in domestic affairs.

Mr. Bush said he knew that some governors, all of them commanders of their states’ National Guards, resented being told by Washington how to use their Guard forces.

"But Congress needs to take a look at circumstances that may need to vest the capacity of the president to move beyond that debate," Mr. Bush said. One such circumstance, he suggested, would be an avian flu outbreak. He said a president needed every available tool "to be able to deal with something this significant."

Here is the full story.  Here is the text of his remarks, with commentary from Glenn Reynolds.

I am hoping to write a longer piece on what we should do, but frankly Bush’s idea had not crossed my mind.  For a start, quarantines don’t usually work, especially in a large, diverse, and mobile country.  The Army would if anything spread the flu.  A list of better ideas would include well-functioning public health care systems at the micro-level, early warning protocols, and good decentralized, robust plans for communication and possibly vaccine or drug distribution.  Might the postal service be more important than the Army here?  How about the police department, and the training of people in the local emergency room?

Stockpiling Tamiflu is worthwhile in expected value terms, but many strains of avian flu are developing resistance; we should not put all our eggs in this basket.  We also should stockpile high-quality masks and antibiotics for secondary infections (often more dangerous than the flu itself), and more importantly have a good plan for distribution and dealing with extraordinary excess demand and possibly panic.  Let’s not ignore obvious questions like: "if the emergency room is jammed with contagious flu patients, where will other (non-flu) emergencies go?" 

A good plan should also make us less vulnerable to terrorist attacks, storms, and other large-scale disasters.  Robustness and some degree of redundancy are key.  You can’t centrally plan every facet of disaster response in advance; you need good institutions which are capable of improvising on the fly.  In the meantime, let’s have betting markets in whether a pandemic is headed our way; that would provide useful information.

Addendum: It is Bird Flu Awareness Week in the blogosphere, Silviu has the appropriate links.

Transhumanism: at what margin?

by  Tyler Cowen in

I tend to sympathize with transhumanist ideals, if only for the same reason that I do not hesitate to use antibiotics.  Furthermore I have never had huge hang-ups over the "identity" concept; I don’t celebrate St. Patrick’s Day and I find it embarrassing to admit that I root for the Washington Wizards.  "The Six Million Dollar Man" was one of my favorite TV shows as a kid, although even then I thought the price was too low.

That being said, the economist in me asks not "whether" but rather "at what margin"?  Is there any margin at which concerns of identity should cause us to reject otherwise beneficial transhumanist improvements?

Most people want their children to look like themselves, and to some extent to think like themselves.  We invest many thousands of dollars and many months of our time to acculturate our children.  Now let’s say your children could be one percent happier throughout their lives, but this would mean they were totally unlike you, the parent.  In fact your children would be turned into highly intelligent velociraptors and flown to another planet to live among their own kind.  How many of us would choose this option?  I can think of a few responses:

1. Transhumanism will bring improvements of more than one percent; we should forget about identity and let everyone become healthier and happier.  What’s wrong with uploads?

2. Governments should not restrict transhumanist innovation.  Let people and their children choose their degrees of identity continuity for themselves.  (Isn’t there a collective action problem here?  Everyone wants a more competitive kid but at the end humanity is very different.)

3. The parental analogy is not relevant for policy choices.  Parents should be partial across identities, but governments should be more neutral.  And surely uploads will still be allowed to vote, no?

4. Identity attachments are, very often, petty and small-minded to considerable degree.  We should be cosmopolitan across chimpanzees and intelligent velociraptors, not to mention enhanced humans.

I still favor laissez-faire for transhumanist innovation.  And all the listed arguments have force with me.  But I would feel better rejecting the critics if I had a framework that would simultaneously recognize the value of identity while giving it limited weight to override medical progress.

These thoughts were stimulated by reading the new and useful More than Human: Embracing the Promise of Biological Enhancement, by Ramez Naam.

Addendum: Here is an excellent Nick Bostrom essay, which argues human evolution may otherwise deteriorate.  He also wonders whether happiness and consciousness have evolutionary advantages in the long run.  Thanks to the Vassar family for the pointer.

In praise of impersonal medicine

by  Alex Tabarrok in

Many people complain that medicine is too impersonal.  I think it is not impersonal enough.  I have nothing against my physician (a local magazine says he is one of the best in the area) but I would prefer to be diagnosed by a computer.  A typical physician spends most of the day playing twenty questions.
Where does it hurt?  Do you have a cough?  How high is the patient’s
blood pressure?  But an expert system can play twenty questions better than most people.  An expert system can use the best knowledge in the field, it can stay current with the journals, and it never forgets.

Consider how many people die because physicians forget the basics. Gina Kolata reports on a Medicare program to rate hospitals on the quality of care provided in the treatment of  heart attacks, heart failure and pneumonia – these three areas chosen because there are standard, clinically proven, treatments that everyone agrees are highly beneficial.

At Duke University’s hospital, for example, when patients arrived
short of breath, feverish and suffering from pneumonia, their doctors
monitored their blood oxygen levels and put them on ventilators, if
necessary, to help them breathe.

But they forgot something:
patients who were elderly or had a chronic illness like emphysema or
heart disease should have been given a pneumonia vaccine to protect
them against future bouts with bacterial pneumonia, a major killer.
None were.

All bacterial pneumonia patients should also get antibiotics within four hours of admission. But at Duke, fewer than half did.

The
doctors learned about their lapses when the hospital sent its data to
Medicare. And they were aghast. They had neglected – in most cases
simply forgotten – the very simple treatments that can make the biggest
difference in how patients feel or how long they live.

…[Similarly, the] hospitals were asked how often their heart attack
patients got aspirin when they arrived (that alone can cut the death
rate by 23 percent). When they were discharged, did they also get a
statin to lower cholesterol levels? Nearly all should, with the
exception of patients who have had a bad reaction to a statin and those
rare patients with very low cholesterol levels. Did they get a beta
blocker?

Once hospitals learned their score, it was up to them what to do.
Over the next year, ones that improved in these measures saw their
patient mortality from all causes fall by 40 percent. Those whose
compliance scores did not change had no change in their mortality rate,
and those whose performance fell had increases in their mortality rates.

"Those are the most remarkable data I have ever seen," said Dr. Eric
Peterson, the Duke researcher who directed the study and has reported
on it at medical meetings.

Unfortunately, we (doctors and patients) have a model in our head of the nearly omniscient doctor carefully attending to the needs of every patient on an individualized basis – medicine as craft.  Instead what we need is medicine by the numbers.  But doctors don’t like being told what to do.

"We tried to come up with a standardized order set," with all the
measures that Medicare was asking about, Dr. Gross said. "But the
doctors didn’t want to use the sheet," insisting they would just
remember those items. Then they forgot.

The solution, Dr. Gross said, was to assign specially trained nurses
to see what care was provided and remind doctors when important steps
were omitted. The result was immediate improvement, Dr. Gross said,
even in items not on Medicare’s list.

The nurses, in effect, are being trained to follow standardized procedures, just as does an expert system.

Thanks to the John Palmer, The Econoclast, for the link.

Are people becoming happier over time?

by  Tyler Cowen in

We are much richer yet in a survey format Americans do not express greater satisfaction with their lives than they did in times past. What does this mean?

Some individuals suggest that we are pursuing an excess of material goods at the expense of true joys and satisfactions. Arnold Kling offers another interpretation:

Imagine that you could go back a few hundred years and ask people if they are “very happy,” “fairly happy,” or “not happy.” Suppose that this survey showed that happiness was approximately the same back then as it is today. Would it be fair to conclude that the tangible goods that we have today contribute nothing to happiness? People a few hundred years ago had no idea what it was like to live with indoor plumbing, abundant food, and antibiotics. People today have no idea what it was like to live without them. How can a “happiness survey” provide a meaningful comparison of the two eras?

In [Robert] Frank’s view, what the surveys show is that consumers have been behaving myopically, striving for more tangible goods without increasing their happiness. An alternative hypothesis is that in answering the surveys the consumers are behaving myopically, reporting on their happiness relative to a near-term baseline. That is, when you ask a consumer in 2004 if she is happy, she instinctively makes a relative comparison to how she remembers 2003. If she could remember how she felt in 1974, and she were focused on that as a baseline, she might answer the question differently.

Happiness research can be used to account for behavioral failures to maximize utility. Most alcoholics are not happy by traditional standards yet they drink of their own volition. So we might use happiness research to suggest a higher tax on alcohol than on vaccines for children. Or happiness research tells us to get the bad news over with, rather than suffering under its expectation. Happiness research is not a suitable tool for making broad comparisons of well-being over long periods of time.

Here is a useful dialogue on happiness research and economics. Here is Bryan Caplan’s earlier post on the policy implications of happiness economics.

Addendum: Try living with 1954 technology for a mere ten days, thanks to the ever-excellent GeekPress.com for the lead.