In the same “Minerva” column, we learn that annual health checks on everyone between the ages of 40 and 75 are likely to be useless, at least as carried out in Britain, except possibly as a mild Keynesian stimulus to the economy. When the records of 130,356 people who had undergone such checks were examined, it was discovered that only about 20 per cent of those at high risk of cardiac disease were prescribed statins and even fewer of those with high blood pressure underwent treatment to lower it.
Since the beneficial effects of treatment with statins are a matter of controversy anyway, as being of value mainly to those who already have ischemic heart disease or have had a stroke, and since the treatment of high blood pressure is only marginally beneficial in the first place, so that the benefit of treating fewer than 20 per cent of those with high blood pressure is likely to be minuscule from the public health point of view, we can safely conclude that annual health checks as carried out in Britain are a waste of time — unless wasting time by occupying it is the whole object of the activity, in which case wasting time is not wasting time but using it gainfully. Gainfully, that is, to the person who wastes his time (the doctor) rather than has his time wasted for him (the patient). His time is well and truly wasted.
Part of the problem is the assumption that doing something must be better than doing nothing. Doctors of the past, because there was so little they could in fact do, employed a technique known as masterly inactivity: they assumed an alert watchfulness, giving the patient the impression, which was false but reassuring, that they would do what had to be done in the event that anything untoward happened. Since most people got better anyway, this seemed to confirm the wisdom of the doctor.
Masterly inactivity, however, is no way to increase your fee for service or gain a reputation for technical mastery. Patients too prefer to think that they are doing something rather than nothing to preserve themselves. That is why some of them are not merely surprised, but aggrieved when illness strikes them: for they have done all that they were supposed to do to remain in good health, from eating broccoli to regular bowel biopsies.
Theodore Dalrymple, “Dubious Cures”, Taki’s Magazine, 2014-11-30.
January 11, 2016
December 29, 2015
Should we consider mandatory graphic warning labels on bottles of booze? Our science reporter Tom Blackwell reviewed various Canadian discussions of the idea in these pages yesterday, suggesting that it is being looked at behind the scenes by addiction researchers. Labels with colour images of diseased esophagi on liquor labels would, of course, mimic the approach Canada has already taken toward cigarettes. So, well, why not? They say if you have a hammer, everything looks like a nail: by a similar token, if your field is addiction, no doubt everything that has addictive qualities looks like an unsolved problem.
But there is one very obvious way in which liquor is not like cigarettes: scientists are reasonably sure that light drinking has positive public-health consequences. If you don’t believe me, you can look up articles like the one I have in front of me here from a 2013 issue of Annals of Oncology: its title is “Light Drinking Has Positive Public Health Consequences.” As a layman I obviously can’t be certain I have summarized this editorial correctly, but you’ll have to trust me.
Colby Cosh, “The real problem with liquor warning labels — there’s such a thing as good drinking”, National Post, 2015-12-17.
December 16, 2015
At Mother Jones, Kevin Drum links to an article that explicitly shows the cost of having monopoly providers in healthcare:
Regular readers of this blog should know that when it comes to the price of hospital care, it’s competition that matters, not insurance companies. In areas with only a single hospital, insurance companies have no leverage and have to accept whatever price the hospital charges. If there are lots of hospitals, they have to compete with each other to earn the insurance company’s business.
But in case you’re still skeptical, a team of researchers has analyzed a huge database of health care claims in the US to check this out. They found enormous regional variation in hospital costs for the same procedure, and one of the biggest drivers of this variation was competition:
Hospital market structure stands out as one of the most important factors associated with higher prices, even after controlling for costs and clinical quality. We find that hospitals located in monopoly markets have prices that are about 15.3 percent higher than hospitals located in markets with four or more providers. This result is robust across multiple measures of market structure and is consistent in states where the HCCI data contributors (and/or Blue Cross Blue Shield insurers) have high and low coverage rates.
Henry Miller on the Faustian bargain Chipotle willingly made and is now paying for:
Chipotle, the once-popular Mexican restaurant chain, is experiencing a well-deserved downward spiral.
The company found it could pass off a fast-food menu stacked with high-calorie, sodium-rich options as higher quality and more nutritious because the meals were made with locally grown, genetic engineering-free ingredients. And to set the tone for the kind of New Age-y image the company wanted, Chipotle adopted slogans like, “We source from farms rather than factories” and, “With every burrito we roll or bowl we fill, we’re working to cultivate a better world.”
The rest of the company wasn’t as swift as the marketing department, however. Last week, about 140 people, all but a handful Boston College students, were recovering from a nasty bout of norovirus-caused gastroenteritis, a foodborne illness apparently contracted while eating Chipotle’s “responsibly raised” meats and largely organic produce.
And they’re not alone. The Centers for Disease Control and Prevention has been tracking another, unrelated Chipotle food poisoning outbreak in California, Illinois, Maryland, Minnesota, New York, Ohio, Oregon, Pennsylvania and Washington, in which victims have been as young as one year and as old as 94. Using whole genome sequencing, CDC investigators identified the DNA fingerprint of the bacterial culprit in that outbreak as E. coli strain STEC O26, which was found in all of the sickened customers tested.
Outbreaks of food poisoning have become something of a Chipotle trademark; the recent ones are the fourth and fifth this year, one of which was not disclosed to the public. A particularly worrisome aspect of the company’s serial deficiencies is that there have been at least three unrelated pathogens in the outbreaks – Salmonella and E. coli bacteria and norovirus. In other words, there has been more than a single glitch; suppliers and employees have found a variety of ways to contaminate what Chipotle cavalierly sells (at premium prices) to its customers.
December 3, 2015
David Warren is rather a skeptic on the long-term usefulness of big medical charities (and not just because, like any big bureaucracy, sooner or later the primary goal becomes for the organization itself to survive and grow rather than pursuing whatever they were originally created to do):
Medical “research” does similar direct damage. Huge foundations are created to “fight” every imaginable human ailment, and find new ones on which to build fresh fundraising efforts, should any of the old ones go stale. Grand sums are expended on “public awareness” campaigns, to encourage hypochondria and psychosomatic disorders. (I suspect, for instance, that the chief cause of lung cancer today is grisly health warnings on packets of cigarettes.) Money is raised in billions to “find a cure” for whatever. (Snake oil sales were on a much smaller scale.)
At the most elementary level, people should try to understand cause and effect. Vast numbers come to rely upon the metastasis of these soi-disant “charitable” bureaucracies. And if a cure is ever found, they will all be out of their overpaid jobs. Moreover, it is almost invariably some isolated, eccentric, unqualified and unfunded tyro, who makes the fatal discovery. That is why one of the principal tasks of any large medical foundation is to locate these brilliant “inventor” types, and sue them into surrender.
Does gentle reader know that almost all the increase in human longevity, over the last century or so, can be attributed to people washing their hands and taking showers? And most of the rest to better sewage disposal? Or that it took until almost the middle of the last century for life expectancy in the West to rise to levels last seen in the parish records of the Middle Ages? Which was when “modern” hygienic practices were last observed. (Large, centralized hospitals are the most efficient spreaders of infection today.)
Painkillers are nice, and I’m inclined to keep them, only if we realize that the blessing is mixed. They turn our minds away from futurity; they displace faith in God, to faith in doctors. They create the mindset that embraces “euthanasia.”
Of course, the main focus of contemporary liberal “philanthropy” is not on saving lives at all; rather on killing off babies — in Africa, by first choice. It is what the proggies used to call “population control,” until they invented better euphemisms. That is what truly gladdens the peons in the foundations of all the Bills and Melindas; and lights the corridors of the United Nations. That and the (still historically recent) “climate change” agenda.
October 28, 2015
The World Health Organization appears to exist primarily to give newspaper editors the excuse to run senational headlines about the risk of cancer. This is not a repeat story from earlier years. Oh, wait. Yes it is. Here’s The Atlantic‘s Ed Yong to de-sensationalize the recent scary headlines:
The International Agency of Research into Cancer (IARC), an arm of the World Health Organization, is notable for two things. First, they’re meant to carefully assess whether things cause cancer, from pesticides to sunlight, and to provide the definitive word on those possible risks.
Second, they are terrible at communicating their findings.
Group 1 is billed as “carcinogenic to humans,” which means that we can be fairly sure that the things here have the potential to cause cancer. But the stark language, with no mention of risks or odds or any remotely conditional, invites people to assume that if they specifically partake of, say, smoking or processed meat, they will definitely get cancer.
Similarly, when Group 2A is described as “probably carcinogenic to humans,” it roughly translates to “there’s some evidence that these things could cause cancer, but we can’t be sure.” Again, the word “probably” conjures up the specter of individual risk, but the classification isn’t about individuals at all.
Group 2B, “possibly carcinogenic to humans,” may be the most confusing one of all. What does “possibly” even mean? Proving a negative is incredibly difficult, which is why Group 4 — “probably not carcinogenic to humans” — contains just one substance of the hundreds that IARC has assessed.
So, in practice, 2B becomes a giant dumping ground for all the risk factors that IARC has considered, and could neither confirm nor fully discount as carcinogens. Which is to say: most things. It’s a bloated category, essentially one big epidemiological shruggie. But try telling someone unfamiliar with this that, say, power lines are “possibly carcinogenic” and see what they take away from that.
Worse still, the practice of lumping risk factors into categories without accompanying description — or, preferably, visualization — of their respective risks practically invites people to view them as like-for-like. And that inevitably led to misleading headlines like this one in the Guardian: “Processed meats rank alongside smoking as cancer causes – WHO.”
Henry I. Miller discusses a worthwhile regulatory change that would increase the availability of medicines in the US marketplace without reducing public safety:
The FDA would be a good place to start. Bringing a new drug to market now requires 10-15 years, and costs have skyrocketed to an average of more than $2.5 billion (including both out-of-pocket and opportunity costs) – largely because FDA requirements have increased the length and number of clinical trials per marketing application, and their complexity.
The detrimental effects of FDA delays in approving certain new drugs already available in other industrialized countries are well-documented and deserve as much attention as drugs’ high costs. An example is the three-year delay in the approval of misoprostol, a drug for the treatment of gastric bleeding, which is estimated to have cost between 8,000 and 15,000 lives per year.
A practical workaround to overcome regulators’ risk-aversion and capriciousness would be “reciprocity” of approvals with certain foreign “A-list” governments, so that an approval in one country would be reciprocated automatically by the others. That would make more drugs available sooner in all of the participating countries, increasing competition and putting downward pressure on prices.
Such an innovation would also help to alleviate another critical problem: The United States is experiencing shortages of certain critical pharmaceuticals, many of which have been essential in medical practice for decades. The majority are generic injectable medications commonly used in hospitals, including analgesics, cancer drugs, anesthetics, antipsychotics for psychiatric emergencies, and electrolytes needed for patients on IV supplementation. Hospitals are scrambling to assure adequate supplies of drugs that are in short supply, or to find substitutes for them. Reciprocal approvals would make numerous alternatives available.
As referenced yesterday, the FDA regulations also create temporary monopoly situations where only one company has the permit from the regulator to produce this or that medicine, so there’s nothing standing in the way of massive price increases if there are no close substitutes to provide price competition.
October 22, 2015
… the great public health achievements between roughly 1850 and 1960. Doctors and public health experts were given extraordinarily broad powers by the government, and they used them to eliminate the scourges that had made cities into pestholes from time immemorial. They built gleaming sewers and water treatment plants to wipe out virulent water-borne pathogens that used to regularly claim thousands of lives. Contact-tracing and quarantine of airborne and sexually transmitted diseases turned former plagues like smallpox and syphilis into tragic but sporadic outbreaks. Changes in building codes helped beat back mass killers like tuberculosis. Poison control cut down on both accidental and deliberate deaths. The Pure Food and Drug Act, and similar ordinances in other countries, reduced foodborne illness, and also, the casual acquisition of opiate or cocaine addictions through patent medicines. Malarial swamps were drained. Environmental toxins were identified and banned. Then they went and invented antibiotics and vaccines and vaccination laws, and suddenly surgery was as safe as a long-haul flight, TB was curable, and childhood illnesses that used to kill hundreds of people every year were a quaint footnote in your 10th-grade history textbook.
Having seen public experts work these miracles through the heavy hand of the state, people understandably concluded we could use miracles in other areas. They had a metaphor, so to speak. The metaphor wasn’t very good, as is often the case, but it took a while to find out that you couldn’t solve a problem in your steel supply chain with the same system that was so good at tracing cholera outbreaks to tainted pumps.
This is an overreaction to a terrible failure, for two reasons. First, big bureaucracies fail all the time, especially in the face of novel threats. A large institution is like a battleship: hard to sink, but also hard to turn. Public health experts of earlier eras made grave mistakes, like dumping London’s untreated sewage into the Thames; public health experts of the future will too. The more important question is whether they correct themselves, as it seems to me the CDC is now doing.
The second is that this is not your grandfather’s public health system. Public health experts were, in a way, too successful; they beat back our infectious disease load to the point where most of us have never had anything more serious than Human papillomavirus or a bad case of the flu. This left them without that much to do. So they reinvented themselves as the overseers of everything that might make us unhealthy, from French Fries to work stress.
As with the steel mills, these problems are not necessarily amenable to the organizational tools used to tackle tuberculosis. The more the public and private health system are focused on these problems, the less optimized they will be for fighting the war against infectious disease. It is less surprising to find that they didn’t know how to respond to a novel infectious disease than it would have been to discover that they botched a new campaign against texting and driving.
Megan McArdle, “Will Ebola Be Good for the CDC?”, Bloomberg View, 2014-10-20.
October 13, 2015
September 30, 2015
Published on 18 Mar 2015
In this video, we show how bees and pollination demonstrate the Coase Theorem in action: when transaction costs are low and property rights are clearly defined, private arrangements ensure that the market works even when there are externalities. Under these conditions, the market properly manages externalities.
September 21, 2015
Published on 18 Mar 2015
What happened to the cleanliness of your clothes after the U.S. Department of Energy issued new washing machine requirements? The requirements — which require washers to use 21% less energy — mean that washers actually clean clothes less than they used to. Is “command and control” an efficient way to achieve the desired outcome (which is less pollution)? Rather than a standard requirement, such as the Department of Energy issued, a tax on electricity would provide users with greater flexibility in their washing—and would prompt people to purchase machines that use energy more efficiently and keep their clothes clean.
Are there times when a command and control solution to a problem makes the most sense? We look at the eradication of smallpox as one example.
September 16, 2015
Published on 18 Mar 2015
What can the flu teach us about economics and externalities? In this video, we go over how vaccines produce positive externalities that help people stay healthy. When someone receive the vaccine, they pass along the positive benefits of the vaccine to others, generating positive externalities. However, when someone gets a vaccine, they bear all of the costs and only reap some of the benefits of the vaccine. The social value is larger than the private value, resulting in an an undersupply of flu shots. One solution to this problem is a Pigouvian subsidy — a subsidy on a good with external benefits.
March 10, 2015
March 5, 2015
At Mother Jones, Kevin Drum talks about all the things we’ve been told about healthy eating … that just ain’t so:
For several years now I’ve been following the controversy over whether the dietary guidelines that have developed over the the past 70 years might be all wrong. And I’ve become tentatively convinced that, in fact, they are wrong. For most people — not all! — salt isn’t a big killer; cholesterol isn’t harmful; and red meat and saturated fat are perfectly OK. Healthy, even. Sugar, on the other hand, really needs to be watched.
Before I go on, a great big caveat: I’m not even an educated amateur on this subject. I’ve read a fair amount about it, but I’ve never dived into it systematically. And the plain truth is that firm proof is hard to come by when it comes to diet. It’s really, really hard to conduct the kinds of experiments that would give us concrete proof that one diet is better than another, and the studies that have been done almost all have defects of some kind.
Randomized trials are the gold standard of dietary studies, but as I said above, they’re really, really hard to conduct properly. You have to find a stable population of people. You have to pick half of them randomly and get them to change their diets. You have to trust them to actually do it. You have to follow them for years, not months. Virtually no trial can ever truly meet this standard.
Nonetheless, as Carroll says, the randomized trials we do have suggest that red meat and saturated fat have little effect on cardiovascular health — and might actually have a positive effect on cancer outcomes.
At the same time, increased consumption of sugars and carbohydrates might be actively bad for us. At the very least they contribute to obesity and diabetes, and there’s some evidence that they aren’t so great for your heart either.
So where does this leave us? As Carroll says, the literature as a whole suggests that we simply don’t know. We’ve been convinced of a lot of things for a long time, and it’s turned out that a lot of what we believed was never really backed by solid evidence in the first place. So now the dietary ship is turning. Slowly, but it’s turning.
His primary take-away from all this: moderation is probably your safest bet, unless you have a condition that requires you to avoid certain foods or types of foods. Oh, and avoid over-indulging in packaged food that uses lots of preservatives. This is certainly one area where the science sure didn’t turn out to be settled, after all.
March 1, 2015
In Mother Jones, Kevin Drum looks at an interesting bit of data from the 1800s:
Here’s the background. Homicides increased dramatically between 1900-11, but most of that appears to be the result of increased rural homicides, not urban homicides. If lead exposure is part of the reason, it would mean that rural areas were exposed to increasing levels of lead about 20 years earlier, around 1880 or so. But why? Nevin suggests that the answer to this question starts with another question: Why are barns red?
Professional painters in the 1800s prepared house paint by mixing linseed oil with white lead paste. About 90% of Americans lived in rural areas in the mid-1800s, and subsistence farmers could make linseed (flaxseed) oil, but few had access to white lead, so they mixed linseed oil with red rust to kill fungi that trapped moisture and increased wood decay. Red barns are still a tradition in most USA farming regions but white barns are the norm along the path of the old National Road. Why?
….The reason the red barn tradition never took root along that path is likely because the National Road made freight, including white lead, accessible to nearby farmers. USA lead output was a relatively stable 1000 to 2000 tons per year from 1801-1825, but lead output was 15,000 to 30,000 tons per year from the mid-1830s through the mid-1860s after the completion of the National Road.
….The first American patent for “ready-mixed” paint was filed in 1867; railroads built almost 120,000 track miles from 1850 to 1900; and Sears Roebuck and other mail-order catalogs combined volume buying, railroad transport, and rural free parcel post delivery to provide economical rural access to a wide variety of products in the 1890s.
The murder arrest rate in large cities was more than seven times the national homicide rate from 1900-1904 because lead paint in the 1870s was available in large cities but unavailable in most rural areas. The early-1900s convergence in rural and urban murder rates was presaged by a late-1800s convergence in rural and urban lead paint exposure.