Quotulatiousness

September 8, 2009

John Snow and the start of modern epidemiology

Filed under: Britain, Health — Tags: , , — Nicholas @ 08:52

Another “on this date” entry for you: in 1854, John Snow persuaded the local authorities in a London borough to remove the handle from a water pump at the centre of a cholera outbreak. The move was successful, and the death rate dropped immediately. Randy Alfred has the story:

BroadSt_cholera_map

Physician John Snow convinces a London local council to remove the handle from a pump in Soho. A deadly cholera epidemic in the neighborhood comes to an end immediately, though perhaps serendipitously. Snow maps the outbreak to prove his point . . . and launches modern epidemiology.

The Soho neighborhood was not then filled with galleries, clubs, restaurants and other fine urban diversions. Some of it was an unsanitary slum where centuries-old cesspits sat chockablock with the wells that provided drinking water to a crowded populace.

Asiatic cholera had stricken Britain in successive waves since 1831. Snow, an obstetrician who pioneered the use of anesthesia in Britain, published On the Mode of Communication of Cholera in 1849. His hypothesis (and supporting data) held that the scourge was caused by sewage pollution in drinking water and “always commences with disturbances of the functions of the alimentary canal.”

September 2, 2009

NHS better than Canadian health system, says Jeremy Clarkson

Filed under: Bureaucracy, Cancon, Health — Tags: , — Nicholas @ 00:03

It’s always surprising to find a British author willing to call their massive National Health Service (NHS) “a monster that we can barely afford”, but that’s exactly what Jeremy Clarkson says in his latest Times column. But that’s merely an aside. The venom in this article is reserved for Canadian healthcare, specifically in Quebec:

Some say America should follow Canada’s lead, where private care is effectively banned. But having experienced their procedures while on holiday in Quebec, I really don’t think that’s a good idea at all.

[. . .]

Now, we are all used to a bit of a wait at the hospital. God knows, I’ve spent enough time in accident and emergency at Oxford’s John Radcliffe over the years, sitting with my sobbing children in a room full of people with swords in their eyes and their feet on back to front. But nothing can prepare you for the yawning chasm of time that passes in Canada before the healthcare system actually does any healthcare.

[. . .]

After a couple of hours, I asked the receptionist how long it might be before a doctor came. In a Wal-Mart, it’s quite quaint to be served by a fat, gum-chewing teenager who claims not to understand what you’re saying, but in a hospital it’s annoying. Resisting the temptation to explain that the Marquis de Montcalm lost and that it’s time to get over it, I went back to the boy’s cubicle

[. . .]

And they also had the cash to employ an army of people to slam the door in your face if you poked your head into the inner sanctum to ask how much longer the wait might be. Sixteen hours is apparently the norm. Unless you want a scan. Then it’s 22 months.

At about 1.30am a doctor arrived. Boy, he was a piece of work. He couldn’t have been more rude if I’d been General Wolfe. He removed the bandages like they were the packaging on a disposable razor, looked at the wound, which was horrific, and said to my friend: “Is it cash or credit card?”

August 24, 2009

Infant mortality rates in the US

Filed under: Health, USA — Tags: — Nicholas @ 07:54

Steve Chapman looks at one of the bigger question marks in the debate over health care in the United States: why such a high infant mortality rate?

The American medical system has the latest technology, the greatest variety of new drugs, and unparalleled resources. But anyone who thinks we’re getting something great for our dollars inevitably encounters a two-word rebuke: infant mortality.

The United States is the richest nation on Earth, but it comes in 29th in the world in survival rates among babies. This mediocre ranking is supposed to make an irrefutable case for health care reform. If we cared enough to insure everyone, we are told, we would soon rise to the health standards of other modern nations. It’s just a matter of getting over our weird resistance to a bigger government role in medical care.

[. . .]

No one denies the problem. Our infant mortality rate is double that of Japan or Sweden. But we live different lives, on average, than people in those places. We suffer more obesity (about 10 times as much as the Japanese), and we have more births to teenagers (seven times more than the Swedes). Nearly 40 percent of American babies are born to unwed mothers.

Factors like these are linked to low birth weight in babies, which is a dangerous thing. In a 2007 study for the National Bureau of Economic Research, economists June O’Neill and Dave O’Neill noted that “a multitude of behaviors unrelated to the health care system such as substance abuse, smoking and obesity” are connected “to the low birth weight and preterm births that underlie the infant death syndrome.”

August 22, 2009

Right wing nutbars, observed

Filed under: Health, History, Liberty, USA — Tags: , , , — Nicholas @ 08:23

P.J. O’Rourke tries to save readers the effort of reading the Washington Post coverage of recent town hall protests:

So there was Rick Perlstein calling everyone to the right of Nikita Khrushchev a candidate for the state psychiatric ward with Alec MacGillis playing his KGB Bozo sidekick, firing blanks and honking his “End-of-life care eats up a huge slice of spending” airhorn. Then, to add idiocy to insult, the Post sent Robin Givhan to observe the Americans who are taking exception to various expansions of government powers and prerogatives and to make fun of their clothes.

Givhan writes a column called “On Culture,” and this is what passes for culture at the Post: “Of the hundreds of thousands of style guides currently for sale on Amazon, not one . . . was prescient enough to outline the appropriate attire for those public occasions when good citizens decided to behave like raving lunatics and turn lawmakers into punching bags.” Meeting with Givhan’s scorn were “T-shirts, baseball caps, promotional polo shirts and sundresses with bra straps sliding down their arm.”

I’ve never seen Robin Givhan. For all I know she dolls herself up like Jackie O. But I have seen other employees of the Washington Post and — with the exception of the elegant and, I dare say, cultured, Roxanne Roberts — they look as if they got dressed in the unlit confines of a Planet Aid clothing-donation bin.

Perlstein, for all the highness of his dudgeon, doesn’t catch the nuts saying anything very nutty. The closest he gets to a lunatic quote is from a “libertarian” wearing a holstered pistol who declares that the “tree of liberty must be refreshed from time to time by the blood of tyrants and patriots.” And those are the words of lefty icon Thomas Jefferson. I myself could point out the absurdity of protestors’ concerns about government euthanasia committees. Federal bureaucracy has never moved fast enough to get to the ill and elderly before natural causes do. And what’s with those “birthers”? Why their obsession with a nonentity like Obama? How about John Adams with his Alien and Sedition Acts choke-hold on the First Amendment? Or Jefferson? He could tell his Monica Lewinsky, “I own you,” and he wasn’t kidding. Or John Quincy Adams, pulling the original Blagojevich, buying the presidency from Henry Clay? Or that backwoods Bolshevik Andrew Jackson? Or William Henry Harrison, too dumb to come in out of the rain? Not one of these scallywags was born in the United States of America — look it up.

August 21, 2009

QotD: Heroin as a treatment for addiction

Filed under: Health, Quotations — Tags: , , — Nicholas @ 11:53

Stripped of the medicalese, what the researchers found is that if you give heroin addicts heroin, they will keep coming back for more. They will also be less likely to buy heroin on the street or commit crimes to support their habit. These findings, similar to the results of European studies, are not exactly surprising. The puzzling thing is that we’re asked to pretend that heroin is a “treatment” for heroin addiction. “Study Backs Heroin to Treat Addiction,” says the headline over a New York Times story that begins, “The safest and most effective treatment for hard-core heroin addicts who fail to control their habit using methadone or other treatments may be their drug of choice, in prescription form.”

What the study actually shows is that the problems associated with heroin addiction are largely caused by prohibition, which creates a black market in which prices are artificially high, quality is unreliable, and obtaining the drug means risking arrest and associating with possibly violent criminals. The drug laws also encourage injection by making heroin much more expensive that it would otherwise be and foster unsanitary, disease-spreading injection practices by treating syringes and needles as illegal drug paraphernalia. When you take these dangers out of the equation, regular use of heroin is safe enough that it can qualify as a “treatment” dispensed by men in white coats. That rather startling fact should cause people to question not just current addiction treatment practices but the morality of trying to save people from themselves by making their lives miserable.

Jacob Sullum, “This Just In: Heroin Addicts Like Heroin”, Hit and Run, 2009-08-21

August 15, 2009

The high cost of coping with Celiac Disease

Filed under: Health — Tags: — Nicholas @ 12:33

An article in the New York Times discusses something near and not-particularly-dear to our hearts — Celiac Disease:

Seven years after receiving his diagnosis, Mr. Oram, who is married and has one daughter, is symptom-free, but the cost of staying that way is high. That’s because the treatment for celiac does not come in the form of a pill that will be reimbursed or subsidized by an insurer. The treatment is to avoid eating products containing gluten. And gluten-free versions of products like bread, pizza and crackers are nearly three times as expensive as regular products, according to a study conducted by the Celiac Disease Center at Columbia University.

Unfortunately for celiac patients, the extra cost of a special diet is not reimbursed by health care plans. Nor do most policies pay for trips to a dietitian to receive nutritional guidance.

In Britain, by contrast, patients found to have celiac disease are prescribed gluten-free products. In Italy, sufferers are given a stipend to spend on gluten-free food.

Some doctors blame drug makers, in part, for the lack of awareness and the lack of support. “The drug makers have not been interested in celiac because, until very recently, there have been no medications to treat it,” said Dr. Peter Green, director of the Celiac Disease Center at Columbia University. “And since drug makers are responsible for so much of the education that doctors receive, the medical community is largely unaware of the disease.”

Elizabeth has suffered from gluten intolerance for most of her life, so we’re very aware of the difficulty (and added cost) of finding food that doesn’t contain wheat gluten. Wheat is a very cheap way of adding bulk and body to foods that traditionally do not contain it . . . it’s distressing the number of times we’ve discovered that a packaged food that used to be gluten-free has been “improved” . . . and the extent of the improvement has been to add wheat in place of more expensive non-gluten ingredients.

QotD: The biggest risk in moving to a single-payer system

Filed under: Health, Quotations — Tags: , , — Nicholas @ 11:05

My objection is primarily, as I’ve said numerous times, that the government will destroy innovation. It will do this by deciding what constitutes an acceptable standard of care, and refusing to fund treatment above that. It will also start controlling prices.

Now, at this point in the discussion, some interlocutor starts chanting what I’ve come to think of as “the mantra”: othercountriesspendlessandhavelongerlifespans. Then they ask me how I can ignore the overwhelming evidence that national health care is superior to our terrible system. Now, what’s odd about this is that all of those countries do precisely what I am concerned about: slap price controls on the inputs, particularly pharmaceuticals. Their overwhelming evidence indicates that I am 100% correct that a government run system in the US will destroy the last really profitable market for drugs and medical technology, and thereby cause the rate of medical innovation to slow to a crawl.

[. . .]

The things that make markets innovate — profit potential — have been mostly squeezed out of the system. The things that hasten market discover — prices — have also been increasingly relegated to central authority. Having something like that in the United States would produce exactly the outcome I’m worried about. So if Matt is right, and this is where the slippery slope ends up, my nightmare will have been realized.

Megan McArdle, “What Does It Mean To Have a Private Health Care System?”, Asymmetrical Information, 2009-08-13

August 14, 2009

If it isn’t Astroturf . . .

Filed under: Health, Politics — Tags: , — Nicholas @ 12:34

. . . maybe it really is grassroots? Jesse Walker decodes some of the hysteria around both the protests and the official responses:

Clashes keep breaking out at the “town hall” meetings devoted to discussing health care reform. Usually the excitement amounts to some angry questions and heckling, but sometimes there’s more. Six people were arrested at a demonstration outside a meeting in St. Louis. Violence erupted at a town hall in Tampa after opponents of ObamaCare were locked out of the building. A North Carolina congressman cancelled a meeting after receiving a death threat; the pro-market group FreedomWorks, which was involved in some of the protests, fielded a death threat of its own. Supporters of the president’s health care reforms, who used to tout the support he’d received from the pharmaceutical and insurance industries, are now accusing the very same companies of riling up “mob violence” to stop the plan.

As the charges and countercharges fly, here are three maxims to keep in mind:

1. It isn’t Astroturf after the grassroots show up.

[. . .]

2. It isn’t unprecedented if there are obvious precedents. When someone like New York Times columnist Paul Krugman claims that the “mob aspects” at the meetings are “something new and ugly,” all he’s demonstrating is that he’s an economist, not a historian. When it comes to bands of angry citizens being disruptive, it isn’t hard to find earlier examples in American history. It isn’t even hard to find earlier examples in 21st century American history. Just go to Google and punch in phrases like “guerrilla theater,” “antiwar protest,” and “Code Pink.”

[. . .]

3. It isn’t fascism if…actually, you can stop there. IT ISN’T FASCISM, you numbskulls.

August 12, 2009

QotD: “an abject failure for the Obama administration”

Filed under: Health, Politics, Quotations, USA — Tags: , , , — Nicholas @ 12:34

But who would have thought that the sober, deliberative Barack Obama would have nothing to propose but vague and slippery promises — or that he would so easily cede the leadership clout of the executive branch to a chaotic, rapacious, solipsistic Congress? House Speaker Nancy Pelosi, whom I used to admire for her smooth aplomb under pressure, has clearly gone off the deep end with her bizarre rants about legitimate town-hall protests by American citizens. She is doing grievous damage to the party and should immediately step down.

There is plenty of blame to go around. Obama’s aggressive endorsement of a healthcare plan that does not even exist yet, except in five competing, fluctuating drafts, makes Washington seem like Cloud Cuckoo Land. The president is promoting the most colossal, brazen bait-and-switch operation since the Bush administration snookered the country into invading Iraq with apocalyptic visions of mushroom clouds over American cities.

You can keep your doctor; you can keep your insurance, if you’re happy with it, Obama keeps assuring us in soothing, lullaby tones. Oh, really? And what if my doctor is not the one appointed by the new government medical boards for ruling on my access to tests and specialists? And what if my insurance company goes belly up because of undercutting by its government-bankrolled competitor? Face it: Virtually all nationalized health systems, neither nourished nor updated by profit-driven private investment, eventually lead to rationing.

I just don’t get it. Why the insane rush to pass a bill, any bill, in three weeks? And why such an abject failure by the Obama administration to present the issues to the public in a rational, detailed, informational way? The U.S. is gigantic; many of our states are bigger than whole European nations. The bureaucracy required to institute and manage a nationalized health system here would be Byzantine beyond belief and would vampirically absorb whatever savings Obama thinks could be made. And the transition period would be a nightmare of red tape and mammoth screw-ups, which we can ill afford with a faltering economy.

Camille Paglia, “Obama’s healthcare horror: Heads should roll — beginning with Nancy Pelosi’s!”, Salon.com, 2009-08-12

August 10, 2009

Healthcare systems compared

Filed under: Cancon, Economics, Health — Tags: , , — Nicholas @ 12:55

No, not the usual red-in-tooth-and-claw US system of mercenary medicine against the shimmering city-on-the-hill of [Canadian | British | Swedish | Generic European] socialized medicine. This one is a bit easier to compare: human verses pet healthcare. Theodore Dalrymple discusses the issue:

As a British dog, you get to choose (through an intermediary, I admit) your veterinarian. If you don’t like him, you can pick up your leash and go elsewhere, that very day if necessary. Any vet will see you straight away, there is no delay in such investigations as you may need, and treatment is immediate. There are no waiting lists for dogs, no operations postponed because something more important has come up, no appalling stories of dogs being made to wait for years because other dogs — or hamsters — come first.

The conditions in which you receive your treatment are much more pleasant than British humans have to endure. For one thing, there is no bureaucracy to be negotiated with the skill of a white-water canoeist; above all, the atmosphere is different. There is no tension, no feeling that one more patient will bring the whole system to the point of collapse, and all the staff go off with nervous breakdowns. In the waiting rooms, a perfect calm reigns; the patients’ relatives are not on the verge of hysteria, and do not suspect that the system is cheating their loved one, for economic reasons, of the treatment which he needs. The relatives are united by their concern for the welfare of each other’s loved one. They are not terrified that someone is getting more out of the system than they.

And, yes, I know it’s extremely bad form to quote yourself, but here is what I wrote on the subject back in 2004:

It boggles the mind to think that it is possible for pets to receive faster, better-organized, more personalized, and more friendly healthcare than their human owners are able to get. And it’s absolutely true.

My wife works in a vet clinic. I know how much the staff at the clinic care about their patients and the families of their patients. They do their very best to ensure that the cats are properly diagnosed and treated. But they are paid for their work . . . by the families of the patients.

One of the comments on Marcel’s original post talks about “the Vet’s next Porsche purchase”. That by itself shows the utter ignorance of the commentator: you do not go into veterinary medicine to get rich. For the length of academic study, it’s probably the worst-paid bio-science field there is. The veterinarians, vet assistants, and vet technicians could all earn significantly higher wages in other fields for the same investment of time and money in training.

Medicine, whether for humans or for other animals, is an expensive field: typical Canadians don’t really know this, as a rule, because we don’t pay for it directly. Vets, as a rule, don’t have the latest and greatest equipment because they are running private businesses which have to finance equipment purchases out of their own funds. They generally have the best compromise they can manage between what’s available and what’s affordable.

Treatment for patients must be decided with an eye to costs: Fluffy may need treatment X, but if it’s going to cost hundreds or thousands of dollars, Fluffy’s owner is left with an unwelcome decision to make. We never think of this in terms of our own healthcare: instead of rationing by dollars, we ration by time. The resources are still scarce, but we pretend that delaying surgery for a painful ailment is better than paying extra to get the surgery done sooner; in fact, in Canada, there’s no choice involved at all.

The other pernicious effect of hiding the actual costs is to increase the demand for relatively trivial treatments (which could often be taken care of by family doctors, walk-in clinics, or even pharmacists). If you never see a bill, you never feel any reason to limit your personal demand on the system. It’s rational for you to extract as much personal benefit from the system as possible: you paid taxes to support it, right?

August 8, 2009

Dieting and obesity

Filed under: Health — Tags: , , — Nicholas @ 00:13

Megan McArdle had an interesting-but-lengthy post earlier this week on obesity and both the scientific and political issues surrounding it:

I don’t agree with Paul Campos about everything, but I do agree with some of his core propositions:

  • Study after study shows that most people are unable to lose more than a small percentage of their body weight and keep it off without major surgery
  • There is evidence to show that this is physiologic rather than pyschological — it is nearly impossible for very heavy people to simply “eat less and exercise more” to a “normal” weight (given that 2/3 of the country is overweight or obese, normal weights, aren’t.)
  • The fact that this often operates through the appetite system does not mean it’s “all in their heads” or a lack of willpower. Appetite is a signal as powerful as thirst or pain. Most people can’t ignore it.
  • The largest environmental determinant of this trend is probably simply cheaper, tastier calories, which will be very hard to reverse

[. . .]

This really is a pattern that you see over and over again in obesity research. It’s as if researchers are terrified to say anything that might be viewed as giving people license to get fat. The CDC researcher who sharply revised downward the estimates of deaths from obesity, finding that overweight was actually healthier, fell all over herself proclaiming that of course, this didn’t account for quality of life. Because we know that a woman who weighs 160 pounds couldn’t possibly have a decent quality of life . . . ?

[. . .]

I know, I know . . . it’s for the children! I am very fond of children. But I do not actually think that they are some sort of master race in whose name anything at all can be justified. And if I did, I’d be a lot more worried about, oh, abortion, than McDonalds ads.

Two final points. Everyone likes to focus on their favorite boogeymen. To read a left-wing blog, you’d think that about 95% of the leading cause of obesity was agribusiness, chain restaurants, and automobiles. To read a right-wing paper, it’s all the infamous lack of self-control displayed by the poor.

But in fact, most of the things effecting kids are side effects of other efforts a lot of people are rather fond of. Processed foods and chain restaurants have exploded in the last two decades because Mom spends more time outside the home, generating more market income, and less time for home cooked meals. Kids exercise less not because crime is higher, or even because we’ve become more suburban, but because they’re no longer allowed to operate unsupervised until they’re quite old, and Mom and Dad both work. Schools don’t have P/E because they’re using the time to teach kids to read. Maybe those were bad tradeoffs. But they’re not irrational tradeoffs, and switching them back is not costless.

One thing Megan doesn’t touch on in the post (although she had done in earlier posts on this topic) is that metabolic changes over individuals’ lifetimes can actively sabotage good intentions on maintaining a given weight. Up until my late 20s, I could lose weight just by thinking about it, and then suddenly in my early 30s, I discovered that taking weight off was something that now needed a more conscious effort. Now I’m finding it even tougher to manage my weight (and also harder to make and take advantage of opportunities to get some exercise). My innate laziness and enjoyment of good food and good wine can usuallyalways overwhelm any urge to go do something healthy instead.

And no, I didn’t copy the entire post . . . there’s lots more, and it’s all worth reading.

August 7, 2009

The error of being generous to your opponents

Filed under: Economics, Government, Health, USA — Tags: , — Nicholas @ 12:48

Megan McArdle is called to task for making a mistake . . . through being too generous to her opponents:

I erred so low because I was trying to be charitable to the cause of national health care. You see, the reason that insurance premia are so high in New York State is that New York State enjoys community rating, guaranteed issue, and a very generous bevy of mandatory services. The result is that the cost of insurance is very, very high. What I failed to realize was just how radically out of line New York’s rules had pushed its health care costs. The average premium across the United States has increased about 25% since 2004. In New York, the rate of inflation has apparently been about 16 times that. I wasn’t “aware” that insurance premiums have doubled and tripled over the last seven years, because for the country as a whole, this isn’t true.

So yes, John, the Atlantic’s economics expert didn’t realize just how much the kind of regulations Democrats are now pushing had managed to screw up New York’s health insurance market. In trying, while writing a blog post on the fly, to err on the side of charity towards my ideological opponents, I grossly misled my readers. Massive state interference in the insurance market is clearly much, much worse than I — the eternal pessimist! — managed to imagine. Thanks for calling that oversight to my attention.

QotD: It’s not insurance, it’s welfare

Filed under: Health, Quotations — Tags: , — Nicholas @ 00:06

Have [New York Times writers and editors] no understanding of risk management? If it is controversial for health insurers to reject sick applicants, it should be controversial for life insurers to refuse to insure the already dead, and for car insurers to refuse to insure cars that have already been wrecked.

Doing that may be required by Congress and cheered by the New York Times, but that doesn’t make it a good thing for America. It doesn’t even make it insurance. It’s welfare. We can debate whether such welfare is good policy, but let’s discuss it honestly. Calling welfare “insurance” muddies thinking.

Requiring insurance companies to cover the sick takes away insurers’ power to encourage safer behavior. This will soon turn insurance into a form of expensive, taxpayer funded welfare.

John Stossel, “Welfare, Not Insurance”, John Stossel’s Take, 2009-08-05

August 6, 2009

QotD: Depression

Filed under: Health, Quotations — Tags: — Nicholas @ 00:01

I will meet October with a great weight off my chest. I will meet December with the novel mostly done. In between now and then I just want to be happy and content and useful. The last two weeks have been a bit unfortunate, with the Black Dog prowling and growling in the bushes outside the reach of the campfire light; I just lost enthusiasm for my enthusiasms. I think it’s lifted. The worst thing about Depression isn’t the sense that you’re ac-centuating the negative, it’s that you’re seeing things the way they really are, stripped of the illusions you use every day to divert yourself from the Yawning Maw of Futility. It’s the wind that blows off the snow and reveals the stone.

James Lileks, Bleat, 2009-08-04

August 5, 2009

Blotting out Rorschach tests

Filed under: Health, Technology — Tags: , , — Nicholas @ 07:50

Colby Cosh examines the furor around James Heilman’s posting of the original Rorschach inkblots to Wikipedia:

It is probably no great loss. Critics of Heilman complain that “decades” of research will have to be abandoned if the Rorschach test becomes impossible to use. But most of this research has been shown, in the last 20 years, to be flapdoodle. As soon as the test became popular — so much so that it became a staple of comedy routines about Freudian psychotherapists, along with couches and thick German accents — it had critics who pointed out that there was little or no statistically validated basis for its interpretation. After the psychiatric profession got around to trying to establish such a basis — and this happened disgracefully late in history — there was little or nothing left of what had once been perceived as the broad general usefulness of the Rorschach.

Much of the folklore that had grown up around specific elements of the test had to be thrown in the trash. It appears to have modest predictive or diagnostic power for a few very specific aspects of personality, and even this surviving foundation is shaky. Yet supporters gave, and some are still giving, the same indignant defences that pseudoscience always receives. Interpreting responses to Rorschach blots is more “art” than “science,” they have insisted. (The mating call of the quack.) Only those who are intimately familiar with the test — i. e., those who believe in it and have come to depend on it — are really qualified to judge whether it “works.”

But can the thousands of psychologists and psychiatrists who have considered the Rorschach test a useful item in the healing toolbox for generations really all have been wrong? Keep in mind that the same practitioners were eagerly recommending and performing lobotomies throughout the same period, and you have your answer.

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