Published on 18 Feb 2017
Catherine had great ambitions to reform Russia according to her own highest ideals, but she soon found that the reality of governance made those ideals difficult to achieve. She also found herself tangled in war, rebellion, and (scandalously) smallpox.
March 18, 2017
Catherine the Great – IV: Reforms, Rebellion, and Greatness – Extra History
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February 21, 2017
Medical Treatment in World War 1 I THE GREAT WAR Special
Published on 20 Feb 2017
Some sources say that during the four years of World War 1, medicine and medical treatments advances more than during any other four year period in human history. The chances for a soldier to survive his injury were far greater in 1918 than in 1914.
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February 14, 2017
Reconstructive and Plastic Surgery During World War 1 I THE GREAT WAR Special
Published on 13 Feb 2017
Filmed at Romagne 14-18 museum: http://romagne14-18.com
Plastic and reconstructive surgery saw rapid development during World War 1. Modern medical care and better equipment increased the chances of survival for the soldiers. But these survivors were often disfigured or lost limbs as a result. To help them return to a somewhat normal life, reconstructive surgeons developed methods to restore their faces and aided them with prosthetics.
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January 23, 2017
Five easy fixes to improve US federal health policies
Scott Alexander finds, to his surprise, that two of the candidates for the post of FDA commissioner in the Trump administration are following his blog or social media profile. To mark that, he offers five easy-to-implement policy fixes that would make a difference:
1. Medical reciprocity with Europe and other First World countries […] Right now, Europe has a licensing agency about as strict as the FDA approving medications invented in Europe. Any pharma company that wants their medication approved in both the US and Europe has to spend a billion or so dollars getting it approved by the FDA, and then another billion or so dollars getting it approved by the Europeans. A lot of pharma companies don’t want to bother, with the end result that Europe has many good medications that America doesn’t, and vice versa. Just in my own field, amisulpride, one of the antipsychotics with the best safety/efficacy balance, has been used successfully in Europe for twenty years and is totally unavailable here despite a real need for better antipsychotic drugs. If the FDA agreed to approve any medication already approved by Europe (or to give it a very expedited review process), we could get an immediate windfall of dozens of drugs with unimpeachable records for almost no cost. Instead, in the real world, we’re cracking down on imported Canadian pharmaceuticals because the Canadians don’t have exactly our same FDA which means that for all we know they might be adding thalidomide to every pill or something. This is exactly the sort of silly anti-competitive cronyist practice that a principled intelligent libertarian could do away with.
2. Burdensome approval process for generic medications […] How come Martin Shkreli can hike the dose of an off-patent toxoplasma drug 5000%, and everyone just has to take it lying down even though the drug itself is so easy to produce that high school chemistry classes make it just to show they can? The reason is that every new company that makes a drug, even a widely-used generic drug that’s already been proven safe, has to go through a separate approval process that costs millions of dollars and takes two to three years – and which other companies in the market constantly try to sabotage through legal action. Shkreli can get away with his price hike because he knows that by the time the FDA gives anyone permission to compete with him, he’ll have made his fortune and moved on to his next nefarious scheme. If the FDA allowed reputable pharmaceutical companies in good standing to produce whatever generic drugs they wanted, the same as every other company is allowed to make whatever products they want, scandals like Daraprim and EpiPens would be a thing of the past, and the price of many medications could decrease by an order of magnitude. […]
3. Stop having that thing allowing companies to “steal” popular and effective drugs that have been in the public domain for years, claim them as their private property, shut down all competitors, and jack up the price 10x just by bringing them up to date with modern FDA bureaucracy.
4. Stop having that thing where drug companies can legally bribe other companies not to compete with them. I like this one because it sounds anti-libertarian (we’re imposing a new regulation on what companies can do!) but I think it’s exactly the sort of thing that the crony capitalists would never touch but which principled intelligent libertarians like O’Neill and Srinivasan might be open to, in order to bring more actors into the marketplace.
5. Stop thwarting consumer diagnostic products and genetic tests […] Srinivasan comes from the genetic testing world himself, so he’s likely to be extra sympathetic to this.
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September 1, 2016
Don’t blame the market for the EpiPen price hike – blame the FDA
Scott Alexander explains why “the market” has very little to do with the outrageous price hike for EpiPens:
EpiPens, useful medical devices which reverse potentially fatal allergic reactions, have recently quadrupled in price, putting pressure on allergy sufferers and those who care for them. Vox writes that this “tells us a lot about what’s wrong with American health care” – namely that we don’t regulate it enough:
The story of Mylan’s giant EpiPen price increase is, more fundamentally, a story about America’s unique drug pricing policies. We are the only developed nation that lets drugmakers set their own prices, maximizing profits the same way sellers of chairs, mugs, shoes, or any other manufactured goods would.
Let me ask Vox a question: when was the last time that America’s chair industry hiked the price of chairs 400% and suddenly nobody in the country could afford to sit down? When was the last time that the mug industry decided to charge $300 per cup, and everyone had to drink coffee straight from the pot or face bankruptcy? When was the last time greedy shoe executives forced most Americans to go barefoot? And why do you think that is?
The problem with the pharmaceutical industry isn’t that they’re unregulated just like chairs and mugs. The problem with the pharmaceutical industry is that they’re part of a highly-regulated cronyist system that works completely differently from chairs and mugs.
If a chair company decided to charge $300 for their chairs, somebody else would set up a woodshop, sell their chairs for $250, and make a killing – and so on until chairs cost normal-chair-prices again. When Mylan decided to sell EpiPens for $300, in any normal system somebody would have made their own EpiPens and sold them for less. It wouldn’t have been hard. Its active ingredient, epinephrine, is off-patent, was being synthesized as early as 1906, and costs about ten cents per EpiPen-load.
Why don’t they? They keep trying, and the FDA keeps refusing to approve them for human use. For example, in 2009, a group called Teva Pharmaceuticals announced a plan to sell their own EpiPens in the US. The makers of the original EpiPen sued them, saying that they had patented the idea epinephrine-injecting devices. Teva successfully fended off the challenge and brought its product to the FDA, which rejected it because of “certain major deficiencies”. As far as I know, nobody has ever publicly said what the problem was – we can only hope they at least told Teva.
[…]
Imagine that the government creates the Furniture and Desk Association, an agency which declares that only IKEA is allowed to sell chairs. IKEA responds by charging $300 per chair. Other companies try to sell stools or sofas, but get bogged down for years in litigation over whether these technically count as “chairs”. When a few of them win their court cases, the FDA shoots them down anyway for vague reasons it refuses to share, or because they haven’t done studies showing that their chairs will not break, or because the studies that showed their chairs will not break didn’t include a high enough number of morbidly obese people so we can’t be sure they won’t break. Finally, Target spends tens of millions of dollars on lawyers and gets the okay to compete with IKEA, but people can only get Target chairs if they have a note signed by a professional interior designer saying that their room needs a “comfort-producing seating implement” and which absolutely definitely does not mention “chairs” anywhere, because otherwise a child who was used to sitting on IKEA chairs might sit down on a Target chair the wrong way, get confused, fall off, and break her head.
(You’re going to say this is an unfair comparison because drugs are potentially dangerous and chairs aren’t – but 50 people die each year from falling off chairs in Britain alone and as far as I know nobody has ever died from an EpiPen malfunction.)
Imagine that this whole system is going on at the same time that IKEA spends millions of dollars lobbying senators about chair-related issues, and that these same senators vote down a bill preventing IKEA from paying off other companies to stay out of the chair industry. Also, suppose that a bunch of people are dying each year of exhaustion from having to stand up all the time because chairs are too expensive unless you’ve got really good furniture insurance, which is totally a thing and which everybody is legally required to have.
And now imagine that a news site responds with an article saying the government doesn’t regulate chairs enough.
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June 10, 2016
A breakthrough in our understanding of the causes of depression
Scott Alexander takes a quick look at a recent discovery in medication for depression:
A few weeks ago, Nature published a bombshell study showing that ketamine’s antidepressant effects were actually caused by a metabolite, 2S,6S;2R,6R-hydroxynorketamine (don’t worry about the name; within ten years it’ll be called JOYVIVA™®© and you’ll catch yourself humming advertising jingles about it in the shower). Unlike ketamine, which is addictive and produces scary dissociative experiences, the metabolite is pretty safe. This is a big deal clinically, because it makes it easier and safer to prescribe to depressed people.
It’s also a big deal scientifically. Ketamine is a strong NMDA receptor antagonist; the metabolite is an AMPA agonist – they have different mechanisms of action. Knowing the real story behind why ketamine works will hopefully speed efforts to understand the nature of depression.
But I’m also interested in it from another angle. For the last ten years, everyone has been excited about ketamine. In a field that gets mocked for not having any really useful clinical discoveries in the last thirty years, ketamine was proof that progress was possible. It was the Exciting New Thing that everybody wanted to do research about.
Given the whole replication crisis thing, I wondered. You’ve got a community of people who think that NMDA antagonism and dissociation are somehow related to depression. If the latest study is true, all that was false. This is good; science is supposed to be self-correcting. But what about before it self-corrected? Did researchers virtuously say “I know the paradigm says NMDA is essential to depression, and nobody’s come up with a better idea yet, but there are some troubling inconsistencies in that picture”? Or did they tinker with their studies until they got the results they expected, then triumphantly declare that they had confirmed the dominant paradigm was right about everything all along?
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March 19, 2016
The Monopoly Markup
Published on 18 Mar 2015
Ever wonder why pharmaceuticals are so expensive? In this video, we show how low elasticity of demand results in monopoly markups. This is especially the case with goods that involve the “you can’t take it with you” effect (for example, people with serious medical conditions are relatively insensitive to the price of life-saving drugs) and the “other people’s money” effect (if third parties pay for the medicine, people are less sensitive to price).
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March 16, 2016
The Social Welfare of Price Discrimination
Published on 7 Apr 2015
Now that we’ve learned a little about price discrimination, we can begin to think about whether or not price discrimination is bad for society. How does price discrimination affect output, and what is this effect on social welfare? If price discrimination increases output, it is likely beneficial for society. If output isn’t increased, social welfare is reduced. What are some examples of perfect price discrimination? Universities practice perfect price discrimination all the time. Students pay different amounts for their education based on many different factors surrounding each student’s ability to pay. This practice increases profits and also increases the number of students able to attend college. For this reason, price discrimination by universities likely increases social welfare.
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March 6, 2016
January 20, 2016
QotD: Nursing
In the company of medical people who know the history of their craft you can get a good discussion going about the exact date after which medical attention was more likely to help than harm you. Opinions generally settle somewhere between 1910 and 1940.
That’s within living memory. People of the generation before my own had little to hope for from medicine. The more realistic among them knew this. My own father, born 1899, regarded the entire medical profession with fear and mistrust. A hospital, he believed, was a place where poor people went to die. A major theme in the background noise of my childhood was the voice of my mother — a professional nurse — nagging Dad to go see a doctor about some ailment he was suffering. “Why won’t you at least go see him? He won’t HURT you.” Dad knew better. Most things mend by themselves. He lived to be 85, dying at last of pneumonia, which was known to people of that generation as “the old man’s friend.”
It wasn’t all negatives before “the early 1950s, when medicine was turning into a science” (Lewis Thomas). There was nursing; there was surgery; there were a handful of useful drugs.
Nursing — the art of keeping patients clean, comfortable, and cheerful — must have saved far more lives than doctoring in the long dark ages before antibiotics. Florence Nightingale (a significant mathematician, by the way) has to be reckoned one of the great benefactors of humanity.
John Derbyshire, “The Scariest Science”, Taki’s Magazine, 2014-11-13.
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January 19, 2016
Non-conspicuous consumption of quality
Don Boudreaux on the amazingly thin line that now separates many of the quality consumption goods of the ultra-rich from the nearly as high quality goods of ordinary North American consumers:
This list includes also non-prescription pain relievers, most other first-aid medicines and devices such as Band-Aids, and personal-hygiene products such as toothpaste, dental floss, and toilet paper. (I once saw a billionaire take two Bayer aspirin – the identical pain reliever that I use.) This list includes also gasoline and diesel. Probably also contact lenses.
A slightly different list is one drawn up in response to this question: When can median-income consumers afford products that, while not as high-quality as those versions that are bought by the super-rich, are nevertheless virtually indistinguishable – because they are quite close in quality – to the naked eye from those versions bought by the super-rich? On this list would be most clothing. For example, an ordinary American man can today afford a suit that, while it’s neither tailor-made nor of a fabric as fine as are suits that I suspect are worn by most billionaires, is nevertheless close enough in fit and fabric quality to be indistinguishable by the naked eye from expensive suits worn by billionaires. (I suspect that the same it true for women’s clothing, but I’m less expert on that topic.)
Ditto for shoes, underwear, haircuts, corrective eye-wear, collars for dogs and cats, pet food, household bath towels and ‘linens,’ tableware and cutlery, automobile tires, hand tools, most household furniture, and wristwatches. (You’d have to get physically very close to someone wearing a Patek Philippe – and you’d have to know what a Patek Philippe is – in order to determine that that person’s wristwatch is one that you, an ordinary American, can’t afford. And you could stare at that Patek Philippe for months without detecting any superiority that it might have over your quartz-powered Timex at keeping time.) Coffee. Tea. Beer. Wine. (There is available today a large selection of very good wines at affordable prices. These wines almost never rise to the quality of Chateau Petrus, d’yquem, or the best Montrachets, but the differences are often quite small and barely distinguishable save by true connoisseurs.)
I’ve made this point about the wines before (I’ve tasted each of those wines, but don’t believe the price difference justifies buying them over nearly-as-good equivalents that lack the prestige factor), but Don is talking a much wider range of goods and services where there’s barely any real quality difference between “ordinary” and what the very richest among us can obtain.
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January 16, 2016
Introduction to Price Discrimination
Published on 7 Apr 2015
Price discrimination is common: movie theaters charge seniors less money than they charge young adults. Computer software companies sell to businesses and students at different rates, often offering discounts to students. These price differences reflect variations in the elasticity of demand for these different groups. When demand curves are different, it is more profitable to set different prices in different markets. We’ll also cover arbitrage and take a look at some examples of price discrimination in the airline industry
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December 30, 2015
QotD: Medicine before antibiotics
Explanation was the real business of medicine. What the ill patient and his family wanted most was to know the name of the illness, and then, if possible, what had caused it, and finally, most important of all, how it was likely to turn out
[…]
During the third and fourth years of [medical] school it gradually dawned on us that we didn’t know much that was really useful, that we could do nothing to change the course of the great majority of the diseases we were so busy analyzing, that medicine, for all its façade as a learned profession, was in real life a profoundly ignorant occupation
[…]
Once you were admitted [to hospital] … it became a matter of waiting for the illness to finish itself one way or the other … Medicine made little or no difference.
Lewis Thomas, The Youngest Science, 1983, quoted by John Derbyshire in “The Scariest Science”, Taki’s Magazine, 2014-11-13.
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December 15, 2015
Hillary Clinton’s well-intentioned plans will make the prescription medicine market even worse
Another older post from Megan McArdle on the nice-soundbites-but-terrible-economic-notions from the Hillary Clinton campaign to fix the prescription medicine marketplace:
Hillary Clinton thinks drug development should be riskier, and less profitable. Also, your health insurance premiums should be higher. And there should be fewer drugs available.
This is not, of course, how the Clinton campaign would put it. The official line is that Americans are just paying too darn much for drugs, and she has a plan to stop that:
- Regulate direct-to-consumer advertising more heavily, and strip its tax deductibility
- Require drug companies to spend a certain percentage of revenue on research and development, or face penalty payments and the loss of their R&D tax credit (I am inferring that this is what she is talking about, since the actual language of the proposal is long on paeans to the importance of federal research funding and short on details)
- Cap out-of-pocket costs for drugs
- Reduce the exclusivity period for biologic drugs
- Prohibit companies from making side payments to generic manufacturers to keep generic competition off the market
- Allow drug reimportation
- Require that new treatments be proved to be a substantial improvement over existing treatments — i.e., eliminate the dreaded “me too” drugs
- Allow Medicare to “negotiate” drug prices
Eliminating the side payments seems eminently sensible. (Yes, yes, you can strip my libertarian card, but market-rigging contracts shouldn’t be enforced.) It also seems reasonable to require some sort of comparative effectiveness research. Other provisions will certainly drive down drug prices, at the risk of also driving down innovation.
Still other provisions, however, are simply bad economics. In what other market do we worry about having a second product available that’s merely just as good as the first? Should we really only have one antidepressant, one statin, one blood pressure medication, and so forth? Might there be variation among patients so that drugs that are statistically about equally effective in large groups are nonetheless individually more or less effective for different people? Might one drug’s side effects be better tolerated by some patients than another’s? Might having two drugs in the category help keep prices down?
Then there is notion that we should force pharmaceutical companies to spend a set percentage of their revenues on R&D. This seems to me to be … what’s the word I am looking for? Ah, I’ve got it: “insane.”
[…]
Economically, large parts of this plan make little sense. Politically, many of these items would be very difficult to pass, not least because the Congressional Budget Office would assess the likely effects and would make it sound much less appealing than it does in a gauzy stump speech. But away from those harsh realities, purely as campaign rhetoric, it probably works very well.
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December 14, 2015
The Monopoly Markup
Published on 18 Mar 2015
Ever wonder why pharmaceuticals are so expensive? In this video, we show how low elasticity of demand results in monopoly markups. This is especially the case with goods that involve the “you can’t take it with you” effect (for example, people with serious medical conditions are relatively insensitive to the price of life-saving drugs) and the “other people’s money” effect (if third parties pay for the medicine, people are less sensitive to price).
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