Healthcare

If, like me, you follow Ones and Tooze, you will know that Adam recently had heart surgery.

It was a big deal. Luckily, America has some of the best surgeons in the world, to whom only a small handful of Americans have access – but Adam Tooze is one of them. In the episode dedicated to the expensive American healthcare system/Adam’s heart surgery, he talks with great (and deserved) admiration about ‘his team’, the ones who will do the surgery.

We really want these surgeons to be good at what they do. The considerable advances in medicine, medical technologies and surgical techniques is what will (we trust) Save Adam’s life, as indeed they did. We want experts.

But we don’t want them to be dickheads about their expertise – meaning, we’d like them to be ‘our team’ who work with us, acknowledging our agency. And not arrogant, bossy, or taking control of our lives.

See, Adam is not only among America’s privileged (as he acknowledges), but he is also a member of the same professional class as his surgical team. As we all know, this doesn’t guarantee an absence of dickheads.

However, chances are higher that we can see other professionals as members of ‘our team’. By recognizing one another as members of the same class, encountering other members of the PMC helps confirm one’s own values and expertise.

What this also shows is that it is possible to be a niche expert but honour other people’s self-determination, our ability to make choices about our own lives.

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(Hi all, wonderful to become part of this great blog! But now, directly on to some content!)

Imagine that you have a toothache, and a visit at the dentist reveals that a major operation is needed. You phone your health insurance. You listen to the voice of the chatbot, press the buttons to go through the menu. And then you hear: “We have evaluated your profile based on the data you have agreed to share with us. Your dental health behavior scores 6 out of 10. The suggested treatment plan therefore requires a co-payment of [insert some large sum of money here].”

This may sound like science fiction. But many other insurances, e.g. car insurances, already build on automated data being shared with them. If they were allowed, health insurers would certainly like to access our data as well – not only those from smart toothbrushes, but also credit card data, behavioral data (e.g. from step counting apps), or genetic data. If they were allowed to use them, they could move towards segmented insurance plans for specific target groups. As two commentators, on whose research I come back below, recently wrote about health insurance: “Today, public plans and nondiscrimination clauses, not lack of information, are what stands between integration and segmentation.”

If, like me, you’re interested in the relation between knowledge and institutional design, insurance is a fascinating topic. The basic idea of insurance is centuries old – here is a brief summary (skip a few paragraphs if you know this stuff). Because we cannot know what might happen to us in the future, but we can know that on an aggregate level, things will happen to people, it can make sense to enter an insurance contract, creating a pool that a group jointly contributes to. Those for whom the risks in question materialize get support from the pool. Those for whom it does not materialize may go through life without receiving any money, but they still know that they could get support if something happened to them. As such, insurance combines solidarity within a group with individual pre-caution.

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In any society, certain needs have to be catered for, either socially or privately. At a minumum, those unable to work, because they are too young, too old, or too sick have to be cared for. Of course, they can be cared for in ways that are better or worse for them, but caring there must be, and that is going to take someone’s time, labour, and money.

I’ve been thinking about these rather obvious facts over the past few days partly because a report came out showing how many people – mainly women – are being driven out of the the UK workforce by the need to care for relatives, given that the social care system is broken. At present, there are also a lot of people out of the UK labour market either because they can’t work due to COVID and its after-effects, or because the underfunded National Health Service has been shattered by the pandemic and they can’t get the treatment they need in a timely fashion for other health problems they have. If left languishing, the skills these people have will atrophy. Many of them will never work again.

At the same time, our soon-to-be-former Prime Minister has been pushing her “pro-growth” agenda, which largely consisted of tax cuts, and her now-former Home Secretary mocked the anti-growth coalition of “Guardian-reading, tofu-eating, wokerati”, of which I am proud to consider myself a member.

Their central assumption is that growth is best served by a low-tax economy and that public spending needs radical reduction, with the fat-cutting exercise of the last twelve years now to be extended to the bones. Well, I hope readers can see the problem. You don’t get growth by pursuing policies that effectively force people to give up productive work either through their own sickness, or in order to care for other people. If these needs are not met socially, they will be met privately, and, again, because it bears repeating, in ways that are disproportionately damaging to women.
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I’m in the UK now, having spent the last (lovely) six weeks in France, an EU member-state with a much more functional government than we have. When we left for France in mid-June, it was on the UK government’s “amber list” and had just started admitting visitors from the UK with proof of full vaccination and a negative COVID test. To get such a test in the UK we had to pay £80 to a private provider. We also had to pay for additional travel insurance to travel to a country that the UK’s Foreign and Commonwealth Office advises against travel to, the advice having rendered our existing travel insurance inapplicable. All went swimmingly on the journey out apart from a 30-second hiccup when a French border guard thought a different set of rules applied to us, requiring urgent reasons for travel, but a colleague set him right.

Our plan had been to stay in France until the UK government moved it to an easier category not requiring quarantine. But the opposite happened. Ostensibly because of a surge in the Beta variant in France, the UK moved the country to an enhanced “amber plus” category, requiring 10 day quarantine even for the fully vaccinated. This measure against France was quite inexplicable, since there were other European countries with higher incidences of Beta, and becauce the French cases were actually overwhelmingly on French islands in the Indian Ocean. Perhaps there were other, more political, reasons behind the change, or perhaps the British government is bad at geography but couldn’t lose face by backing down once the error had been pointed out? Who knows? Rumour has it that France will be taken out of “amber plus” this week, and that the fully-vaccinated will be allowed quarantine-free admission to the UK from France this week, as visitors from the US and most of the EU are. That’s no good to us. (And note this is at a moment when nearly all internal restrictions have been lifted in the UK.)
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This Paul Krugman column helped crystallize the weirdness of the ongoing economists versus epidemiologists spat, perhaps more accurately described as the ‘some economists, especially those with libertarian politics, versus epidemiologists spat.’ Different theories, in turn below the fold.
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From a new article in Stat.

In a four-day blitz at the end of April, they swabbed and drew blood from 4,160 adults and children, including more than half of the residents in the 16 square blocks that make up San Francisco Census Tract 229.01. In the heart of the Mission District, it is one of the city’s most densely populated and heavily Latinx neighborhoods. While Havlir expected to see the Latinx community hit hard by the virus, the actual numbers came as a shock. About 2% of people tested positive for the coronavirus. Nearly all of them — 95% — were Latinx. The other 5% were Asian or Pacific Islander. Not a single white person tested positive, though 34% of the tract’s residents are white, according to the U.S. Census; 58% are Hispanic.

… One of Havlir’s motivations for the testing was to understand how the virus was being transmitted even after the city had been locked down for six weeks. Questionnaires administered with the tests gave her an answer: 90% of those who tested positive could not work from home. Most were low-income, and most lived in households with three or more people.

“What really comes out of these data is that low-wage essential workers are victims of this disease,” Havlir said. Many of those infected were working in food service, making deliveries, or cleaning offices despite shutdown orders. “These people were out working the entire time,” she said.

“Anecdotally, we knew this, but the hard data is heartbreaking,” said Susana Rojas, executive director of the Calle 24 Latino Cultural District and a leader of the Latino Task Force for Covid-19 that partnered with UCSF to run the study. “Our community was out working, keeping the city moving and fed. Of course they were more exposed and getting sick.”

Among the many consequences of the Covid-19 pandemic, and the measures taken to control it, there has been an epidemic of whataboutery. The starting point is the claim “we have locked down the entire economy to reduce the number of deaths from Covid-19, but we tolerate comparably large numbers of deaths from X”. Popular candidates for X include smoking, road crashes and influenza. In most, though not all, cases, the inference is that we should accept more deaths from the pandemic. Indeed, the majority of those using this argument are also opposed to any proposal to do more about the various examples of X they cite

I’m going to take the contrapositive, and argue that the inconsistency pointed out here should be resolved by taking stronger action to reduce avoidable deaths from a wide range of causes, with the primary examples being road deaths and smoking.

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The news of deaths from bird flu in Indonesia is pretty scary. Although, as I’ve mentioned recently Indonesia has made a lot of progress in many respects, the handling of this threat so far seems to show the worst of both worlds: all the ill ffects of authoritian habits combined with the timidity of weak politicians. There have been a lot of coverups, and an unwillingness to tackle the necessary but unpopular task of slaughtering affected flocks of birds. Things seem to be improving now, but there’s a long way to go.

It seems very likely that, sooner or later, bird flu will make the jump that permits human-human transmission, and quite likely that a major flu pandemic will result. The world, including Australia, is very poorly prepared for this. One thing we could do to prepare is to adopt a national program encouraging annual flu vaccinations for everyone, instead of just for limited categories of vulnerable people.

The main benefit of this is not that the shots would provide immunity against a new and deadlier flu variant (though there might be some limited benefit of this kind) but that we would have the infrastructure, production facilities and so on to undertake a mass vaccination against such a variant if it arose. As it is, it seems likely that many countries will be scrambling to get access to an inadequate world supply of vaccines, but if Australia and other developed countries ramped up normal levels of production, it would be much easier to generate extra supplies for our neighbours.

I haven’t looked into it, but my guess is that, even without considering the possibility of a pandemic, the benefit-cost ratio from such a measure would be pretty high. Flu is very costly in economic terms, and I suspect that, if pain and suffering were thrown into the balance, a program of universal free vaccination would come out looking pretty good.

Notes  I wrote this in 2005 thinking about new flu strains. The only difference I see with “novel” viruses is that the time taken to produce the initial batches of a vaccine is likely to be longer. As is usual with my policy advocacy, little if anything has been done along the lines I suggested.

I’ve recently been in Germany which, to a greater extent than many other countries (such as my own), is a functioning and prosperous liberal democracy. It wasn’t always thus, as every participant in internet debate know very well. By the end of the Second World War, Germany had suffered the destruction of its cities and infrastructure, the loss of a large amount of its territory, and the death or maiming of a good part of its population and particularly of the young and active ones. Yet, though not without some external assistance, it was able to recover and outstrip its former adversaries within a very few decades.

Thinking about this made me reflect a little on whether people, in the sense of talented individuals, matter all that much. That they do is presupposed by the recruitment policies of firms and other institutions and by immigration policies that aim to recruit the “best and brightest”. Societies are lectured on how important it is not to miss out in the competition for “global talent”. Yet the experience of societies that have experienced great losses through war and other catastrophes suggests that provided the institutions and structures are right, when the “talented” are lost they will be quickly replaced by others who step into their shoes and do a much better job that might have previously been expected of those individuals.

I imagine some empirical and comparative work has been done by someone on all this, but it seems to me that getting the right people is much less important that having the institutions that will get the best out of whatever people happen to be around. I suppose a caveat is necessary: some jobs need people with particular training (doctoring or nursing, for example) and if we shoot all the doctors there won’t yet be people ready to take up the opportunities created by their vacancy. But given time, the talent of particular individuals may not be all that important to how well societies or companies do. Perhaps we don’t need to pay so much, then, to retain or attract the “talented”: there’s always someone else.

Early last year, I began to experience some pains in my hands. I associated them with bringing a large turkey back from the butchers. Hadn’t taken the car, because parking, but it was heavier than I appreciated and I struggled with the bird as the handles of the plastic bad tore on my fingers. I went to the doctor. Tendons, probably, he said. Most likely be better in a few months.

Then in September, back from a touring holiday in France which had involved a lot of lugging of boxes and cases up and down stairs, the pain was back, worse. I lacked the strength to open cans and bottles. Some movements were fine but turning a knob or using a key sometimes — ouch!
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I got a preview of Drug Wars by
Robin Feldman and Evan Frondorf. It’s not about the War on Drugs, but about the devices used by Big Pharma to maintain the profits they earn from their intellectual property (ownership of drug patents, brand names and so on) and to stave off competition from generics. Feldman and Frondorf propose a number of reforms to the operation of the patenting system to enhance the role of generics. I’m more interested in a fundamental shift away from using intellectual property (patents and brand names) to finance pharmaceutical research.
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So I think we’re all breathing a little easier now that the truly astonishingly terrible AHCA (aka TRUMPCARE) has gone down in flames. Paul Ryan has made hundreds enemies and no friends, having managed to come up with a bill hated by both the I-might-get-voted-out-most and hating-poor-people-most wings of his party and then fail. Certainly Trump is upset insofar as it makes him look like a HUGE LOSER, and is lashing out at everyone and everything. He’s probably tweeting at this very moment about how the bill’s failure to pass can be laid at the feet of an elephant-shaped paperweight on his desk. When he threw it at a scarecrow Bannon hastily constructed for him out of pillows and inside-out Breitbart T-shirts that has “Freedom Cacus” scrawled on it in gold sharpie, the paperweight fell against the hearth and shattered, not in the fashion of the GENUINE COSTLY JADE McConnell assured him it was but like CHEAP SOAPSTONE. Some welcome and good luck present from the Republican Establishment that turned out to be. SAD! But is anyone else particularly broken up about it? Trump-organ Breitbart (not linking tho) itself has drawn the knives out for that spineless cuck Ryan (and Trump appears to be heading in this direction.) However I don’t see a lot of wailing or gnashing of teeth in any actual “our precious bill didn’t pass” way. John and I have made our sickly rounds of right-wing sites, and, as John noted even in his current feverish state, no one seems particularly upset about the failure (like, he has an actual fever; our reading of right-wing sites merely emblematizes a spiritual sickness). Some are saying “great; it wasn’t conservative enough.” No one seems to be coming out and saying “it broke all Trump’s campaign promises and would have made a bunch of the voters that pushed him to the presidency way worse off, and immediately, so they would notice by 2018, and we’d be screwed, so, dodged a bullet there,” although they have to be thinking it. What say ye, Plain People of Crooked Timber? Are there any conservatives who are rueful about the failure of their awesome bill, which was great on the merits?

Being in a multi-bed room overnight, or being in the OR, or even sometimes when the chemotherapy room is crowded over-full and they are putting people in cheap plastic chairs before hooking them up to clear bags of poison–this is the worst. And the worst thing about being in the hospital overnight is that you can’t sleep. I understand intellectually that your doctors need to know what your blood pressure is. I mean, sort of. What if you don’t have any heart problems? Why always with the blood pressure? But between your IV bag running out and beeping and the irrational fear that air bubbles will get inside you and kill you, and the checking of the temperature and blood pressure every four hours, and the breakfast you actively don’t want being slammed down at 6:30, and the cleaning staff, well, you don’t sleep. No knitting up the raveled sleeve of care for you! And this is true even in a private room! This article in the NYT explores a very obvious point, namely that multi-bed wards are a terrible idea all the time. I felt vindicated to read that the decrease in hospital-borne infections outweighs the cost of constructing a hospital with individual rooms.

As a doctor, I’m struck daily by how much better hospitals could be designed. Hospitals are among the most expensive facilities to build, with complex infrastructures, technologies, regulations and safety codes. But evidence suggests we’ve been building them all wrong — and that the deficiencies aren’t simply unaesthetic or inconvenient. All those design flaws may be killing us.

It’s no secret that hospital-acquired infections are an enormous contributor to illness and death, affecting up to 30 percent of intensive care unit patients. But housing patients together very likely exacerbates the problem. Research suggests that private rooms can reduce the risk of both airborne infections and those transmitted by touching contaminated surfaces. One study reported that transitioning from shared to private rooms decreased bacterial infections by half and reduced how long patients were hospitalized by 10 percent. Other work suggests that the increased cost of single-occupancy rooms is more than offset by the money saved because of fewer infections. Installing easier-to-clean surfaces, well-positioned sinks and high-quality air filters can further reduce infection rates.

The whole thing is worth a read. Perhaps unsurprisingly, having a window out of which you can look at trees or nature has a huge impact on recovery time. I personally have always wanted to get the Magic Mountain treatment in which I am bundled in specially folded blankets and put out on a lounger to enjoy a view of the Alps.

The author doesn’t discuss bad fluorescents, though the commenters do. New compact bulbs can mimic the warmer light of incandesents reasonably well now, and that is another terrible hospital thing that could be fixed. I feel I should note two things here. One, the staff at hospitals is almost uniformly composed of kind helpful people who are working very hard. Nurses are great. The sub-nurses who are supposed to be just emptying bedpans or whatever are delightful. But let’s be honest: the actual doctors are the least friendly. Sorry actual doctors. I know you are busy. (But so are the ladies emptying the bedpans, probably?) Two, I am not in the hospital or accompanying anyone to same at the moment and this is just a general complaint so don’t worry about me; more importantly my migraine treatment worked. Since I made it to the first week (at which the Botox takes full effect) I have used my migraine meds only once. John was disappointed that I can have a headache at all but he doesn’t know that not having a real migraine every day after having had that happen for months oh God is a fairy wonderland (I don’t know why I’m not being more sparkly and cheerful all the time; I’m sorry, beloved family. I have terrible jet lag still). I asked my neurologist if there were any side effects and he said, “you’ll be running back here every twelve weeks begging me to do it again, but other than that, no.” OMG Dr. Fineman you are right. Thanks for the Tinkerbell-clapping, everyone! Now tell me of your experiences with flimsy curtains separating you from people with dementia shouting all night. The airing of grievances can be therapeutic; anyway it’s better than reading articles about politics amirite?

The Guardian today [publishes a vast number of leaked reports from Nauru](https://www.theguardian.com/australia-news/2016/aug/10/the-nauru-files-2000-leaked-reports-reveal-scale-of-abuse-of-children-in-australian-offshore-detention), one of Australia’s offshore processing sites for asylum-seekers (in reality, a camp for the indefinite detention of asylum-seekers). The reports, or “unconfirmed allegations” as the Australian government would have it, are a harrowing catalogue of physical and sexual abuse, and of consequences for mental and bodily well-being, often suffered by children. These places exist to appease an Australian citizenry hostile to the arrival of “boat people” who believe that such people — even those determined to be refugees by Convention criteria — are not their problem. Though Nauru is a particularly vile example, it would be wrong to think that Australians are alone in their attitudes to refugees and asylum seekers. Other Western governments are happy to do deals with other states beyond their borders to ensure that the wretched of the earth are out of sight, where they can exist as an abstraction, not disturbing the conscience of their own citizens. Human rights, together with other liberal principles like the rule of law, have become, for many liberal democratic states, the exclusive right of the native-born citizen or, at best, someone else’s problem, somewhere else.

I’d be interested to learn from people in Australia now, how much traction this latest leak is getting in the Australian media. A surf to the websites of the Australian and the Sydney Morning Herald suggests not much.