Healthcare

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.

This week’s picture is quite an old one, of the sculpture outside the then-new Bristol Children’s Hospital which is directly adjacent to the Bristol Royal Infirmary, where I spent a good past of the last week following an acute gallstone attack (with associated pancreatitis) last weekend. On the Thursday I had my gall bladder removed (which turned out to be slightly more complicated than anticipated) and by Friday I was home. I’m now resting and recuperating, but basically feeling fine. Some reflections on the experience below the fold.
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I realize our blog was curiously silent when we were all thinking, “gay marriage–in your FACE bitches!” And, “isn’t it a good thing that not quite enough Supreme Court justices were swayed by a ludicrously weak argument first tendered in the spirit of ‘0bummercare’ on IIRC the Volokh Conspiracy; at the same time, wasn’t that scary? Still, in your FACES hypocritical Jesuitical bastards!” And, “oh Lord why in the church why? How did he steel himself to it after they welcomed him and he did bible study for an hour. An hour! What kind of mordant acid of racism could etch a stain so black on the filth-splattered escutcheon of Dixie?” And, “I love the president of the United States of America. I am crying watching YouTube. There is snot on my face.” And, “holy shit, people are giving a crap about the confederate flag?! Are you serious? No, really, what?” I’ll be honest as a girl born in Savannah “home of the official platinum-level flag of bigotry” GA; a girl whose step-father was Edmund Kirby-Smith (the fourth and only)—this last one has me reeling. Also, has me realizing that I wasn’t cool in the 90s when I used a metal Dukes of Hazzard lunchbox as a purse for like 3 years. I was a dick. Well, truth be told I was going to post about the evil of Tom Bombadil, but then I felt like I needed to explain myself, so I’ll just wait a short while (and don’t you steal my thunder!).

The thing was, we flew to my in-laws in Eugene, OR (via HK and SF) and then I found out I had to do something in Indonesia so I flew back another 24 hours maybe six days later, to Singapore and then Bali, and now I’ma sort this out, fly back to Singapore, fly HK to SF to Eugene, and then the next day fly from Eugene to SF to Newark New Jersey to Savannah, and then 6 days later to Dulles, then National, then Martha’s Vineyard? No, I must have to fly to Boston. Whyyywwyyyy? OK, some people have real problems that don’t involve them flying around the world to beautiful places, so I’ll stop moping and let’s join in a carefully composed round of huzzahs and somber reflection and sore winner uncharitable triumph, shall we? In short, America: F@#k Yeah.

MIGRAINES ARE THE WORST. Well, no, I mean, obviously having your children be sick and not having money for the doctor is the worst.* Our domestic helper here in Singapore is prone to really bad migraines and yesterday she was totally felled, lying down in the dark and vomiting so much I had a hard time bringing her water–since you can’t drink water just after you’ve thrown up. We have O.R.S. but she hates them, and she was so miserable I didn’t want to force them down her. It is so hard to make her rest when she’s ill that if she ever listens or lies down of her own accord we know she is feeling truly awful. John half-hoped some common unknown environmental factor was the culprit and that she and I would both get better when we moved out of our old, colonial-era house. Sadly, no. I have also been having terrible migraines for the last 18 consecutive days, and unfortunately they are remodeling in the flat upstairs. This has been a source of unhappiness. THEY HAVE BEEN DRILLING.

I have also cut my pain pills down slowly over the last six months, which was clever and virtuous of me, but now I don’t have enough pain medicine and I’m like “I forgot quite entirely how horrible this was! Pain! It’s your body’s way of saying, ‘hey something is probably sort of broken or something.'” Also topamax, medicine which I take for migraines, and which I am taking more of, makes you stupid. It’s called “dope-a-max” for a reason. The combination of all these factors has made it difficult for me to learn my Japanese characters (kanji), I’ll tell you what. This is some Harrison Bergeron shit on the 24th floor. I got all 15 right on the practice quiz Zoë made for me and then I blanked on a full five when I took the real quiz half-an-hour later on Sunday evening. Years of caring about academics make it very painful for me to do badly on quizzes. Really, it is like a knife in the guts. If she would just give us a list of the English meanings it would be OK. But our tutor gives us an actual sentence with any other, as-yet-unknown-to-us kanji spelled out (in Japanese they can write the pronunciation in hiragana or katakana on top of them, small and light; they would do this for very rare words, I think, in an adults’ book, and they do for commoner ones in a book for children or learners), and then the hiragana or katakana for the kanji we are meant to have learned underlined, and we have to write the kanji below that. So we need to read the sentence correctly as well as remember that, for example, ‘ka’ can mean ‘borrow’ as well as like five other things (I say this, and we have learned only about 50 kanji so far.) Violet continues to enjoy mocking me (in the most friendly, cheerful way imaginable!) about my troubles, criticizing my disinclination to use the large full squares in my notebook (I have small, very neat handwriting, and the big boxes don’t appeal), and writing Chinese characters in the margins that are similar but a million times harder, just to put things in perspective for me.

Now, a person can listen to music in this situation, but sometimes that’s just like turning the whole thing into a rock concert. It’s better than drilling, though, usually. I don’t like to listen to podcasts, but John does and he listened to one about a year ago that was an interview with Brian Eno. In it, the interviewer was saying how much he loved Here Come The Warm Jets and Eno said that he hadn’t actually listened to it in over twenty years?!? This was flabbergasting and wrong and bad, since we should all be listening to it, be we Brian Eno or no which, on balance, we are unlikely to be. I feel awkward about your experience of this song, because on the LP, the harsh intro of the next song, “Blank Frank” starts really soon after the last note of this–sooner than the start of a hypothetical next measure. I thought of linking to within a youtube clip of the whole album but am not certain it would come off. It’s distinctive and crucial, though, so I recommend you listen to the whole of Here Come The Warm Jets on principle.

This song somewhat resembles the Cure’s “Just Like Heaven” in that the sad, sweet vocals only enter after what seems an unexpectedly-long music-only intro, and that it is shorter than you want it to be, such that you want have to re-play it.
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