Any maiden aunts who read CT possibly ought to skip this post, as it contains, in the interests of plain speaking on an issue where squeamishness might cost lives, one use of the “v-word“. I’m back on an old pedantic hobby-horse; the epidemiology of MRSA and the British political culture’s dangerous and annoying refusal to understand it properly. But this time, I have an actual policy suggestion.
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From the category archives:
Healthcare
Watching from the UK, the Terri Schiavo case makes the US look like a very weird and deeply troubled polity. All those homely and patronising sermons about “government of laws not of men &c”, and then the US Congress passes a law to deal with a particular case and to subvert a prior decision of the judiciary, just so that Republicans can grandstand to their Christian fundamentalist base (see Obsidian Wings for the best commentary so far ). And all this signed into law by a President who, when governor of Texas, approved a measure to switch off life support where people didn't have the money to pay any more . I note, by the way, that the so-called “right-to-life” brigade have been pretty free with their use of Nazi analogies on this one. Since any Nazi-comparison (however casual) involving George W. Bush, Ariel Sharon, Daily Mail journalists or Abu Ghraib elicits instant howls of outrage from the British-based neocon cheerleaders, I expect we’ll be hearing from them shortly. Or not.
Congratulations to the team at King’s College London, who have managed to achieve the first claimed “cure” of Type 1 Diabetes via transplanted islet cells. Just to drive the point home, the technique that they used was originally developed in Canada, so it’s a double win for socialized medical research.
The temptation is almost overpowering to speculate that the reason this particular procedure was developed outside the USA might have something to do with the fact that curing a disease with a single operation doesn’t produce a lifelong dependence on patented pharmaceuticals. But this temptation probably ought to be resisted; it’s only a single case. But well done King’s College, and perhaps this will shame our government into funding London’s hospitals properly.
Bill Gardner notes an uptick in infant mortality in the US, and links to the National Center for Health Statistics report which tries to explain it. As Bill points out, undertsanding a slight rise in the rate is all very interesting, but not to the point when we know what can be done to lower the rate, even if what we know doesn’t address the sudden (and slight) increase. Here are his suggestions:
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Matt Yglesias mentioned a few days ago that he didn’t see anything that was morally wrong with paternalism, with the implication that paternalist policies ought to be evaluated on purely pragmatic grounds. The Washington Post has an interesting test case today for those who might disagree with him. It describes how “aggressive direct-to-consumer advertising campaigns” for Celebrex and Vioxx persuaded consumers to take these drugs, even though they would predictably have been better off if they had taken other non-prescription drugs instead. As the article says, the US is highly unusual in allowing direct-to-consumer marketing of drugs – Western European countries typically only allow these drugs to be marketed to doctors through specialist publications etc.
None of this is to say that the European system is perfect – drug companies pour an awful lot of money into “seminars” in nice places, golf excursions etc where they try to persuade doctors to prescribe their drugs. But there is a strong pragmatic case to be made that doctors are going to be better informed as a rule than their patients over the benefits and drawbacks of particular courses of treatment (otherwise why use them in the first place?). Thus, they’ll be better able, most of the time, to figure out when pharmaceutical companies are trying to con them into prescribing expensive and potentially dangerous medications where off-the-shelf drugs would work as well or better. Of course, this is not to say that consumers shouldn’t be able to get their hands on relevant information (doctors aren’t infallible) – but it’s surely a bit of a stretch to argue that aggressive TV advertising campaigns provide such information. Thus, I’m pretty well convinced of the case for banning direct marketing of drugs to consumers – it’s a relatively mild form of paternalism, which seems to me to have quite substantial payoffs. Any dissenters out there?
Update: via Bill Gardner, I see that James Surowiecki is similarly critical of the marketing of Vioxx:
bq. But companies like Merck, which spend hundreds of millions on ads targeting consumers, have themselves to blame, too. Instead of getting people to think about drugs in terms of costs and benefits, these ads encourage people to think of medicine in the same way they think of other consumer goods. It would be one thing if Merck had marketed Vioxx only to people who really needed it—people who couldn’t take ibuprofen or aspirin safely. Instead, the company marketed it aggressively to everyone, so that some twenty million Americans had Vioxx prescriptions. That’s why the potential damages against Merck are so vast. If juries have a hard time accepting a risk-benefit trade-off when it comes to drugs, it’s in part because the drug companies have convinced them that no such trade-off has to be made.
The latest terrorist bombings in Iraq came closer than usual to home for Australia, with two soldiers suffering (reportedly) minor injuries in an attack on the Australian embassy[1], while 20 more Iraqis were killed, adding to the tens of thousands already killed by both/all sides in this terrible war, which seems to get more brutal and criminal every day.
It’s pretty clear by now that Iraq is approaching full-scale civil war and that, as is usually the case in civil wars, the presence of foreign troops is only making things worse. But rather than arguing about this last point, it might be better to put it to the test. This NYT Op-ed piece by three researchers from the Center for Strategic and International Studies suggests a referendum on US withdrawal to be held soon after the forthcoming elections. They make a pretty good case that it would be hard for the Baathists to justify disrupting such a referendum, though no doubt some would do so anyway. At least, this would be true if the main Shiite parties adhered to their previously stated position of favoring withdrawal.
Following a lead from Bill Gardner (and a tip from Henry) I’ve been reading The Status Syndrome : How Social Standing Affects Our Health and Longevity by Michael Marmot[1]. The core of Marmot’s book, which is fascinating in itself is his empirical work showing that, as you move up any kind of hierarchy (Marmot looked at British civil servants) your health status improves. I’ve done a little bit of work myself relating to the links between health, education and life expectancy at the national level, and Marmot’s micro findings fit very neatly with mine.
What’s even more interesting though (to me and to Bill, I think) is the general idea of autonomy as a source of good health[2]. He debunks, for example, the long-discredited, but still widely-believed notion of executive stress and shows that the more control you have over your work environment and your life in general, the less likely you are to suffer the classic stress-related illnesses, such as heart disease.
It seems to me that autonomy, or something like it, is at the root of many of the concerns commonly seen as part of notions like freedom, security and democratic participation. I’m still struggling with this, but reading Marmot has crystallised some thoughts I’ve had for a long time. I’ve put some thoughts over the page – comments appreciated.
I’ve been looking through the headlines on international AIDS day. The BBC discusses the disproportionate impact on women in Africa . India has 5.1 million people infected with HIV , and nobody really knows how many victims there are in China (CNN). “HIV and Aids are expected to kill 16 million farm workers in Southern Africa by 2010” reports the South African Independent Online . In Britain the Guardian tells us that a fifth of respondents to a poll blame the victims. In Lebanon , only a quarter of victims receive any kind of treatment. In Uganda a government minister warns the UN not to give advice to gays on safe sex because homosexuality is illegal. Please add more links in comments throughout the day.
Regular Crooked Timber readers will remember Bill Gardner, who joined us as a guest blogger immediately before and during the election to describe the scene on the ground in Ohio.
The bug has bitten him, and he’s started a blog called Maternal & Child Health, about the health of children and their parents. Says Bill:
I want to spur discussion on a broad range of topics in this area. The struggle to improve the health of children and families involves the disciplines of medicine, public health, the social and behavior sciences, economics, the information sciences, and the law.
I hope to provide a forum for discussion among both specialists and laypersons about what determines parental and child health, and how we can improve it. I hope to see discussion of how the health system works at every level, from international public health to the interaction of clinicians and families in an office visit. I would love it if any of the Crooked Timber readership would visit and comment.
These sort of blogs, like the Public Health Press, are rare in that they generate a lot more light than heat. I hope that Bill enjoys himself.
Arnold Kling has a new book out, with the title What’s a nice guy like me doing in a flack shop like this? “Learning Economics”. If what you want is an introduction to economics from a somewhat aggressively libertarian perspective, I daresay it will be pretty good; in my experience, Arnold has almost never been intellectually dishonest himself (which further raises the question, why’s he providing window dressing to TCS?).
However, in plugging his book, Arnold repeats a mistake I’ve corrected him on a couple of times, so let battle commence. Specifically, he claims that
“If you think that paying for your own health care is too expensive, I argue that it is mental illness to believe that paying for each other’s health care is affordable.”
I think that this is based on a pretty egregious confusion between a dull statement about health care, about which this statement is trivially true, and health insurance, about which it is probably false. Read on …
I’ve spent the past couple of days at the latest in a series of conferences under the name Priority in Practice , which Jo Wolff has organized at UCL. I don’t think I’d be diminishing the contribution of the other speakers by saying that Michael Marmot was the real star of the show. He’s well known for the idea that status inequality is directly implicated in health outcomes, a thesis that he promotes in his most recent book Status Syndrome and which first came to the fore with his Whitehall Study which showed that more highly promoted civil servants live longer even when we control for matters like lifestyle, smoking etc. Even when people have enough, materially speaking, their position in a status hierarchy still impacts upon their longevity. One interesting other finding that he revealed was that being in control at home (as opposed to at work) was massively important in affecting women’s longevity, but didn’t really impact upon men. There’s an excellent interview of Marmot by Harry Kreisler of Berkeley in which he outlines his central claims.
One interesting recent strand of research on justice and human well-being has been that inspired by Amartya Sen’s “capability” approach. There’s now an association dedicated to this, with Sen as its first President and Martha Nussbaum as President-elect. Details here .
In reading the discussion on my post on pharmaceuticals and the US-Australia Free Trade Agreement, I thought it might be useful to look at the more fundamental question – how should we pay for medical research ? In the framework of neoclassical economics, it’s natural to start by looking at the free-market solution. In the absence of government intervention, firms innovate in the hope of securing above-normal profits by offering a superior product. They discourage imitators using a variety of methods such as branding and trade secrets. While these methods don’t work forever, in some cases they deliver enough profits to finance a satisfactory rate of innovation. But, as far as I know, no-one seriously suggests this is the case in relation to medical research. To finance adequate levels of medical research, we need some form of government intervention. There are three main options
* Patents
* Research grants
* Research rewards
Of these options, patents involve the most intrusive government intervention and the largest welfare costs.
Most of my blogging time this week has been devoted to criticism of the Free Trade Agreement between Australia and the United States. Wait! Don’t stop reading yet!
I know that “Trade agreement said harmful to small faraway country” is the stereotype of a boring newspaper story, but this one is really important to Americans as well as Australians, and to anyone interested in health policy. If you ever hope to see affordable health care in the US, you’d better hope that (against all the odds) this agreement falls at the final hurdle.
Don’t forget to cast your vote in the poll Ross is running over at The Bloviator about what phrase would offer “the best Progressive frame to encapsulate the commitment to remedying America’s myriad problems with health care”. The poll is a result of some lively discussions that occured here on CT while Ross was guest blogging with us earlier this week.