Tag Archives: Medicine

Why Wash?

By Robin Hanson · March 11, 2010 1:45 pm · Comments (16)

In 2005, Boston-based doctors published the very first clinical trial of alcohol-based hand sanitizers in homes and enrolled about 300 families with young children in day care. For five months, half the families got free hand sanitizer and a “vigorous hand-hygiene” curriculum. But the spread of respiratory infections in homes didn’t budge, a result that “somewhat surprised” the researchers. A Columbia University study also found no reduction in common infections among inner-city families given free antibacterial hand soap, detergent, and cleaning supplies. The same year, University of Michigan epidemiologist Allison Aiello summarized data on hand hygiene for the FDA and pointed out that three out of four studies showed that alcohol-based hand sanitizers didn’t prevent respiratory infections. Then, in 2008, the Boston group repeated the study—this time in elementary schools—and threw in free Clorox disinfecting wipes for classrooms. Again, the rate of respiratory infections remained unchanged, though the rate of gastrointestinal infections, which are less common than respiratory infections, did fall slightly. Finally, last October, a report ordered by the Public Health Agency of Canada concluded that there is no good evidence that vigorous hand hygiene practices prevent flu transmission. …

In hospitals, outside of these clinical trials, just half of doctors and nurses regularly clean their hands before patient care, despite widespread publicity. More worrisome: In hospitals where massive educational efforts have increased hand-washing rates from 40 percent up to 70 percent, there has been no overall reduction in infection rates. Even in highly regulated places like hospitals, the promising benefits of hand-washing remain largely unrealized.

More here; HT Tyler.

Added 12Mar: Yvian lists may pro-washing studies here.

Tagged as:

Hard Facts: Med

By Robin Hanson · March 10, 2010 1:00 am · Comments (6)

Yet more wisdom from Hard Facts:

Bloodletting was used routinely until 1836 when French physician Pierre Louis conducted one of the first clinical trials in medicine.  Louis compared pneumonia patients whom he treated with aggressive bloodletting and those he treated without it.  Louis found that bloodletting was linked to far more deaths. … George Washington, the first president of the United States, … died two days after a doctor treated his sore throat by draining almost five pints of blood.  … A remarkably high percentage of medical decisions still reflect the often-obsolete practices that a doctor learned in medical school, the ingrained traditions of a hospital or region. (p.13) …

What she thought was a straightforward study of how leader and coworker relationships influence errors in eight nursing units. … [She was] flabbergasted when nurse questionnaires showed that the units with the best leadership and best coworker relationships reported making 10 times more errors than the worst. … Better units reported more errors because people felt psychologically safe to do so. …

Nurses whom doctors and administrators saw as most talented unwittingly caused the same mistakes to happen over and over.  These “ideal” nurses quietly adjust to inadequate materials without complaint, silently correct others’ mistakes without confronting error-makers, create the impression that they never fail, and find waits to quietly do the job without questioning flawed practices.  These nurses get sterling evaluations, but their silence and ability disguise and work around problems undermine orgainzational learning.  (pp105,106)

Clearly most med errors are not reported, and docs reward nurses more for covering doc asses than for improving patient outcomes.

Tagged as: ,

Managing Our Cut

By Robin Hanson · March 6, 2010 8:40 pm · Comments (39)

Our income tax system gives each of us a stake in the work of others – the more money others make, the more we each get via taxes.  In principle we could use this fact to justify a great deal of intervention in everyone’s work lives.  For example, one might argue: why should we let folks choose fulfilling but poorly paid jobs like social worker, veterinarian, or forestry agent, if they are capable of becoming an lawyer, doctor, or engineer?  Or why should we let folks work part time to focus on a music or acting hobby, or choose to live anywhere but the city where their skills are worth the most?

To most folks such regulations seem intolerably intrusive.  But when people are asked to justify our common and extensive regulations and subsidies of medicine and education, they often mention exactly this issue – that such interventions make sense because we all have a stake in the work of others via the income taxes those folks pay.  Why the asymmetry?  Why do folks think these arguments make sense regarding medicine and education, but not regarding choice of career or location?

My guess: humans inherited intuitions that the community should have more say in and contribute more to medicine and education.  This is the way our distant ancestors did things in their small nomadic forager bands, and we intuit we should act similarly today.  The stuff about managing our cut of others’ income is just a rationalization.

Tagged as: , ,

Legalize Dud Drugs

By Robin Hanson · February 28, 2010 6:00 am · Comments (17)

According to Engber['s article], Human Growth Hormone (HGH or GH) has little to no performance enhancing-benefits. … I have the benefit of working down the hall from several exercise physiologists.  I forwarded [his] article to my colleague, John McLester. … “Oh yeah, I agree with [Engber]. This isn’t even controversial in exercise physiology. … There is no evidence of [benefit from bigger muscles]. It seems that the muscle that is developed is abnormal and not mature. I’ll point you to some studies (see below). …

With [Major League Baseball]’s adoption of mandatory testing for steroids, many thought that home run rates would drop dramatically. They didn’t, and many felt that the lack of a test for HGH could be part of the explanation. Well, it’s time for the scientists working on such a test to start something else more important.

That is John Bradbury.  He interprets:

The illegality of growth hormone actually promotes its use in sports. … The banning of a drug by anti-doping authorities sends a loud and incorrect signal that it works. … Therefore, I believe that legalizing growth hormone is needed to send the signal that it doesn’t work, largely to undo the widespread common belief that growth hormone does improve performance. … Think of the powerful effect it would have if MLB pulled growth hormone off its banned list. I can’t imagine a more powerful signal of a drug’s lack of potency as a performance enhancer. If we are going to be paternalists, let’s be effective paternalists.

Added 5Mar: See also here, HT Tyler.

Tagged as: , ,

Soothing the Sad Savage

By Robin Hanson · February 24, 2010 11:15 pm · Comments (30)

In the latest New Yorker, Louis Menand reviews reasons to be skeptical of psychiatric drugs, including this stuff I teach in my health econ class:

Fifteen years ago, [Irving Kirsch] began conducting meta-analyses of antidepressant drug trials. … Kirsch’s conclusion is that antidepressants are just fancy placebos. … Drug trials are double-blind: neither the patients (paid volunteers) nor the doctors (also paid) are told which group is getting the drug and which is getting the placebo. But antidepressants have side effects, and sugar pills don’t. Commonly, side effects of antidepressants are tolerable things like nausea, restlessness, dry mouth, and so on. … This means that a patient who experiences minor side effects can conclude that he is taking the drug, and start to feel better.

But after 6000 words of such skepticism, Menand still concludes: take the meds.  Why?  Because impressive authors have written eloquent testimonials:

The recommendation from people who have written about their own depression is, overwhelmingly, Take the meds! It’s the position of Andrew Solomon, in “The Noonday Demon” (2001), a wise and humane book. It’s the position of many of the contributors to “Unholy Ghost” (2001) and “Poets on Prozac” (2008), anthologies of essays by writers about depression. The ones who took medication say that they write much better than they did when they were depressed. William Styron, in his widely read memoir “Darkness Visible” (1990), says that his experience in talk therapy was a damaging waste of time, and that he wishes he had gone straight to the hospital when his depression became severe.

The only reason Menand can imagine resisting such artists is a perverse religious desire to suffer:

What if there were a pill that relieved you of the physical pain of bereavement—sleeplessness, weeping, loss of appetite—without diluting your love for or memory of the dead? Assuming that bereavement “naturally” remits after six months, would you take a pill today that will allow you to feel the way you will be feeling six months from now anyway? Probably most people would say no. … Gerald Klerman once called “pharmacological Calvinism” … the view, which he thought many Americans hold, that shortcuts to happiness are sinful, that happiness is not worth anything unless you have worked for it.

Numbers schmumbers – only uncivilized animals, or religious nuts, would not let eloquent authors soothe their savage doubts, until they accept being comforted by their culture’s conventional ways to show that folks care.

Tagged as: ,

What Med Theory Matt?

By Robin Hanson · February 15, 2010 2:30 pm · Comments (19)

Matt Yglesias:

A few points on the insurance status and mortality debate:

— Normally we require overwhelming empirical data to overturn a principle that has strong theoretical support.

— The empirical data to support the “insurance status doesn’t impact mortality” conclusion is not overwhelming. [Matt lists contrary studies] …

— I don’t believe that the people touting these studies really believe them; if widespread beliefs about the desirability of health insurance are totally wrong, this should have dramatic policy implications that should be explored.

Strong theoretical support?!  Here’s what our theories actually say: Continue Reading "What Med Theory Matt?" »

Tagged as:

Megan on Med

By Robin Hanson · February 12, 2010 2:10 pm · Comments (27)

How Many People Die From Lack of Health Insurance? … The most recent available study, which also had the largest sample and controlled for the most variables, found no effect at all. … The left is predictably fond of the study which got the largest number [dead], 45,000 a year.  Unfortunately, its authors are political advocates for a single-payer system, who also helped author the notorious studies on medical bankruptcies.  Those studies are very shoddily done. … The right, meanwhile, shuns the subject like the plague.  It will not do anyone’s career any good to be attached to an argument that sounds like the health care equivalent of “let them eat cake”.

That is Megan at her blog.  More from her in the Atlantic:

Ezra Klein declared that Senator Joseph Lieberman, by refusing to vote for a bill with a public option, was apparently “willing to cause the deaths of hundreds of thousands” of uninsured people. … In the ensuing blogstorm, … few people addressed the question that mattered most: …  If we lost our insurance, would this gargantuan new entitlement really be the only thing standing between us and an early grave?  Perhaps few people were asking, because the question sounds so stupid. Health insurance buys you health care. Health care is supposed to save your life. So if you don’t have someone buying you health care well, you can complete the syllogism. …

The possibility that no one risks death by going without health insurance may be startling, but some research supports it. Richard Kronick of the University of California at San Diego’s Department of Family and Preventive Medicine, an adviser to the Clinton administration, recently published the results of what may be the largest and most comprehensive analysis yet done of the effect of insurance on mortality. He used a sample of more than 600,000, and controlled not only for the standard factors, but for how long the subjects went without insurance, whether their disease was particularly amenable to early intervention, and even whether they lived in a mobile home. In test after test, he found no significantly elevated risk of death among the uninsured. … Continue Reading "Megan on Med" »

Tagged as: ,

Africa HIV: Perverts or Bad Med?

By Robin Hanson · February 11, 2010 12:15 am · Comments (28)

Why is AIDS so much more common in Africa than elsewhere?  The standard theory is, essentially: Africans are sex perverts.  Details have varied over the years: too much prostitution or polygamy or anal sex, too many partners, not enough condoms or circumcision, or girls starting too young.  Most of these theories haven’t found much support, or (like circumcision) are too weak to explain African excess.  (For example, polygamy reduces risk.)

The currently popular version is that Africans have too many concurrent (at the same time) long-term partners.  There is some evidence that this happens in African more than elsewhere, and there are theoretical reasons to expect it to speed sex epidemics.  But a December review says the case is far from closed.  From Lancet in October:

A four-city African study actually found lower rates of concurrency in places with larger HIV epidemics, and a study using nationally representative surveys in 22 countries (all but one of which was in Africa) concluded that ‘‘the prevalence of concurrency does not seem correlated with HIV prevalence at the community level or at the country level, neither among women nor among men.’’ Additionally, Wellings and colleagues reviewed global sexual behaviour and could not find sufficient data to assess whether rates of concurrency differ across the world.

The main reply is:

[Critics] offer no credible alternative explanation … It is simply not plausible that serial monogamy by itself could generate the explosive generalised epidemics.

But Karl Smith and David Friedman suggest bad med instead:

Much of the transmission may be due to sloppy medical procedures, in particular the reuse of needles for injections.

In fact, there is a whole journal devoted to this thesis:

Seven years ago the International Journal of STD & AIDS (IJSA) began actively encouraging reexamination of the prevailing view that penile–vaginal sex was driving African HIV epidemics, … Although the IJSA-published dissenting views have largely been ignored, dismissed or fiercely resisted by established HIV researchers and allied health agencies.

A 2007 Annals of Epidemiology paper found:

In regression analyses, nonuse of disable syringes is associated robustly with greater HIV prevalence in all models. … Greater HIV prevalence also is associated with higher Gini Index, less female economic activity, less urbanization, and less percentage of Muslims.

World-wide, resusable needles are the second biggest binary predictor of HIV (after Sub-Saharan African location and before gender-literacy ratio): Continue Reading "Africa HIV: Perverts or Bad Med?" »

Tagged as: ,

Hide Death?

By Robin Hanson · January 31, 2010 6:30 pm · Comments (23)

Kübler-Ross took a job as an assistant professor of psychiatry at the University of Chicago. … She began a series of seminars, interviewing patients about what it felt like to die. … Many of Kübler-Ross’s peers at the hospital felt that the seminars were exploitative and cruel, ghoulishly forcing patients to contemplate their own deaths. At the time, doctors believed that people didn’t want or need to know how ill they were. They couched the truth in euphemisms, or told the bad news only to the family. Kübler-Ross saw this indirection as a form of cowardice that ran counter to the basic humanity a doctor owed his patients. ….

Kübler-Ross began to work on a book … It came out in 1969, and, shortly afterward, Life published an article about one of her seminars. … Angered by the article and its focus on death, the hospital administrators did not renew her contract. But it didn’t matter. Her book, “On Death and Dying,” became a best-seller. …

Her argument was that patients often knew that they were dying, and preferred to have others acknowledge their situation: “The patient is in the process of losing everything and everybody he loves. If he is allowed to express his sorrow he will find a final acceptance much easier.” And she posited that the dying underwent five stages: denial, anger, bargaining, depression, and acceptance. … Today, Kübler-Ross’s theory is taken as the definitive account of how we grieve.

More here.  Pause to see things from those old docs’ point of view.  While we usually prefer to be honest and forthcoming, we make exceptions.  Some of our reasons are selfish, but we also say that telling people some truths only makes them feel bad, without actually helping much to make decisions.

So isn’t imminent death a great examples of a truth that makes folks feel very bad without much helping decisions?  Look how fiercely people avoid thinking about death when it is only a slight possibility, and how more anxious they get as death becomes a larger possibility.

Sure, most folks say they want to be told the truth about imminent death.  But most folks also say they want to know if their partner is cheating, if their career is tanking, if their neighbors hate them, etc.  If you asked folks straight out, most would even say they want the truth on “do I look fat in this.” So if you are going to hide some type of truth from people for their own good, you must do so in the face of the fact that most folks say they want to be told.

Yes, we may like the closure of taking their time in saying goodbye to folks, but don’t similar modestly useful actions correspond to most truths we think of hiding from folks?  Does this gain so obviously outweigh the terror of knowing you will die soon?  I want to be told about my death, but I’m weird and want the truth on most everything.  What is a better example than imminent death of a truth we’d consider hiding from folks?

Tagged as: ,

Prefer Fem Babes?

By Robin Hanson · January 27, 2010 1:00 pm · Comments (32)

People often talk as if they are extremely concerned about health, and would give up a great deal of everything else to get just a bit more health.  “When you’ve got your health, you’ve got just about everything.” This sort of justification is often offered for spending vast sums on apparently ineffective end-of-life medicine.

So I think it important to ponder our strong disinterest in big ways we could improve health.  For example, women very consistently live longer than men.  In the US, Australia, Japan, Spain, etc. they live 4-7 years longer; studies that control for many other factors typically find males dying about twice as often.

Yet we see almost no interest in preferring female children on the basis that they will live longer.  We see parents prefer to gender balance their kids, and in some cultures parents prefer males.  Do parents not care how long their kids live, do they think male lives are worth more per year, to compensate for fewer years, or what?

See also Bryan on gender imbalances less harmful than supposed.

Tagged as: ,