Tag Archives: Medicine

Placebos Show Care

Something similar to the placebo effect occurs in many animals. … Siberian hamsters do little to fight an infection if the lights above their lab cage mimic the short days and long nights of winter. But changing the lighting pattern to give the impression of summer causes them to mount a full immune response.

Likewise, those people who think they are taking a drug but are really receiving a placebo can have a response which is twice that of those who receive no pills. In Siberian hamsters and people, intervention creates a mental cue that kick-starts the immune response. …

The Siberian hamster subconsciously acts on a cue that it is summer because food supplies to sustain an immune response are plentiful at that time of year. We subconsciously respond to treatment – even a sham one – because it comes with assurances that it will weaken the infection, allowing our immune response to succeed rapidly without straining the body’s resources. … Farming and other innovations in the past 10,000 years mean that many people have a stable food supply and can safely mount a full immune response at any time – but our subconscious switch has not yet adapted to this. (more)

OK, but the key question is: why would getting a placebo pill ever have been a credible signal that you could safely turn on your immune system? If for our ancestors treatments like pills tended to be very effective at improving health, you might think that a pill would give you so much extra energy that you could afford to spend some of that extra on your immune system. But pills are rarely that effective, and your body would quickly notice that fact.

My showing that you care theory, that the main function of medicine is to signal concern, fits well here. The idea is that we are reassured by the fact that people take the trouble to take care of us.

The most severe part of our ancestors’ environment wasn’t the weather, it was other humans. When people were sick, they worried that their rivals and enemies would use that opportunity to hurt them. If such harms were coming, they had to be attentive, wary, and ready to act — they couldn’t afford to turn on their immune system, which would make them lethargic.

But if someone had caretakers, who spent time and other resources to take care of them when they were sick, why then such caretakers would probably also protect them from rivals. So they could afford to turn on their immune system. If your associates spend resources to buy you pills, and then take time to make sure you take certain pills at certain times, they probably care enough to protect you from rivals.

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Dirty Air Kills

I’ve long been struck by how consistently different methods find large health harms from air pollution. Most people seem to think we no longer have an air pollution problem, because we mostly don’t see much air pollution. But the particles that are too small to see continue to cause great harm.

The US Federal EPA standard for air pollution in the form of particles of size 2.5 microns or smaller is an annual average of 15, and a 24 hour average of 35, micrograms per cubic centimeter. Many places are not in compliance with these standards (check your area here and here).

A 2009 paper in the New England Journal of Medicine estimated that decreasing this pollution number by 10 units on average increases lifespan by 0.61±0.20 years. A 2006 paper in the American Journal of Respiratory and Critical Care Medicine estimated that such a change would decrease mortality by about 15%, adding about two years of lifespan. (Quotes below.)

These are huge gains, which could be achieved at a modest expense, especially compared to the vast costs we pay for tiny health gains via medicine. More should be done.

Those promised quotes: Continue reading "Dirty Air Kills" »

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Brain Prize Eval Fund Near Enough

Great news: The cryonics organization Alcor is adding $10,000 to the Brain Preservation Technology Prize Evaluation Fund. With the other donations counted here (including my $5000), that should bring the prize evaluation fund to near $30,000, which might be near enough (so please donate more):

We [Alcor] are committing $10,000 towards the Evaluation Fund. … Although the Prize itself is fully funded, funds are needed to conduct the evaluation. Alcor’s contribution will make a big difference, since the tests are estimated to cost $25,000 to $50,000.

Alcor does not directly have a horse in this race. The cryopreservation approach is represented by a team from 21st Century Medicine. 21CM aims to demonstrate the quality of ultrastructure preservation that their low temperature vitrification technique can achieve when applied to whole rabbit brains.

We will follow up this announcement of Alcor’s contribution with a longer piece. That article will address claims (currently untested) for the advantages of chemopreservation over cryopreservation. We will critically examine the claim that chemopreservation or plastic embedding would be much cheaper (for individuals not committed to whole body preservation), look at some reasons to expect significant damage caused by chemopreservation of whole brains, identify problems for chemopreservation under less-than-ideal circumstances, explain why the Prize handicaps the cryopreservation option because of the way the test is to be carried out, and will argue why brain preservation technologies should be evaluated by viability criteria as well. (more)

While I look forward to reading their critique, I’ll note no one has accepted my bet offer:

I offer to bet up to $5K that plastination is more likely to win this full prize than cryonics. (more)

My thinking has evolved a bit over the last month. In chemopreservation [= plastination], one fills a brain with plastic-like chemicals, which make strong cross-links bonds between most everything they touch. So there are two times when brain info can be lost: before it is filled with plastic, and after.

Assuming you can keep them safe from melting, burning, etc., plastic brains should last for a very long time:

Brain researchers have looked at samples preserved many decades ago, and see almost no change. Tissues preserved in amber seem to have remain unchanged for forty million years. (more)

So the main issue is how much info is lost before filling with plastic. Now it is obvious that non-fresh brains with collapsed blood vessels pose a serious problem – the plastic might just not get to some places. But for brains filled with plastic within a few minutes of live blood flow, I just can’t see the problem.

For example, imagine that key brain info is encoded in certain key protein densities at tiny synapse pores, with different nearby pores having different key proteins. As long as there are thousands of copies of each key protein in each pore area, the plastic will almost surely usually preserve the info of which kind of proteins were in which areas. Even if some key proteins move away from their pores, most will stay near, and the amino acid sequences that define the proteins will mostly be preserved by the cross-link bonds the plastic makes.

And even if this isn’t true for twenty percent of the key proteins, there is almost surely enough brain system redundancy for this to not matter. Yes, you’d need a finer scan than the Brain Preservation Prize will use to read it, but the info is still there.

So as far as I can tell, the main issue with plastination [= chemopreservation] is how quickly brains can fill with plastic after ordinary blood flow has stopped. If we can find ways to do that well, plastination just wins, I think, at least for the goal of saving the info that is you.

Added 19July: Sad news:

The [Brain Preservation] Foundation has declined [Alcor’s] donation because of concerns that it might be perceived as influencing the judges’ decisions.

Added 13Jan’13: They reached their $25K goal!

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Frozen Or Plastic Brain?

My post Monday on donating $5K to a Brain Preservation Prize testing fund has induced commentary (here, here, here, see also here). They’ve raised many issues on the choice between freezing brains or fixing them with chemicals.

Some prefer the term “chemopreservation” over “plastination”, which some artists have used to describe approaches that don’t try to preserve fine spatial detail. But I don’t like to replace clearer short terms with long vague awkward ones, just to avoid a weak association. If needed, I’d clarify by saying “ultra plastination”.

Some worry that we can’t prove plastic brains will last a long time. But brain researchers have looked at samples preserved many decades ago, and see almost no change. Tissues preserved in amber seem to have remain unchanged for forty million years. We have pretty good chemistry reasons to expect these plastics to last a long long time.

Some worry that plastic forgoes the prospect of reviving brain tissue directly after thawing, and relies instead on transferring its info to a new substrate, as with emulation. But direct revival seems extremely difficult given freezing and anti-freeze damage, and I think brain emulation is the future anyway.

Some worry that tests on fresh brains won’t show how well the techniques preserve less that fresh brains. But we could cheaply do tests now on not so fresh brains, after we test fresh ones.

The big issue, I think, is that plastination probably merges and diffuses some relevant chemical densities. If we knew about the minimal sufficient sets of chemicals to track, we could probably design dyes to mark such a set before we sent in the plastic. But since we aren’t sure which chemicals to track, we’ll have to make educated guesses, guesses that could be wrong.

Now many of us expect an awful lot of redundancy in brain cell spatial shape and various chemical densities, such that it will probably be enough to know the cell shapes, connection strengths, and the chemical densities that happen to be preserved in the first otherwise good plastination approach. If we go out of our way to tag a few more chemical densities, this can increase our odds. This is hardly a guaranteed approach though, so you might think freezing is safer, at least if anti-freeze can be shown to preserve more chemical densities.

But the much bigger risk, however, is that cryonics organizations won’t last long enough to keep brains frozen long enough. Most cryonics customers signed up a while ago, and their age distribution is slowly aging. If they can’t restart exponential growth, they’ll have more and more old dying customers relative to young paying supporters, and then may have a declining customer base. In addition, a great many managerial, political, social, etc. surprises could result in patient thaws even in a growing healthy organization.

Thus we unfortunately must choose between two unwanted risks – we must either suffer a plastination risk of not saving enough chemical densities, or suffer a cryonics risk of thaw by organizations with limited long term reliability. Since I judge the info saving risk to be mild, and the organization reliability risk to be severe, I’d choose the former.

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Why National Med?

People offer many noble rationales for public education, but the data suggest they were adopted to create patriotic citizens for war. I suspect a similar data analysis could show why so many nations have recently adopted national medical systems:

Even as Americans debate … Obama’s healthcare law and its promise of guaranteed health coverage, … many far less affluent nations are moving in the opposite direction – to provide medical insurance to all nations.

China … is on track to .. cover more than 90 percent of the nation’s residents. … Two decades ago, many former communist countries … dismantled their universal health-care systems amid a drive to set up free-market economies. but popular demand for insurance protection has fueled an effort in nearly all these countries to rebuild their systems. Similar pressure is coming from the citizens of fast-growing nations int Asia and Latin America. …

Some countries have set up public systems like those in Great Britain and Canada. But many others are relying on a mix of government and commercial insurance, as in the United States. …

In countries such as India, politicians have learned that one of the surest says to secure votes is to promise better access to health care.  … The Thai system, set up a decade ago, has survived years of political upheaval and a military coup. “No party dares touch it.” …

Columbia’s universal system, set up in 1993, has cost more than twice what as expected.  (Today’s Post, article by Levey, p. A11; link will go here when available)

My guess: for our distant ancestors, medicine was a way to show that they care about each other. So today there is a demand for medicine to be provided by units of organization toward which we, or they, want us to feel solidarity. But I’m not sure what are the most direct and proximate causes of such a need for solidarity.

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Consulate Care

Here’s another idea for medical reform: consulate care. Let countries like Sweden, France, etc. with approved national health care systems have bigger consulates, and open them up to paying customers for medical services. For example, you could sign up for Swedish Care, and when needed you’d go to their consulate to get medical care as if you were living in Sweden.

Now we might not approve consulate care for say North Korea or Uganda, but surely most developed nations are good enough. We don’t issue travel warnings suggesting people not travel to Sweden, for fear of getting sick there. So why not let folks travel to a Sweden nearby for their medical care?

Since most other nations spend far less than the US on medicine, consulate care should be a lot cheaper. And since those other nations seem to suffer no net health loss from their cheaper care, consulate care should be no less healthy.

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Med Media Mangle

The media holds medicine to a lower standard than it holds alternative medicine, such as say crystal healing. No way would an article in a major paper complain that we aren’t subsidizing crystals enough for poor folks, based on the observation that rich folks buy more crystals and rich folks are healthier. But for medicine, that sort of correlation is enough.

For example, this week the Post has not one but two long articles celebrating a new breast cancer study, which it says shows:

“Nearly five black women die needlessly per day from breast cancer” because they don’t have information about the importance of breast screening and they don’t have access to high quality care.

But in fact, the study shows only that across 25 US cities, the ratio of the black vs. white breast cancer death rates correlates (barely significantly) with median city income and a measure of city racial segregation. It is a huge leap to conclude from these correlations that black women don’t have enough info or care!

The very robust health-status correlation predicts more health for higher status folks, and thus more race-health disparity when there is a higher race-status disparity. It seem quite plausible that the race-status disparity is higher in cities where races are segregated and incomes are low.

More from the Post:

It would be nearly nine months before she told herself it was time to act. By then, the lump was the size of a small egg. … Doctors and advocates say the fear that kept her from acting quickly is all too common among black women. It is among the factors that contribute to a disturbing trend: Although they are less likely than white women to get breast cancer, black women are more likely to die from it. … Poverty and racial inequities are the primary factors driving the disparity, according to a study. … The study, which compared mortality rates between black and white women in the nation’s 25 largest cities, states that “nearly five black women die needlessly per day from breast cancer” because they don’t have information about the importance of breast screening and they don’t have access to high quality care. The authors … said genetics play only a small role in the disparity.

More from the study:

[In] the 25 largest cities in the US, … non-Hispanic Black : non-Hispanic White [breast cancer death] rate ratios (RRs) were calculated … Almost all the NHB rates were greater than almost all the NHW rates. … From among the 7 potential correlates, only median household income (r = 0.43, p = 0.037) and a measure of segregation (r = 0.42, p = 0.039) were significantly related to the RR.

Note that white women may seem to “get” more breast cancer because they are tested more often for it.

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Just A Flesh Wound

ARTHUR: You are indeed brave, Sir knight, but the fight is mine.
BLACK KNIGHT: Oh, had enough, eh?
ARTHUR: Look, you stupid bastard, you’ve got no arms left.
BLACK KNIGHT: Just a flesh wound. (more)

In the US the top 5% of medical spenders spend an average of $40,682 a year each, and account for 49.5% of all spending. (The bottom half spend an average of $236.) Not too surprisingly, 60.3% of these people are age 55 or older. Perhaps more surprising, on their health self-rating, 28.9% of these folks say they are “good”, 19.9% “very good” and 7.5% “excellent”, for a total of 56.3% with self-rated health of “good” or better (source).

So, are these folks in serious denial, or is most of our medical spending on hardly sick folks?

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Doctors Dominate

We humans pretend to resist domination, but actually tend to submit, and are often consciously unaware of the contradiction. I recently posted on our relating this way to police. We also relate this way to doctors. For example, people are basically scared to post negative web reviews of doctors. No, they don’t consciously feel scared. They’ll talk about how busy they are or they don’t feel qualified to judge. Yet their usual arrogance lets them rate lots of other things they know little about. And they are scared for good reason: doctors do got out of their way to retaliate against negative reviews. Details:

The Web Is Awash in Reviews, but Not for Doctors. Here’s Why.

… It is puzzling that there is no such authoritative collection of reviews for physicians, the highest-stakes choice of service provider that most people make. Sure, various Web sites like HealthGrades and RateMDs have taken their shots, and Yelp and Angie’s List have made a go of it, too. But the listings are often sparse, with few contributors and little of substance. … Not enough people take the time to review their doctors. …

RateMDs now has reviews of more than 1,370,000 doctors in the United States and Canada. But getting in the faces of the previously untouchable professional class has inevitably led to legal threats. He says he gets about one each week over negative reviews and receives subpoenas every month or two for information that can help identify reviewers, who believe they are posting anonymously. …

Several years ago, a physician reputation management service called Medical Justice developed a sort of liability vaccine. Doctors would ask patients to sign an agreement promising not to post about the doctor online; in exchange, patients would get additional privacy protections…. Medical Justice has now turned 180 degrees and embraced the review sites. It helpfully supplies its client doctors with iPads that they can give to patients as they are leaving. Patients write a review, and Medical Justice makes sure that the comments are posted on a review site. Sound coercive? … p

Patients may be steering clear for a far more ordinary reason: if they live in a small town or are only one or two degrees of social separation from physicians or their family members, they may not want to create any awkwardness. … An Angie’s List customer who read my column about the service last week raised a related concern. She said she would never talk negatively about her doctors on the site because there were only two decent hospital systems where she lived and she didn’t want to end up blackballed by doctors at either. …

Others idolize their doctors … Insurance giant WellPoint, … has found that only roughly 20 percent of customers will switch to a generic drug or use a less expensive imaging center, even if there is no health risk. Why? Because their doctor told them so. It is exactly this sort of unquestioning mind-set that may cause such low participation (or disproportionately positive reviews) at many review sites. …

WellPoint tracks doctors’ communication skills, availability, office environment and trust, but it doesn’t yet provide information about medical outcomes. .. It pays many physicians more when they achieve better results. But it’s not ready to share all of its outcome data. .. “The unintended consequences would be if certain surgical specialists would not take on the most challenging, needy and difficult patients.” … the big health care law requires Medicare to share all sorts of such data about doctors starting Jan. 1, 2013, assuming legal challenges don’t get in the way. The A.M.A. has raised many concerns about “risk adjustments.” (more; HT Tyler)

Risk adjustment is an issue for most products, since most have variations in who uses them. Yet we let people rate other products and collect track records on experiences with them. But for docs, we allow risk adjustment as an excuse to avoid accountability. This is an old issue is health econ — the story has always been that of course giving consumers info is a good idea, but we’d have to wait to give patients info until we “solve” the risk adjustment problem, which never happens, and never will. Mark my words, we will long delay publication of doc track records.

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How Social Are Signals?

We are aware that do many things for show, and I often suggest that we do such “signaling” more often than we realize. But while I’m eager to see writings on signaling theories and their empirical support, I’ve come to suspect that most tend to be unrealistically asocial. Let me explain.

In the iconic signaling story, one person has a hidden feature, which they choose to show to one other person, via some visible action. For example, on Valentine’s day a man traditionally buys a gift, writes a poem, etc. to show a women the strength of his feelings for her. The bigger the gift, the bigger his feelings, supposedly.

In this iconic situation, only these two parties matters. And this allows for simple sharp predictions. For example, if the person watching can’t see the signal, or already knows about the feature, there is no point in signaling. And there is no point in taking an action A to show feature F if that feature is unrelated to willingness to do A.

In realistic signaling, however, third parties typically matter a lot more. For example, the man might want to signal that other women want him, or that he knows that other men want her. The woman might care less about what she infers from his signal, and more about being able to let slip details to her friends, to show them the kind of man she has. This inclusion of a wider social circle makes it harder to find simple sharp tests.

I’ve talked about how schooling could be such a more social signal, and how that could complicate empirical testing:

Firms want to impress customers, suppliers, investors, etc. with the quality of their employees, and hiring graduates from prestigious schools helps them signal such quality. Hiring such graduates can also help a manager to impress his bosses, potential employees, and sister divisions about the quality of his employees. … The fact that attending school seem to cause changes in students that employers are willing to pay for does not show that school isn’t all about signaling. (more)

Similarly, people often respond to my suggestion that medical care functions in large part to “show that you care” with the example of people buying medicine for themselves. “Surely that can’t be signaling,” they suggest. But consider that unattached women often buy themselves flowers or chocolates on Valentines day. As signals become more social, and involve wider circles, it gets harder to isolate situations where no signaling should happen.

By the way, one way to think about “status” is as the limit of very social signals. The more that an action or sign is generally seen as positive, without being very specific about what good features it indicates or who exactly cares about such features, the more that this action or sign looks like a signal of general social status.

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