(2024-01-16) Zvi M Medical Roundup1

Zvi Mowshowitz: Medical Roundup #1

Vaccination Ho!

We have a new malaria vaccine. That’s great. WHO thinks this is not an especially urgent opportunity, or any kind of ‘emergency’ and so wants to wait for months before actually putting shots into arms. So what if we also see reports like ‘cuts infant deaths by 13%’?

Also, EA and everyone else who works in global health needs to do a complete post-mortem of how this was allowed to take so long, and why they couldn’t or didn’t do more to speed things along. There are in particular claims that the 2015-2019 delay was due to lack of funding, despite a malaria vaccine being an Open Phil priority

Oh, and also we invented a vaccine for cancer, a huge boost to melanoma treatment

Katalin Kariko and Drew Weissman win the Nobel Prize for mRNA vaccine technology.

the University of Pennsylvania also refused to allow Kariko a tenure track position, calling her ‘not of faculty quality,’ and laughed at her leaving for BioNTech, especially when they refer to this as ‘Penn’s historic research team.’ Did you also know that Katalin’s advisor threatened to have her deported if she switched labs, and attempted to follow through on that threat?

Reflections on what happened with medical start-up Alvea. They proved you could move much faster on vaccine development than anyone would admit, but then found that there was insufficient commercial or philanthropic demand for doing so to make it worth everyone’s time, so they wound down

Potential Progress

London hospital uses competent execution on basic 1950s operations research management, increases surgical efficiency by a factor of about five. Teams similar to a Formula 1 pit crew cut sterilization times from 40 minutes to 2.

Dementia rates down 13% over the past 25 years, for unclear reasons

Claim that Viagra was significantly associated with a 69% reduced risk of Alzheimer’s Disease. Nice. There are supposed mechanisms involved and everything

Amazon is now offering medical services, at very low prices. No insurance accepted

chat medical visits (not even video) with physicians and NPs for $35 cash if you think you have COVID. Or a yeast infection. Or need birth control

It’s Not Progress

Economist reports (HT MR) that health insurance providers have a cap on direct profits, so they are buying health providers in order to steer customers to them, then paying those providers arbitrary prices

An interesting note is that Matthew Yglesias says he thought that this position was the consensus. It is simultaneously the consensus in the sense that people believe it, and also contrarian in the sense that the establishment and public health plan to do it all over again

Dylan Matthews makes a convincing case that while deaths of despair and overdose deaths have increased, the bulk of the decline in American life expectancy so far has been due to problems with cardiovascular disease. It is also noted that the decline is focused on the worst-off locations and among high school dropouts, as opposed to being about whether you go to college. (Opioid)

Not that the overdoses don’t matter. We have a rapidly growing, out of control problem with overdose deaths, and it is already having a real impact on life expectancy, and if it continues growing exponentially it will soon be far worse. It is scary as hell.

It looks exponential. It would be scary anyway since it is already almost 3% of deaths in 2021. What happens if it doubles again in the next decade?

My mind still boggles that asking questions with the intent to learn or prove something requires ‘ethical’ clearance and worries about ‘potential harm’, and people keep endorsing this on reflection, burn it all to the ground. Keller Scholl: The idea that asking people questions requires approval by an ethics board is a position unique to science/health.

Cost Plus

United Healthcare pushed employees to follow an algorithm to cut off Medicare patients’ rehab benefits, says StatNews, to the tune of our way or the highway. If you want a ‘human in the loop’ the human needs to be able to determine the outcome of the loop. Here, it seems, they did not.

Yes, a lot of the reason Canadian health care is cheaper is that they sometimes tell you they’re not going to give you the surgery and instead suggest you consider assisted dying instead, whereas in America they will operate on you

Tyler Cowen makes the case for a big push for hospital pricing transparency. As in, we need to insist on this like we insisted on ending the Vietnam War

New Findings

Scott Lincicome: An excellent @JoshZumbrun dive [in WSJ] into what I've been preaching for years now: so-called "expiration" dates are costly scam.

they provide reasonable approximations on how long various items can remain edible. Does that make them reliable markers of either spoilage or safety? No. It is a problem when sticklers treat them as gospel, again in either or both directions. I’m still glad they are there.

FDA Delenda Est

Scott Alexander notes that fully abolishing the FDA would require additional adjustments in the system. How would we deal with liability? What if doctors are stupid or fooled by advertising?

*He comes down suggesting the FDA have a safety-only pathway for making drugs allowed, and legalization of artificial supplements.

That would be a reasonable practical compromise, but I think you can go a lot further. All these questions have reasonable answers.*

Spanish covid tests are dual-Covid/flu tests and why in the hell are these not available everywhere?! (rapid test, the flu)

Medic Kim: Why don’t we have at-home antigen tests? Because the FDA panels are composed of these people: A 2016 FDA advisory_panel, meanwhile, was split on whether the benefits of over-the-counter influenza tests outweighed the risks.

Also, the FDA continues to move forward to regulate lab tests

*Also, why don’t your cold medicines work? Oh right.

John Arnold: Americans have been wasting billions a year on cold medicines like Sudafed & Benadryl with the active ingredient phenylephrine, despite conclusive evidence they don't work*

FDA approval for these medicines was grandfathered without any clinical trial because the active ingredient was shown to be safe and to work if given intravenously. But, since approval, there have been 4 trials of oral form and all have shown no benefit vs placebo.

The FDA has been monitoring these drugs since 2007 and finally ordered a formal review.

Baron St. Rev Dr. von Rev: Reminder that fedgov allowed drug makers to substitute phenylephrine (which is useless) for pseudoephedrine in order to hamstring public opposition to their crackdown on the latter. It wasn't a mistake, it was a con-job.

Covid Response Postmortem and Paths Forward

As Nate Silver reminds us, the Covid-19 vaccine was the one thing that we know worked to prevent Covid deaths. ((2023-09-29) Silver The 2 Key Facts About US Covid Policy That Everyone Should Know)

Former NIH director Francis Collins says the quiet parts out loud (1:18 video, worth watching) regarding Covid policy and the public health mindset. They don’t think about the impact on the lives of ordinary people. They don’t do trade-offs or think about cost-benefit. They care only about lives saved, to which they attach infinite value.

Some good news on Covid is new claims that vaccination before first infection reduce risk of Long Covid greatly.

House passes ban on toddler mask mandates without a vote after opposition fails to provide any evidence whatsoever that masking toddlers is helpful. Took long enough. Turns out people say things are evidence-based without, ya know, evidence

Covid Origins

Nate Silver continues to be loud about the ‘Proximal Origins’ paper, the damage it and related efforts to convince us we could assume natural origins of Covid have done to trust in science, and in particular the lack of willingness to admit and call out what happened. He links to this post about it. Things do not look better over time

there is an 18 hour recorded debate, a third of which is published, six figures at stake on the outcome and a prediction market on the outcome. Daniel Filan: One thing I'd like to emphasize: I think this is the best debate I have seen in my life.

Ian Birrell: New study reports 309 lab acquired infections and 16 pathogen lab escapes between 2000 and 2021

If we have almost one confirmed lab leak per year, and given the other circumstances, it would almost be surprising if Covid-19 wasn’t a lab leak. Was Covid a lab leak? We don’t know. At this point it seems more likely than not.

This is very similar to the question of existential risk from AI. Any reasonable person, given the evidence, should say the lab leak has substantial probability, as does natural origin

The good news is that it likely has succeeded in at least cancelling Deep VZN.

You think this is the worst that can happen? Well, remember that time Australian researchers were actively trying to create a ‘contraceptive mouse virus’ for pest control, which is totally not how any science fiction dystopia stories start, and they instead accidentally created a modified mousepox virus with 100% mortality? Check the linked thread out, because it keeps… getting… worse

Ban Gain of Function Research

House unanimously votes to defund gain-of-function experiments with potential pandemic pathogens. I would prefer a ban, but unanimous support for at least not paying for it is a great start. Why am I worried this will still not get implemented?

Cause Areas

Reducing third world lead poisoning continues to be a plausible high-value cause area

I find it likely that $1 billion well-spent on this would be a good use of funds. I also can think of ways one could plausibly spend that money badly, and it ends up wasted or even making things worse. Seriously, let’s buy out the patent rights and offer these drugs for free to anyone who wants them, what are we waiting for. New EA cause area.

Robert Wiblin: Paying people in exchange for their blood is very bad — but saying misleading things so they'll give you their blood for free is very good.

The expected QALYs from you donating blood is more like 0.01 rather than the 200 which they're suggesting. Still a good thing to do but you can't save 3 lives in an hour.

I think a lot of what's going on is that "was money exchanged?" is a relatively discrete and legible question, whereas "was a falsehood stated?" is often a lot fuzzier, depending on how vague language is interpreted, and on where you draw various lines

So bureaucracies have a much easier type setting actionable policies about money than about truthfulness

The end result being that bureaucracies end up with all sorts of wacky rules about money, because humans have emotional hang-ups about Everything and money is an easy thing to regulate. Whereas even the most scrupulous bureaucracy will tend to lie a lot, because this is harder to regulate and incentive gradients toward lying abound: you fudge the truth a tiny bit and it helps, then you fudge it slightly more...

Want to get more people to donate? Yes, you could and should pay them.

But also I once again iterate to those in charge of blood donations: By requiring appointments, you are greatly raising the effective cost of donations. If you could take walk-ins, even confirmed right beforehand on the web, I would happy do this much more often. If I have to block out an appointment time days in advance, that’s so much harder.

GLP-1 Has Barely Begun

Wegovy (a GLP-1 agonist) cut the rate of major heart problems in a 17k patient trial - heart attack, stroke, or cardiovascular-related death by 20%. It also cut all-cause mortality by 19%, which I would have led with, with no major side effect issues

Market Monetarist thinks GLP-1s are a huge economic deal.

Obesity, particularly severe obesity, involves enormous healthcare costs

The actual health benefits, of course, would be very real, including productivity.

There are also big productivity gains to general impulse control. GLP-1 inhibitors help with a wide variety of addictive and unproductive behaviors. My presumption is you would see substantial productivity gains.

Cate Hall: Ozempic doesn't provide willpower; it eliminates the need for it. These might sound like similar things but the internal experience is wildly different, as any addict can tell you.

It looks like GLP-1s reduce alcoholism, which on its own is a huge freaking deal

No One Understands Nutrition

An epic and righteous rant about how much people obsess over vegetables and what is rightfully called morality-based dietary planning. Eigenrobot’s 100-year-old grandfather is literally starving to death because his grandmother keeps insisting on these elaborate ‘healthy’ meal plans that took him hours to consume, when instead it turns out you can just feed the guy stuff like ice cream and he can get it down fine, and obviously that is what any sane person would do in this spot

My model is that we know four things about nutrition with any certainty:

• Different people work very, very differently here.
• There are things you need, often but not always your body lets you know.
• Vegetables good.
• Sugar bad.*

How important are rules two and three? Great question. We don’t know that.

Model This: Exercise Edition

What are the returns to exercise? Roger Silk does some math, attempting to think like an economist

the marginal return on the final hours is likely more like 4%.

Is that a good investment? As Roger points out, there is no inflation in years.

What key considerations are being ignored in the calculation here?

Correlation is not causation. Exercise is claimed to be ‘associated’ with 8 extra years of life. But it is trivial to see why this is almost certainly an overstatement of the causal effect of choosing more exercise.

Exercise has major positive impacts other than lifespan. This is the reason why I am able to motivate myself to exercise

Exercise can be good or bad in many other ways. Are you using up willpower or generating more? Learning to form good habits, or using up your habit budget?

As is noted, what kind of years are you getting? Are you getting extra healthy years, extra aged years on the end, or a slowing of the aging process?

You could also make up for it via future technology

The time you spend exercising is not worth zero. If you hate it, it could be strongly negative. If you find something you like, or a way to like it, it can be substantially positive.

I have at times found exercise where the net experience is positive due to ability to watch television or listen to podcasts while doing it

We do not have 16 flexible, valuable hours to spend each day. There are a lot of fixed costs beyond sleeping that eat into our time

Risk of injury is a real thing, with exercise both causing it directly and preventing it indirectly

Also, the real story of people not exercising is pretty damn simple. Mostly true story. Afro—Arakkii Leo Says Resist: most people don’t exercise because it’s fucking boring dude.

people are always going to be iffy about it until we normalize play as exercise. (play ethic)

you know what would be great for heart health? Tag. We should all go to the park and play tag.

A Bold Stand Against Torture

Matthew Yglesias takes a stand against dentistry. Well, maybe not quite against dentistry writ large, but against the current regime of dentists being a cartel taking a large cut of every cleaning

Studies show, he says, that letting dental hygienists work on their own improves dental health, in addition to improving equality and lowering costs. The mechanism is that if routine dental services cost more, you will consume less of them.

William Ecenbarger did a great investigative report for Readers’ Digest years ago where he visited dentists in different cities and asked for their recommendations and got prescribed courses of treatment ranging from $500 to $25,000.

Back at Vox, I used to work with Joey Stromberg (whose dad is a dentist), who wrote a piece about how “while seeing other dentists, my brother has been told he needed six fillings that turned out to be totally unnecessary

Yglesias also quotes Ferris Jabr in the Atlantic here: The Cochrane Collaboration, a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of oral-health studies since 1999.

most of the Cochrane reviews reach one of two disheartening conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there is simply not enough research to say anything substantive one way or another.

And perhaps it gets worse? Here’s MF Bloom quoting the AP saying there is no evidence that flossing works. The government seems to have agreed that no one has ever properly researched the question. The AP looked and its findings where that the evidence is “weak, very unreliable” and of “very low” quality. Ouch.