Thursday, September 30, 2004

Show Me A Drug With No Risks, And I'll Show You A Drug That Doesn't Work. 

And show me a drug with "too much" risk and I'll show you someone who should mind his own damn business.

Don Boudreaux weighs in onthe Vioxx controvery with this question:
The arthritis drug Vioxx was pulled from the market today, by its maker Merck & Co., because of recently discovered high risks to users of heart attack and stroke... A report I heard on WTOP news radio in Washington, DC, featured a physician who complained that Merck took too long to remove Vioxx from the market. The news report went on to mention critics of the Food and Drug Administration -- all of whom apparently believe that the FDA's procedures result in too many drug approvals.

Nowhere in this story or in any account that I've (so far) read does anyone propose that each arthritis sufferer be given the freedom to choose which level of risk he or she endures. The unquestioned presumption is that that there is one proper level of risk and that it is up to national-government bureaucrats to discover and enforce it.
Vioxx was pulled from the market voluntarily, but it is still a valid question. The risk of the side effects of Vioxx is somewhere between 0 and 100%. The efficacy of Vioxx for arthritis pain is somewhere between 0 and 100%. Where you think the two balance out is a personal question. Of course, in the real world, the government and trial lawyers answer these questions for us. And their answers will always undercut many people's risk-reward ratio.

I can't seems to find the actual study (didn't look really hard), but I think I remember reading that Vioxx approximately tripled the risk of heart attack or stroke over 18 months in all comers (is this right?). But I haven't seen one quote for the absoute risk. Can somebody tell me? To take a wild stab, without the appropriate info, I would presume that it's fairly small, and that a reasonable individual would undertake the risk to make his arthritis pain go away (especially, say, if other drugs have failed). But they can't because Merck has sunk Vioxx because they rightly fear government or legal action.

Would I take Vioxx if it could help me? Maybe. Would I prescribe it? Probably not. Would I approve it if I was a government regulator? Certainly not. But in only one of those instances should I get the final say.

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Wednesday, September 29, 2004

It's Good To Still Be Here 

Just experienced a rather harrowing event. As I was grilling a chicken breast, or, more precisely, starting my grill, a collection of gas in my patio ignited and my head was momentarily engulfed in a flame (while not, thankfully, on fire). For those of you who enjoy seeking thrills, I gotta say pass on this one, unless you're the sort of person who enjoys having your own eyebrows singed. Phew.

As a publc service, I think this calls for a post from The Good Surgeon about the medical care of burns. Or maybe just a review of Stop! Drop! and Roll!

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A Good Question 

Glen Whitman poses something I have privately pondered before:
When it comes to marriage, what’s an atheist libertarian to do? What kind of ceremony is appropriate, and who ought to officiate? For an atheist, the obvious choice might appear to be a judge or justice-of-the-peace. But for a libertarian atheist, state idolatry is as objectionable as spiritual idolatry. Sure, libertarians recognize the existence of the state (while atheists do not recognize the existence of a god), but why go inviting the state into what is ultimately a personal commitment? And while many people, including libertarians, might choose to invoke the state’s contract-enforcement apparatus, that act is conceptually distinct from the act of wedding another person (as I argued here).

I was once briefly married. Since my wife-to-be was also an atheist (or agnostic), we opted for the justice-of-the-peace default. But I doubt I’d do that again. As we discovered during our first and only year of joint tax-filing, there are few if any benefits of legal marriage for couples without children. Indeed, we ended up paying a marriage penalty amounting to about $300 of our paltry incomes (yes, I filled out the “dummy” tax forms to find out what we would have paid if we’d been single). If I ever went down that path again, I’d be inclined to postpone the legal marriage unless and until children made it worthwhile. But without ministers or judges, what’s left? Ship captains?
My first thought: While the institution of marriage is a good thing for society, it may be pointless to a given individual. How about just finding someone I love and trust, and promising her I will spend the rest of my life with her. I don't thnk I've ever needed an enforceable contract to hold my promises to the people I love.

If one wishes to celebrate such promise in the presence of friends and family, by all means throw a huge party - there's no reason to get the law of a diety involved. There's always a good a excuse for a big bash and an open bar.

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A Storm of Stupidity 

I'm a little late to the game, but Marginal Revolution and Cafe Hayek have properly pissed on this article from USA Today that claims that the endless parade of hurricanes in Florida is actually good for the economy there:
Although natural disasters spread destruction and economic pain to a wide variety of businesses, for some, it can mean a burst in activity and revenue.

For that reason, economists tallying the numbers expect the hurricanes will be neutral in their effect on the U.S. economy, or may even give it a slight boost, particularly because of an expected reconstruction boom in the already red-hot construction industry.
Any economist who thinks this is so deserves to have their degree revoked immediately, permanently, and after criminal proceedings for fraud. Any layperson who beieved this nonsense deserves to have all their worldy possessions pummeled to smithereens by the first passerby.

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I've Been Published 

Unfortunately, it wasn't the study that proves the efficacy for my miracle cure for aging (that one's still being peer reviewed).

Baylen Linnekin has posted my first two "Paternalism in Medicine" installments over at the Drug Policy Alliance blog, D'Alliance. Gives me a good excuse to link to them. Read the first about physicians and prescription drugs here, and physicians and illicit drugs here (you know you've hit the big time when you're published in PDF format).

And go check out the DPA and Baylen's blog. They do good work over there - particularly, I would point to DPA director Ethan Nadelmann's recent debate in the pages of The National Review with drug czar John Walters. Read Nadelmann's original article, Walter's reply, and Nadelmann's rebuttal.

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Thank God I'm Going Into Pathology 

Just came off my first night on call as an acting intern. As Roy Basch would say, they can't hurt me anymore.
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Wednesday, September 22, 2004

The Wonders Of Special Interest 

Apparently Chicago mayor Richard Daley is pushing for marijuana decriminalization:
Daley emphasized that most charges involving small amounts of pot are thrown out in the state court system in Chicago.

"If 99 percent of the cases are all thrown out and you have a police officer going, why? Why do we arrest the individual, seize the marijuana, [go] to court and they're all thrown out? It costs you a lot of money for police officers to go to court.

"It's decriminalized now," the mayor added. "Sometimes a fine is worse than being thrown out of court."
All well and good even if I don't totally trust yhese guys. But you have to love this objection to the policy:
Fraternal Order of Police president Mark Donahue acknowledged too many cases involving small quantities of marijuana are "pitched at the initial hearing." But FOP members stand to lose thousands of dollars in court overtime if the city starts ticketing marijuana users instead of jailing them, he said.

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Common Sense 

Medrants beat me to it, but today in California the Governator signed a bill that opens the door to allowing syringes and needles to be sold over-the-counter:
Gov. Arnold Schwarzenegger on Monday signed into law what some advocates describe as one of the state's most important public health policies in two decades - a five-year experiment to reduce the spread of AIDS and other diseases among intravenous drug users by making needles and syringes available without a prescription.
The legislation leaves it to local governments across the state to decide whether to take part in the pilot project. Beginning next year, in cities and counties that embrace the concept, pharmacists will be permitted to sell adults up to 10 sterile needles and syringes at a time. The measure also decriminalizes possession of needles without a prescription.
Jacob Sullum points out that this strategy is much more preferable to the comonly advocated needle-exchange:
Philosophical objections aside, the latter have always struck me as the wrong approach strategically, seemingly confirming the canard that what critics of the war on drugs really want is subsidized addiction (a charge that drug czar John Walters hauled out in his recent National Review exchange with the DPA's Ethan Nadelmann). In this case, by contrast, the government is removing a legal barrier to sanitary injection practices by allowing over-the-counter sales of needles and decriminalizing their possession without a prescription.
Slowly, but surely, reason will win these battle.

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Monday, September 20, 2004

Do You Trust Them, Redux 

Last week I posted this from the anniversary of 9/11, an article whose point was we should not put our faith so blindly in government actors to protect us from terrorism. The same day I tried to illustrate this by pointing out that we couldn't even trust them to respect our oen liberties, i.e. the War on Drugs. How would they instill a government in Iraq that respects liberty? Is the connection I was trying to make a stretch? I don't think so, and I offer this from Radley Balko:
We all know now about the Bush administration's pre-9/11 $43 million gift to the Taliban -- in thanks for the regime's prohibition on opium. Still, this Robert Scheer column written in May of 2001 is simply chilling:
Enslave your girls and women, harbor anti-U.S. terrorists, destroy every vestige of civilization in your homeland, and the Bush administration will embrace you. All that matters is that you line up as an ally in the drug war, the only international cause that this nation still takes seriously.

That's the message sent with the recent gift of $43 million to the Taliban rulers of Afghanistan, the most virulent anti-American violators of human rights in the world today. The gift, announced last Thursday by Secretary of State Colin Powell, in addition to other recent aid, makes the U.S. the main sponsor of the Taliban and rewards that "rogue regime" for declaring that opium growing is against the will of God. So, too, by the Taliban's estimation, are most human activities, but it's the ban on drugs that catches this administration's attention.

Never mind that Osama bin Laden still operates the leading anti-American terror operation from his base in Afghanistan, from which, among other crimes, he launched two bloody attacks on American embassies in Africa in 1998...

...Sadly, the Bush administration is cozying up to the Taliban regime at a time when the United Nations, at U.S. insistence, imposes sanctions on Afghanistan because the Kabul government will not turn over Bin Laden.

The war on drugs has become our own fanatics' obsession and easily trumps all other concerns. How else could we come to reward the Taliban, who has subjected the female half of the Afghan population to a continual reign of terror in a country once considered enlightened in its treatment of women?

...The Taliban may suddenly be the dream regime of our own war drug war zealots, but in the end this alliance will prove a costly failure. Our long sad history of signing up dictators in the war on drugs demonstrates the futility of building a foreign policy on a domestic obsession.

The sad irony here is that the same government that signed checks to the Taliban in the name of the drug war just months before September 11 to this day accuses drug users of supporting terrorism (a charge that doesn't stick, by the way).

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Saturday, September 11, 2004

Would You Trust Them? 

To expand on the post below (regarding trusting our government abroad), read this article in The New York Times about a 25-year-old man who will be sentenced to at least 55 years in prison for selling marijuana (first offense) on multiple occasions and carrying (but neither showing nor using) a gun during the deal. Note that the 55 years is the mandatory minimum sentence for this non-violent offense. His life is effectively over:
"It would appear effectively to be a life sentence," the judge, Paul G. Cassell of Federal District Court there, wrote in a request to the prosecution and the defense for advice about whether he has any choice but to send the man to prison forever.

Judge Cassell, a brainy, conservative former law professor, surveyed the maximum sentences for other federal crimes. Hijacking an airplane: 25 years. Terrorist bombing intending to kill a bystander: 20 years. Second-degree murder: 14 years. Kidnapping: 13 years. Rape of a 10-year-old: 11 years.

He noted that Mr. Angelos would face a far shorter sentence in the courts of any state. In Utah, prosecutors estimate that he would receive five to seven years.
The federal government, of course, doesn't see the injustice.
The Justice Department supports mandatory minimums, said Monica Goodling, a spokeswoman.

"Tough but fair mandatory minimum sentences take habitual lawbreakers off the streets, lock up the most dangerous criminals and help ensure the safety of law-abiding Americans," Ms. Goodling said. "Since these common-sense policies were created, we've seen crime plummet to a 30-year low. The public, the Congress and presidents of both parties have supported mandatory minimums for a simple reason - they work."
There is no doubt if you set a mandatory minmum of a death sentence for each and every crime and infraction, crime would plummet. But one would be hard-pressed to call such a system of law just. Only someone who has totally failed to examine or question the very basis for their power would think that a life sentence for a non-violent "crime" is fair or just.
In court papers, prosecutors said Mr. Angelos "trafficked in hundreds of pounds of high-grade marijuana," "distributed cocaine and synthetic narcotics" and "affiliated himself with a violent street gang." These assertions, however, were not proved to a jury.

Last year, Justice Anthony M. Kennedy of the United States Supreme Court told the American Bar Association that "in too many cases, mandatory minimum sentences are unwise and unjust." The association appointed a commission, which recently issued a report urging the abolition of such sentencing.

"There are real economic and human costs," said Douglas A. Berman, an Ohio State University expert on sentencing law, "to putting everyone away for as long as humanly possible."

Melodie Rydalch, a spokeswoman for Paul M. Warner, the United States attorney in Salt Lake City, said his office had no comment on the Angelos case. In general, Ms. Rydalch said, "we will continue to enforce mandatory minimums so long as Congress tells us to."
Again, faced with what seems to be a case of injustice, this government official passes the buck. And this is most cetainly not an isolated case.

The government of the United States is the least oppressive and guarantees the most freedoms of any in the world. And still, it never ceases to perpetrate injustice and tyrrany here within our borders. How can it possibly be trusted to usher in justice and freedom in another nation?

This is cross-posted at Galen's Log.

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Wait 'Til Next Year 

Good friend, softball extraordinaire, and fellow Cub fan Scott Lange, for one day, experiences what it's like too be a Cub:
We get pounded on all game, and eventually this garbage team we are playing is leading 23-8 going to the bottom of the last inning, and talking trash to boot. We plate a couple runs, make a couple outs, and I come up as the potential last out of the game. Now understand, for the year I have solid numbers. However, as the potential last out of the game, I am like 1-8. Its uncanny. However, I am not going to let it happen again. Although the game is way out of reach, I am determined to not make the last out for once. I grit my teeth and bear down. I take the first pitch high for a ball. The second pitch is to my liking, and I turn my hips, turn my wrists, and snap a line drive base hit to center! Its the small victories that count.

Oh, and then seven straight batters reach safely and I come up again to line out and end the game with the tying run on deck. Boo ya.
Make that 2 for 10. Hey, Scott, what's that OPS?

This is cross-posted at Galen's Log.

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The Anniversary 

Roderick Long points to his essay written at the second anniverary of 9/11:
For me, the chief lesson of 9/11 is the simultaneous power and impotence of government.

9/11 vividly demonstrated how powerless government is to protect us and make us safe. The United States government is the most powerful organisation that has ever existed in human history. It possesses untold wealth, unmatched military might, and a globe-spanning spy network.

And in a few short hours, a handful of murderous fanatics armed with nothing more impressive than boxcutters were able to inflict a series of devastating attacks against which this almighty government was helpless.

Our rulers talk blithely about preventing future attacks, but the truth is they haven’t got a clue how to do it. If some nut wants to inflict a lot of damage and is willing to sacrifice his life to do it, there’s very little that the government can do about it. The 9/11 attacks exposed the protective nation-state as the fraud it is.

But if the government lacks much power to protect, 9/11 also showed how much power it does possess to do harm:

To pursue the arrogant foreign policy that invited the attacks in the first place.

To ensure that no one on board the hijacked planes was carrying weapons that could have been used against the hijackers.

To respond to the attacks by stepping up the assault on civil liberties at home.

To respond to the attacks by raining down death and destruction on innocent civilians in Afghanistan and Iraq, thus ensuring that even more American citizens will be targets for retaliation for the next fifty years.

A form of social organization whose power to do evil is enormous while its power to do good is minuscule is a form of social organization that needs to be mothballed.
Regardless of whether one thinks the struggle of the United States in Iraq is justified, I find it obvious that our government, regardless of who leads it starting in November, will prove incompetent in a) securing our safety from terrorism, b) instilling a free, democratic government in Iraq, or c) diffusing the bomb of poverty, tyrrany, and fanatacism that creates terrorism. Indeed, I think it will have a negative impact on all three counts.

This is cross-posted at Galen's Log.

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Wednesday, September 08, 2004

The Tobacco Industry 

A few random thoughts from ABCs special on the tobacco industry (all quotes approximate)(full disclosure: I'm a nominal stockholder for Altria, the parent company of Philip Morris):
  • ABC made a big deal of the inconsistency that sees tobacco completely unregulated, yet tobacco replacement products were heavily regulated. Peter Jennings tell us cigareetes should be regulated. Unfortunately they never entertain the idea that this inconsistency can be resolved in two ways: regulate cigareetes, or deregulate tobacco replacement products. If these products do work, as implied by their FDA seal of approval, then the cumbersome regulation process cost many lives before the first of these were approved and later approved for OTC sale.
  • A public health scholar from Harvard School of Public Health stated something to the effect: "The tobacco industry should be given zero trust to make a safer cigarette." Within, oh, about 45 seconds, he said this about a Philip Morris effort to make a safer cigarette: "If they are successful it would a huge boon to thei company; they would become the cigarette monopoly of the United States." How can an educated person hold these two totally opposite views. One would think such a brain would implode under the weight of such cognitive dissonance. It seems obvious to me that if some cigarette company could actually design a cigareete that was truly safer, or actually caused zero death, they would see profits unrivaled in the history of capitalism. One must have a profound hatred for the industry to believe that they would eschew such profit opportunities for the sake of...for the sake of what? Becasue they enjoy killing people just for the hell of it? Please.
  • They ended the special by stating ominously that "today only the tobacco company, with no imput from the federal government, has the ability to determine how what a smoker inhales." Uh, maybe I'm late to theparty, but don't smokers have even a little say in the matter?
This is cross-posted at Galen's Log.

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Plastic Honor 

The one glaring hole in the medical blogosphere is, unless I have missed it badly, is the lack of an OB/Gyn blogger (presumably because they're all tied up in court).

If there were, I would ask them about what I just saw on a show about various plastic surgeries. Apparently there are some OB/Gyn's who specialize in hymenoplasties - a surgery undergone mostly by women of Middle Eastern culture to recreate the appearacne of a virgin. I both feel happy about the fact that these women can save their "honor," and more importantly save their life from an "honor killing;" and saddened that they have to.

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Understanding Costs And Benefits 

Ross at The Public Health Press notes that varicella vaccination save $100 million annually in hospitalization expenses. Medpundit says not so fast:
It doesn't mention how much it cost to immunize the population during that time period. A single dose of the vaccine is $88. According to the CDC, 85% of children were vaccinated against chickenpox in 2003. According to the Census Bureau, in 2000, there were 19 million children under age 5. (I couldn't find data for 2003.) That means that 16.1 million were immunized against chickenpox, at a cost of 1.4 billion dollars. It's possible that there were fewer children under five, or that the CDC was referring to a smaller group of children. But it still appears that the vaccine costs more than it gives.
I'll ignore for a second the fact that her calculations don't quite equal an annual cost, the way I read them. I still think that the true number is well north of $100 million.

The problem is her reasoning that the vaccinations "costs more than it gives" because the $100-million-plus is greater than the hospitalization cost savings. This assumes the main benefit of varicella vaccination is to prevent hospitalization. I think the main benefit of the vaccination is to prevent kids (and adults) from enduring the misery of getting chicken pox. In that regard, i'm pretty sure it's worth the 88 bucks.

Speaking of costs and benefits, in the same post Ross has this to say about the increase in Medicare Part B premiums:
Bush and Kerry fight over giving Medicare the power to negotiate lower drug prices, and the Administration, in yet another Friday news release quietly shores up the doctors' vote for the GOP and lines the pockets of their friends in the insurance industry by announcing a 17% increase in Medicare Part B premiums (which includes reimbursement for physician visits) in 2005. This increase is the largest in Medicare's 40 year history, and comes when seniors' Social Security payments are expected to rise by about 3 percent.
I don't think it's unfair to read into this that Ross thinks the premium increase is a bad thing. If he thinks it's a bad thing because there's politics involved and it may be used to increase the wealth and power of those in control in government, well no argument here; but then again, this wouldn't differentiate it from anything else in this arena now would it?

If instead Ross believes that it's a bad thing because seniors now have to pay "just too much," my questions are: How much is enough (you can't think something is too much without saying what is "enough")? With a present value of all future defecits projected in the tens of trillions of dollars, how else would you propose we bring this back in line (do people realize that Medicare is projected to consume half of taxes in 50 years at current government taxes and spending levels)?

This is cross-posted at Galen's Log.

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It's Kinda Like Blogging In That Way 

The Sports Guy on how roto-league baseball consumes his life:
When noncontenders started to shop assets for prospects and picks, I even negotiated a possible Ichiro trade waiting in line on the ESPYs' red carpet. A woman in front of me caught the Sports Gal's eye, and said sadly, "My husband does fantasy baseball, too." She may as well have been talking about a leper. Decked out in a black cocktail dress and new heels, my wife responded, "If my husband doesn't hang up in the next 30 seconds, I'm going home with LeBron James." I hung up.
This is cross-posted at Galen's Log.

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Accounting Is An Art, Not A Science 

Via Arnold Kling, Holman Jenkins discusses our various "unfunded mandates:"
It would take $3.9 trillion today to retire the visible national debt, and $72 trillion today to pay off unfunded promises to retirees. Yet only the first debt is reported to voters. That's the kind of accounting "oversight" that, in the private sector, leads straight to a cellblock.

...Why is this important? Because suddenly the $1 trillion in "transition costs" to finance the creation of the Bush-touted private retirement accounts for younger workers doesn't seem so outlandish compared to the real federal debt, visible and invisible.
Those who would oppose Social Security privatization based on "transition costs" are helping to perpetuate the fraud.

This is cross-posted at Galen's Log.

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Tuesday, September 07, 2004

Direct-To-Consumer Advertising 

As I have pointed out time and time agian, the constant refrain of "pharmaceuticals spend more on sales and advertising than on R&D" is an absurd, pointless argument against the power of these companies. The relative percentages of revenues spent on any two types of costs means nothing, because believing so misses the very fundamental issue of marginal revenues and marginal costs. Companies that spend X on advertising couldn't just divert it to R&D and make more profits - if they could, they would. No, they spend X because it maximazes their profits.

But this analysis doesn't address something that needs addressing: While advertising by pharmaceuticals increases their profits, what does it do for the consumers? Are the costs simply passed on to them, thus meaning an increased price? Or does the effect of marketing decrease the price overall?

This is an important question now because of what I read recently at Medrants, where Dr. Centor was detailing his solution to the problem of prescription drugs:
First, I would outlaw direct to consumer marketing of prescription drugs. DTC puts physicians in a difficult situation. We do feel pressure to prescribe the medication that the patient requests. Some of us have the time and presence to resist that pressure, but many physicians are so harried that writing the prescription rather than arguing is the easy way - saving them 5 precious minutes.
For a supposed free market advocate, he seems pretty agressive about restricting market freedom.

The role of advertising is very misunderstood. Indeed, for decades economists argued over the total impact it had on consumer prices. Economist George Bittlingmayer:
Economic analysis of advertising dates to the thirties and forties, when critics attacked it as a monopolistic and wasteful practice. Defenders soon emerged who argued that advertising promotes competition and lowers the cost of providing information to consumers and distributing goods. Today, most economists side with the defenders most of the time.
In response to the argument that advertising creates monopoly power:
Contrary to the monopoly explanation (and to the assertion that advertising is a wasteful expense), advertising often lowers prices. In a classic study of advertising restrictions on optometrists, Lee Benham found that prices of eyeglasses were twenty dollars higher (in 1963 dollars) in states banning advertising than in those that did not. Bans on price advertising but not on other kinds of advertising resulted in prices nearly as low as in the states without any restrictions at all. Benham argued that advertising allowed high-volume, low-cost retailers to communicate effectively with potential customers even if they could not mention price explicitly.
Advertising creates branding that provides information to the consumer:
Advertising messages obviously can be used to mislead, but a heavily advertised brand name also limits the scope for deception and poor quality. A firm with a well-known brand suffers serious damage to an image that it has paid dearly to establish when a defective product reaches the consumer.
So the consensus is well established: in general, advertising serves to give information to the consumer and break up monopoly power. Advertising creates competition that drives prices down.

But this is a general conclusion. One could argue that this may not describe the role of direct-to-consumer advertising from pharmaceuticals who are peddling prescription drugs. Indeed, Dr. Centor and many others (because I have heard them many times before) would argue that this type of behavior is harmful to patients who shouldn't be getting "information" from companies, it's harmful to doctors who have to spend time hearing their patients repeat the jingle for Celebrex, and it's harmful to society who has to pay for a large portion of our quaisi-socialist health care industry.

So what is the economic effect of DTC advertising? Economists Kurt R Brekke and Michael Kuhn sought to answer this question:
The advertising industry is one of the most advertising-intensive industries. Promotional expenditures often amount to 20-30 percent of sales, sometimes even exceeding expenditures on R&D. However, contrary to most other industries the vast amount of promotional spending are not targeted at the consumers, but rather at the physicians making the prescriptions. While this can be explained by the important role of the physician as the patient's agent, another important reqason lies with the regulatory restrictions on direct-to-consumer advertising (DTCA) of prescription drugs that are present in most countries.

...The role of DTCA has generated a controversial debate. Opponents claim thta DTCA causes physicians to waste valuable time during encounters with patients and encourages the use of expensive and sometimes unnecessary medications. Proponents argue that DTCA increases the consumers' awareness and knowledge about available medical treatments, and this may enable them to detect a possible disease at an earlier stage and more actively take part in the decision of which drug to prescribe.

The debate on DTCA seems to ignore that pharmaceutical companies already spend tremendous amounts of money on promotion aimed at influencing the physicians' prescription choices in ways favourable to the companies(ed: I disagree; I am not sure if anyone ingores this). In this paper, we therefore seek to contribute to the debate by investigaing the interaction between advertising directed at consumers (DTCA), on the one hand, and promotional activities targeted at physicians (detailing), on the other.
The authors go into a discussion of their assumptions and a discusson of the aspects of DTCA and detailing. I think they make valid assumptions, but you may have to read it for yourself. It is important to note that this paper discusses an economic model, and does not present original empirical data - it draws on prior reserach. What did they find?
  • DTCA and detailing are substitutes, meaning when DTCA goes up, detailing goes down. Consequently, if DTCA is banned, doctors will be a big beneficiary, as they will se increased competition for their prescriptions. More pens, I guess.
  • A ban on DTCA is beneficial to the pharmaceuticals if there exists price competition. There is not perfect competition among pharmaceuticals with patented drugs, obviously, but me-too drugs do provide some semblence of competition.
  • A ban on DTCA may be desirable if the regulated prices are too high (for the purpose of stimulating R&D). But this is not the case if the regulated price is set correctly.
What does this mean to me? First, in general, it seems that physicans and, likely, pharmaceutical firms would benefit from a ban on DTCA. Thus, the lesson of advertising in drugs is similar to the general lesson of advertising discussed above. Second, the problem of DTCA in a setting of too high prices, which could well apply to the US, doesn't seem to be a problem to me. It could be mitigated by doing what I have advocated before: reduce the monopoly power inherent in patents that create too high prices in the first place. I believe in the necessity of enforcing patents (though I could be persuaded otherwise); but their current length is a total political construct, and likely has no basis in economic efficiency for drug innovation.

This paper presents merely a model, however a valid one, and is by no means the end of the question. However, it conforms to general trends in this area of study, and I could no studies to refute the case presented here. I have to believe, until presented with evidence to the contrary, that these conclusions are valid. To those of us who understand the power of the free market, it comes as no surprise that actually advocating for freedom, in this instance the freedom to advertise to your consumers and the freedom as a consumer to find information, will help the market match the patients with the drugs they need. For physicians to ask the government to give them a total monopoly as the information gatekeeper (they already have successfully established a role as a prescription gatekeeper) will be harmful to the patient/consumers for which they are supposed to advocate.

This is cross-posted at Galen's Log.

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Monday, September 06, 2004

The Solution 

Here's a wonderful article by Roderick Long dealing with the history of some government solutions for health care:
Today, we are constantly being told, the United States faces a health care crisis. Medical costs are too high, and health insurance is out of reach of the poor. The cause of this crisis is never made very clear, but the cure is obvious to nearly everybody: government must step in to solve the problem.

Eighty years ago, Americans were also told that their nation was facing a health care crisis. Then, however, the complaint was that medical costs were too low, and that health insurance was too accessible. But in that era, too, government stepped forward to solve the problem. And boy, did it solve it!
Read the whole thing.

This is cross-posted at Galen's Log

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Random Thoughts From the Road 

Some musings from the Indiana Open:
  • I got my ass handed to me in my first tournament. Not that I was outmatched - on the contrary, I had a late lead in every match; just couldn't turn it into gold. Classic choke-artist, I guess. There are some strange birds who play backgammon - not that this is news.
  • I couldn't get it confirmed, but it's possible that there is a radio station in Indiana that plays all John Cougar Mellencamp, all the time.
  • I heard some advertisement (for whom I don't know) on the radio that stated at the end of the commercial something along the lines of: "We support a drug-free environment and are commited to maintaining diversity in the workplace." Is it just me, or could not a more self-contradictory statement been made if they had tried? Obviously they don't maintain a completely diverse workplace if they discriminate against people who use drugs in their spare time. How disingenuous.
  • There isn't too much about the interstate that one could describe as "beautiful," but how about this phenomenon: when you look of into the horizon where the road is straight, you can actually see clear reflections of the sky, trees, and cars on the black asphalt. I've always noticed this, but I find it truly amazing. (Any students of optics out there to explain this?)
I'm back!

This is cross-posted at Galen's Log.

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Friday, September 03, 2004

Clinton On Larry King Live 

Bill Clinton just told Larry King: "I was on a cholesterol medicine, but I quit taking that medication because I got my cholesterol down real low." Just goes to show, the former leader of the free world can still be non-compliant.

Money quote: "The Republicans aren't the only ones who want four more years." Get well Mr. President.

This is cross-posted at Galen's Log.

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Hoosier Daddy? 

Well, I'm off to Indianapolis for the 52nd Indiana Open Backgammon Tournament. I'll be kickin' asses and takin' names. Be back in a few days.
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Selective Memory 

It's funny how Matthew Holt remembers basic principles when he wants to. On tax-exempt health-saving accounts:
It also means that we spend marginal dollars on health care when we should be spending on something else. But I guess they missed that day in micro-economics class when MR=MC was brought up.
Geez, I think he finally learned. If now he could only apply that to pharmaceutical advertising (sales, marketing, whatever).

But Matthew is right to point out that, in a world with HSA's, people will purchase more health care than they "need." Tax breaks for certain behaviors or purchases does falsely increase the demand for those things. And in a world where governements didn't pursue such illegitimate social engineering, we wouldn't have to worry about that problem.

The only real argument in favor of HSAs is this: they are better than tax-exempted employer plans, they are better than "health insurance" that pays for every single nominal health expenditure instead of true catostrophic insurable disasters, and they are certainly better than nationalized health insurance. But until getting rid of all of that stuff, HSAs will be the next best alternative.

It's similar to Social Security private savings accounts: you don't really think that I would like to compel us into saving a set amount of our earnings set for retirmement. But until it becomes poltically viable for government to leave the enterprise altogether, it's the best alternative.

This is cross-posted at Galen's Log.

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Reactions To Bush 

Last week I wrote of Haper's Lewis Lapham, who made the following "prediction:"
The speeches in Madison Square Garden affirmed the great truths now routinely preached from the pulpits of Fox News and the Wall Street Journal--government the problem, not the solution; the social contract a dead letter; the free market the answer to every maiden's prayer.
While I complained about his lack of integrity in writing this before the convention, I now am saddened by the fact that he was wrong.

Other libertarian-minded bloggers feel my pain. Andrew Sullivan:
People like me who became conservatives because of the appeal of smaller government and more domestic freedom are now marginalized in a big-government party, bent on using the power of the state to direct people's lives, give them meaning and protect them from all dangers.

...I've said it before and I'll say it again: the only difference between Republicans and Democrats now is that the Bush Republicans believe in Big Insolvent Government and the Kerry Democrats believe in Big Solvent Government. By any measure, that makes Kerry - especially as he has endorsed the critical pay-as-you-go rule on domestic spending - easily the choice for fiscal conservatives.
I quibble with his assertion that tax-and-spend is better (or worse) than borrow-and-spend, but the larger point still remains. This shit's gotta stop.

So that leaves us with a big-government party and a bigger-government party. At least we can turn to the Dems to stem the tide of social conservatism. Robert Clayton Dean says no:
The bugaboo of the left (and their organ the Democrats) in the US is the "religious right," and my comments in the paragraph above are directed primarily to this bugaboo. Aside from religiously driven moral concerns, though, the major driver of real social/cultural conservatism in this country is the puritan streak that has been handed down through the ages as the antithesis of the hedonistic American thesis.

In recent decades, this puritanical impulse has been mated to the statist impulse, yielding such unholy offspring as the radical environmental movement, the anti-smoking crusade, the nascent anti-fat crusade, and of course the drug war. You will note that the puritans reside comfortably all across the political spectrum in America, and have had a much greater impact on state activities than religious devotees.

This is cross-posted at Galen's Log.

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Thursday, September 02, 2004

Unmitigated Success, Revisited 

Got a few responses to yesterday's question. So far, nominations are up for antibiotics, statins, and eyeglasses (with a shout out for phenergan; yes, it's good stuff). I should be more specific about my question. I consider cervical cancer screening a huge success because a) it has brought a deadly disease to it's knees, b) it is not too costly, and c) there are virtually no health risks in getting a Pap. It may be valid to criticize that I was advocating the CIN protocol overall, and thus, the risks of biopsy come into play. Maybe; I'm not sure yet. Anyway, I'll take one-by-one on these accounts.

Antibiotics: certainly belong in the top ten, but I was searching for more specifics. Which antibiotics (or classes) have contributed the most success?

Statins: while there is no doubt they are beneficial, the juries still out on how beneficial. Plus they are not cheap and their are real risks. Fails on all three counts.

Eyeglasses: an extremely interesting suggestion. I did state "in the past 100 years," but that mya have been too arbitrary. Don't save many lives, but have indirectly expanded wealth (don't beleive it? how many people could be 10% of productive if they needed glasses but didn't have them), which improves health. A stretch? I don't think so. And it got me thinking: do glasses have any risk?

Any more suggestions?

This is cross-posted at Galen's Log.

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Gross Response 

Graham threw out some quick and random responses to my quick and random thoughts. So in the words of Jules Winfield, allow me to retort (quick and dirty):
  • "The administration savings argument" - Setting aside the studies for right now, the point I was making is that your whole argument rests on this; take it away, and your case crumbles. That is not even a criticism, just a fact.
  • On a free lunch" - You might not have said that your idea is a free lunch, but that's sure as hell what it is. Call it whatever you want, but when you say this system will give those covered better coverage, and provide free care to the uninsured (free not as in $0, free as in at no increase in overall health insurance), that's a free lunch. Again, regardless of whether one thinks that is what will happen under single payer, your proposed consequence is a free lunch.
  • "Social Security and Medicare" - I was a little sloppy with my words, but you totally ignored my argument about Social Security. Which is appropriate for you because it provides a good historical example against your free lunch argument. There is no doubt that I have characterized SS (if you care to actually look at the numbers) correctly. There is some element of truth that this does not apply to Medicare. But here's the thing: 30 years ago, SS was not in fnancial trouble, was good "insurnace" and may or may not have trapped anyone in poverty. The 30-year head start of SS over Medicare suggests that Medicare may (likely will) go down the same road. Given the massive present value deficit it faces, and the cut's in benefits and/or tax increase that would be necessary (since you would obviously take privatization off the table), the future return on Medicare and the tax burden will mean that Medicare will soon become "sunstandard insurance."
For discussion: Do the readers agree with my cahracterization of Social Security, and my prediction for Medicare? And do you see nationalized health insurance an apt analogy for Social Security?

This is cross-posted at Galen's Log.

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The Long Run Is Shorter Than You Think 

One of the best, out of a myriad, arguments for "price-gouging" is that it increases incentives for producers to keep extra supply on stock before the disatser hits. If you allow price gouging after the fact, it will increase reserve supplies before the fact. But otherwise, you get this:
Many gas stations are beginning to close, Lay said, and future shipments will be limited since the Port of Tampa is closed.

"It's going to be a precious commodity before long," said Lay.
Unfortunately, this is a "in the long run" arguments that rings hollow when a hurricane hits. It is, nonetheless, true. And the fact that the next hurricane hits less than a month later means the long run ain't that long.

Another good argument in favor of price gouging is that when you make it illegal to pay the market price in money, they will just have to pay it in other ways. However, since paying in dollars is more economically efficient, it makes everyone worse off when they can't. I heard on NPR today how inland Home Depots had empty shelves; people were coming from the coast where the Home Depots there were empty to begin with. Now these people weren't being "price-gouged" (because that would be against The Law), but they were nonetheless paying a higher price in the form of their time and gas. True prices are like matter in a manner of speaking - they can neither be created nor destroyed, they just change form.

Maybe these back-to-back disasters will make the economic arguments more appreciable. I doubt it, but maybe. It's unfortunate that we have to learn these things the hard way. But it's a hell of a lot better than not learning them at all.

This is cross-posted at Galen's Log.

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Who Ya Votin' For? How's the Weather 

Don Boudreaux draws the apt analogy for people who think the president creates or destroys jobs:
I've noticed that Washington seems cooler this summer than in summers past. Must be due to Bush's policy to reduce global warming.

This is cross-posted at Galen's Log.

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Wednesday, September 01, 2004

Unmitigated Success 

As I spend a whole quarter of my day these days looking at cervical squamous cells, I have a pretty constant reminder of the success of Pap screening for preventing cervical cancer. Combined with colposcopy and the various treatment methods for CIN, cervical cancer has been relatively defeated (which in medicine doesn't mean it's gone - a good friend's sister just passed away from cervical cancer). The most common casue of cancer in women worldwide, it has dropped out of the top ten in cancer mortality in the US.

And all of that is due to a fairly simple and inexpensive test. That has to be one of the biggest successes for medicine in the past one hundred years. Any other nominations for the top 10 unmitigated success in medicine over the past 100 years?

This is cross-posted at Galen's Log.

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Top Five 

I had "Five Things That Would Persuade Me To Vote For the Democrats" during the DNC. Here are the top five things that would persuade me to vote for the Republicans:
  • This one by itslef would do it: stop the gay bashing. Stop covering it up in the "family" wrapping paper and calling it "values." Stop tying on the bow of your God and calling it "moral." It's hate regifted and called love. It's The Great Conservative Shame.
  • Stop giving free markets and small government a bad name. You talk about the libertarian ideal of free economies and limited government and practice the very anti-libertarian economy of privelege and growing state.
  • Follow through with "The Ownership Society," mean it, and don't fuck it up. It's the foundation of the first true political revolution in my lifetime.
  • End the drug war, end the drug war, end the drug war.
  • Tell the Christian Right to go to hell (which I'm sure they'll oblige in good time). Your God is not my god and I won't be ruled by Him.
Which is all another way of saying I'll never vote for either party, 'cause they ain't gonna happen.

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Take That DeBeers! 

You're a gem, Trent!

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