Monday, December 15, 2008

Thank You Michael Crichton

First, I would like to point out that whoever scheduled a total of ten different examinations over the course of a three-week period needs to be informed that cruel and unusual punishment is prohibited by the Bill of Rights. I suspect that by the end of this week I will have lost what little sanity I have left.

But that's not what I'm posting to say--complaining about examinations may be part of student life, but there are more entertaining remarks that I can make. So here are a couple funny highlights from recent work shifts.

A girl calling me for a refill on her oral contraceptive pills expressed sincere belief when I told her that we didn't have the item in stock and that it would not come in until Thursday. The particular product recently went generic and there are still a few holdovers (despite the fact that they're made by the same company), but either way supplies of the brand name are not as numerous as they once were on our shelves.

I believe her exact phrasing was "wow, you guys can run out of drugs?" No, silly me, let me go open up the extradimensional pharmaceutical holding chamber where we keep the infinite supply.

But why reference Michael Crichton?

Those of you who have seen the movie Jurassic Park may recall a particular scene in which the power is out and most of the main cast is sealed in one of the bunkers, hiding from the rampaging dinosaurs. Attempting to formulate a plan, game warden Robert Muldoon brings up "the lysine contingency," a totally ridiculous safeguard thereafter explained by Samuel L. Jackson's computer programmer character:

"The lysine contingency - it's intended to prevent the spread of the animals is case they ever got off the island. Dr. Wu inserted a gene that makes a single faulty enzyme in protein metabolism. The animals can't manufacture the amino acid lysine. Unless they're continually supplied with lysine by us, they'll slip into a coma and die."

Of course, this makes absolutely no sense. Lysine is an essential amino acid, meaning that it cannot be synthesized by the human body--it must be consumed in the diet. In fact, no animals "manufacture" lysine. And as it is common enough--contained in many plants and all meat products--the "lysine contingency" isn't much of a plan at all.

I mostly mention this because I had trouble refraining from laughing the other day when a woman was desperately searching for L-lysine supplements. I should've asked her if she needed it to keep her pet dinosaur alive.

Thursday, November 27, 2008

Happy Thanksgiving!

It's been a busy few weeks around my small corner of the world, but there's no way I'd miss the opportunity to take two minutes to wish those of you in the blogosphere a happy Thanksgiving.

May you surround yourself with good company on the outside and fill yourself with excellent food on the inside!

Friday, November 7, 2008

Stop RFK Jr.

Robert F. Kennedy, Jr. is on the current list of potential appointees for President-elect Obama's cabinet. While RFK Jr. has had a very successful political career, the positions for which he's being considered are the EPA or the Department of the Interior.

This cannot be permitted to happen. Why? Because he's a total crank when it comes to science. He believes the vaccine/autism link is plausible and has praised antivaccination movement leader Dan Olmsted--who has continually pushed junk science disproven years ago. He blamed Katrina on global warming (errr) and has opposed the building of wind turbines near Martha's Vineyard on because "it would damage the view" despite the project having support from many other environmentalists. He's got a track record of politicizing science to serve his own needs--and that's bad for reasons that should be obvious.

You can contact the Obama transition team and let them know how you feel about this. Not sure what to say? Consider Mark Hoofnagle's letter as an example:

RFK Jr. must NOT be appointed as head of the EPA. He is NOT a scientist. He does NOT understand science. He does NOT respect science. He is, in fact, a crank, who believes in pseudoscientific nonsense like vaccines causing autism. And when people are cranky and unscientific in one area of belief, it is never restricted to just that area. It reflects a fundamental misunderstanding of science and an incompetence in evaluating the quality of data and scientific information. This is not remotely a partisan letter, this is a plea for your administration not to make a horrible error.

This is a BAD choice. Do not do this or you will alienate scientists from your campaign very early on, not to mention doctors and especially pediatricians. This man is a crackpot, and I simply can not condone his presence anywhere in government.

Wednesday, November 5, 2008


Congratulations, Barack Obama, on becoming the 44th President of the United States in what will probably be remembered as one of the most significant elections of my generation. And I have no doubt that I will remember it despite all the champagne I consumed last night in celebration.

It's going to be a long road, but this is a step toward fixing a lot of the problems that have sprung up over the past decade.

Tuesday, October 28, 2008

A Tenuous "Alli"ance

It appears that GlaxoSmithKline has recieved approval to market Alli overseas to our European cousins.

This means the product will now be proposed for final approval by the European Commission and marketing authorisation could be granted in the coming months. On licence grant, orlistat 60 mg would be the first licensed weight loss aid available without prescription throughout Europe.

You hear that? An FDA-approved weight-loss supplement! It's a miracle!

Alli was actually released to US markets last summer as one of the more unusual Rx-to-OTC product conversions that we've seen recently. Popular once prescription-only Zyrtec I expected, but Alli was really out of left field. I actually meant to blog about Alli when it was released, but somehow it got away from me. Now I can do so to commemorate its release across the pond.

What is Alli? Alli contains the same active ingredient as a prescription drug that was developed by the Swiss company Roche Pharmaceuticals--the generic name for it is orlistat. It is the first over-the-counter drug approved as a weight loss aid by the FDA, mostly because there's good clinical data that it's actually effective when used properly.

OTC "diet pills" generally contain high doses of stimulants/caffeine, claim to suppress appetite, or somehow purport to "melt fat" or "block calories." Some stimulant weight-loss supplements contain as much caffeine per capsule as three cups of coffee and have "serving sizes" of two or three caps at a time! Clever wording is usually employed to conceal the simplistic nature of these products--Zantrex-3 refers to its caffeine content as "a proprietary xanthine-based stimulant." Caffeine is part of a chemical family called methylxanthines. Other times numerous herbal ingredients or Latin names for botanicals obscure the true content of the supplements except to the most attentive consumers.

Alli, true to its claims, is different. How does it work?

First, a bit of basic biochemistry. There are three major "macronutrients" required for human nutrition--carbohydrates (sugars), lipids (fats), and proteins. All of these are absorbed through the intestine whenever you eat. Macronutrients are then delivered to the liver or various cells of the body that can use them. Carbohydrates are easy; the body breaks them down into smaller units and uses them to produce ATP, a small molecule that is the primary source of energy for the body at the cellular level.

Proteins and fats cannot be used directly by most cells. Instead, the liver processes them into more readily useful forms. Some proteins can be converted into glucose, the most basic (and preferred) form of fuel for body systems, especially neurons. Fat metabolism is more complicated and involves many steps that ultimately culminate in the release of free fatty acids; these are also usable as fuel by many body systems.

If you eat too much of anything, be it proteins, carbohydrates, or fats, the body is remarkably efficient at storing the excess energy produced. The most energy-dense form of stored energy is fat; fats produce the most energy (in calories) per gram. This fat winds up getting stored throughout the body as a reserve for times when food sources are scarce. Each pound of fat on your body represents a total stored reserve of 3,500 calories. Yum!

I've heard it mistakenly stated that you "can't get fat" eating a high-protein diet because "carbs make you fat" or, more obviously, "fat makes you fat," but this is completely false. Your body can (and will) make fat out of anything the liver can get on.

What does this have to do with Alli?

Alli is not actually absorbed into the bloodstream. Instead, it floats around in the intestines and binds to fat molecules, preventing those from being absorbed. If your body doesn't absorb the fat molecules, it can't process them--in a sense, it's like you never ate them in the first place. Alli binds an average of 25% of consumed dietary fats, potentially reducing caloric intake from a fatty meal significantly.

Problem: Alli is not magic. It cannot break the laws of physics and destroy matter (and I suspect converting fats to energy in your intestine would have odd effects, were it possible). If you don't absorb the fats, they still have to go somewhere. Since they're already 3/4 of the way through your digestive tract, and getting the whole system to flow in reverse is both very unpleasant and very difficult, I'll let you think about it on your own for a second.

A funny aside: The makers of Alli recommend that you not wear light-colored pants while taking it.

I personally like to think of Alli as "negative reinforcement." Operant conditioning is basic psychology. Continuously eat fatty meals on Alli and you're going to suffer chronically oily stools. You're either going to learn to control your dietary fat intake or you're going to throw away your Alli.

This isn't to say that Alli is bad. As part of a comprehensive diet and exercise plan, it will help you lose more weight, even if it's only a few extra pounds. But the reason Alli can get FDA approval, aside from the fact that it's been subjected to more rigorous clinical trials, is that Alli doesn't claim to be magic. "Eat all you want and still lose weight!" "Melt fat away while you sleep!" Due to loose regulations, dietary supplement manufacturers make these kinds of claims all the time. But the makers of Alli had to be realistic about the potential benefits of their drug to get it approved. This isn't a bad thing. It's what we should expect from all drug and supplement manufacturers--indeed, it's what should be legally required.

Anyway. Now Europeans can experience the thrill of Alli without a doctor's prescription!

...just remember to wear dark pants.

Monday, October 27, 2008

Tagged, I'm "It"

It would appear that I have been tagged with some infectious, self-propagating idea by Abel Pharmboy.

Well, I've only got five exams this week. Why not take a few minutes to answer some simple questions?

Here are the rules for the game.

1. Link to the person who tagged you.
2. Post the rules on your blog.
3. Write six random things about yourself.
4. Tag six people at the end of your post and link to them.
5. Let each person know they've been tagged and leave a comment on their blog.
6. Let the tagger know when your entry is up.

One and two are done. Six random things? You'll have to settle for six pseudorandom things since I don't feel like making a list of personal traits with more than six elements and generating random numbers to determine which things to include. Yes, settle for pseudorandomness. Settle...and suffer!

1. If you ever need to bribe me with something, I suggest a Japanese dinner. I can't get enough salmon sushi, ever, and will continue to eat the stuff until I explode. Please stop me before then so that the restaurant staff doesn't have to clean up N.B. bits.

2. My university was not my first choice school; my actual first choice was Duke University, which, in retrospect, would've been a terrible idea. Duke has no pharmacy program, so I would've needed to transfer after two years. My reasons for wanting attend Duke despite its lack of a pharmacy program? Like so many other messes guys get into, it was because of a girl. Not the most rational motivation.

3. Over the past four years I have transformed from passionately foofy-doctrineless liberal Christian to skeptic and atheist. My conversion to skepticism is actually a result of my studies of alternative medicine. I was first exposed to altmed two years ago when I inadvertently wound up at the Quackwatch website while doing a research project. Thorough investigation of the subject really improved me as a scientist; I would say that before poking into the innards of altmed that I wasn't thinking like a scientist.

Of course, skepticism in medicine led to me applying skepticism to other areas, and when I was exposed to atheism as "skepticism of religious claims" instead of "disbelief in god--as much a matter of faith as any religion" it hit me that there was no other choice than to turn the skeptical eye in the direction of my religious beliefs. They were predictably destroyed once suitably scrutinized.

4. I own a cat. True to family tradition, I didn't get the cat at a pet store, nor did I adopt her from an animal shelter; I simply picked her up off the street as a kitten (roughly 6-8 months old, by the vet's estimation). After pulling onto my street and nearly hitting the poor thing with my car I stepped out of the driver's side door and there was a tuxedo-print cat mewing at me. I did what any soft-hearted but clueless animal-lover would do and took her inside for a saucer of milk (and, when that seemed insufficient, a can of solid white albacore tuna)--all this despite the fact that my lease specifically prohibited pets. I spent the next two hours thinking "what do I do with this animal now?" until I picked my girlfriend up from the airport and informed her that we needed to stop for cat food. She'd owned cats; I hadn't.

5. I used to live in Dayton, Ohio, the so-called "birthplace of aviation" as it is home to the Wright Brothers.

6. I was a Boy Scout as a teen, but I never achieved a rank higher than First Class. I was the first member of my troop to earn a climbing merit badge; I didn't care about promotions or decorations, I just wanted to go camping. I still can't reliably tie any knots.

Tag six, you're it! Go to!

Cobalt at Secher Nbiw
James McGrath at Exploring Our Matrix
Bad of the Bad Idea Blog
The Bronze Dog of The Bronze Blog
Dana of En Tequila es Verdad
and Greta Christina of the aptly-named Greta Christina's Blog!

Tuesday, October 21, 2008

But Think of the CHILDREN!

You ought to recognize that line as a classic refrain of those in a state of "moral panic."

According to a recently released study, 3% of all children and adolescents in the United States go without health insurance at some point in a given year:

That translates into almost 3 million U.S. children with no medical care at all and no access to prescription drugs over a full year. Slightly more than half of that number qualify for public coverage but aren't enrolled.

Overall, more than 9 million U.S. children are uninsured; some 18 million have a coverage gap at one time or another, according to the study.

But, surprisingly, this includes kids whose parents have coverage:

The authors of the first study looked at data from 2002 to 2005 on children and adolescents under the age of 19 living with at least one parent. The study included more than 39,000 participants.

Their analysis found that 3.3 percent of children and adolescents were uninsured, even though they had at least one insured parent. (emphasis mine)

What about demographic information?

Uninsured children and adolescents were 58 percent more likely to be Hispanic than white non-Hispanic; had double the odds of being from a low-income versus a high-income family; were 48 percent more likely to be from a middle-income rather than high-income family; and twice as likely to come from a single-parent home than a home with two married parents.

...children whose parents had less than a high school education were 44 percent more likely to be uninsured; they were also 64 percent less likely to be insured if their parents had public coverage rather than being privately insured.

None of this should be a surprise. Poor kids don't have adequate health care coverage. Middle-class kids are less likely to be insured than kids from richer families; kids whose parents make between $38k and $72k a year are just as likely to be uninsured as their poorer counterparts. Kids with parents who have limited education are less likely to be insured, probably because the parents are less likely to have jobs that offer comprehensive family healthcare plans.

Why haven't we passed legislature to provide all children with health care coverage? Remember, the people who typically vote against candidates daring to propose universal health care are also the people who are most opposed to family planning.

"But N.B.," say some members of the audience, "the article says that over half the kids involved qualify for public assistance but aren't signed up. That's the fault of parents, not the government."

You're right. But not providing health care for children is sheer negligence, and we punish people for child neglect already. The definition of child neglect is "any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation." It is considered neglect to fail to provide for a child's basic needs, and medical care is included among them.

About half of U.S. children without health insurance had to go without medical care or prescription medications while they were uninsured, said researchers from the University of Rochester Medical Center. Even more children went without preventive care, including receiving necessary vaccinations.

If you don't see why this is a problem, you're part of it. And if you don't see why there need to be laws mandating health coverage for children (and adequate government assistance for those who need it), you're still part of the problem. Until there are laws mandating health care coverage for all children, we're losing a battle. There are kids out there who don't get treatment for the most basic illnesses because they lack health care coverage. Maybe one of them is yours.

"Children are like flowers," they say. "You can never have too many."

If you aren't watering your garden and your flowers are dying, maybe you should rethink that assertion.

So...please! Think of the children!

Friday, October 10, 2008

Five "Myths" about Socialized Health Care

A friend of mine and I were having a discussion about "socialized medicine" the other night. After a lot of verbal parrying and thrusting we concluded at about 3:30 AM. When I woke up, I found that he had left me a message--a link to an article called "five myths about socialized health care." Here's the article. It's written by a "John Goodman."

Here's what I think about each of Goodman's "myths" and his ultimate conclusion.

Myth: "Socialized medicine gives you a right to health care."

Goodman argues that socialized medicine does not REALLY give you a right to care. In Canada, he claims, you don't have a right to heart surgery. You don't even have a right to a place in line.

In a sense, Goodman is correct. Just because the government provides single-payor insurance doese not mean that all people have the right to care automatically. That's why single-payor insurance/health care coverage is necessary but not sufficient. We need both single-payor health care AND a government declaration or law stating that citizens have a right to health care.

This argument is fallacious because it has inverted cause and effect. People aren't saying they want socialized medicine because it gives them a right to care. People are simply asserting that they have a right to care. People don't have a right to care under the current "free market" system, either.

Goodman claims that the market provides a means for people who need care more to get it--by paying more for it. He asserts that patients "waiting for care" in socialized systems are suffering. This is completely ridiculous. Hospitals in single-payor systems rank patients based on priority. The patients who are in most urgent need of care get it first. Care costs money; what Goodman is saying is that someone who really, really needs to get to "the front of the line" will magically produce as much money as it takes to get there. Where does this model account for people who really, really need to get to the front of the line but have no money for care?

Furthermore, many people are already sitting around and suffering because they can't afford medical care. Right now we are rationing care based on people's ability to pay rather than the severity of their illness. From a medical perspective, this makes absolutely no sense. You should treat the sickest patients first, not the wealthiest patients.

Myth: "Socialized medicine gives people higher-quality care."

Goodman claims that patients in Canada and the UK get worse care based on the number of patients in chronic renal failure who get dialysis or the number of patients who get coronary artery bypass surgeries. He also asserts that British doctors spend less time with their patients than American doctors.

In one study done in America (Ohio to be precise) physicians spent an average of 17.5 minutes with each patient. And it's true that physicians in Britain spent, on average, just under 10 minutes. But Goodman is exaggerating when he says that the physician barely has time to take the patient's temperature. Routine examination tasks like checking temperature and blood pressure are now relegated to nurses; doctors almost never do these things themselves.

If a patient is complaining of "coughing up yellow gunk" and "sinus congestion" and similar symptoms it generally takes about five minutes for the physician to listen to the patient's lungs and diagnose the problem appropriately because he's seen the same presentation of symptoms ten thousand times. The mean visitation time is likely skewed downward by the fact that some illnesses honestly don't take that much time to diagnose. Medical professionals report a prevalence of 62 million cases per year for the common cold; you can't really expect them to spend 20 minutes explaining proper treatment for that sort of thing.

Dialysis and coronary bypasses are strange endpoints. Dialysis is only actually medically necessary when kidney function declines to about 10%. 485,000 patients in America are estimated to have end-stage kidney disease requring dialysis or transplant; in 2005, 341,000 patients recieved dialysis, or 70% of patients with ESRD. 17,429 kidney transplants were performed, so 3.5% of patients recieved a new kidney instead (which is better).

In 2005 there were 32,375 Canadians requiring renal replacement therapy. Of these, 19,721 recieved dialysis, or 61%. It's true; this number is lower. But 12,654 patients recieved a functioning kidney transplant. So 33% of Canadians who needed a new kidney got one. That's TEN TIMES more people who recieved a new kidney, which is infinitely better than dialysis as far as patient quality of life and outcomes.

Also, we shouldn't brag about how many coronary artery bypass surgeries we're doing. The fact that people need bypasses means that preventative measures have failed. Ideally we'd do fewer bypasses because fewer people would need them because we provided better preventative care.

Myth: "Socialized medicine gives people more per dollar in terms of care."

Goodman claims that Americans don't get more care despite spending more money. He asserts that life expectancy is the primary measure used to judge "health care quality."

The WHO created a scale to assess health care quality in different countries based on five criteria:

-Overall level of population health
-Health inequalities (or disparities) within the population
-Overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts)
-Distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system)
-Distribution of the health system's financial burden within the population (who pays the costs)

So no, no one is claiming that life expectancy is the primary criterion for evaluating health care quality.

Goodman also claims that more people who get breast cancer or prostate cancer in the US survive than those who develop these conditions in other countries.

See page 4 of this document.

It is true that the US outranks Canada and England in terms of breast cancer survival rates (in fact, it is 14% higher). But the survival rates for colorectal cancer are better in the UK and Canada. Childhood leukemia survival rates are better in Canada than the US. So are kidney transplant rates, as I already pointed out. So are liver transplant rates (about 20% higher, in fact).

Cherry-picking breast and prostate cancer is dishonest. Disease survival rates, incidences, and other statistics vary from country to country. Choosing two examples where the US outperforms other countries does not prove anything in the grand scheme of things.

Myth: "Socialized medicine gives people equal access to health care."

Goodman claims that care in countries with socialized medical programs does not really offer equal access because minorities still get less care. That's a terrible thing, but it doesn't really help his point. It isn't damning that socialized medicine isn't perfect.

Goodman then cites a survey of the elderly. According to the results, the elderly think that it is easier to get care in America, that they have shorter wait times, and that services are better.

This survey doesn't prove jack the way he's citing it. It's terribly misleading because as the author is presenting it he's basically saying "more elderly people think health care is good in America, so it is!"

I found the actual study cited--"The Elderly's Experiences with Health care in Five Nations" by Cathy Schoen et al., published May 2000. Let's see what it says.

12% of polled US elderly said it was "very difficult" to get care. 15% said the same in the UK; not a huge difference, and potentially attributable to randomness. 13% of Canadians said it was very difficult to get care--again, not terribly significant. Only 6% of Australians and 9% of New Zealanders thought it was very difficult to get care.

7% of those polled in the US said they had to wait five weeks or more for nonemergency surgery compared to 51% in the UK. So? That's the point--it's "nonemergency surgery." There's less rush to get it done. Having to wait to get an appointment to remove a mole or get a vasectomy is not a serious problem.

32% of those polled in the US rated their health care as "excellent." It is true that only 25% of those in the UK did the same, but New Zealanders had the highest rate at 39%. And again, 40% of US respondants reported "excellent care from their doctors," whereas 51% of New Zealanders did.

27% of respondants in the US described their most recent hospital stay as "excellent" compared to 39% in New Zealand.

9% of US respondants complained that their hospital stay was "too short." What in the world is this about? I think a team of medical professionals is in a better position to judge when you're well enough to go home than you are, especially since the longer you have to stay in the hospital the more it costs (both you and them).

I'm not going to go into the part of the study about prescription drugs because this study was released before Medicare Part D, and I'm sure that things have changed significantly.

As far as "younger patients preferentially getting care," which makes more sense--a liver transplant for a 30-year-old or a liver transplant for an 80-year-old? Who will ultimately benefit more?

In short, the US is somewhere in the middle of the pack. We do better than the UK and Canada on some issues but are vastly outperformed in most categories by New Zealand and Australia (and they have socialized medicine there, too). All this means is that if we institute universal health coverage we should learn from the flaws of the UK and Canadian system and emulate the good parts of systems from countries like New Zealand.

Myth: "National health insurance is an efficient way to deliver care."

Goodman says that the US health system is more efficient than other systems. He first asserts that this is true because the US has shorter hospital stays than anyone else. But he just cited a study where respondants complained that their hospital stays were "too short!"

What he says is true, to a point:

A 2006 survey says that in England the average length of stay was 6.3 days whereas in America it was 4.8 days (average of all diagnoses). One day's difference, really. That's not terribly significant in the long run. And hospital length of stay is not really an appropriate sole measure of the efficiency of health care systems.

Goodman continually uses the UK as an example of a poorly-run socialized health care system. What he fails to take into account is that the UK is not the only country with socialized medicine, and it does not have the best system by any stretch of the imagination. Saying that Britain's health care system is socialized but not as good as ours in terms of efficiency does not prove socialized health care is bad, it proves that Britain's health care system is less efficient. We would have to compare America to more than one country. Furthermore, if the British model is bad, we can choose to do things differently than they do, taking examples from what works in other countries and throwing out whatever doesn't.

Goodman also asserts that when you incorporate the cost to hospitals and doctors that Medicare and Medicaid are inefficient, but he doesn't provide numbers to back his assertion.

Cato: "Capitalism will fix the problem."

No it won't.

The free market won't fix health care because as far as the "free market" is concerned there is no problem. People who can't pay for goods and services in a free market economy don't get them. Ability to pay is the primary rationing mechanism. This means that it's okay if people don't get medical care if they can't pay for it because you only deserve things you can pay for.

What medical insurance does is not provide you with health care--it protects you against the astronomical cost of health care. Insurance works by spreading out the risk of illness over many people. This is why it's cheaper to insure a whole company, where the risk is distributed over a larger group, than it is to buy private insurance. Health care is not going to get cheaper. As we develop more advanced technology it requires more specialized knowledge to be a doctor or nurse. This means doctors and nurses require more expertise and education. This translates into increased costs.

To quote someone else's words on the subject:

For most Americans, providing health care ought to be different from selling soap; they won't tolerate doctors acting like commissioned salesmen and investment bankers. And if that means having less market competition and more regulation in the health care system, it seems to be a trade-off they're willing to make.

The free market is fantastic for regulating the price of most goods. Grecian urns? They're worth whatever someone is willing to pay. Luxury cars? Caviar? Designer clothing? Pepsi versus Coke? Price is a good rationing factor for all of these things. If people won't buy Pepsi because it costs more than Coke, Pepsi can lower their prices and see if people change their minds.

If you have a heart attack you don't have time to comparison shop. There is no incentive for hospitals to charge less. If you need a drug and there are no other drugs on the market that are just as good because the only drug that treats your illness is too expensive for you to afford, why should drug companies lower their prices to accomodate you? Medicine isn't a luxury, it's a basic human need. It cannot be subjected to the whims of the market. It cannot be treated like "just another service." There is no other industry where "buy" or "don't buy" is literally a decision between life or death.

Seriously. Every choice you make regarding health care directly impacts your chance of survival. We as a society, if we value the lives of our members, cannot afford to permit people to make the wrong choices. This doesn't mean people should be treated against their will. It means that people who want care should be provided with the best care available.

Patients often have no idea how to choose which care is best--that's why they go to doctors. If you develop an infection, do you know which antibiotic to use to treat it? In a true "free market" scenario drug companies would advertise their antibiotics directly to consumers and let them choose which one to use. This would be an absolute disaster; patients would wind up choosing antibiotics based on who connected with them through advertising rather than which antibiotic would actually treat the infection. If you have trouble believing this, consider the fact that 75% of consumers purchase brand-name drugs when buying over-the-counter medications despite the fact that on average generics cost about 2/3 as much and are equivalent products. They choose the more expensive product even though it is no better than the cheaper product. They do this because of brand recognition, faith in companies that produce brand name drugs, misconceptions about generic drugs, and many other reasons.

I have a hard time with the idea that patients who won't buy generic acetaminophen because they like Tylenol better will choose the right therapy for complicated illnesses. Which insulin should a diabetic use? Which ACE inhibitors have the best data to prevent strokes and heart attacks? What chemotherapy regimen is best? Giving patients full control over these choices is a mistake because they typically do not have the information necessary to make them--and most people overestimate their ability to make the right choice. If I had a dollar for every time a patient told me they should be able to get antibiotics whenever they wanted (and pick the ones they should get) because "I know when I'm sick" I would be a millionaire.

And that's what I think.

Wednesday, October 8, 2008

One More Thing to Write your Congressman About

PalMD has pointed out yet another area of healthcare that is clearly lacking and potentially in need of intervention.

In order to know how much short-acting insulin to take, a diabetic has to insert a test strip into their glucometer, prick their finger with a small needle, and touch the drop of blood to the test strip. This is usually done (at least) on waking, before every meal, and at bedtime---at least four times per day. Thankfully, blood glucose monitors are quite inexpensive and last a long time. Test strips, however, are expensive and disposable. How expensive? Depending on the brand of meter being used, and how many times you need to test, $30-$200 per month. These strips are usually not covered by insurance.

To give a comparison, good medical treatment for coronary heart disease, which usually requires about four medications, costs around $16/month. Older forms of insulin are also rather inexpensive (but the newer ones are costly). Without insulin, diabetics die---fast. Without test strips, diabetics don't know how much insulin to use.

He's absolutely right--and this is an absurd situation. Why don't insurance companies generally pay for something that is at least as necessary as insulin itself? something about it! Write, using this link. Or perhaps this one. Do both. The first is for the House and the second the Senate.

Don't know what to say? Try starting with what Pal suggested:

Diabetes is a serious disease affecting more than 20 million Americans. Part of the treatment of diabetes is the regular testing of blood glucose levels. In order to do this, diabetics must purchase glucometer test strips, which cost around a dollar a piece, and are usually not covered by insurance. For diabetics, especially those who have financial difficulties, the cost of test strips, which can be up to hundreds of dollars per month, makes diabetic treatment impossible.

I respectfully request that you look into potential solutions for this very serious problem, and bring this to the attention of your colleagues.


Tuesday, October 7, 2008

Selected Conversation of the Evening

From tonight's work shift. This phone call left me thinking.

"Hello, thank you for calling CorpoPharmacy, this is N.B., how can I help you?"

[shrill old woman's voice] "What's the name of that disease that's going around, it's killing lots of people and everyone is getting it?"


"You know! It's that disease, everyone has it..."


"Why can't you just tell me what it is!?"

"Ma'am, you're being very vague. I don't actually know what you're asking."

"Everyone's getting it!"

" you have some idea as to what causes it?"

"NO! Nobody knows what causes it!"

"Er, no, I does it spread? Animal bites..."

[she cuts me off] "NO! You get it, it's spreading, it affects your brain, and you forget things!"


"YES!" *click*

Monday, October 6, 2008

Generics and Allergies Redux

I've covered generic drugs and their supposed inferiority to brand-name drugs before. But something came up at work the other day that made me want to take a second look at the topic.

Scenario: Male patient, age I forget, military (so he has Tricare insurance, which pays for everything except for the things that it doesn't). A middle-aged woman is driving him around and apparently in charge of his care (wife? mother? again, I forget the guy's age).

Four new prescriptions. Metoprolol XL (beta-blocker), raniditine (antacid), warfarin (Coumadin, anticoagulant/"blood thinner"), furosemide (diuretic/fluid mobilizer). All new meds for him. I guessed post-heart attack or maybe heart failure, but didn't actually ask what was wrong.

Doctor signed the Coumadin script dispense as written. Tricare won't pay for brand-name Coumadin for this patient. Other three drugs come back $0. Zero, zip, nothing, free. Coumadin comes back $55. The patient has two options: Wait for someone to call the doc tomorrow and get authorization to dispense generic or pay for the brand. For $55, I'll tell you what I'd do. He didn't; he paid the $55. Why?

"His doctor is very particular, and he has a lot of allergies, so he's going to go with the brand name. He might be allergic to one of the fillers in the generic, you know."

To the credit of the woman managing his care, she was actually pretty smart. She asked a lot of good questions and knew a thing or two about the medicines she and some of her family members were on. Best kind of patient. But here was an example of what she knew getting her in trouble, and she wouldn't be talked out of it. I had previously explained to her that it didn't matter whether he went brand or generic as long as he stuck with his choice (warfarin is a fickle mistress, and you want to be consistent).

I'd heard this line of reasoning before--once from a patient and once from a tech I used to work with. "I might be allergic to the fillers in the generic."

News flash. You might be allergic to the fillers (excipients) in the brand, too. There are probably only about two dozen different ingredients that you can put into tablets and have them still do what they're supposed to do. The brand and the generic probably differ by only one or two excipients. If you've never taken either one, you are just as likely to be allergic to a component of the brand as the generic. Generic drugs are not made with ingredients that are somehow more likely to be immunogenic.

So. Unless you know you're allergic to something (a dye, for example) and you know the brand or generic version of a particular drug contains that something there's no reason to assume you are "less likely" to be allergic to something in the brand name drug.

Another day, another victory. Generics are still the way to go, 99.999% of the time.

Retail Pharmacy: Bringing Home the Bacon

I'm afraid that I must both simultaneously agree and disagree with a recent post by The Angry Pharmacist about an issue that hits fairly close to home.

Pharmacy professors wield the term "patient care" to their students like its what brings home the bacon every pay-period. Hate to break it to you kiddies, but they are full of shit.

You know what makes the store money? Filling prescriptions. Like it or leave it, filling an Rx fills your paycheck. This precious 'patient care' where you go out front and waste your time consult Mrs Smith on how to take her atenolol for the 4th time this month ends up costing the store money in the long run because you are not filling prescriptions. Spending hours with patients may make you feel warm and fuzzy, but getting off your ass and filling Rx's is what keeps your paychecks from bouncing.

As one of those ignorant pharmacy students, I'm sure my opinion is worthless, but I think that this sort of thinking is both immensely practical and startlingly backwards.

When I settled on pharmacy as a career I was 16. No one in my family was a pharmacist. No one in my family was a healthcare professional of any sort, for that matter. What initially appealed to me was medicinal chemistry. I wanted to research the next generation of drugs, develop treatments or cures for man's most devastating illnesses, and spend most of my life in a lab surrounded by bubbling beakers.

Once I actually got into heavy lab science (analytical chemistry) I decided I hated it. I made some phone calls and arranged for a summer job at a pharmacy in my hometown. After about three weeks of working there I was solid enough on all the mundanities of the job (register duty, cleaning and organization, data entry, etc.) that I was able to start dedicating my "brain time" at work to learning about drugs.

I started learning drugs in the most disorganized fashion possible, which is probably good because my mind wraps itself around trivia and traps it forever. I asked questions of the pharmacists on duty. I pulled package inserts off bottles while I worked and read eagerly. I was lucky to have preceptors that were willing to take the time to answer my inquiries and who encouraged me to continue trying to soak up as much knowledge as I could. The "big secret" that helped everything fall into place was the pharmacist who told me that drugs in the same class have similar names (like all ACE inhibitors ending in "-pril"). Suddenly I realized that I could generalize my knowledge about some specific drugs.

What was the point of that long story?

I started out thinking I wanted absolutely nothing to do with patients because I hated dealing with people and loved chemistry. Loving chemistry translated into loving drugs. I started studying drugs in a vacuum, practically absent of other knowledge about the human body. I learned about the functions of the body based on the activity of drugs, not the other way around. This is probably the most detached-from-reality way to go about the process. The people involved were irrelevant. The drugs were cool. They weren't.

Four years later I live for patient care. Not because I necessarily like patients more, although I did discover that I'm not as misanthropic as I thought. No, I live for patient care because patient care is when I'm getting the most out of the effort I've put into learning things. Not being able to do patient care would be like telling a carpenter that he needed six years of school to get licensed but that on the job all he'd be allowed to do is hold the toolbox and make sure that the boss was using the right tools.

But N.B., you're thinking, TAP didn't say patient care was unimportant or bad. He said it wasn't profitable. "Patient care" doesn't pay the bills. Dispensing prescriptions does.

I agree that somebody does need to be paying attention to whether or not a business is making money. I don't ever want to be that person. That's why I would never start my own pharmacy, although I considered it at one point (it's also business suicide in today's climate, but whatever). I want to take care of patients without being worried about whether or not I'm filling enough scripts per week to pay my overhead, and if that makes me an empty-headed pharmacy student, so be it. Because if script volume is the most important indicator of whether or not I'm doing a good job then I am not a clinician, I'm a salesman.

Modern big-box stores and corner pharmacies are taking a loss on operating their pharmacy departments. It's the honest truth. The money is made elsewhere. How else could the big-boxes justify giving away generics at $4 or select antibiotics for free? They know the pharmacy doesn't make money; the pharmacy attracts customers. The pharmacy is not making money no matter what. What you are doing by filling more scripts is not making money, it is losing less money.

TAP's opinion on this subject is that the solution is to target the PBMs, or pharmacy benefits managers, that screw pharmacists over by reimbursing them considerably less than what they deserve. A business cannot operate by selling its product at a loss, but the PBMs essentially say something like this: "Well, you collected the patient's $10 copay and you charge uninsured patients $150 for the drug? It costs you $120 to order the drug? Yeah, we'll give you $90 + $3.50 for the dispensing fee, take it or leave it." Fix the industry regulations that let the PBMs get away with robbery and we're all good.

Because I'm young and naïve, I'm too stupid to know my ideas are bad. So here's mine. Pitch out the idea that pharmacy is a business altogether. Fuck pharmacy entrepreneurship. Stop assuming that pharmacies should operate as "drug sellers" and start thinking of them as "drug providers." The old business model doesn't work anymore. No longer does Joe the Pharmacist open his own shoppe on the corner and grind powders with a mortar and pestle all day so that he can punch capsules or roll pills. Nobody sells patent medicines anymore (unless you count the altmed scammers). Pharmacy is now ruled by giants, not Joes.

We should turn pharmacy over to the ultimate giant--the Feds. No more corpo-pharma. Pharmacists become government-salaried employees. Prescription drugs (not OTCs), patient care, whatever, they all become services funded by your tax dollars, free or practically free depending on your income level. Pharmacists already counsel for free. They're already giving away their services without collecting a dime--because it's viewed as a professional responsibility. The only thing stopping them from giving away the drugs is the perception that it's necessary to make a profit because no one will keep you afloat otherwise. Currently, that's true. But it doesn't have to be.

Laugh if you want, call me a socialist (the ultimate bad word), whatever, but at least have the courtesy to tell me why you think it wouldn't work. Spain has a system sort of like this. Germany has its own version. A lot of European countries have variations on this model; even if the pharmacies aren't government-owned, public healthcare provisions cover the cost of patient care. Clearly the government is not expecting pharmacies to "operate at a loss." If it did, the pharmacies would go out of business and there would be be no more pharmacies, which is a rather self-defeating model if the purpose of having universal health coverage is to make sure people have access to care.

I know I'm committing the error of "is versus ought" here, saying all this. But that's okay. The current fight in pharmacy is trying to keep pharmacy a working "business" under the present model. We'll never win. Pharmacy is too big now for Joe pharmacist to contain its girth. The business end of pharmacy needs to be abandoned altogther in favor of a patient-focused model.

Here's the bottom line. If you operate a pharmacy (or a doctor's office, for that matter) like a business, profit must trump patients. This is contradictory to every code of medical ethics in existence. It's true, you might take some patients at a loss in "real" practice. But there still exists a conflict of interests; as long as pharmacists are concerned about keeping a roof over their heads and worried about "the bottom line" they will never be giving 100% to the patients they serve. Healthcare is a service field. It is lucrative for many people. But ideally the point of being a doctor or pharmacist is not to get rich. It is to help people--and be sufficiently compensated so that one can live comfortably during his "off hours."

Don't recoil reflexively when someone says "socialist" or "government-subsidized." Abandon the idea that individualism--i.e., capitalism--is the best solution. You can't even start your own pharmacy anymore and have it survive; claiming that starting a pharmacy is a sound business idea at this point is utterly foolish. Quit thinking about you and how you want to run your own business which is the American dream. Stop being a selfish prick and put your patients first!

And if that's not why you went into healthcare, leave. Because we don't want you here.

Friday, October 3, 2008

Thought Experiment

What if more things worked like health insurance?


DISPATCHER sits over a bank of computer terminals, nervously adjusting his headset. He reaches for a volume dial. CHIEF sits at a table in the background behind Dispatcher, nursing a cup of coffee.

DISPATCHER: Chief, we're getting a call. It's the Taylor house on 38th.

CHIEF: Mmm. That's too bad. Nice place. How's their coverage?

DISPATCHER: They don't have any, sir. Their policy was cancelled two months ago when Mr. Taylor was laid off.

CHIEF: What!? They didn't bother to get private coverage? How irresponsible can Mr. Taylor be?

DISPATCHER: Well, they said they couldn't afford the premiums. And Mr. Taylor is a smoker. You know what that does to rates. Besides, with the deductibles on the private plans, they'd have to burn down two houses before we picked up anything.

CHIEF: Yeah, you're probably right. Well, that settles it. We can't afford to respond. The risk of not receiving payment is too high. We can't operate a business like that.

DISPATCHER: Too true, sir. Actuaries are in full agreement. And the initial assessment is sound. The house is too far away from neighboring property for the fire to be contagious. It'll burn itself out without any trouble.

CHIEF: Oh, good. No worries about liability. I'll take the call. (dispatcher presses a button on the console) Mrs. Taylor? I'm sorry, but we're just going to have to let your house burn down.

MRS. TAYLOR's voice breaks in over the intercom.

MRS. TAYLOR: (clearly distressed) baby is in there! You have to save my baby!

CHIEF: I'm sorry, ma'am, but we just can't help you. Why don't you call the emergency fire department? They're required by law to come help, even if you don't have coverage.

MRS. TAYLOR: But everyone's calling the emergency fire department lately! It could take them hours to get here!

CHIEF: Well, Mrs. Taylor, I'm sorry to say this, but we wouldn't have that problem if people would just be responsible and make sure they always had fire insurance. This is America, and people have to be willing to be accountable for their own bad decisions. We can't make the taxpayers bear the burden of a few careless people whose houses catch on fire. (he coughs) Especially smokers like your husband. It's just a disaster waiting to happen.

Mrs. Taylor continues to weep in the background. The Dispatcher and Chief exchange glances, shrug, and terminate the connection.

DISPATCHER: I really think that the free market has done wonders for the firefighting industry. We spend so much less time answering unnecessary calls.

CHIEF: It's like my father always said. There's nothing that can't be improved by privatization. Who wants the government interfering with our lives?

DISPATCHER: Yep. Besides, there's no "right to firefighter services" listed anywhere in the Constitution. America really has become a nation of whiners.

CHIEF: You said it. You want a cup of coffee?

DISPATCHER: Cream and two sugars, please.

Wednesday, October 1, 2008

Student Finds Classical Reporting on "Holistic" Medicine Still Lacking Critical Rigor

The rise of "alternative medicine," if you can claim that it has risen at all, has mostly been due to word of mouth and unwarranted exposure by an uncritical press. Seeing as how CAM itself never actually changes, it should be no surprise to anyone that neither does reporting on it. We hear the same fallacies, the same appeals to authority and tradition, and the same overweighting of anecdotal evidence over and over again.

So I wasn't even a little shocked at this typical article on the common cold. asked four holistically minded doctors what they do when they feel under the weather. Their prevention and treatment advice might help you dodge or short-circuit the next bug that comes your way.

I'm not even entirely sure where to begin. "Holistically-minded doctors?" What does that even mean? Proponents are going to spout some gibberish about doctors that "treat the whole person, not just their symptoms," but let's see what these doctors recommend to "treat the whole person."

Let's start with Dr. David Rakel, MD.

There's no firm evidence that any medication or herb will prevent the common cold, said Rakel.

Hey, cool, he's actually concerned with whether or not there's evidence for the stuff he suggests!

At the first sign of symptoms, the goal is to attack the virus early because it replicates the most within the first 48 hours, pointed out Rakel. He might drink more green tea, which appears to have antiviral and antibacterial properties. And he would also drink three big glasses of orange juice to get more vitamin C...

...besides consuming more liquids, Rakel might take 20 to 30 milligrams of zinc acetate lozenges twice a day to improve his immunity. He takes zinc only for the first two or three days of a cold, when he feels it's most effective. He might add andrographis, an herb that's sometimes called "Indian echinacea." He would take 400 milligrams of this immune-stimulating herb three times a day.

That's why when it comes to his own health he takes a shotgun approach and tries everything that has ever been suggested for treating the common cold. Vitamin C, zinc, green tea (antioxidants), and "Indian echinacea," which must be better than "Western echinacea."

At least Dr. Rakel gets an annual flu shot, but he bemoans the presence of thimerosal in flu shots. I guess the fact that thimerosal-free flu shots is not important to him, or maybe he just thinks the CDC has it all wrong.

Strike one, MD's out. Who's next? Lynne Shinto, ND. You can probably guess where this is going.

She says she thinks that too much sugar can weaken immunity...when she gets a cold, her philosophy is to let it run its course. She'll turn to the usual suspects: bed rest, more fluids and chicken soup -- or because she's Japanese-American -- miso soup with shiitake mushrooms, fungi known for their immune-strengthening compounds.

Go Lynne! You strengthen that immune system! Is that the humoral or cellularly-mediated immune system? What do you mean you don't know? You're just sure it works? Well, as long as you're treating the real cause of disease instead of just addressing symptoms, like a good holistic doctor.

These approaches may make the symptoms feel better, she admits, but they likely won't make a cold go away faster.

Oops. I guess not. So you fail at both science and pseudoscience.

If Shinto's sinuses are congested, she turns to an "old naturopathic therapy" thought to stimulate the immune system. Called hydrotherapy, she might stick her bare feet in hot water for three minutes then in ice-cold water for 30 seconds, and she repeats this hot-cold sequence three times.

This is a fantastically plausible treatment for nasal congestion. Maybe the alternating peripheral vasoconstriction and, this really is so implausible as to not warrant investigation.

What about another MD's perspective? Surely a second opinion is worthwhile. Dr. Kevin Barrows?

He's a big believer in meditation and has found this mind-body approach helps increase his awareness of subtle body shifts, a tip-off that he may be getting sick. For him, a sore throat is his early warning sign of a cold, his cue to start taking echinacea.

That's great, doc. I'm glad that you can recognize one of the most common symptoms of the common cold as...indicative of the common cold. But he didn't learn that in medical school. No, he figured it out through meditation! Once he determines that his chakras--er, his throat hurts--he knows it's time to start taking echinacea, the herb that a Cochrane review states "shows inconsistent benefit."

Sixteen trials including a total of 22 comparisons of Echinacea preparations and a control group (19 placebo, 2 no treatment, 1 another herbal preparation) met the inclusion criteria. All trials except one were double-blinded. The majority had reasonable to good methodological quality. Three comparisons investigated prevention; 19 comparisons investigated treatment of colds. A variety of different Echinacea preparations were used...

...there is some evidence that preparations based on the aerial parts of E. purpurea might be effective for the early treatment of colds in adults but the results are not fully consistent.

I know that whenever I have a problem, I'm willing to rush out and spend money on things that "might work."

Outside of a mental health context, I know that if I ever had a doctor who suggested "meditation" as a serious method for identifying or treating any illness I'd pull up my pants and walk out the door. Three doctors I'd never want to visit--assuming that their beliefs are being accurately portrayed in this article. Well, what about Dr. David Leopold, our fourth contestant?

At the first sign of a cold, Leopold treats his symptoms extremely aggressively. His goal is to support his immune system so that it helps clear the virus and slows down the spread of symptoms.

He takes zinc gluconate lozenges, drinks plenty of herbal tea and also uses a liquid tincture of echinacea. Despite research that questioned the herbs' benefits, "I'm convinced that most of the well-done studies of echinacea suggest it seems to be effective for reducing the severity and duration of a cold."

Just what I need, a doctor who flunked both statistics and immunology. No thanks.

The thing is, I'm not entirely sure that the blame is entirely on the doctors being quoted here. Now, granted, I don't think that their words (or positions) are being fabricated; I'm sure that, when interviewed about their "holistic medicine" use, all of these doctors (and the naturopath) volunteered honest information.

But here's the problem. This "sound-bite medicine" doesn't actually leave room for--or invite--serious discussion of anything beyond "some doctor said you should try this." And, in the interest of "unbiased journalism," the reporter behind this story didn't bother to fact-check any of the claims made by the doctors. After all, they're just harmless claims; the article isn't about "what is good medicine" but rather opts to provide some opinions by licensed medical practitioners.

Unfortunately, this approach is seriously misguided. Most people think of physicians of all stripes as having a good, solid understanding of medicine, and this implicit trust that doctors know what they're talking about is crucial. If patients think doctors are idiots, why would they ever solicit one for an opinion? The drawback to this is that off-the-cuff "opinions" about vitamin C, echinacea, or other various treatments that don't stand up as effective under serious scrutiny reinforce the misconception that these treatments actually work. Just try telling a patient whose doctor takes vitamin C that vitamin C doesn't treat or prevent colds. "If it doesn't work, why does my doctor do it?" What surprised me about this article is that it didn't even contain the "token skeptic" interview, but then, the article is subtitled "what alternative medicine experts do when they get sick."

Physicians who succumb to non-evidence-based thinking do more than harm themselves. They drag down patients with them, even patients they'll never meet, because their endorsement of unproven remedies assures that these treatments will never die out despite the immense evidence against their efficacy. As long as there are doctors promoting these remedies, no amount of double-blinded, well-controlled, properly randomized research is going to convince the public that they aren't effective--because their doctors, expected to be the gatekeepers of knowledge, are ignoring it.

Friday, September 26, 2008

But Doctor, I NEED Antibiotics!

How often do you go to the doctor? What prompts you to seek care?

For many people, the answer to that question is "at least once a year" and the reason is upper respiratory tract infection (URTI). Because of the amount of time and effort involved in isolating precisely what is causing an upper respiratory tract infection, doctors quite frequently prescribe unneeded antibiotics:

Various bacterial respiratory infections were diagnosed during 6.5% of physician office visits in 1999. One or more antibiotics were prescribed during 51.0% of those visits. The probabilities of resistance to the most frequently prescribed antibiotics varied from 20% to 40% and showed a weak positive correlation with the frequencies of antibiotic prescriptions.

It is a well-established fact that a huge percentage of antibiotic prescriptions are dispensed for conditions where they will have no effect, such as the common cold, simply because doctors feel that they have some obligation to write patients a prescription--or because the patients pressure the doctor and insist that they need an antibiotic.

But statistics released in this month's Pharmacist's Letter make the issue very clear. Overtreating with antibiotics does more harm than good.

There's only a 1 in 4000 chance that an antibiotic will help most acute upper respiratory infections.

But there's a 1 in 4 chance of diarrhea...a 1 in 50 chance of a skin reaction...and a 1 in 1000 chance it'll cause an ER visit.

...antibiotics [overuse] can also lead to more resistant infections that are harder to treat.

Now, as always, I encourage readers who believe that they might be suffering from any illness to consult their physicians. But think about those numbers for a second. There's only a 0.025% chance that it's going to do you any good to beg your doctor for an antibiotic prescription. The odds that you will wind up in the ER because of a bad antibiotic reaction are higher than the odds that the antibiotic is going to do you any good.

This does not mean that you should avoid antibiotics at all costs, believing that the risks always outweigh the benefits, because that is patently untrue. Keep in mind that these numbers only pertain to (generally non life-threatening) respiratory infections. What this really mean is that you should ask your doctor to be straight with you, especially if you are going to the doctor because you're coughing up phlegm or have a stuffy head. "Do you really think I need an antibiotic?" Make it very clear that you will take no for an answer if it is that physician's professional opinion that you don't need one. They didn't go to school for nothing.

Tuesday, September 23, 2008

Adding to the Growing List

Epididymal Superinfection needs to be the name of a band.

Monday, September 22, 2008

Like Decaf Coffee, but More Dishonesty

I got a kick out of this article about a "new" dietary supplement that supposedly contains the FDA-banned stimulant ephedra while still being legal through various loopholes:

Garza, a bodybuilder who nearly won the Mr. USA competition in 2004, said XP2G is manufactured for his store by a private lab.

He said his pills are made from the same plants used to make traditional ephedra products but lack the ephedrine alkaloid chemicals named in the bans.

Garza said because XP2G lacks those particular chemicals, it does not present the same risk of side effects as traditional ephedra products, and it is not in violation of the bans.

Hmm. So it contains "ephedra" but it doesn't contain ephedra. Do you follow?

Ephedra is actually the name for a genus of plants. Extracts from the Ephedra sinica plant, known in Chinese medicine as ma huang, contain the stimulants ephedrine and pseudoephedrine (yes, the same stuff that's in Sudafed). The popularity of ephedra stems from its so-called "thermogenic" properties--it increases heart rate and blood pressure and raises blood sugar by stimulating the sympathetic nervous system. Most people know the sympathetic nervous system as the system responsible for the "fight-or-flight" response. Essentially, ephedrine acts on the same cellular receptors that epinephrine does. Epinephrine, if you aren't aware, is the same thing as adrenaline; they're just different names for the same chemical.

So what Garza is claiming that his proprietary formula contains parts from ephedra--the plant--but not the alkaloid stimulants that make ephedra "worth" adding to diet pills in the first place.

Why would you do this? Well, because, as I've previously stated, most people don't read anything beyond the front of the bottle when they're buying drugs or supplements. By being able to put "new and improved! Totally contains ephedra!" on the packaging, Garza will sell more product, especially to consumers who liked the old ephedra products that are now subject to FDA ban. What those consumers probably won't realize is that they're being scammed even worse than they were before; the manufacturer is using some loophole to claim the formulation contains ephedra when it doesn't contain the chemicals that make ephedra desirable. It's a bit like selling "coffee" to caffine junkies on the basis that your product "contains real coffee extracts!" without letting on that your product is actually decaf.

More troubling is the fact that Garza may, as they say in France, be totally full of merde:

University of Maryland professor Dr. Fermin Barrueto said legal ephedra is only a marketing gimmick. He said the only way to remove banned chemicals from ephedra is through a complicated extraction process that manufacturers are unlikely to perform.

Which means one of two things: The manufacturer is lying about including ephedra (and not including it, but listing it on the label anyway), or the manufacturer is lying about lying about including ephedra (including it despite it containing the banned alkaloids).

As they said in Smash TV: Big money! Big prizes! I love it!

It's Ozone Action Day: Don't Use Your Inhaler

Do you remember the CFC reduction efforts that went into effect in the latter half of the 20th century? CFCs, or chlorofluorocarbons, are a class of compounds that were traditionally used as refrigerants, solvents, or propellants in aerosol spray cans. When scientists determined that CFCs were contributing to the hole in the ozone layer. CFCs participate in a reaction with ozone where they act as a catalyst--i.e., they are not used up--that breaks ozone down into oxygen gas. Because individual CFC molecules are not used up in the reaction, a single CFC molecule may continue to break down thousands of ozone molecules over its lifetime.

What does this have to do with inhalers? By the end of 2008, CFC-containing inhalers will no longer be sold.

Traditional inhalers used to treat respiratory diseases like asthma used CFC-based propellants to deliver an aerosolized spray of medication directly to the lungs. But the time has come to phase out the old inhalers and replace them with new, more environmentally-friendly alternatives. The replacements, HFA inhalers, are just as effective as the old standbys without causing damage to the ozone layer or contributing to greenhouse gas production. The switch is a good thing, on the whole.

For once, Pharma is releasing a bunch of variations on their old products that aren't just a scam to extend their patents. They're actually doing something to help the environment. Y'know, aside from the fact that they're doing so because of Federal mandate.

There are a few minor issues that must be addressed. The new inhalers are just as good as the old ones, but FDA regulations consider them to be different, non-equivalent drug formulations. This means that you can't simply switch back and forth from CFC to HFA--in most states, the physician who writes the prescription must specify that the inhaler to be dispensed is an HFA inhaler. HFA inhalers are also going to cost slightly more--about $50 versus $30 for the old inhalers. But many manufacturers are distributing coupons that might help reduce costs for patients making the switch.

So if you use an inhaler, be prepared--you're going to have to switch, and soon. But the sooner the better, really. With every puff you're taking on an HFA inhaler instead of a CFC inhaler, you're contributing to the efforts to repair the ozone layer. That's like saving the world, one inhalation at at time.

Sunday, September 21, 2008

New and Improved! Now With Even MORE Sodium!

Er, wait a minute, I'm not advertising Grandma Georgia's Lard-o-hardtack, I'm throwing Mike the Mad Biologist another set of major props.

There's just no way I could've said it better myself. Mike is nailing this healthcare thing lately.

...the key point is this: people don't want exciting 'health insurance products', they want adequate care when they are sick. Also, how are we supposed to choose the 'right' healthcare...

...none of us have any way to evaluate if the insurance we have picked will provide the healthcare we need if something disastrous (or even mildly annoying) strikes. I have no idea if something bad happens (and there are many kinds of 'somethings bad') whether my plan will provide the healthcare I need. Would I have access to the specialists I might require? Which treatments would be covered, and for how long?

Tonight, I raise my scotch glass to you, Mike, for a succinct and elegant explanation of everything that's wrong with McCain's vision of healthcare.

Also, Chuck Dupree, a commentor on Paul Krugman's blog, has hit the nail on the head and driven it through the board with one swift stroke:

Add me to the list of those who can’t figure out why we’re talking about insurance. I don’t want insurance. I want health care, and I don’t see why insurance companies should be involved.


St. John's wort is to pharmacists what garlic is to vampires. It is the most evil herb ever conceived.

I swear that if you hung a sprig of the plant somewhere you could probably repel all the pharmacists within fifty feet. Keep this in mind if for some reason you ever need to keep pharmacists from approaching you.

Friday, September 19, 2008

Caveat Emptor: Drugs and the Free Market

First reported (within my circle of sources and reading material) by PalMD of denialism blog, the FDA is cracking down on the sale of many unapproved "cancer cures" being sold online and elsewhere. This, in itself, is excellent.

It is also a fantastic example why trusting the free market to solve all problems is a completely bogus idea.

I always come back to healthcare whenever I want to talk about the free market. This is partly because healthcare is what I know; I am much more capable of talking about the prices of drugs (in particular) and medical services than I am talking about the prices of various other products because I'm surrounded by them. But, more importantly, the healthcare "market" is a spectacular example of an area where "natural market forces" are completely insufficient regulation.

The short answer for why this is is that the costs of healthcare services are not always clear up front, so there's no way to "comparison shop." You usually get treated and worry about how much it will cost later, especially in an emergency situation. The capitalist model of self-regulation requires consumers to be able to discern the cost of services in order for it to make any sense. How can you be an informed consumer if you can't evaluate the cost or the utility (worth) of goods?

Sure, this is true on some massive scale when we talk about hospital stays and surgeries, but the problem with those is that the only consumers who actually know what they cost are already bankrupt because of them (everyone else is insulated from the scary truth of the real costs thanks to insurance companies). But those are the big-ticket items of the healthcare world. And you might argue that in some cases that they're often essential to the point where price is no object, because most people would rather pay any amount of money than die. (They might regret this decision later when they're being suffocated by hospital bills, but few rational people are going to say "nah, let me die, saving my life will cost too much.")

So let's talk about small out-of-pocket expenses of non-urgent matters.

Buying drugs is, in many cases, like buying any other good. There exists genuine competition in the market, especially when we're talking about non-prescription items. Should I buy Alavert or Claritin? Benadryl or the "store brand?" Which pain reliever do I choose? The fact of the matter is that 99.9% of the time all of these goods are equal. It doesn't matter, from a medical perspective, whether you buy Claritin or Alavert. They're the same drug. The only reason consumers might prefer one over the other is because of advertising and brand recognition--this is a "Coke or Pepsi" scenario.

Most consumers know that Coke and Pepsi are equivalent products (more or less). Sure, they might have a preference for one over the other, and that preference might even stand up to blind taste-tests. But how many consumers really know that the "store brand" is as good as the brand name when it comes to drugs?

If marketing research is any indication, the answer is not many. In 2005, generic versions of OTC drugs made up only 23.4% of the market share. Conversely, generic prescription drugs made up over 75% of the market share. Hmm. Why might this be?

When filling a prescription, most pharmacies will automatically substitute the generic if one is available as long as the physician has indicated that such a substitution is acceptable. Some states (Massachusetts, for example) actually mandate substitution unless the physician indicates otherwise. It's easy to see why generic prescription drugs predominate the market. Many commonly prescribed drugs are more or less only available as generics; the brand names are no longer made or no longer carried by pharmacies (how many people really care about getting brand name Amoxil?). I think it is safe to say that one major reason generic drugs predominate in the prescription drug market is that patients are not actively involved in the brand versus generic decision. They are leaving the decision to someone who is more educated about the product they are buying. The doctor and the pharmacist both know (and will reassure the patient if necessary) that the generic is just as good as the brand for a fraction of the cost.

Letting your pharmacist substitute a generic to save you money is kind of like getting insider information on stocks or letting your broker decide where to invest your money. You're not stupid for consulting your broker. You're smart. You're using your broker's expertise to your advantage. He probably knows a lot more about the stock market than you do, and you will make more money if you let him help you.

There's also the fact that the price difference between brand and generic in the prescription drug market is pretty large. Consider lisinopril, a drug used to lower blood pressure, prevent recurrent strokes, and protect the kidneys of diabetics. Generic lisinopril costs about 50 cents a tablet. The branded product costs twice as much. Cholesterol-lowering simvastatin's (Zocor) generic is about $2 per dose. The brand is about $5. Does it really make sense to pay twice as much for something if you don't have to? Of course not. Consumers aren't stupid.

The short story is that about 75% of consumers, given what amounts to "expert advice," will pick the cheaper prescription drug product. So why do only 25% of consumers pick the cheaper generic when making an OTC drug purchase?

The same reasons why they would choose a branded drug if there weren't a pharmacist between them and their prescriptions.

Brand reputation. Perception of generics as inferior products--misconceptions about quality, purity, and efficacy. Prior "bad experiences" with a generic drug. Inability to pronounce the generic drug's name (yes, I'm serious). And people are suspicious about the origins of "store brand" drugs. I'm not sure where people think they come from--they're made in the same factories and held to the same manufacturing standards as the brands.

There's limited standardization in naming generic OTC drugs. Because drug chains can't rely on brand recognition the same way ("Claritin is for allergies, I saw it on TV") most generic OTCs have very...generic...names. "Non-drowsy allergy relief." "Non-aspirin pain reliever." "Stomach acid relief." I kid you not when I say that there are probably half a dozen products on a given pharmacy shelf that have some variation on the phrase "cold symptom relief" as their only name, leaving the consumer to decide which product to purchase.

If the consumer does not first consult an "expert" (the pharmacist), they is left using the same reasoning tools that affect their decision about brand-name drugs. Anecdotally, I would say that most consumers don't know the active ingredients in their preferred OTC cocktails. They know the color of the box. They know what the product is called. And, most important to the consumer, they know what worked last time they were sick. They want that again, whatever it was, even if it's the wrong drug for the symptoms they have this time.

(Walgreens is brilliant in this regard by shoving the "Wal-" prefix in front of all their generic names. I get a lot of people who ask me for Wal-itin. I don't work for Walgreens. Our Claritin generic is obviously called something else. Many of them don't even seem to realize that Wal-itin is Walgreen's name for their Claritin generic--they think Wal-itin is its own unique drug, brewed in some secret Walgreens facility.)

The price difference between brand and generic OTC drugs seems smaller, which is another major factor. A box of 50 Tylenol costs $6.50 at Walgreens. A box of the generic costs $4.50, $2 less. Normally, when someone offers you the same product at a lower price, you take it. The generic market should be totally destroying Tylenol sales, but McNeil Consumer Healthcare still sold $129 million worth of their flagship product, "extra-strength Tylenol tablets," in 2003. That doesn't include sales of the popular Tylenol PM, Tylenol Cold, or liquid Children's Tylenol. The sum for all these product lines from 2003 is about $242 million.

Think about that for a second. Consumers spent an average of $2 more per purchase to buy products with the Tylenol brand name so frequently that McNeil made $242 million dollars. And they did it for the reasons I've already mentioned above--or perhaps others. Marketing experts spend their whole careers trying to understand and capitalize on this stuff; my understanding of it is very basic.

This isn't like buying generic foods, where you might get something you don't like as much as the brand product. The generic drug industry is tightly-regulated by the FDA. You can't sell generic drugs that are inferior to the brand names, unless your definition of "inferior" is different from the FDA's. The drugs have to work just as well.

You could argue that consumers might be buying the brands over the generics because of factors other than how well they work as drugs. Sometimes brand name drug tablets have coatings or flavorings that make them taste better than their generic counterparts. Maybe the packaging is easier to open. Some people are legitimately allergic to certain dyes or additives that might be present in the generic that aren't in the brand (but this is extremely rare). But this probably wouldn't account for 75% of consumers choosing brands over generics.

No, the short answer to why consumers choose branded products when buying OTC drugs is that they don't actually have all the knowledge necessary to make an informed purchase.

Man, that was long-winded. Let's come back to the original point of the entry.

If consumers aren't making informed decisions about whether to buy brands or generics when making OTC purchases, who the hell thinks that consumers will be able to make informed decisions about how to treat their own cancer?

I'm not talking about violating patient autonomy here. Patients should never be forced to accept treatments against their will. Patients should talk with their physicians and discuss treatment options, then choose whatever they feel is most acceptable. But it is up to the doctor--who has many more years of education on the subject--to lay out the options. If the patient believes that there is an option that the physician has not mentioned, he or she should certainly bring it up.

But when physicians say "no, I don't think that's a good idea," the answer is not to go ahead and do it anyway. By all means, ask for a second opinion. You're entitled to one. But do not decide that somehow you are more qualified than a trained oncologist to choose your own cancer treatment. You are not. Ignoring the advice of experts to pursue the beat of a different drum to your own detriment isn't individuality. It's idiocy.

This is why holding up "freedom of choice" when talking about unproven (and often highly suspect) treatments for cancer or any other disease is a bullshit move intended to distract from the real issue at hand. Your doctor telling you that herbal tea will not cure your cancer is not oppression. Shutting down salesmen who commit fraud isn't oppression, either.

But in the worldview of the champions of truly deregulated free-market medicine, the consumer is granted a delicious variety false empowerment. You have the right to choose any treatment you want--even those that don't work. And if you choose treatments that don't work instead of those that do, well, caveat emptor. May the buyer beware. All sales are final and non-refundable. The only person you have to blame for getting scammed is yourself. And this is disgusting.

So go ahead. Fight for your freedom to get ripped off. The primary characteristic of the free-market is that it's self-correcting, right? Frauds will eventually be exposed and people will stop buying their products.

But how many people should be allowed to die before we say "enough is enough?"

Abortion Issue Major Deciding Factor for Catholic Voters

I realize that this is probably kind of like saying "water issue major deciding factor for fish voters," but:

Many "small-town Catholics" are opting to support McCain on the abortion issue alone. Or so they say. That can't be the whole picture:

One parishioner ruled out voting for Mr. Obama explicitly because he is black. “Are they going to make it the Black House?” Ray McCormick asked, to embarrassed hushing from a half dozen others gathered around the rectory kitchen. (Five of the six, all lifelong Democrats who supported Mrs. Clinton in the primary, said they now lean toward Mr. McCain.)

Man, you can still say things like that in public without being ostracized for being a terrible human being? We sure have made progress in America these past 50 years or so.

Many parishes distributed a voter guide, produced by an outside conservative Catholic group called Catholic Answers, which identified five “nonnegotiable” issues for faithful voters: abortion, embryonic stem-cell research, human cloning, euthanasia and same-sex marriage.

I think that's pretty stellar. It's totally acceptable to re-elect a member of a political party whose flawed policies have sent our economy down the tubes. We should definitely consider with seriousness a candidate whose health care plan is no health care plan at all. We should get behind a man who doesn't seem to realize that "clean coal" technology doesn't fix the fossil fuel reliance problem.

We should do all of these things because we care more about blastocysts than ambulatory human beings and the idea of gays having proper civil rights is just terrifying.

America the beautiful.

(H/t Mike the Mad Biologist).

Wednesday, September 17, 2008

Doing One's Duty

Most people have heard of the Hippocratic oath. Physicians traditionally took the oath upon graduation. Some parts of the oath are less applicable today; I think a lot of people would object to swearing in the name of a bunch of Greek gods. And while some doctors may not want to perform abortions, I think that it's unlikely that anyone is going to prescribe insertion of a silicone ring as a method of doing so. You get the idea.

But did you know that there's a pharmacist's oath? And a written code of ethics?

The oath is pretty brief. But that's good. It's concise. Here's what it comes down to: You, as a pharmacist, have obligated yourself to serve people. You're going to do this by knowing lots of stuff about drugs.

Likewise, the code of ethics is pretty to the point. You're going to serve patients, and you're going to do your best to be fair about it. You're going to respect and utilize the knowledge of other professionals. And you're going to respect your patients' autonomy.

So why do so many pharmacists think that it's somehow acceptable to refuse to dispense contraceptives?

Now, what I think this guy (Koelzer) is doing is stupid. But in one sense, he's doing this the right way. He's started his own pharmacy. He is not asking businesses that he does not own to make a special exception for his religious beliefs. If people want to patronize a pharmacy that refuses to stock contraceptives, it deserves to stay open as much as a pizza parlor that won't stock non-Kosher toppings. It would be an unfair imposition to tell Koelzer that he has to shut down his pharmacy, because he has the right to run whatever kind of business he wants. It would be wrong.

Koelzer might be a good business owner. But is Koelzer a good pharmacist?

I don't think so, because he's violating the pharmacist's code of ethics. He's violating his oath. He swore to make patient care his first priority--and he isn't. Guaranteeing women control over their own reproduction is patient care. It's not some kind of luxury. Koelzer might say that if women want to control their reproduction that they should refuse sex. But that's not respecting his patient's autonomy, either. His patients in search of contraceptives have clearly decided that they would like to have sex. A lot of people who use contraceptives are married, so this isn't just about sinful, blasphemous fornicators.

So if you want contraceptives, you won't go to his pharmacy. He owns his own business. It's his right not to offer them, and it's your right to shop somewhere else.

But he's still a bad pharmacist.

Monday, September 15, 2008

ScienceDebate '08

McCain responds to ScienceDebate 2008. Obama answered the questions a while ago; you can also read a side-by-side comparison.

I've decided to summarize each question and the candidate's responses in addition to providing my own thoughts on their responses.

1: Innovation. How will each candidate encourage innovation in science and technology?

Obama: Service scholarship program intended to pay the costs of college for students committed to teaching in high-need areas after graduation. Increase National Science Foundation graduate fellowships. Provide all Americans with broadband internet. Make R&D tax credits for businesses permanent.

McCain: Increase capital by lowering taxes, ideally broadening the infrastructure for technological development. Appoint a Science and Technology advisor to the White House to increase scientific integrity of policies. Eliminate earmarks and allocate some of the money to sci-tech investments, including funds for emerging fields (biotech, nanotech, etc). Reform science and math education. Create employment in rural areas with technology. Meet with academics and business leaders to develop a global agenda.

Pretty much what you would expect from party politics. Obama is focused on getting individuals educated and encouraging them to become teachers; McCain is primarily concerned with businesses and big R&D firms.

2. Climate change. What do you think about existing measures to address global climate change; what other policies would you support?

Obama: Anthropogenic global warming is happening; US needs to decrease greenhouse gas emissions. Market-based cap-and-trade system with the goal of reducing emissions by 80% of 1990's levels by 2050. All "pollution credits" must be auctioned by the Federal government. Cooperate with UN and other countries to reduce emissions. Create Technology Transfer Program dedicated to developing green technologies.

McCain: Notes that greenhouse gas emissions threaten to alter climate. Proposes a cap-and-trade system. Goal is reduction of greenhouse gas levels to 60% of 1990's levels by 2050. Wants to increase penalties for violating minimum gas mileage standards by auto manufacturers. Tax credit of 10% of R&D funds to green entrepreneurs and 2 billion USD/year for the next 15 years will be spent on clean coal research. The first company to develop an emission-free automobile will recieve a $5000 tax credit per vehicle sold. Suggests offering a $300 million prize for the development of a battery that will fully supply an electric car.

McCain's cap-and-trade system has a huge hole--he wants to give away "pollution credits" instead of auctioning them, which defeats the purpose of cap-and-trade. The whole point of C-a-T is to create artificial scarcity by inventing an imaginary resource.

Consider a physical resource like oil. There is a limited amount of oil, and oil costs money, so companies want to use as little oil as they can get away with because being wasteful cuts into profits. Conversely, there is no limit to how much pollution a company can put into the air (short of some point where air quality decreases to where people start dying). What incentive is there for companies to reduce emissions, especially if it will cost them more money to do so? C-a-T creates scarcity by turning "amount of pollution you're allowed to produce" into a commodity--like oil. If you have more "pollution credits" than you need, you can sell them to other companies, much like you could sell any other commodity you accidentally bought too much of.

Suppose the government auctions off 80% of available pollution credits. How do you decide who gets the rest? If the government is going to just give them away, who gets them? Short answer: Whoever lobbies the hardest. True, you have to pay lobbyists to lobby, but the system rapidly becomes crooked. Instead of giving pollution credits to whoever is willing to pay the most, you're giving credits to whoever is most influential with congress. Since the whole point of the system is to give companies an incentive to "stay green" because they have to pay for the pollution they put into the atmosphere it should be pretty easy to see why being able to lobby for more credits destroys the purpose of C-a-T.

Obama's Technology Transfer Program is supposed to encourage the export and trade of green technologies (see page 10-11). The technologies will be ideally traded freely between developing countries to reduce global emissions. Sounds pretty good, but lacking in specific details. Then again, I'm not sure how specific you can get in an 11 page "fact sheet." I think that the idea is to provide green tech to countries like China in exchange for whatever they're able to give us in return--if nothing else, it's a gesture that says "the US cares about reducing emissions." It's pretty hard to convince developing countries to do that when we aren't.

I have mixed feelings about research prizes. They make sense from one perspective; offering a "bounty" on a particular tech development may spur people to think about the problem who previously hadn't. Sometimes research prizes even create entirely new fields. The problem is that research prizes mean that a lot of people who want to research the problem but don't have the money to start researching can't do anything, even if they have good ideas. It also punishes researchers for every failed attempt; the cost of prototypes and whatnot is ultimately subtracted from the prize money. This means that research prizes are biased in favor of preexisting entities that can afford a greater initial investment to win the prize. If a start-up business gunning for a research prize ultimately spends more money than the prize is worth getting to the desired solution, the company is going to flop and everyone who invested in it suffers a huge financial loss. If a big company spends more money than the prize is worth they can probably afford to abandon the "competition" and focus on other projects. The drug companies do this all the time, in a sense--every drug that doesn't get approved is a huge loss, but they eat it and move on, whereas a start-up that tried to do the same thing would go out of business.

Another issue is that you can't measure the value of all scientific research on whether or not it solves a problem outright. Many times science is a stepwise process; assuming that only one arbitrary endpoint is valuable is a mistake. Also, prizes for specific projects creates an artificial demand that will skew private research budgets toward solving problems that someone (i.e., the Federal government) has decided need solved. Doesn't this go against promoting innovation by "setting an agenda" instead of letting individual firms decide what to research?

3. Energy. What are your thoughts on developing economically and environmentally sustainable energy solutions?

Obama: More federal research dollars for alternative energy ($150 billion over the next ten years). Research dollars should go toward alternative fuels, energy-efficient designs, advanced energy transmission and storage tech, greenhouse gas-sequestering tech, and nuclear power. Increase fuel economy standards 4% per year. Provide loans to automotive industry to build fuel-efficient cars domestically. Increase building efficiency by (50% new buildings, 25% existing buildings). Require 10% of American energy to be derived from renewable resources by 2012 and 25% by 2025. Expand mass transit.

McCain: Reform energy economy "over time." Build 45 new nuclear reactors by 2030. Reform tax credits in favor of renewable power; existing tax credits have been "patchwork" without solving the problem. The market can decide which ideas will move us toward clean energy. Commit federal government to "green tech" agenda. Reduce greenhouse gas emissions (see point 2).

I have to give this one to Obama. His plans are more concrete by a longshot. He wants to set hard limits intended to improve efficiency and renewable energy use; McCain seems to think that the market will solve the problem. The market hasn't solved the problem; people are going to use fossil fuels freely as long as they believe the supply is large enough and they can afford them. Investment in alternative energy over the past several years has gone up, but the oil industry is still the biggest energy industry in America. We can't afford for the end of oil to be in sight before we solve the problem of what we're going to do when we run out--we have to be prepared well in advance.

Increasing nuclear power is a great idea, but there's a lot of resistance to it by people who are ultimately too stupid to realize that nuclear power is both safe and clean. Liberals are to blame for this one; NIMBY and other organizations that keep yelling "CHERNOBYL!" every time somebody mentions nuclear power have so maligned nuclear plants that nobody wants them built anywhere nearby--or at least, they don't want to know about it.

People occasionally accuse Obama of being "an empty suit," but he's thrown out some very specific suggestions for the energy problem.

As an aside, McCain claimed in one of his ads that he would support renewable energy, but at the time of airing, his energy plan didn't even mention wind, solar, or hydroelectric power. Most of his energy policies are focused on developing "clean coal" technologies--which is nice, but coal is not a renewable resource. His website now has a blurb about wind, solar, and hydro power at the end of the segment on alternative energy.

4. Education. The US is behind in math and science scores. What do we do?

Obama: We need more science/math education, even for people not in STEM careers, because an educated populace is good. Supports developing new STEM instructional materials and methods. Federal and state grants and organization will be necessary to make this work. The teaching profession needs to be elevated; too many teachers are underqualified and too many good teachers are underpaid. Need to focus on developing reading skills in children 0-5 years old. Higher education (college) should be more affordable; proposes a $4000 tax credit to pay for the cost of college.

McCain: We need to train new students, but we also need to offer re-training for displaced workers. Supported grants for digital and wireless tech for community colleges. We need more science students ("we must fill the pipeline"). Private corporations should be encouraged to sponsor math and science students. Teachers need better training; 35% of Title II funding should go to training. The other 60% of Title II funding should go to teachers who excel as bonuses to encourage good teachers. Supports a $250 million grant to expand online learning opportunities. Continues to support national organizations (NSF, NOAA, DOE, NASA).

Call me biased if you want, but I think having a science-educated populace is a good thing, and Obama apparently agrees.

I've liked the education tax credit ever since I first heard it mentioned. It makes a great deal more sense to give tax breaks to people for doing things that benefit society than it does to give them tax breaks for other things. Giving tax breaks to people for having children makes sense because children are expensive, but nobody gets a tax break for going to college. People bitch about "the welfare state," but giving tax credits for having kids doesn't solve the problem. Giving people tax breaks for getting an education (which helps reduce the overall cost of said education) helps people land higher-paying careers and actually has a chance of fixing the problem instead of patching over it. I'm not saying people shouldn't get tax breaks for having to raise dependents; I'm saying that if you're going to "reward" someone with a tax break, it makes more sense to reward people for pursuing a degree than popping out kids that they ultimately won't be able to support.

The only thing I don't like is the fact that a tax credit doesn't do jack for many students (who aren't working and therefore not paying taxes). An increased stipend or grant would ultimately make more sense.

I like McCain's idea about providing financial perks to good teachers and for teachers willing to teach math and science. I'm not sure how they would ultimately be distributed; my concern is that perks would be handed out based on student improvement of standardized test scores, which is a bad, bad, bad idea.

No matter what we do, we need to find a way to encourage more people to become teachers and a way to increase the quality of teachers in our school systems.

5. National security. Technology is a big part of national security. How should we best use it?

Obama: The space race pushed science education forward in America; bioterrorism and nuclear weapon threats should do the same. We need research for the sake of homeland security. Would like to double the Department of Defense's applied research funding and renew DARPA. The Department of Homeland Security needs to shore up defenses against bioterrorism and cyberterrorism. Reduction of our petroleum dependence (foreign oil reliance) will improve security. We must eliminate erosion of the US manufacturing base and keep defense production domestic.

McCain: We need to adequately fund the military to make sure that our homeland is secure. We need to make sure the American military retains its technological edge, so we need to advance R&D funding.

Er. McCain is always talking about how he was in the military and people are always saying that McCain's national defense plan will more or less be automatically superior to Obama's because of McCain's military record. But all he has to say on the subject of science as it relates to national security is "we need to make sure America remains awesome."
Conversely, Obama points to specific threats (cyberterrorism, biological warfare) and has some specific plans (double DoD research funding, renew DARPA). Keeping defense production domestic seems like a no-brainer; how secure can you be when someone else is building all your weapons?

6. Pandemics and biosecurity. Avian flu (for example) could be a serious threat. What should we do about this?

Obama: Bioterror is a serious threat; wants to invest $5 billion over 3 years in a Shared Security Partnership to form an international intelligence organization against terrorism. Suggests expanding US bioforensics program. Wants to invest in vaccines against potential bioterror agents and technology to trace bioweapons to their origins. Hospitals need to form collaborative networks to respond to any major health crisis. Expand local and state funding for disaster response programs. Stresses funding for drug development and distribution systems--ideally, this will create high-wage pharmaceutical industry jobs.

McCain: We don't know if H5N1 (avian flu) will cause a pandemic, but we need to address threats of bioterrorism. Favors implementation of strategies intended to contain pandemics and alleviate any crisis while still maintaining a functioning economy and community. We need to develop better analytical tools to detect and identify bioterror agents. We must also fund R&D of drugs and vaccines and make sure that we have adequate stockpiles and a response plan if an outbreak occurs.

I really wish the question hadn't been about avian flu just because there's limited evidence that H5N1 is likely to become a pandemic in humans. Oh well. Solid answers from both sides, really.

7. Genetics research. What is the right policy balance between benefits of genetic advances and their potential risks?

Obama: Genetics has raised numerous legal and ethical questions; supports Genetic Non-discrimination Act and introduced the Genomics and Personalized Medicine Act of 2007, which is intended to ensure safety and accuracy of genetic testing. Modifying plants and organisms to improve agriculture is fine as long as we make sure they won't have negative impacts on the environment. Using recombinant DNA (rDNA) to produce protein drugs or replace faulty genes is awesome, but we have to make sure it's safe and proceed cautiously.

McCain: The genetic privacy of all people is incredibly important because of the potential ethical problems involved in storing genetic information. Genetic research can help increase the productivity of agriculture; we should focus on developing higher-yielding crops and improved farming infrastructure.

I think people are panicking about the potential for genetic information way too much. I blame Hollywood. Thanks, GATTACA. The Genetic Non-Discrimination Act is a good idea, though, because the potential for "abuse of genetic information" is still there.

I'm impressed that Obama mentioned rDNA technology because that's some cutting-edge biotech. He probably has some good science advisors.

8. Stem cells. What is your position on government regulation and funding of stem cell research?

Obama: Stem cell research might find cures for several serious diseases. The federal ban on embryonic stem cell research is restricting our ability to find cures for these diseases. Hundreds of thousands of human embryos are stored in fertilization clinics that will ultimately be destroyed anyway; why shouldn't we use these embryos for research instead? Adult stem cell research is good, but embryonic stem cell research should still be pursued because of potential advantages. The National Research Council must be responsible for overseeing embryonic stem cell research to make sure it is being conducted ethically.

McCain: We should fund embryonic stem cell research with federal dollars, but we must not sacrifice our values for the sake of science. Supports adult stem cell research and amniotic fluid cell research. Opposes creation of human embryos for research purposes and voted to make use of fetal tissue created for research purposes a federal crime.

This issue annoys me because it attracts the creation of a horrible straw man: "We shouldn't fund embryonic stem cell research (ESCR) because it hasn't actually produced any cures for any diseases." Aaaaargh! Yes, it is true that no approved medical treatments have been derived from ESCR. It's true that there is no "ban" on embryonic stem cell research, so that's not the problem. There are a fair number of existing embryonic stem cell lines available for research, though not as many as scientific organizations would like.

The real problem people have with ESCR is not that it hasn't produced approved treatments--the real problem is that it violates their personal morals. Even if it had produced viable treatments, these same people would still oppose it. The statement that it hasn't somehow validates their belief. It's essentially saying "not only is ESCR immoral, it's useless, so we don't need to do it." But there's no way to know that ESCR won't eventually produce useful treatments unless we try, and there's no shortage of available embryos. In 2001 it was estimated that 110,000 frozen embryos were stored in the US; the number has only increased. Nobody has to create embryos purely for research; couples utilizing in vitro fertilization have already supplied researchers with a huge number of embryos, and many of them have explicitly wished to donate their surplus embryos for research purposes! Is it really more moral to throw them away than to use them for potentially life-saving medical research?

Saying that ESCR shouldn't be pursued because it hasn't produced viable treatments is a self-fulfilling prophecy. Handicapping researchers of embryonic stem cells is obviously going to reduce the number of ESCR-related breakthroughs.

Enough said; you can probably tell from my position on ESCR that I'm in agreement with Obama on this issue.

9. Ocean health. Scientists estimate that 75% of the world's fisheries are in decline and coral reefs are threatened. What should we do?

Obama: Oceans are important; global climate change could have negative effects on ocean ecosystems, so we should reduce greenhouse gas emission (see item 2). We should expand research on the effect of climate change on marine life. Supports US ratification of the Law of the Sea Convention, an international treaty regarding use of ocean resources. Obama likes long walks on the beach.

McCain: Oceans are awesome; state, local, and federal coordination is needed to reduce issues like invasive aquatic species and agricultural runoff. It is difficult to manage ocean ecology because so many other factors affect oceans without obviously being ocean-related. We need to research the ocean's impact on the carbon cycle, the melting of polar ice, and coastal storms. I was in the Navy, so I love oceans.

Oceans are good. They cover 72% of our planet.

Obama's concerns about ocean health tie into his concerns about global warming, so his statement is basically that his plans to reduce greenhouse emissions should also improve ocean health. Both candidates think more research is needed regarding ocean ecology; McCain makes the excellent point that things that seem to have nothing to do with the ocean affect oceans. I'd like to know what sort of solutions he has in mind for reducing agricultural runoff, for example.

10. Water. How should we address water shortages and the fact that water is a limited resource?

Obama: Prices and policies should encourage efficient water use and discourage waste. Farmers should be encouraged to shift to more water-efficient practices and potentially receive economic assistance to make the shift possible.

McCain: Water is a valuable resource that must be protected. The Department of the Interior and states should make agreements and implement technology to reduce water demand.

Water: Republicans and Democrats alike agree that we need it.

11. Space. How should we prioritize space exploration/research?

Obama: NASA should not only explore space but be involved in researching climate change, energy independence solutions, and aeronautics technology. Wants to encourage the private sector to support NASA. Believes we should re-establish the National Aeronautics and Space Council to oversee space activities.

McCain: Space activities have driven scientific discovery for the past 50 years. The Cold War is over, and this has left NASA uncertain as to what to do; however, we are heavily dependent upon satellites and other space-based assets for communication. Other countries are exploring space (Japan, India, Russia, China, Europe). The role of manned space flight goes beyond exploration; it encourages national pride. Supports funding for more space exploration and science; sponsored legislation supporting the commercial space industry. Wants to maximize the research potential of the International Space Station, maintain space infrastructure, prevent wasteful earmarks that divert potential money away from space research, and guarantee adequate investments in aeronautics.

McCain is seriously excited about space. Who knew? He's definitely got a point--the "space race" is a big part of what pushed science and engineering in the latter half of the last century, and once we'd "beaten the Russians" and been to the moon several times people seemed to get kind of burnt out on space. What they've forgotten is that NASA's technologies ultimately wound up in everybody's homes, partly because we'd spent so much money developing them. Many packaged food technologies, for example, are a product of the space race.

I'm not sure we could artificially engineer another "space race" to push technological development, but space technology has been seen as a proxy for overall technological advancement for the past fifty years or so. The whole reason we wanted to beat the Russians to the moon was that it would somehow prove American ingenuity was better than Russian ingenuity. Now China and India are launching manned space flights. The point is not to go the moon--we've been there. The point is to get people excited about technology with a big, visible symbol. The space shuttle is an excellent symbol of the modern era for that very reason.

12. Scientific integrity. Many government scientists report politics interfere with their jobs. Is it acceptable for government officials to alter or hold back scientific reports if they don't like the results? How will you balance scientific data with political and personal beliefs?

Obama: Decisions should be made based on the best available scientific evidence, not ideology. Transparency is important. I have a bunch of science advisors, including some Nobel Laureates! Plans to appoint people with strong sci-tech backgrounds and ethical qualifications to positions requiring scientific expertise. Wants to establish a Chief Technology Officer to make sure that government agencies have the right infrastructure and strengthen the role of the President's Council of Advisors on Science and Technology. Would issue an executive order requiring the release of government research publications and wants to guarantee that the results are not distorted by political biases.

McCain: The government spends lots of money on research; the public deserves to see the results. Denying facts will not solve problems; policy should be based on sound science. Wants qualified engineers and scientists to join key technical positions in his administration. Believes integrity is critical to scientific research.

I would like to quote McCain's last line verbatim:

"My own record speaks for integrity and putting the country first, not political agendas."

Um. I don't know about his opinions regarding the integrity of scientific research, but McCain has put his political agenda before his "integrity" (if he's using the word to mean the same thing that I am) on many occasions:

-He accused Obama of voting for "corporate welfare" for oil companies. He actually raised taxes on oil companies.
-He accused Obama of planning to raise taxes on the middle class when in fact tax rates would only increase for families making above $250,000 a year, among other miscellaneous lies about Obama and taxation, like the claim that small businesses would pay more taxes under Obama.
-He also grossly mischaracterized Obama's health care plan.

Politicians are notorious for being dishonest, and Obama has also stretched the truth on several occasions, but I'm not sure why McCain thinks that he can claim that he always puts the country before his political agenda when he...doesn't. He endorsed the Iraq war and reversed his position on torture to curry favor with his party and secure his presidential bid.


13. Research. What priority will you give research in upcoming budgets?

Obama: Federally supported research is essential and must be continued. Laments the decline in federal research dollars for the physical sciences and engineering. Would double basic science, math, and engineering research budgets over the next decade.

McCain: We must maximize the value of our research spending; has supported increases in funding for the NSF and would like to see "top scientists" decide how to utilize funding. Wants to make sure federal research dollars are allocated based on quality, not earmarks.

Obama wants to double federal funding over ten years; the Bush administration requested $137.2 billion for federal R&D funding. $50 billion of that is supposed to go to science education and modernization of research infrastructure. The remaining $86 billion finances R&D tax incentives. The linked report was updated in 2006; at the time, Bush also called for doubling federal R&D funding over the next ten years. In a sense, Obama wants to leave the existing plan intact.

McCain's budget is based on cutting earmarks, which he claims will save $100 billion. But most sources suggest that "cutting earmarks" will save less than $20 billion. If the $137.2 billion figure is accurate for federal R&D grants, that means we're going to need to come up with about $274 billion over the next ten years. Obama doesn't say where that money is going to come from (troubling), but McCain seems to think that cutting earmarks is going to cover it. This seems improbable.

There's also the fact that earmarks direct funds from executive agencies to specific topics--cutting earmarks won't cut government spending, it will just change the way the same dollars get spent. I'm not sure we're going to get sufficient R&D money from "cutting earmarks" much like I'm not convinced McCain can reduce the federal budget by $100 billion "without cutting into federal programs," especially if he plans to increase defense spending.

This might just be me, but I would rather a candidate offer no details (assuming they will come later) as opposed to offering a plan that is verifiably wrong.

14. Health. How do you see science and tech contibuting to improved health and quality of life?

Obama: Medical science has made huge steps in combating disease; he notes, specifically, advances against heart disease, stroke, cancer, AIDS, mental illness, infectious diseases, and surgical techniques that reduce hospital stays and costs. Notes that US health care spending per capita exceeds other countries but low-income groups suffer from reduced access. Believes that America's health care system is more beneficial for pharma and insurance companies than it is for citizens. Wants to increase employer-based coverage benefits, require insurance companies to cover "preventative medicine" and limit charges by insurance companies. Insurance companies would be required to cover preexisting conditions. Wants to provide tax credits to small businesses and individuals to pay for the cost of health insurance and provide coverage for all children. Would like to see the healthcare system become more efficient, continue to support research to treat diseases, and provide healthcare to all citizens.

McCain: Medical science has developed some amazing cures for illnesses. Telemedicine is an opportunity to increase health care access, especially for patients in remote areas. Insurance costs a lot and many Americans are unable to afford it; we should promote R&D and wellness to reduce costs.

I'm in the healthcare field, so I feel very close to these issues. If you forced me to pick one issue to focus on, I would say that improving the American health care system is at the top of the list.

Private insurance costs a fortune; it isn't reasonable to expect people to purchase private insurance because in the long run it doesn't save them money unless they are struck down by dire illness. My girlfriend has a private insurance plan because she doesn't get coverage through her current employer. She pays $70 a month in premiums. She has a $5000 deductible. For those who don't know what that means, it means that until she pays $5000 out of pocket in a given year, her insurance covers nothing. She is responsible for the first $5000 in health expenses. Now, I don't know what your financial situation looks like, but having $5000 in health expenses would bankrupt her right out. In other words, by the time her insurance picks up the cost, it's too little, too late. All of her standard medical needs--doctor visits if sick, annual OB/gyn appointments, prescriptions--have to come out of her own pocket. The average doctor's office visit costs about $60; the average ER visit costs $383. The last time I went to the doctor I paid $125. The national average cost for a hospital stay, depending on what sort of treatment you need, was $6525 in 1999. In 2007, that figure climbed to around $10,000.

If you make minimum wage, going to the doctor represents more than a full day's wages in cost. That's more than enough to discourage low-income families from visiting the doctor if they have to pay out of pocket--and that doesn't include the cost of medications or travel to and from the office or the lost wages from having to take off work (if it is necessary to do so, and it often is). Even if you make more than minimum wage, it's pretty clear that health care is prohibitively expensive. The median household income in the US is just over $50,000. In what universe can people be expected to afford dropping one-fifth of their yearly income on a hospital stay?

McCain's statements on health care here don't even touch the issue. Telemedicine? Being able to have your doctor examine you with a video camera instead of you having to go to his office is not going to matter if you can't afford an exam in the first place.

McCain's website has more details about his health care plans. I wonder why he didn't bother going into any of these details for ScienceDebate--I actually have reservations about critiquing his health care plan as described on his site when what I'm primarily doing is talking about ScienceDebate. But I've already done it, so let's do it. In case you're curious, here's Obama's website on his health care plans.

Anyway, McCain favors a tax credit to offset the cost of insurance; the credit would go directly toward purchasing a chosen plan, and any extra dollars will be deposited directly into a tax-free health savings account. The credit would be $2500 for individuals and $5000 for families.

Obama's health care plan involves a tax credit to small businesses equal to 50% of what those businesses spend on health care premiums for their employees. How much money is that? A report from a 2004 NY Times article states that California businesses paid $6.30 per $100 in employee payroll for employee insurance benefits.

So let's run some numbers. Suppose you run a small business with 30 employees, yourself included. You're extremely charitable and your business is doing well enough that the mean income for your employees is about equal to the national median of $50k per year. No, this doesn't mean the janitor is getting $50k; it means that the average of your employee's annual wages is $50k, which allows for a minimum-wage janitor and a high-paid CEO. The average can still come out the same. Anyway, $50k x 30 employees = $1500k. You spend 6.3% of that on providing healthcare for your employees, which is $94,500 per year. Obama wants to give your company $47,250 in tax relief every year. McCain wants to give you and each of your employees $2500 per year (you're all bachelors for some reason), which is $75,000. So McCain actually wants to give you more money.

But what will the benefits be? Obama wants everyone to be able to have coverage equivalent to the Federal Employees Health Benefits Plan (FEHBP). Here's a table showing plans available nationwide. I could get a Blue Cross/Blue Shield insurance plan for myself for $37.97/month or $90.26/month. This chart shows deductibles; I've chosen the BC/BS standard plan, which is the second row on the table. The total per person deductible is $300 per year. Once I met my deductible, an office visit would cost $15 and a hospital stay no more than $100. I would pay 25% of the cost of prescription drugs as my copay, which isn't too bad. I personally would have to spend about $150 a month on prescription drugs (and I'm only on one medication), so I would pay ~$28/month for drugs.

Let me summarize. Obama wants to give you (private citizens) the ability to purchase benefits comparable to the following:

-Premiums of $90/month for a family of four
-$300 out-of-pocket responsibility per person per year
-A copay structure where office visits cost as little as $15-20 and hospital stays run between $100-400
-A prescription drug plan where generics cost as little as $5 and even the most expensive drugs only cost you 50% of their retail value

McCain wants to give your hypothetical family of four $5000 to purchase health care. I don't think he realizes that private insurance for families cost an average of $9950 per year in 2004 and that that price is continually increasing.

I don't think I can stress that enough. If you don't get insurance through your employer and have to buy private insurance, McCain wants to give you half what your annual health insurance costs will be in the form of a tax credit. $5000 sounds fantastic until you realize that the average family will have to pay another $5000 just to get coverage. And that's just premiums. Deductibles are not included--and for privately insured patients, deductibles could easily add up to another $5000. In short, McCain's plan involves families spending as much as $10,000 per year before their health insurance pays a dime.

I've said enough on this subject.

That concludes my analysis of ScienceDebate '08. Hopefully you found it informative. We report, you decide!