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!

Sunday, September 14, 2008

A Semi-random Thought

I wonder if Orac of Respectful Insolence(TM) knows that he shares his name with a commonly cited assay used by woo-meisters to promote the health benefits of their products?

Oxygen Radical Absorbance Capacity (ORAC) is a method of measuring antioxidant capacities of different foods...correlation between the high antioxidant capacity of fruits and vegetables, and the positive impact of diets high in fruits and vegetables, is believed to play an important role in the free-radical theory of aging.

Saturday, September 13, 2008

Yes, We Have No Tobacco

There's an old joke of sorts that goes something like this:

Why do sick people have to walk all the way to the back of the pharmacy to buy medicine when healthy people can get cigarettes in the front?

Legislature passed in San Francisco in July might make this joke completely unintelligible to the next generation. But drugstore giant Walgreens is throwing a fit.

The ban, which is scheduled to take effect Oct. 1, doesn't extend to grocery stores or big-box stores that also have pharmacies. That's why the company wants the plan stopped, said Walgreens spokeswoman Tiffani Bruce.

In short, Walgreens thinks it's unfair for Meijer, Wal-Mart, Target, and various other grocery store chains that have tacked pharmacies onto their business in recent years to continue selling cigarettes if they can't.

The reasoning here gets kind of weird. Walgreens is claiming that somehow it's more appropriate for cigarettes to be sold at pharmacies than at grocery stores because pharmacies offer a greater opportunity for patient contact with pharmacists. Pharmacists, as they continually remind us in school, are as responsible for public health as any other health care professional. The logic is apparently that a patient buying cigs at Walgreens, Rite-Aid, or CVS is more likely to have an encounter with their pharmacist during the same trip. During this encounter, the pharmacist is expected to "do the right thing" and encourage the patient to quit if given the opportunity.

Huge logical flaw: I would wager that only a small percentage of customers at my workplace who are buying cigarettes are also there to talk to a pharmacist. It's true that sometimes customers come in to pick up both meds and smokes, but the items are sold at different check-out counters, which means that a great number of cigarette purchasers never speak to a pharmacist. And even buying your smokes at the pharmacy check-out doesn't guarantee you're going to talk to a pharmacist. He or she is probably too busy making sure Mrs. Johnson isn't going to inadvertently get a lethal dose of digoxin or calling some doctor who forgot to write an actual dosage on Mr. Smith's prescription.

In other words, your chances that a pharmacist is going to swoop in like Superman and rescue you from yourself are very slim. So much for the idea that it's somehow healthier to have cigarettes in pharmacies than in grocery stores.

I don't know what message Walgreens' lawyers are trying to send, but here's how I read it: We all know cigarettes are unsafe, but if you're going to buy them, you should at least buy them somewhere where someone might try to talk you out of it. So they carry cigarettes in hopes that you will encouraged to quit buying cigarettes. What? Do they really expect us to believe that?

I think the ban sends precisely the right message. Why? It's all about public perception.

Most customers at your typical big-box store will never use its pharmacy component. The pharmacy is an afterthought; the stores were not built to be pharmacies, they simply contain pharmacies, much the way that they occasionally contain lawn and garden sections or automotive departments. The pharmacy is there to complete the one-stop-shop set. Business moves like Wal-Mart's $4 generic initiative make it pretty clear that the big-boxes don't actually expect to make a lot of money running pharmacies. The pharmacy is a way to get you to do your other shopping at their store. It is a lure, like the dangling light of an angler fish.

There's nothing inherently altruistic about today's corner drugstore, but I'd wager that there's a reason the big-boxes have had to resort to bargain-basement prices to get people to use their pharmacy services--the corner drugstore just "feels" better to the consumer. They're smaller and feel more focused. The message from the corner drugstore is that pharmacy is the purpose of their existence. The drink case, the cigarettes, and the greeting cards are for your convenience. It's more like the store is attached to the pharmacy than the pharmacy is attached to the store. (This isn't exactly true, given the history of corner drugstores in America, but we're talking about consumer perceptions, not truth.)

So if you take the cigarettes out of grocery stores, people are going to throw a bloody fit. They'll spew all kinds of vitriol about the nanny state and freedom of choice. And, to some degree or another, they'd be right. No, you don't have an inherent "right" to buy cigarettes, but cigarettes are sold, and a broad ban on cigarette sales would provoke a lot of rage. Even most non-smokers would say that the government had gone too far.

Conversely, if you take cigarettes out of drugstores, a few people are going to complain about the inconvenience--smokers, of course--but everyone else is likely to congratulate you for reinforcing the notion that the drugstore is a place where medicine and health care are the number one priorities. Can you imagine a doctor's office with a cigarette vending machine in the lobby? Nevermind the fact that cigarette vending machines have gone the way of the dinosaurs--most people would find the notion appalling these days. (This is, of course, a product of changing culture. It wasn't long ago that doctors had no problem endorsing their favorite brands, and pharmacists were no less guilty of "promoting" smoking.)

The corner drugstore isn't what it used to be. Gone are the days of pharmacists doing double duty as soda jerks. The modern pharmacy is trying to become an arm of the healthcare system, not just "a store"--and eliminating cigarette sales goes a long way toward reinforcing that idea.

Friday, September 12, 2008

Nationwide Pen Shortage Imminent

As any doctor or pharmacist knows, drug reps are a great source for office supplies. I have to question how much information about their products that they disseminate, and I've mentioned in the past that occasionally reps get way, way too enthusiastic about pushing products that are honestly mediocre attempts to extend the patent life on drugs no one is using anyway. I suppose that's their job, so I can't fault them for it...too much.

But there won't be any more free stuff for listening to their sales pitches.

Starting in January, drug detailers will have a lighter load to carry when they visit physician offices. That is when new industry guidelines take effect that bar them from leaving behind drugmaker-branded pens, notepads, coffee mugs and other reminder items.

Here's the interesting bit--this is voluntary. The major drug company association, PhRMA, is adopting these new standards in hopes that they'll avoid legislation actually banning the practice. In essence, they're surendering before the battle even begins because they know that the legislature will not be kind to their pen-pushing ilk. Various bills are already in circulation, so it's probably just a matter of time; voluntary actions on the part of Pharma are unlikely to impress legislators at this rate.

Educational items are still okay, as long as the total value is less than $100. So reps can still hand out literature, books, subscriptions, patient education materials, whatever. Just no more pens and pads. I'm not sure what we're going to write on at my pharmacy now. We have a stockpile of post-its from various pharmaceutical companies, but the supply will eventually run dry. I guess we'll have to settle for store-using real post-it pads.

I think that the best part of this whole story is a statistic cited by Pharmacist's Letter. Only 16% of physicians think that drug rep gifts influence their prescribing. But 61% of physicians think that other doctors are influenced by rep gifts. Hah!

Thursday, September 11, 2008

Today is an Anniversary

There is simply nothing I can post today that will compare to what PalMD has already said on the subject. That noted, today is September 11th, whatever that means for you. This does not affect me particularly strongly; I think it is a good sign that people have, as a whole, moved past the tragedy. The wounds are no longer as fresh as they once were. While I don't think we should forget the WTC attacks, I think that it would be a terrible mistake to dwell on them; I prefer to look forward, not back, whenever possible.

For those who lost loved ones seven years ago, you have my sympathy. There is simply nothing else I have to say.

Sunday, September 7, 2008

Bizarro Health Savings Account

So the company I work for automatically lists items as "FSA eligible" if they are commonly covered by a flexible spending account for health purchases, sometimes known as an HSA. An HSA, if you're not familiar with the concept, is essentially a "bank" of money that you pay into (often with each paycheck). This money is tax-free, but you can only use it to pay for your medical expenses. Some plans allow your unspent dollars to roll-over at the end of the year, whereas others do not, leading to a last-minute spending frenzy. Most HSA plans allow you to spend the dollars you have on any health-related purchase, but there are always exceptions. As a general rule, it's safe to assume that standard over-the-counter products are probably covered, so those last-minute spending frenzies usually turn into people buying more aspirin and bandages than they are ever going to use just so that the money doesn't disappear unspent.

Anyway, at my store, both the register and the customer's receipt specifically note items that are eligible purchases; the customer can keep the receipt in the event that there is a dispute with the insurance company. This also allows the customer to just swipe their HSA card and have eligible items paid for while ineligible items remain unpaid. This saves the cashier from having to ring the items up separately if the customer wants to pay for some items that are eligible and some that are not.

There used to be an occasional problem where ineligible items would get rung up with an HSA debit card by mistake. Ultimately the consumer would get an audit from their insurance company bitching at them about trying to use their HSA to pay for bread and greeting cards. A recent update to the system actually prevents the register from accepting an HSA card for items that the register does not recognize as eligible; the cashier will get an error message saying that the customer needs to use a different form of payment.

So imagine my surprise today when Mucinex and Benadryl didn't ring up as FSA-eligible items. That was odd, and potentially noteworthy, but not that strange. It was conceivable that recent policies had changed to prohibit consumers from buying OTC items without a prescription.

Then Oscillococcinum rang up as FSA-eligible and I stared at the register screen in disbelief.

To make a long story short, "Oscillo" is a homeopathically-prepared dilution of the organs of a muscovy duck. It is a "200C" dilution, which is impressive even by homeopathic standards; the original formula has been successively diluted in a 1/100 ratio 200 times, meaning that the ultimate concentration of duck organ solution is 1 with 400 zeroes following it. This is four times the estimated number of molecules in the known universe, so the probability that the resulting solution contains any of the original "duck molecules" is basically nil unless somehow we have an entire universe filled with "Oscillo." Not that that's a problem for devoted believers in homeopathy. The preparation is touted by its manufacturer as a remedy for "the flu." You know, an illness that actually kills people from time to time.

So let's get this straight. According to the computer system at work, your insurance company is more likely to let you spend your tax-free savings on fake medicine than real medicine. In fact, the register would not let me charge a box of Benadryl to this guy's HSA because it considered the drug "an ineligible purchase."

See why I used the word "bizarro" in the post title?

Friday, September 5, 2008

Two Birds, One Stone

Jack Davis, Democratic congressional candidate from New York, has some amazingly unique ideas about how to solve his city's problems:

“We have a huge unemployment problem with black youth in our cities,” Davis told the Tonawanda News recently. “Put them on buses, take them out there [to the farms] and pay them a decent wage; they will work.”

That's just BRILLIANT! Let's buy this man a Guinness! It gets better.

“If we take away the magnet of good-paying jobs from illegals, they’ll go home,” Davis said in an interview with The Buffalo News this week. “If they can’t make a good living here, they’ll go home.”

So wait. The average hourly wage of an illegal immigrant is $5.45. Oh, man! If we just stop illegals from working for less-than-minimum-wage by giving those jobs to black youth they will give up and go home! Especially if they came all the way to New York. I wonder if he can get federal money to start some cotton plantations?

Even if you agree with him on other issues, you have to wonder what planet he's living on when he starts proposing these kinds of plans.

(In case you're curious about his stance on other issues: He's not sure which presidential candidate has a better health care plan, thinks global warming is due to solar irradiation increases [I am really tired of hearing this argument], and is pro-drilling in Alaska.)

Thank You, Orac, or: A Little Knowledge

This is what happens when people who know absolutely nothing about how to do science get their hands on a little bit of scientific data. An excerpt from Orac's post:

According to Mrs. Janak, less than one milligram of histidine is going to cause nausea, vomiting, and irritable bowel syndrome. Mrs. Janak needs to learn some units before she embarrasses herself by posting such burning stupid to the web. But she's just getting warmed up. She fixates on an observation that histidine is involved in the regulation of of trace minerals and concludes that getting all that histidine (remember, 0.78 mg worth, to be precise!) must somehow mess up the body's metabolism of heavy metals and cause heavy metal poisoning.

Orac, know that if I could, I would have your children. You've probably already found someone else to do that by now, assuming you want them, and I lack the essential plumbing, but the offer stands in some sort of metaphysical context.

"Pray for McCain's Death"?

You know, when I started this blog I specifically told myself I didn't want to get into talking about politics except when necessary. I wanted to talk about pharmacotherapy and pharmacoeconomics and maybe the politics of medicine, but I really can't resist passing this along. Hat tip to Ed Brayton (and also compliments to PZ Myers, who also mentioned this story):

Palin is a Christian, so she ought to get elected president. Here's the "plan":

1. Vote Constitution Party. (I vote my conscience and cannot support McCain even with Palin.)

2. Hope and pray for McCain/Palin to win. (I am an idealist, but also a realist!)

3. Pray for John McCain's salvation and pray specific imprecatory prayers if he fails to pro-actively defend the sanctity of human life. (Google The Forerunner's articles on Impecatory Prayer if you don't understand this.)

You can't make this stuff up, folks. Some people are totally batshit crazy. Even if you believe in the existence of a god or gods, explain to me how it's even remotely moral to pray for someone's death so that you can get the president you want? Aren't these the same people who are always saying that the ends don't justify the means (which is why abortion is terrible, even if it's to save a woman's life)?

I just don't get it.

FYI, for anyone who's going to come along and say, "no one is praying for McCain's death!" I did as the writer suggests and looked up "impecatory prayer," which is actually spelled "imprecatory prayer," but you will get a billion google results for the former because everyone is reposting this story.

Anyway, imprecatory prayer is when you pray for God to help you hurt somebody else or defeat some enemy (because supposedly you are praying for a "righteous" reason, otherwise God won't help you and you're a dirty, dirty sinner. What is "righteous" is presumably up to the individual to decide by reedin' his Biiiiible).

Wednesday, September 3, 2008

Doing the Minimum

So I managed to get myself into a dispute with someone in another arena about the minimum wage. He seemed to think that the free market would sort everything out equitably if we eliminated it. (He also provided no data to support this assertion. I have to charitably assume that he thinks this will be the case because he just has that much faith in humanity to "do the right thing.")

I'm not even going to touch that, but someone came along and attempted to defend Mr. Free-market's viewpoint. At the end of his post, he posed a philosophical question of sorts. What is the intent of the minimum wage?

I think that the "intent" of the minimum wage is to make sure that employers aren't paying employees less than they are able to live on. I decided to dig up some information on the subject.

The Economic Policy Institute has an interesting calculator that lets you put in typical family structures and locations to calculate a "basic family budget." The budget only covers the cost of food, shelter, and clothing. It includes "no savings, no restaurant meals, no emergency funds--not even renter's insurance."

I decided to calculate the cost of living based on two parents and one child for Indianapolis, Indiana. I myself live in Indianapolis, so I can tell you exactly how much I pay to live here for comparison. I live with three other roommates and we all pay equal shares, but we also all earn wages and are employed at least part-time (I work about 10-12 hours a week). I am also lucky to have parents that pay some portion of my expenses (I am a full-time student). Unless stated otherwise, I am only listing my share. To estimate the "actual" cost, multiply by four.

  • My monthly rent is $1000, of which I owe 1/4 (I have roommates) for a total of $250/month.
  • I spend about $125/month on groceries.
  • My basic utilities cost me about $150 a month.
  • I also have phone and internet access that costs me $12/month.
  • I don't pay my own car insurance, but I decided to estimate it by getting a quote from my insurance company. Basic coverage would cost me $100/month.
  • Gas to operate that car currently costs me about $45/month.

Total: I spend $632/month for my barest necessities, not factoring in entertainment or savings, which amounts to $8,184 per year. It also doesn't include health insurance, which I have through my family. I suppose I could tack an extra $75/month on for a health care plan that basically doesn't cover anything--that's what my girlfriend has (and a $2500 deductible, to boot). If I had to pay everything myself it would cost $32,736 per year. None of this accounts for my $30,000/year education, which I can only pay for because the government is subsidizing some loans and I have a small scholarship.

The budget calculator suggests the following monthly expenses for a family of two with one child living in my city:

  • Housing: $726
  • Food:: $514
  • Child care: $542
  • Transportation:: $447
  • Health care: $286
  • Other necessities: $298 (I assume they mean toiletries, clothing, etc)
  • Monthly taxes paid: $377

The monthly total is $3,189 and the annual total is $38,273. I have zero problems believing that this calculator is accurate at estimating the cost of a family of three living in Indianapolis.

Indiana's minimum wage is $6.55/hour as of July 24th, 2008.

$6.55/hour x 40 hours/week x 52 weeks/year means that if you take no unpaid vacation, get no overtime, and work every day you possibly can you make $13,624 per year in Indiana. If you are married or in a domestic partnership and your spouse has the same earning potential you will therefore make $27,248 per year, before taxes.

You are about $10,000 short.

As far as state taxes go, Indiana has the third lowestindividual income tax rate of any state as of 2007. Federal income tax for this family will be filed jointly (let's assume they're married). For reference, here is a tax bracket calculator. They make between $16,050 and $65,100, so they pay 15%, or $4,087. But hey, they get it all back, right?

In short, anyone arguing that the minimum wage is actually sufficient to live on clearly hasn't done any math lately. How is the average American family supposed to live with a $10,000 budget deficit? And that's without any recreational expenses. No movies, no restaurant dinners, no mommy-and-daddy dates, no alcohol or tobacco purchases. The answer is that they borrow it, and that's where we get into trouble.

Here's the thing. You have to be a dreadfully callous human being to say that people who work minimum wage jobs (mostly those who didn't or can't get a college education) don't deserve a living wage. Should people with more education make more money? Of course. But should people with only a high school diploma be paid less than they can afford to live on?

Tuesday, September 2, 2008

Rumours of My Death...

...have been greatly exaggerated.

I've been lurking in the blogosphere the whole time, but I haven't been saying much, mostly because I've been busy and I haven't made blogging a priority. But fear not! Loyal readers, assuming I have any at this point, know that I intend to return and get back on some sort of regular posting schedule.

Repetition =/= Truth

Apparently Tim Pawlenty, governor of Minnesota, was recently questioned about his position on teaching creationism/intelligent design--mostly because it's something that's come up with VP Sarah Palin, who favors "teaching the controversy."

GOV. PAWLENTY: I saw her comments on it yesterday, and I thought they were appropriate, which is, you know, let's -- if there are competing theories, and they are credible, her view of it was, according to the comments in the newspaper, allow them all to be presented or allow them both to be presented so students could be exposed to both or more and have a chance to be exposed to the various theories and make up their own minds.

Emphasis mine.

That's it. Full-stop. If they are credible. They aren't.

Evolution is a scientific theory. So is natural selection. They are supported by data, research, and observation. They don't just explain something, they invite further questions. How do things evolve? What pressures favor which adaptations? What conditions affect the visible "rate" of evolution? Thousands of issues are being explored by biologists using what we know about evolution as a starting point because it's been thoroughly demonstrated that it happens.

Creationism doesn't invite any serious questions that can actually be answered ("so, who is this designer, anyway?"). It doesn't present any hypothesis other than "stuff was designed," and that hypothesis isn't scientifically valid because it isn't testable. It is not a competing theory because it is not science.

It's disgusting that people are offended that their children are learning science in science classes because science apparently offends their theological sensibilities. And the politicians that are using this talking point--"it's a local issue"--are doing the smart thing, politically, and dodging the issue altogether. They're not saying they don't have an opinion. They're saying that they won't voice their opinion because they're afraid of alienating some portion of their constituency. No political candidate who wants to keep his career is going to stand up in front of America's 75% Christian population and tell them that their faith and beliefs are irrelevant when it comes to determining what is and isn't verifiably true.

Even if local school boards don't want their kids exposed to scary ideas like evolution, it's a waste of taxpayer dollars to teach them bullshit instead just so that they can be sheltered from theologically unpalatable truths.