Albuterol and Political Correctness

Nobody get all prescriptive versus descriptive linguistics on me, but I'm noting a bizarre thing lately. It may not be new, but there's this odd tendency for people to call decisions or acts that they disagree with that they think are clearly done to please somebody not them "politically correct."

There's a fair deal of politics in this post, but I swear it's about a pharmacy-related issue.

Political correctness, PC-ness or PC-ism is a term mostly associated with liberals and liberal thinking. The basic gist of PC-ness is the idea that you shouldn't offend people, but it extends beyond that; you shouldn't do things that might offend people. Furthermore, everything you do is potentially offensive to someone, no matter how mundane it seems to you. Taken to its extreme, PC-ness is "left-wing censorship." It is frequently assumed within the context of PC that white males are not really offended by anything, but that women, racial minorities, and religious minority groups are "sensitive" to "careless speech." Women in particular are used as an example, partly because some feminist groups really do go way too far, insisting that the word "human" is offensive because it contains the word "man" and that alternative terminology needs to be developed.

The idea of what is and is not offensive is highly affected by cultural and subcultural norms, so I'm not even going to go into that. You could write a book on the subject. I'm sure someone has.

What I'm going to take issue with is the use of the phrase PC being grossly misapplied and my understanding of why it happens. The most recent example of this that I've seen was when I, out of morbid curiosity, clicked a link to "saveCFCinhalers.org" (I'm not going to link them because I don't want to boost their google ranking).

Summary: CFCs, or chlorofluorocarbons, are compounds that have been used as aerosol propellants and refrigerants for roughly the past century. CFCs react with ozone in the upper atmosphere and catalyze its destruction. Because CFCs are a catalyst, they are not used up in the reaction, so a single CFC molecule may destroy a number of ozone molecules, converting them to oxygen. Ozone blocks ultraviolet radiation, specifically UVB rays. It is well-established that CFCs deplete ozone and that this will increase the amount of UVB rays that reach the earth's surface. CFCs were phased out of aerosol paints and other products during the last decade. 2008 was the last year that CFCs could be included in metered-dose inhalers (MDIs, or "puffers").

MDIs containing a different, non-CFC propellant (HFA inhalers) have been on the market since 1996. As of December 31st, 2008, CFC inhalers may no longer be sold and supplies have basically been exhausted anyway since nobody has been making them for a while. The most commonly used MDIs are albuterol "rescue inhalers" that expand the passageways in the lungs. This is a big deal drug--if you want to know what it's like to have an asthma attack, go get a straw. Put it in your mouth. Breathe only through the straw without opening your mouth wider or using your nose.

Anyway, the old inhalers have been replaced with environmentally-friendly versions. Same drug, same dose, same efficacy. Some people are throwing a fit about this.

There are a few big complaints.

1. The HFA inhalers cost a little more. The old albuterol generic was about $25, less if insurance picked up part of the tab. The new inhalers are about $35-40 and insurance pays less since they're generally "brand name" products now. The whole insurance payment thing might change soon if enough people complain about it.

2. The HFA inhalers don't "feel" the same when sprayed--they're a bit less "forceful," which leads people to think that they don't work.

3. The propellant contains a very tiny amount of ethanol, which might leave a bad taste in the user's mouth. It is not enough to get you drunk by any stretch of the imagination.

The websites railing against HFA inhalers are full of comments that basically tell the same story. My inhaler doesn't work anymore. My daughter changed to an HFA inhaler and she died of an asthma attack a few months later. I changed to an HFA inhaler and now I have a huge long list of health problems I didn't have before. The government and the FDA are ripping us off and lying about the safety and efficacy of HFA inhalers. Here's a list of doctors that don't believe the HFA inhalers work as well. The American Lung Association is full of shit. Etc. I actually got into an "argument" of sorts with a coworker over this one day--not someone that works in the pharmacy. He was convinced that albuterol had been taken off the market completely and that you simply couldn't get it anymore, and when I informed him otherwise he seemed incredulous--but I didn't get an opportunity to talk to him about it further.

The comment that piqued my interest (and inspired this entry) was the complaint that CFCs had been removed from inhalers to "be politically correct."

I don't know exactly what train of thought the commentor used to get to that point, but here's how I see it. Before anyone accuses me of straw-manning anybody, I'm quoting statements made by my incensed coworker. While his thoughts may not be echoed by everyone who opposes this particular bit of regulation, this is the only dialogue I've had with someone who had a problem with the banning of CFCs on principle rather than because of some specific complaint (such as the new inhalers costing more).

1. Some people ("environmentalists") think that CFCs damage the ozone layer.
2. People who want to be "environmentally-friendly" by using CFC-free products should have the right to buy them; let the market decide.
3. I'm not convinced that CFCs damage the ozone layer.
4. Not letting me choose which product to buy is an unfair limitation of my personal freedom.
5. Therefore, a CFC ban limits my personal freedom.

This train of thought hinges on one particular premise, which, again, lest you think I'm constructing a straw man, was basically the crux of my coworker's entire argument: I'm not convinced that CFCs damage the ozone layer.

Let's go with the "free market" approach. In order to make an informed decision about which product is best, you have to understand several things. First, you have to know what the ozone layer is. Second, you have to know that CFCs damage the ozone layer. Third, you have to know the consequences of damaging the ozone layer. Once you have all of that information, you can make a choice: Do I care whether or not the ozone layer is damaged by the products that I use?

Here's the problem. This isn't a personal choice that's (primarily) going to affect only you, like what color to paint your shutters or whether or not to snort cocaine. Your decision is going to affect everyone living on the Earth for at least the next 50 years, which is how long an individual CFC molecule can remain in the atmosphere destroying ozone molecules. You are contributing to an increase in UVB radiation reaching the planet's surface during your lifetime, much of your children's lifetime, and at least part of their children's lifetime. You are increasing the risk of skin cancer for everyone alive now and everyone who will be born over the next several decades.

Frankly, I don't think you should be allowed to make that decision any more than you should be allowed to shoot me and take my wallet or dump sewage on my property, and the fact that you're too short-sighted to see the consequences of your actions shouldn't affect my personal health. I have rights too, you know.

(Incidentally, to preempt the slippery slope, I don't favor smoking bans because if second-hand smoke bothers you, don't go where people are smoking. If the owner of a particular piece of property opts to ban smoking for the comfort of their non-smoking patrons, that's their call, but nobody should be able to tell you you can't smoke outside or in your own car--though exposing your kids to second-hand smoke is certainly irresponsible and I have mixed feelings about it.)

What does any of this have to do with PC-ness?

Well, PC-ness is about not offending people. One of the things that I've heard said several times, more by conservatives than by liberals, is that "you don't have a right to never be offended," and I agree. Sometimes, people are going to do or say offensive things, and unless they're hurting you or there's a specific rule against whatever they're doing (sexual harassment at work, for example), you just have to get over it and move on. That doesn't mean you have to like it, and you can certainly say you don't like it, because criticism is not the same thing as censorship. Plus, some things are just socially unacceptable within a specific culture because enough people have decided that they don't like thing X that doing or saying thing X will get you publically ostracized (being openly racist in many circles in the US is a good example).

At this point, environmentalists become a minority group identified by a set of opinions or beliefs. If you don't accept the whole CFC-ozone layer thing, you might call it an "environmentalist belief," which puts it on par with any other faith-based assumption that you don't share. At that point, the government banning CFCs does seem like a "PC thing." They're doing it to appease some minority's feelings.

Which means that you're treating the CFC-ozone "belief" kind of like the beliefs of religious groups that are not your own. It's like if the government banned pork products because Muslims consider them unclean. You don't care what Muslims believe if you aren't one. Why should the "belief" of a minority group infringe upon the rights of the majority? Stupid political correctness!

This is why calling something PC in this context is just an empty smear--we're not talking about offending people here. We're talking about reducing the risk of skin cancer for human beings all over the world. There is a concrete reason for banning CFCs that has nothing to do with anyone's feelings. The EPA, NASA, National Weather Service and National Oceanic and Atmospheric Administration all concur. So do independent researchers at Manchester Metropolitan University in the UK and scientists from Germany, Belgium, Denmark, Norway, Spain, Switzerland, Finland, Canada, and Greece. Some very compelling evidence would be necessary to invalidate current theories.

Here's the part of all this that I don't entirely comprehend. Conservatives are generally very black-and-white--things are true, or they aren't. They pride themselves on being practical thinkers and denounce liberals as naïve idealists. The reason I think that this is funny is because calling evidence-based environmentally-friendly legislature "PC" is essentially invoking a kind of relativism. "You and I believe different things. Neither one of us can produce proof that will convince the other, so let's just agree to disagree." Except that you can't do that, because whether or not CFCs affect the ozone layer (for example) isn't a matter of opinion. It's either true or it isn't. And if we're talking about laws, something is either a law or it isn't; we have to decide. To "agree to disagree" in that context is to suggest shutting down dialogue on the subject--therefore, nothing is changed and the conservative viewpoint "wins" by default.

Inappropriate use of relativism regarding what is valid knowledge--which I see on both the far left and far right--is actually an interesting enough topic to warrant its own post, and I might have to make one later.

So. Here's the tl;dr summary: You can't criticize someone for being "PC" when what they're doing is not about avoiding offending people but about responding to objective, measurable conditions. This is true even if you think that the thing being done is intended to appeal to a "minority group" because you don't care about the issue at hand. Using the phrase PC doesn't make a damned bit of sense--but as with all language, you're free to use the phrase to mean whatever you want. You just shouldn't expect your listener to interpret what you're saying properly.

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.

Congraturation!

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.

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!

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.

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?

So...do 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.

Sincerely...

Thought Experiment

What if more things worked like health insurance?

INT. A FIREHOUSE AT NIGHT.

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) But...my 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.

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.

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).

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.

Anyway.

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!

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.

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!

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.

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.)

"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).