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Tuesday, July 31, 2012

TPP

Only in America.  The TPP -- the latest international agreement on Intellectual Property Rights -- is being negotiated in almost absolute secrecy -- the only nongovernmental people with access are "cleared advisers" -- the (mostly-)copyright industry reps who presumably wrote the agreement.  The only thing the U.S. public knows about it is what is contained in a leaked text that is 16 months old.  Read more from David Levine in Slate, but you won't learn much about the agreement itself.


Monday, July 30, 2012

Thomas Salmon -- Present State of Nations (1744)

My family happens to own copies of the first two volumes of Thomas Salmon's 1744's "Modern History, or The Present State of All Nations," in which Salmon goes through nation after nation, discussing the history, geography, culture, and attitudes of each nation of the world, one by one.  Apparently, he also wrote 11 separate volumes on England itself.  I haven't read very far in the book, and for all I know the author has been deservedly forgotten for many years.  Nevertheless, it was an impressive effort, and although much of it seems based on hearsay, the author's earnestness and desire to impart truth seems to come through on every page. 

I was particularly struck by the introduction (reproduced in part below, courtesy of Google Books), where Salmon explains that he believes that "all men are naturally inclined to acts of humanity and benevolence, and it is only prejudice and an unhappy education, which induce them to commit acts of cruelty and injustice, and treat strangers with inhumanity."  He knows of "scarce instance" where a native people behaved rudely or barbarously to foreigners without provocation.  Although he dedicates the book to his King, on the first page of the introduction he makes it clear that he feels that the conquering Europeans, and not the natives, of Asia and America are the "barbarians," and that European barbarity tends to confirm the natives in their superstition, rather than provide a basis for conversion to Christianity.  It is clear that he is talking about the English here, because he goes on to discuss the shortcomings of England's attempt to spread Protestantism as compared to the Catholicism spread by other European conquerors.  Here's the passage I'm talking about:



So it's good to know that even then, at least some educated Englishmen understood that English expansionism was being carried out in a less than charitable manner.

So what does this have to do with this blog?  Just that it's a tidy historical (and possibly metaphorical) example of the imperfections of unregulated capitalism. It's another example where letting people act in their "self-interest" certainly can accomplish the goals of a nation (conquest and tribute), but is not necessarily good for humanity in general.  When a conquering adventurer (think Columbus, Cortez, and Pizarro; I can't name their less-famous British counterparts) took control of a new land, he almost always treated the natives abominably, while sending vast profits back to the mother-land.  Today we often assume that the maltreatment was the result of innate cruelty or prejudice, but really, it was nothing more or less than self-interest (the great god Profit), placed above the interest of others.  It's the same sort of self-interest that allows those who profit off of the meat industry to simply ignore the suffering that they are inflicting on the animals that they raise, torture, and slaughter.  And those who benefit from that cruelty -- those of us who can't resist a tasty lamb chop, veal, or hamburger -- should probably question where their meals are coming from.

Wednesday, July 25, 2012

Vaccination Clinics for Pets -- Save Vet Fees!

The dog's shots were set to expire on August 4, but I'll be boarding him from August 6-11.  So he needed more shots.  I took him to the vet in the town I was visiting at the time, told the receptionist the situation, and requested that the shots all be updated so that I could send the updated shot records to the kennel where he will be staying.  When I picked him up, I was assured that his shots were updated.  I guess I was a bit groggy, because I didn't check until a day or two later when I prepared to fax the updated shot records to the kennel.  At that point, I noticed that his bordetella shot and his distemper shot would expire on August 4.  I called the vet and asked what had happened, and they explained that they only updated the shots that had actually expired (i.e., the rabies shot).

I called a local vet and explained the situation.  They would be happy to give me the two shots -- at about $20 and $30 respectively -- and of course, I would also have to pay $50 for an office visit.  There was no getting around the office visit charge; the vet must be paid for his time, no matter how little he does.

I first looked on line and found a pet supply place that sells vaccines, and provides a video showing you how to administer them to your dog.  The vaccines themselves sell for less than $5.00 apiece (so the vet's markup is literally 500% or more, not even including the office visit), although they recommend that you ship by air, which would cost an additional $20 or $25.  I considered doing this, but wasn't sure how I would document that I had effectively administered the vaccine to the dog; not sure that the kennel would take my word for that.  I.e. even if I could prove that I purchased the vaccine, there's no way I could prove that the dog didn't jump or whatever while I was trying to administer it.  I called the pet supply place and they didn't have any bright ideas; in the end, it probably depends on the kennel.

I then googled around and found that the local Humane Society, as well as another local animal shelter, provide "vaccination clinics" on a weekly basis.  On those days, for a 2 or 3 hour period, you bring the dog in and get the shots.  The shots are $10 each, and there is no fee for the office visit.  There is no income restriction or anything like that.  In fact, they are still making a profit, given that the vaccines themselves only cost half of that.  The Humane Society doesn't offer bordetella any more -- they say it's just not needed (another scam, see below) -- so I went to the shelter's clinic.

I don't know if the person who gave the shots was a vet or not, but she was extremely competent.  I only had $25 with me, so I gave it all to them.  But the donation of $5 seems paltry given the service that they provide and given that they saved me a full $80.  If they are on my CFC form, I'll contribute more to them next year.

In the course of my research, I also found that an outfit called luvmypet holds regular vaccination clinics at local PetCos, but they don't seem to be held on a weekly basis (the next one at my local PetCo was more than 10 days off).  They charge about $20 per vaccine, which is less than the vet charges (but still a big markup), and there's no office visit fee.  So for many people (who don't have access to the animal shelter that  used), the PetCo clinics might well be the best bet.  Anything to save the pointless $50 vet fee.

So if you need to get your pet vaccinated, but don't feel like he needs a whole physical examination, then find the nearest vaccine clinic, check their schedule, and go there!  You don't need to see your vet every time something needs to be done with your dog.

--
And now on the bordetella scam.  Bottom line is that any responsible vet will tell you the shot lasts a year.  And any responsible vet will probably also tell you that a dog with a cough is a rare thing indeed, and it's not all that dangerous a condition anyway.  But the drug companies have clearly been at work persuading vets -- especially boarding vets -- that the vaccine needs to be given every 6 months.  And of course they are easy to persuade, since it means more profits -- often in the form of office visit charges -- for them.  If you drop your pet off for boarding at one of these places watch out -- they will insist on vaccinating the dog, and because they had to vaccinate the dog, you'll be charged another $30, $40, or $50 for the office visit (some kennels offer $10 discounts on physicals if you board your dog there).  All for nothing, except the vet.

What's interesting is that the original patent on the bordetella vaccine has almost certainly expired.  Here it is, I think.  Issued in 1989, so unless it received extensions, it expired in 2006 (and 6 years of extension seems highly unlikely for a pet medicine). That's doubtless why I can get the vaccine so cheap on-line (and at the clinics).  So it seems quite possible that the vets (all of them acting together, but without actual collusion) have just kept their vaccine prices at the same levels even as the prices of the vaccines have plummeted.  And the ones that see kennel cough vaccine as a profit center will keep telling you to get it every six months, and will keep charging you for those office visits.  Can't blame them (everybody in business wants to get the highest possible price for their product, and is entitled to try to get it), but it's something the rest of us should be aware of.

Friday, July 20, 2012

Anemia Drug Scam

A must-read article in the Washington Post today: Anemia Drug Made Billions, But at What Cost?

Another example of what we have long known to be the case -- Drug companies persuading doctors -- by means of enormous financial incentives -- to overprescribe extremely expensive (and in this case quite possibly useless and even harmful) medications, at great cost to taxpayers and patient health.  But, like my discussion of the LIBOR rate manipulation, this is simply capitalism at work -- the temptations to act immorally (or, most charitably in this case, to convince oneself that one is acting the the patient's best interest) -- is almost certainly irresistible to those who have to face it.  If I were an oncologist who stood to gain something like $500 every time I injected someone with this particular medication, I'd probably err on the side of over-medication too.  Who among us wouldn't?

If I'm a pharmaceutical rep and my compensation and promotions depend on how much my efforts contribute to drug sales, then I'll do everything I can to increase drug sales.

And that's why this isn't just a problem with the doctors or the pharmaceutical companies.  It's a fundamental problem with the "socialized capitalism" that we call a health care system.  This is the sort of thing that SHOULD have been addressed by ObamaCare, but simply wasn't.  


To recap -- the socialization aspects of health care -- the fact that drug companies get patents and market exclusivity in exchange for coming up with new drugs, as well as the fact that many of the drugs are sold though socialized programs -- medicare, medicaid, and even health insurance -- distorts the market in a way that prevents market forces from working.  If there were a true market here -- with perfect information -- patients would know whether this stuff is good for them or not.  Doctors would compete with each other so that they would not be making enormous profits for every dose.  And pharmaceutical companies would not have patents -- the most socialist of all programs.


Elsewhere, I will discuss the obvious "counterargument" that the drug companies need patents to make the inventions that they do, and I'll offer alternatives.  But for now, please just admit that giving a company the ability to charge $2500 for something that costs just a few dollars to make is a NOT capitalism is antithetical to free markets and is therefore is a kind of government intervention that might (in the bipolar nomenclature of the times) well be labeled socialism (although of course, it gives socialism a bad name). 


Below are the most troubling excerpts from the article:


 -- 


Then a nurse said he needed another dose of anemia drugs.
, , ,

The shots, which his cancer clinic had been billing at $2,500 a pop, were expensive.
, , ,

Hours later, Lenox was dead.

The article goes on to say that these drugs -- Epogen, Procrit and Aranesp -- generated more than $8 billion a year for Amgen and Johnson & Johnson, and that for several years, U.S. taxpayers put up as much as $3 billion a year for the drugs (the original sentence was ambiguous -- this is probably just Medicare payments, and it might even be limited to Epogen only).  Apparently, the benefits (which supposedly included “life satisfaction and happiness” per the FDA-approved label) were greatly exaggerated while the side effects -- cancer and strokes were ignored.  After many years of these drugs being on the market, Medicare researchers last year issued a study declaring that among kidney patients (the biggest market) "there was no solid evidence that they made people feel better, improved their survival or had any 'clinical benefit' besides elevating a statistic for red blood cell count."


The article explains that unlike prescription medicine that the patient will pick up at CVS, doctors can make big bucks off of the "spread" between what they pay the drug company and what they charge patients for a drug.  Here, drug companies helped ensure large spreads -- offering discounts to doctors who used more of the drug, and overfilling vials, which allowed doctors to further widen the spread even more.  And of course, they lobbied Congress to ensure that Medicare would foot the bills for much of the spread, and somehow they managed to get private insurers to reimburse even more than Medicare (I wonder how that particular component of the "free market" failed here; that's one thing insurance companies are supposed to be good at).

The article says that in 2007, more than 80 percent of 175,000 dialysis patients on Medicare were receiving the drug at levels beyond what the FDA now considers safe (and those are just the patients we have good records for).  The result was that an an oncologist could make an extra $100,000 to $300,000 a year simply by administering this drug.

The drug itself is a man-made version of erythropoietin, a natural hormone, which stimulates red blood cell production.  This then seemed like a "natural" and improved way of treating anemia (where the body doesn't produce enough red blood cells (needed to carry oxygen from the lungs to the rest of the body)), where the old method involved a four-hour transfusion of red blood cells.

Dialysis patients became the core market, since they often have anemia, and studies showed that giving the drug to these patients increased their red blood cells and reduced their symptoms of anemia.  No question there were significant benefits for some patients.  Amgen assured the FDA that any risks associated with the drug were minimal.

The drugs were first approved in June 1989, which suggests that patent applications were on file (if not granted) even before that.  Although the article doesn't mention patents, it's worth noting (and remembering) that the original patent for erythropoietin expired in 2004.  So at some point, I'll figure out and report what sort of patent manipulations left us in a situation where in 2007 and beyond, the drug companies were still making blockbuster profits.  Doubtless they received various follow-on patents, and somehow convinced people that simply practicing whatever the original patent taught was simply not good enough (or worse, infringed the follow-on patents).

Not all dialysis patients need blood transfusions -- only about 16 percent do.  But the use soon spread to nearly all dialysis patients.  Although that's an enormous market already, the incentives to sell this kind of treatment to a broader market resulted in the drugmakers pushing for and gaining approval for additional uses and larger doses (average dose size tripled), for milder anemia and other illnesses.for patients with a wider array of illnesses.  The FDA approved it for treating anemia in patients with cancer and AIDS, as well as those getting hip and knee surgery.

Ad campaigns touted the drugs as providing "strength for life," which was essentially what the FDA label said, until the FDA tightened its standard of proof for such claims.

Although the FDA required Amgen to do safety studies, the studies were done only belatedly (if at all), and apparently at least one of them was "misfiled."is currently lost.  One incomplete study suggested that small-cell lung cancer patients given a placebo had a better chance of survival than those given the drugs, although the data was (according to Amgen) "sparse."  Another study was due in 2004, extended to 2008, and now won' be complete until 2017.  By which time, of course, it won't matter for the drug's bottom line, since any possible patent on the treatment will have expired.inally completed in 2008, which, per the above, is longer after the original patent expired.  Another study among dialysis patients having heart disease was designed to answer the question whether it made sense  to bring these patients' hematocrit up to normal levels.  The study was stopped after an increased rate of heart attack for reasons that were reported as "unknown."  The results were reported somewhat favorably in the New England Journal of Medicine by four Amgen employees, two Amgen consultants, and two others.  This report left out the important fact that those with smaller doses of the drugs experienced just as much enhanced quality of life as those with larger doses, and suggested that the increased risk of heart attacks was not significant.  It took 3.5 years for the FDA to respond to a FOIA request for the actual data underlying the study, without which the discrepancies noted above would not have been known.

Anyway, read the original article for more details on the reports.  The health issues concern me (and on a human scale, they might well be more concerning than the "price" concerns), but in my role as PriceFixer I must focus on the price issues.

But they are certainly connected -- the whole point of the "normalize hematocrit" study was to produce data that would support additional treatments on a massive scale -- i.e. by showing that anyone with low red blood cell count could benefit from the drugs.  Even after the study was stopped due to fatalities, the New England Journal of Medicine published the afore-mentioned misleading study, and one of the non-Amgen authors of that study continued to promote hematocrit normalization in the press.

Bottom line is that Amgen continued to push -- and get (from both FDA and doctors) -- higher doses, all on the basis of unsubstantiated claims that these doses promoted better "quality of life," and without any mention of the increasingly known potential dangers.  This resulted in huge profits to Amgen.

And it should come as no surprise that Amgen manged to infiltrate the National Kidney Foundation, which issued dosing guidelines (for which Amgen was "founding and principal sponsor") for doctors, recommending doses at the high end of the FDA recommendations.  10 of the 16 members of the panel that created the guidelines had received consulting fees, speaking fees or research funds from Amgen or Johnson & Johnson’s subsidiary, Ortho Biotech.

Predictably, we learn that Amgen spent $2.4 million in one year on lobbyists -- including C Boyden Gray and Haley Barbour -- to fight a proposed policy by HCFA to reduce reimbursements when dosages significantly exceeded FDA recommendations.  Arlen Specter, for a paltry $7000 from Amgen plus $2000 from Johnson & Johnson, led the Congressional charge gainst HCFA, and HCFA apparently backed down, and even raised the limit to a level proposed by Specter.

The nation’s dialysis clinics -- which received something like 25 percent of their revenue from using the drugs -- likewise promoted higher dosages and helped to block reform (even offering a bonus to its chief medical officer if he were to do so).

And patients were recruited to help out as well -- both companies set up websites to combat a 2007 Medicare proposal (www.Protectcancerpatients.org and www.Voiceforcancerpatients.com).  Amgen became Nancy Pelosi's biggest contributor ($42K) and managed to get the majority of both houses to sign a letter to Medicare that warned that the proposed Medicare limits on the drugs could have a “broad range of unintended health consequences.”  Defending this approach, one of the Congressmen (Rogers) said “The federal government should not be in the business of dictating the practice of medicine.”

During this time, the OIG issued at least seven reports recommending either that the reimbursement price be reduced or the incentives (for prescribing the drugs) changed, and the GSA an the Medicare Payment Advisory Commission made similar recommendations.  None of these proposals were acted on (Clinton proposed a change of incentives a couple of times, unsuccessfully).  Instead, for years, the profit margins remained wide. The result was that as late as 2009, dialysis clinics were still making a 9 to 17 percent profit on pushing the drugs.

Finally, the health warnings overcame everything else.  Studies started coming in linking higher doses to higher risks of hospitalization, strokes, tumor growth, and death, as well as tumor growths.  FDA finally took action and prohibited use of the drugs in curable cancer patients and slightly anemic cases, and lowered its recommended doses. And when it took a second look at the supposed benefits, it found that they had been grossly oversold.  Finally, Medicare stopped reimbursing per dose, but shifted to a per patient (bundling) basis.

Tuesday, July 17, 2012

Being Wrong -- Adventures in the Margin of Error


The title of this post is the title of Kathryn's Schulz's book, which I am currently reading (i.e. listening to).


Nice title for a book.


From the book's website:


Bill Clinton calls it "a brilliant book with a sweeping grasp of philosophy and physics and all points in between." Harvard President Drew Gilpin Faust chose it as the book she wishes all Harvard freshman would read. Amazon and Publishers Weekly both named it one of the Ten Best Nonfiction Books of 2010. It was shortlisted for the Guardian First Book Prize


The other reviews lead me to think that Schulz is a profound thinker and witty guide on topics ranging from neuroscience to philosophy to Shakespeare to Alan Greenspan.

I'm listening to this on my mp3 player.  I've finished Chapter 1 so far, so it's too early to tell.  But I have a bad feeling that I won't like this book and that I will finish it with the impression that it was badly over-hyped.   That doesn't mean that I will conclude that nobody could possibly like this book.  Most of the reviewers on Amazon like it (although of course, most of the positive Amazon reviews are fake or motivated by considerations other than a desire to be absolutely honest).  So know that my views seem to be in the very tiny minority.  It's very hard to find anything but lavish praise for this book and the author anywhere other than in the 1-3 star reviews on Amazon.  Say what you will about the corruption of that system (and I just did), you can almost always be sure that the majority of low-star reviews are someone's honest opinion.


But I just haven't got anything much out of the first chapter.  I haven't laughed out loud, as some of the reviewers have done.  I haven't yet been impressed by any particular instance of "lucid prose with perfect comic timing," and it's too early in the book for me to conclude that "Schulz is not just a quotable writer; she is also a canny and original observer, ­adept at pointing out things that we should have known, but didn’t."  The last two quotes come from Daniel Gilbert (who has his own books on the equally mostly-self-evident topic of "happiness" to sell), and the last one can serve as a jumping off point.  I HATE IT WHEN AUTHORS REFER TO THEMSELVES AND THEIR AUDIENCE AS "WE."  I just find it extremely annoying and condescending, especially when "we" (as in Gilbert's quote) really refers to people who seem to be almost willfully unobservant of the world around them.  I have to admit, there probably is no easy authorial choice here.  "People" or "most people" would get old in a hurry.  And neither "I" nor "You" would work out.  But I cringe every time I hear "we", which, with this book is almost every sentence.

But of course, that's why I keep reading (i.e. listening to) the book.  It engages me, because I am constantly evaluating whether or not I fit into her "we."

I'm sure I do sometimes -- I'm human.  And I don't have any particular examples at hand.  But the basic theme of the book seems to be "we" think we are right most of the time, even when we aren't, and then when we come to see the error in our ways, we often simply forget that we were wrong in the first place.  And of course she litters the book with numerous conflicting examples -- e.g. the friend of hers who claimed he was wrong all the time but then couldn't come up with a single instance, as well as her own long-term recollection of having mispronounced "Goethe" when she first encountered the name.  In other words, sometimes we are mortified that we were wrong and remember it forever even after others have long forgotten it, and sometimes we "forget" that we were ever wrong in the first place.

At a certain point in the writing process, she apparently came to realize that there were many serious students of "wrongness" out there -- there's a whole field called "wrongology," or maybe "error studies" that is primarily devoted to cataloging errors and figuring out how to avoid them.  Given that she has been preempted, she hastens to assure us that her goal is not to help us avoid errors (i.e. it's not a self-help book), but instead to explore how we think about errors and wrongness.  That's not all that interesting to me, because I have a feeling that I've thought about errors and wrongness more than most people, with the possible exception of the author (she has been able to do it nonstop for several years).  Unfortunately, from what I've heard so far, I don't think I'm going to learn much new from the author.  But I could be wrong.

So far, the only "thinking" about wrongness she has been able to convey to me is that we should embrace it.  Wrongness is responsible for all kinds of wonderful things.  I can't remember what her examples were, probably because they were so obvious.  But that's my point.  Her whole theme is extremely well known.  In fact, it's the theme of the Magic School Bus cartoon series for kids:  "Take chances, make mistakes, and get messy!"

Maybe I'm a bit jealous because I didn't write the book.  I once kept a notebook in which I only wrote down the errors that I had made in my life.  I wonder where it is now?

Part of why "we" is so annoying here is because I have known a lot of people who simply can't admit they are wrong, even when they plainly are.  It's worth noting that these are often managerial types -- it takes a certain kind of self-confidence and ability to self-promote (as well as a blindness to one's weaknesses) to get those positions.  And then simply having a position like that (where you are often surrounded by a high percentage of yes-men and yes-women) only reinforces the self-delusion.  So even if I fit your "we" some of the time, please don't group me with those other a-holes.

I always admired something I read in Robert Rubin's (somewhat premature) first autobiography.  In it, he explains that he doesn't understand how some people can be so sure about everything.  I think he says something like some people are more sure about everything than he is about anything.  And he explains how he is a "probabilistic thinker"; certain about nothing, but willing to give everything a probability, which can shift as more data comes in, and to act in accordance with those probabilities.  That's what I have always aspired to.  I've also aspired to make a lot of money the same way he did -- push for laws to be passed for the multi-billion dollar benefit of a company like Citigroup, and then be rewarded with a 100 million dollar a year do-nothing job for the same company.  And I think I heard somewhere that he honestly believes that he was worth that $100 million a year, even as Citigroup began its trajectory toward bailout-dom.  I wonder what the probability that he was worth a hundred million a year really was.  I see I have digressed.

Listening to the author's Ted Talk, which is going over some of the stuff from Chapter 1.  One of her great "aha" points is that we never really understand the experience of "being wrong."  In other words, by the time we realize that we were wrong, we now are no longer wrong.  It's the coyote who doesn't realize he has gone off the cliff, before he looks down.  So that's a clever point, sort of -- that while we're wrong, we don't realize it.  She calls it "error blindness."  But I heard it in the book, and by the time I heard it on the TED Talk, it had gotten old.  She asks the question how it felt sometime when you were wrong.  And people naturally responded about how it felt to find out that they were wrong.  But then she said "gotcha" - that wasn't the question.  And then back to the above.

But that's where we probabilistic thinkers just don't fit in.  I know I might be wrong on any number points; it's just a matter of probability.

Now she's talking about how people are scared of getting bad grades -- being wrong -- and that leads them to get As.  Fine, but then we freak out at the possibility of getting something wrong, because that means something is wrong with us, so we insist we are right because it makes us feel responsible and virtuous and safe.  Ugh.  I can't handle the "we's".  I'm not sure what the point of this is -- don't use grades in school, because the smarties will all end up really uptight?  But then how do you get a system where the marketplace can relatively easily identify who will work hard and NOT make gratuitous mistakes?  And who are the people getting 50% on a spelling test?  Is it that they are the "dumb kid" (I think she said this)?  Where do they end up?  There might be an interesting discussion in there -- how the whole point of public school was to teach kids -- future workers -- how to show up on time and obey rules, and how grading even at an early age helps these future employers draw distinctions between the good and bad prospective employees.  The point is that "fear" of doing badly on a test is what motivates a certain fraction of the kids to study so hard that they won't make any mistakes.  But that is surely a "good" byproduct of the fear of making mistakes.  The problem with the kids who don't have that fear is that they don't study and they don't care so much when they get bad grades.  And I seriously doubt Kathryn Schulz would be where she is now if she hadn't gotten some very good grades in school.

Now (back to the Ted Talk) she's telling about someone who had the wrong leg amputated. The point of that story is don't just trust in the "feeling" of being on the correct side of anything -- esp. someone you are doing surgery on.  That "sense" is not a reliable guide of what's going on.  It results in oil spills and torpedoing the economy (what she said).  Here she is of course right; I am a person who very rarely says "my gut tells me", and whenever I hear someone say that, I brace myself.  I think there certainly is such a thing as "intuition" -- the sort of unconscious "getting it right at first glance without knowing why" that I think Malcolm Gladwell described in Blink. But sometimes people's "guts" tell them things, where a close consideration of ALL of the data -- all of the inputs -- would still leave any neutral arbiter far below 100%.

Still from the TED talk -- The first thing we do when someone disagrees with us, we assume they are ignorant.  When that doesn't work, that means they are idiots.  When that doesn't work, they know the truth but are deliberately distorting it for their own malevolent purposes.  We we we.  I can't handle it.  But I have to admit, sometimes I do get to the third stage she just described.  But in all of those cases, I've turned out to be right.

Ok, that's what I can say about the first chapter.  I'll report back periodically, probably simply by adding to this post.

Now it's a day later and I'm in the second chapter.  She really likes to create false conflicts.  To hear her speak, you'd think there has been an ongoing debate about whether error is good or bad over the centuries.  Aquinas says it's bad, William James says it's good.  The reason I know there is no real debate going on is that she makes no reference to a rebuttal.  There's nobody saying that William James is "wrong" or misguided in his discussion of wrongness.

So I'm still not sure what the author's contribution is.  She's now dropped at least four big names that have studied and written on the plus side of error before -- James, Erasmus (of course, In Praise of Folly), Descartes, and Montesquieu (the latter two seemed to be approximating the "probabilistic" Robert Rubin approach mentioned above).  To her credit, she's dropped the name Al-Gazali, one of my heroes, for an observation about dreams and reality -- when we're in them, we don't realize it; yet when we wake up we know it was a dream.  Who's to say we won't one day "wake up" from this reality and immediately know that it was never real either?

She's told me that people take drugs in part because they like the altered reality, and people are willing to take all kinds of risks to get there.  I guess the point is that sometimes "we" strive to be "wrong."

She's also told me that King Lear is a play full of error -- the King is wrong about his daughters, the fool is wise, Lear is mad without realizing it, Edgar pretends to be mad, etc.  But so what?

She has taught (or perhaps reminded) me that in Indo-European, the word for "go" was "ur" (that's what I heard, not sure of spelling).  And this led to "errare" in latin, which perhaps means go astray and eventually that led to "error".  And then she points out how knights errant was actually a compliment -- these mythical people were out there trying to learn more about their world.  And then there's Don Quixote -- who was in error about being a knight errant in the first place.

In the end, I can concede that she does seem to be a decent writer, although she sometimes uses longer words when shorter ones will do.  And at least once she said "it begs the question" meaning "it raises the question."  [yes, I know, the repeated misusage of the phrase has now rendered her usage acceptable.  I'm not a linguistic purist, but I really hate to see an old meaning die -- "begs the question" had a very specific meaning in the field of logic (like "red herring," "straw man," etc.), and now the meaning is disappearing or at least becoming diluted].

But there have been no trenchant observations, no aha moments yet.  We'll see.

I'm listening on.  She's now discussed mirages -- inferior, superior, and fata morgana.  That's all actually kind of interesting, and perhaps good to know.  If I was aware of John Ross's attempt to find the Northwest passage -- and his encounter with a superior mirage when he tried to find a way to connect Baffin Bay to the Pacific -- I had forgotten it.  And the point about even ships appearing as mirages (i.e. the images of real ships appearing, even though the ships are very far away, very far over the horizon) reminded me of something I read about while very young -- a person who was somehow able to predict the arrival of ships in a particular port with uncanny accuracy, by looking at the sky.  I had always thought that that was simply an old anecdote that would fall apart under scrutiny -- and I've never heard about it since -- but perhaps there was something to it -- he was just able to perceive mirages better than the rest of us.

Ok, I looked that up.  With Google, we can get to the bottom of all hazy childhood recollections.  The guy was named Bottineau and he actually was detecting changes in the atmosphere, which actually were caused by ships several days away.  There's no question that this was not merely luck -- he made good money betting others about the arrival of ships, and tested himself in a scientific way, accurately predicted the arrival of 575 ships over a 4 year period (and when he was wrong it was confirmed that the ship had been there but had changed course) and once predicted the arrival and diversion of a fleet, which was confirmed.  Not mirages, but impressions nevertheless. But apparently he never told anyone his secret -- even when offered large amounts of cash -- and no one else ever figured it out.  And maybe it actually was the same natural phenomenon that gives rise to those fata morgana mirages, just on a much less obvious scale, which he somehow learned to detect.  I might have read this in The People's Almanac, but I actually believe I read it long before I first encountered that book (and probably long before it came out).  The People's Almanac says that history did not record his first name, but several websites have it as Etiene, and one of them says he was born on May 4, 1738.  He called his science "nauscopy."  He led people to think that his theory was that everything that moves causes a disturbance, and that he could somehow detect those disturbances in the sky.  What I'd like to see (or hear) is an explanation of the physics of superior mirages and fatae morganae (sp?) and see exactly what becomes of the image over space.  And why it happens or when it happens.  Of course, since we now have radar, it's all kind of pointless.  I think.  But perhaps there is an application for it that isn't quite so obvious . . . .  I wonder what it could be?


So Bottineau may or may not be related to mirages.  Query -- I wonder if it would be possible to run some experiments to replicate Bottineau's observations, and figure out what he saw.  If he saw the ships themselves somehow (in the sky?), then perhaps a computer studying photographs would be able to pick that up.  Don't know where this would lead, but it could be interesting.


As I think about it, this is just the way popular psychology writing works.   You pick a topic -- hopefully one that can be stated in one word or phrase:  Wrong, Happiness, Tipping Point, Blink, Bonked, etc.  And then you open yourself up to every interesting fact that you can connect to that word.  And then you collect the most interesting such facts -- googling for them if necessary -- and try to organize them somehow around your chosen word.  Then you look for a bunch of famous quotes related to your interesting facts, and throw them into the mix.  If you're a good writer -- and most journalists are -- you'll have produced something readable and interesting, and if you're lucky, people will start describing you as brilliant and profound.  Of course, these books tend to overlap, since one of the pools they all draw from is that of experimental psychology, and if one reads enough of these books, one reads about the same experiments over and over again.  Can't remember if that's happened in this book yet.  But if I hear the one about the fact that a female "confederate" with a questionnaire was rated more attractive when she was met on a scary suspension bridge, that will be something.  (I've heard it several times in several such books, including some CDs on evolutionary psychology).


Back to the book.  After mirages, she moved on to the idea that our senses often deceive us -- if we look at the night sky, we perceive it to be revolving around us, and yet in fact, it is we (i.e the Earth) that are moving.  Then a discussion of the ancient Greeks.  Apparently the sophist Protagaras said something along the lines of reality being what is sensed, and the answer to different people sensing different realities is that they are both right.  Plato rightly called this nonsense (and could have given Protagaras a thermometer), but it leads to some vexing questions about our senses and perceptions.  The answer seems to be that there are two steps -- one is sensing (sensation) and the next is perception (which means processing the sensation to draw a conclusion).  Something in our machinery tells us that receding objects are not actually getting smaller.  And then there is the blind spot -- where the optic nerve enters the retina, where we are literally blind, but which the brain is able to paint over with something called "coherence" or something.

And now, somewhat predictably, we are on optical illusions.

Ok, I should probably grudgingly concede that the book has some interesting stuff in it.  But all books do.  I think what I resent are e.g. the quotes from Bill Clinton (sweeping grasp of philosophy and physics) and Drew Gilpin Faust (should be read by every student entering Harvard), and others.  It's just not that exceptional, as such books go.  It all sounds way too much like a publicity campaign.  Interesting fact:  although the author is a fairly famous person -- a successful journalist who has written a book that everyone who is anyone just loves -- it's not easy to figure out where she comes from.  Initially that caused me to think that perhaps she is the daughter of someone rich, famous, and powerful, and that's how she has gotten everyone to fall over themselves heaping praise on this book.  But I finally hit on the idea of searching her name and "alumni", and that's how I figured out she went to Brown and that she's from New York.  So that pretty much establishes "rich," but not necessarily powerful.  And she's not without talent, so that's a dead end.


--
Continuing.  The stuff about optical illusions just didn't grab me.  The difference between them and being unexpectedly wrong is that you know you are going to be fooled, and you know that whatever momentary embarrassment you'll feel will be superseded by the feeling of having experienced something clever.  What they teach US (ugh) is that sometimes (though not often) WE (ugh) can treat being wrong that way, and take some pleasure in the way we were wrong.  Or something like that.  I don't deny it.  But it's still kind of boring.


Then some mention of diseases where people think they can see but are really blind, and apparently that kind of thing can happen to all of US.  In other words, because we know it can happen to us, how can we be sure that it hasn't already happened to us?  It happened to Justice William O Douglas after a stroke -- he thought he was capable of going on a hike but he wasn't.  But that stuff should have been put under the insanity section.  Yes, eventually I might go insane, or "catch" one of these afflictions (or have a stroke), and in that case I'll be wrong much of the time.  *yawn*


But then on to "implanted" and "false" memories.  A great psychologist remembers Dec. 7, 1941 -- he was listening to a baseball game on the radio.  But many years later he realizes that they don't play baseball in December.  He does an experiment after the Challenger disaster -- asks his students the day after to describe some details of how they learned of the event etc.  Then three years later asked the the same thing.  He said that only 7% (I think) lined up, and that most of them contained major discrepancies.  One woman looked at what she wrote three years before and acknowledged that it was her handwriting but claimed she never would have written it. This is actually interesting, and I'd be very interested in seeing the original data.  I've been aware of this sort of thing and it's one reason that I never completely trust my memory.  So this could be an area where WE (well, not me, since i never completely trust my memory) go around knowing something is true, even though it isn't.  She also mentions that it's possible to implant memories - I think she said in 25% of people, more for kids.  But then she got anecdotal about one kid who had been fooled into thinking he had been lost in a shopping mall.  details lacking.  


But I had heard of this sort of thing before, and even tried it on my own kids.  I used to hit tennis balls up very high in the air.  And one time when I wasn't hitting them, I happened to mention the time we were all there and I hit one so high that it never came back down.  Later, they remembered that as if it were a fact.  I wonder if they still do.


More about me:  I think the author essentially challenged her readers to try to remember where they were on Sept. 11, and seems willing to bet that we will be sure of everything, but will be wrong on key details.


OK.  Here's how it went for me.  I was driving into work to DC in the morning.  I was listening to Howard Stern.  He was talking in a very disrespectful way about a female celebrity (I think it was Pamela Anderson). Robin Quivers (I think) said that she had just received a report from somewhere (I guess a news desk) that a plane had hit a building.  Stern said "it was bound to happen sooner or later" or something like that and went back to talking about Pamela Anderson.  I'm pretty sure he kept talking about her and other inane topics (with perhaps occasional interruptions from Robin referring to being able to see the smoke) until the second plane hit.  At that point he began to understand it wasn't a coincidence.  I must have parked in the garage at my building soon thereafter, and went up the parking elevator, and caught the main elevator.  There were several people on there, and one was someone with whom I regularly talked, and he asked "did you hear about the tragedy in New York"  Not sure if he said New York, but he said tragedy.  I said I had, but I don't recall having an extended conversation -- it was a short elevator ride.  I don't remember anyone else on the elevator saying anything.  I got to my office and I don't particularly remember any sequence of events.  This was 2001, so I assume I was able to get on the internet and get some information.  But I remember at the time nobody had clearly identified Al Quaeda in the press.  Just a few spotty memories after that.


There was a period -- maybe an hour -- before the Pentagon was hit.  I remember talking to a client (actually counsel for a client) in Chicago, and talking about the attacks, and speculating on whether Chicago would be hit or not.  But i don't recall if this was before or after the Pentagon.  At a certain point the firm management sent an email out telling us that the best thing to do was to stay in our offices. But there were continued reports of planes that were unaccounted for, and the idea that they might hit the White House or the Capitol or both (my firm was right in between).  I went down a floor (or maybe up a floor) and told the woman I was going to have lunch with that day that I couldn't make it.  I think I agreed to drive another woman home, and I'm pretty sure that's what I did.  I know I ended up taking the Chain Bridge out of town.  It was slow going, but I got out.  I think I picked up the kids where they were -- Trey might have been at Mount Daniel and Aiesha at TJ.  But no clear memory; just an inference.  Later that day remember having a conference call with two friends (not sure if my phone had that capability, but I'm sure it happened) speculating on how it was done.  I didn't think an arab terrorist group could have pulled it off.  But what did I know.  I think we agreed that it was political suicide for Bush and Cheney to immediately go into hiding -- which no one, even in the days just after seems to remember they did.  But at the time, the nation felt leaderless -- no word from our commander in chief or even the second in command -- both seemed to be busy saving their skins.  But someone wrote a speech for GW and he emerged as some kind of a hero, inexplicably I always thought.  I feel like I was at home with the TV on for much of the rest of the day, and a certain point one, then the other, building fell down.

Interestingly, I remember making a tape recording of myself on that long drive home.  If I find it, I should probably destroy it.  Although now this is getting interesting.  I "remember" that above I didn't believe it was Al Quaeda that had done it until sometime later, but on the other hand, I also "remember" saying some harsh words about how security had to be beefed up everywhere, if it meant not letting anyone into the country (or something like that).  But perhaps that tape recording will provide a kind of record of the event that I could compare this to.

Continuing.

So above I said she should have grouped the people who don't know that they can't walk or can't see with the insane.  But she says that's not right -- they are actually lucid rational people in every way except when it comes to their affliction, and then they confabulate -- i.e. make stuff up.  I'm not sure it's a distinction that makes a difference for our purposes.  Both are mental conditions that cause one to not realize that one is "wrong."  But anyway.

Then she moved on to dreams.  The most interesting feature of dreams is the lack of surprise.  I.e. all kinds of weird things happen -- hybrids of people you know, in impossible situations.  And you never feel surprised.  ok, that's an insight that I had not considered before.  Thanks for that.  Not sure what I'll do with it now that I have it, but it's changed my life.

As I think about it, all I'd really need to get all the insights that are in this book is the outline.  I can ruminate just about as well as she can on any topic, so I really could skip most of the ruminations.  I feel like her outline probably says:  ruminate about dreams:  5 pages.  And then the task was to come up with 5 pages about dreams.  nice work if you can get it.

Continuing.

I would probably have to get a hard copy at this point to do a blow-by-blow summary.  I am still very annoyed by the use of "we."  Interestingly, at one point (so far) -- and only one point (which I believe was a discussion of the fact that "we" like political leaders who are decisive even if wrong), -- she took pains to acknowledge that although she was saying "we", not everybody thinks that way.  But she only said that in that particular case, and went back to saying "we" for everything else.  Again, many people who have thought about these issues can simply avoid being grouped in her "we" most of the time.  This discussion got extremely annoying when she went on to talk about how much "we" dislike voters who have not made up their minds.  She repeated jokes about undecideds from David Sedaris and Jon Stewart as though those somehow validated her belief that "we" all just can't stand the "undecideds."  She has more respect for those who have "decided" the other way, than those who are still making up their minds.  But wake up and take a look at the candidates that we are offered, election after election.  Look at the two political parties and the long history of corruption in both of them.  The whole idea that in every single election I need to "decide" between two candidates that I consider mediocrities, both in the pocket of big business, rubs me very much the wrong way.  This discussion doesn't seem to have any scientific support or point, and seems to simply be a rant about how much SHE dislikes people who haven't taken sides.


She also wanders into a weird digression about the Swiss.  Apparently, women there did not have a federal right to vote until 1971, and individual cantons still resisted women's suffrage until the early 1990s, when the last holdout was forced into suffrage by the Swiss Supreme Court.  There's a vague connection to her basic theme about "wrongness" here -- apparently the Swiss men were under peer pressure from each other, and the screaming harpies on the outside telling them they had to change their system only caused the position to become more entrenched.  But still, they voted 2-1 back in 1971 for women's suffrage.  That's 40 years ago now.  And yes, they took longer to give women the vote than other Western countries (but not than other Eastern and Middle-Eastern countries -- Saudi women still don't have it -- but so what?).  We took longer to free our slaves than most countries.  The "moral" development of countries can proceed at varied paces, for any variety of reasons, and most don't have to do with individual psychology.  When will the Swiss get around to repealing their banking secrecy laws?


But although I still haven't heard anything that will change the way I think (which I believe is one of the things reviewers say the book will do), I'm warming to the idea of recommending this to others, and perhaps Drew Faust's idea of making every new Harvard student read it isn't so bad.  They (and other entering college students) will likely not have read all the pop psychology that I have, so many of the old or obvious points in this book might seem new and fresh to them.  And in some cases, that will benefit them and the way they think.  


Right now I am thinking of her discussion of the "French Resistance Effect."  She said that when discussing the French Resistance (to the Nazi occupation) "we" all like to assume that we would have been among the 2% of the population that actively supported it.  But of course, the odds against this are very high.  And she earned my eternal gratitude by then going on to say something like "for that matter, we can't say how we would have acted if we had been Germans during the Nazi period."  


This is a point that I have considered often and made often.  I think of it every time I hear someone  saying (and I've heard it even in 2012) that the Germans -- current day Germans -- still need to be held accountable for the Holocaust.  The assumption being that the failure of the German people at large to somehow step in and stop the Holocaust is an enduring reason that we should not be buying German goods (or whatever).  These people continually hold the "German people" responsible.  Apart from the basic fact that it's very unclear how much information the "German people" had about the Holocaust while it was going on (much less whether they would have had any means of stopping it), the idea of judging people this way is rather ridiculous.  How can anyone today know for sure how they would have reacted to the rhetoric of the Nazi party if they had been born and raised in Germany, by German parents, in the aftermath of the First World War?  Hitler never got a majority after all, but how can any of us even say that "we" would not have voted for him?  In short, it wouldn't have been the "we" of today -- it would have been someone else.  And it was someone else.  As we can see from our modern genocides and genocidal tendencies, large numbers of people -- who are products of their environments -- can become willing cogs in a murderous machine.  But it's pointless to say "they should have known better."  Obviously, they didn't, and if we had been "them", we wouldn't have either.

Monday, July 16, 2012

Genetic Evidence of Cannibalism?

In Blogging the Human Genome in Slate today, Sam Kean is on chromosome 20, and he tells how the  the "prion" gene -- and mutations thereof -- could provide evidence of cannibalism in our past.  We all have two copies of the gene, but in some of us, one copy is slightly different, either as a result of heredity or the environment.  One kind of mutation leads to horrible brain disorders, which can be transmitted to someone who eats your brain.  The other kind of mutation actually prevents the brain-eater from getting the disorder.   Although this is considered "highly conserved" DNA -- DNA that nature does tinker with much -- the protective mutations in it are reasonably common.  Apparently this same thing came up in the mad cow disease scenario in the 1990s, where all but one of the people who died from eating "mad cow" did NOT have the beneficial mutation (I think we'd need to know more to understand how this proves anything -- since only 100 people died, perhaps that just means that one in a hundred people have the mutation).

So a 2003 study suggests that the presence of the mutation that protects cannibals from getting the disorder is evidence of widespread cannibalism in our past.  Other researchers have questioned this conclusion.  I'm neutral, and haven't read either competing side, but from the blog I'm having trouble understanding why this necessarily has to be correlated with cannibalism -- why can't it protect people who eat bad meat (e.g. mad cows?).

BTW, I ate some very tough and stringy beef (at least that's what they said it was) at a Vietnamese restaurant last night, on one of my occasional breaks from vegetarianism.  It wasn't worth it (practically inedible; I left much of it), and it will be a long time before I eat beef again.

I learned something else about mad cow disease from the article:  the cause of it was that the cows were forced to eat each other on factory farms.  Here again, Shakespeare was prescient:

ROSS
And Duncan's horses--a thing most strange and certain--
Beauteous and swift, the minions of their race,
Turn'd wild in nature, broke their stalls, flung out,
Contending 'gainst obedience, as they would make
War with mankind.
Old Man
'Tis said they eat each other.
ROSS
They did so, to the amazement of mine eyes
That look'd upon't. Here comes the good Macduff.
--

In other words, when hoofed animals start eating each other, you know there's something wrong with society, as in MacBeth.

And here's a Family Guy take on another factory farming practice.

Sunday, July 15, 2012

Andrew Leonard v David Brooks

Further to my most recent post (titled LIBOR something or other), the "debate" between Brooks and Leonard is symptomatic of the problem I identified there.  Brooks seems to think that the lax morality of Wall Street is due to the flower-children counterculture of the 1960s, while Leonard says no, the problem was the deregulation caused by the Republican backlash to that counterculture.

Brooks imagines a time when the banking titans had the same opportunities but believed in "restraint, reticence, and service" and took moral responsibility for what their organizations did.  But the temptations just weren't there, and in any event they were not so dispersed.  With the global markets and computerized trading we have today, there are literally thousands if not tens of thousands of individual actors who can fudge something somewhere in order to skim a million or two off of the torrent.  It just wasn't like that back in the age of restraint.  You can't blame the Democrats or the flowerchildren for that.

And Leonard is just as far off the mark.  The Reagan deregulation was the start, but it coincided with the computer revolution AND in any event it was the Democratic Clinton administration that continued the deregulatory slide for the financial services industry.

Interestingly, Leonard takes Brooks to task for describing the elites as harder-working than the middle and lower classes, wondering whether Brooks has ever spent time picking strawberries or cleaning toilets.  But that misses the point too.  As I said in my last post, the financial services sector -- and I, like Brooks, will go so far as to say the elites generally -- work harder than others.  Yes, there are certainly people doing really hard work (e.g. in a slaughterhouse) for long hours and little pay.  But either that's because they are immigrants (illegal or otherwise) and didn't have the opportunities that we citizens get, or it's because they just didn't work as hard at school as the elites.  It's not necessarily their fault -- they might come from broken homes or cultures that either do not value or simply cannot assist in the educational process -- but the fact is, they did not work as hard at school as the strivers who became (or continued to be) the elites.  If they're working hard now, good for them, but if it's a a minimum wage job, it's because they didn't work hard enough early on.

And on reading Brooks's piece, I see that he didn't even characterize the elites as harder-working; he just said that they work much longer hours and invest more time and money than those lower down on the income scale.  I'm pretty sure that on average, that's true.

So, although I don't often agree with Brooks, and I don't agree with his overall point in this article, I have to say that Leonard's critique was unfair, superficial, and beside the point.

LIBOR manipulation -- inevitable?

Let's say you have the opportunity to gain a million dollars by doing something that you know isn't right, but which isn't really all that wrong, and won't really hurt anybody that will notice.  E.g. say a briefcase with a million dollars in it falls off a truck and you can pick it up without anyone knowing.  And you know that it's insured.  You might not break into a car to get the briefcase, but maybe you'd pick it up and not tell anyone.  Or maybe you wouldn't.  But a lot of people would.

Most Wall Street (or other market) traders are -- and have been since early in their lives -- richer, smarter, more ambitious, harder working, and better educated than other people.  You can't get a job like that without having those attributes, often in spades.  They are also likely people who started off more moral than most -- they wouldn't dream of shoplifting, cheating on taxes, or stealing a car.  Rich people are less likely than others to do that stuff.

But here's the problem.  They are put in a position where the tiniest little manipulation -- sometimes what might seem like a tiny fib -- can result in millions of dollars flowing their way.  Why do we expect them to resist?  I'm actually getting a little bit tired of everyone complaining about the "moral breakdown" in the banking community.  They are no less moral than the rest of us.  The problem is that their temptations are much much greater than anything the rest of us have to try to resist.  Few of the rest of us can resist even the simplest temptations -- like chocolate, fatty food, and adultery. 

What's the cure?   I don't know, but identifying the problem -- a system that puts people in a position to skim even a tiny percentage off of a huge torrent of cash -- is the necessary first step toward a cure.  Until we come up with a system that works without creating these opportunities for skimming, we will continue to have dangerous and manipulative behavior up and down the financial markets.

Saturday, July 14, 2012

Artemisinen and Coartem continued

OK, was in a hurry yesterday (and am still today), but found this December 2008 Scientific American article which clears up a lot.  It turns out that the second ingredient in Coartem -- lumefantrine -- is not a placebo, but rather is a "a broad-spectrum antibiotic that stays in the body for about seven days."  Artemether clears the system in three days, so it's good to have the antibiotic still around, apparently.  Having both the drug and the antibiotic in the same pill can be important in the third world, where compliance is a problem.

The CSPI in 2008 was very favorable to the drug -- "It is the preferred treatment for falciparum malaria because many strains are resistant to choloroquine. As the strain developed resistance, there was a horrible need for new drugs, and this drug met it."

But the main thing I learned was in the following bracketed paragraph at the end of the article:

"[The Tropical Disease Priority Review Voucher law, which took effect this fall, allows drug companies that develop treatments for neglected diseases like malaria an expedited review by the FDA. That means that in the future, Novartis can bring another, more lucrative drug candidate before the agency for quicker approval — or sell that right for hundreds of millions of dollars, Goozner says. “Yes, well, this is a gift from heaven,” Silvio Gabriel, who manages Novartis' malaria initiatives, told today's New York Times.]"

I wonder how heavily Novartis lobbied for that law.  I haven't been able to find anything one way or the other.  The law was based on a proposal by David B. Ridley, Henry G. Grabowski and Jeffrey L. Moe, all business school professors, in a Health Affairs article with "research support" provided by the GlaxoWellcome Foundation and the Center for the Advancement for Social Entrepreneurship.

As of July 2011, it appears that the ONLY drug to receive a priority review voucher was Coartem, and that Novartis tried to use it for its anti-arthritis drug ILARIS, but an FDA committee had voted 11-1 against approval, so it seemed unlikely that the PRV would do Novartis any good.  The FDALAWBLOG post does mention that at the time PRVs were introduced, it was thought that they would trade for $50-$500 million, due to the potential for faster approval of blockbuster drugs.

A little more digging shows that when Novartis applied for the PRV for ILARIS, people thought Novartis was gaming the system, because Coartem was already on the market and in use outside the US, and didn't really require FDA approval to begin with.  So the big question is why was Congress so stupid as to create an "incentive" law whose only effect was to give an apparent windfall to Novartis?  Why can't they draft legislation that makes it clear that the rewards are only for new initiatives taken AFTER enactment of the law, not before?

I've looked into the sponsors -- Sam Brownback and Sherrod Brown -- and don't find any obvious links to big Pharma or Novartis.  Brown actually seems to be fighting the good fight against big Pharma outsourcing, which he says results in poor quality control (I wonder what Roger Bate would say about that), as well as against the recent post-approval KV Pharmaceuticals price hike from $10 to $1500 for an injection of anti-preemie drug Makena (which might have to be injected 20 times over the course of a pregnancy).  So really, it might just have been stupidity.










Friday, July 13, 2012

Roger Bate and phake drugs (cont'd)


As usual, I'm late to the party.  Roger Bate wrote a similar piece in the NYT a few months ago (though focusing on different drugs), and provoked a similar reaction from someone else.  Felix Salmon of Reuters has this to say about Bate's work:


"Roger Bate has a curious op-ed in the NYT today. He’s the lead author on a study which bought 370 drug samples from 41 online pharmacies around the world, and then tested their authenticity. The results? With the exception of Viagra bought from non-verified websites, every single drug was 100% authentic. But you’d never guess that from his op-ed."

Apparently, the op-ed was not about that particular study, but was about other problems that Bate had heard about more or less anecdotally.

"The “more and more cases” of fake drugs being found by the FDA? The FDA’s counterfeit medicine page lists exactly six cases in the past 24 months, of which just two — Tamflu in June 2010, and Vicodin ES in March 2012 — were linked to online pharmacies. The bogus Avastin, by contrast, was being distributed through legitimate channels by two distributors: Quality Specialty Products (QSP), a/k/a Montana Health Care Solutions, and Volunteer Distribution in Gainesboro, Tennessee. It had nothing to do with online pharmacies at all."

I find it extremely annoying when economists try to support their conclusions not just with bad or misleading data, but by reference to non-existent authority -- urban legends and other myths.

"But Bate doesn’t seem to believe the evidence of his own eyes. Instead, he relies on urban myths: his July 2011 paper, for instance, said in its second sentence that “according to the World Health Organization, substandard and counterfeit drugs have been found in both developed and developing countries, accounting for more than 10% of the global medicines market and over US$32 billion in annual earnings.” This is a classic bogus counterfeiting statistic: if you go to the WHO page he links to, the WHO in fact makes no such assertion at all. Instead, it attributes the factoid to the FDA, with no footnote.

"I’ve been trying to track down these statistics to their source for years, and I’ve never yet found one with a solid empirical grounding. Certainly Bate’s own studies would seem to disprove this assertion, but that doesn’t stop him, in his op-ed, talking authoritatively about “criminal networks” which “launder billions in profit”. As far as I can tell, no such network has ever been identified, and while there might be billions of dollars of profit in illegal drugs, that money is much more likely to come from marijuana and cocaine than it is from fake pharmaceuticals."

I reprinted the last two paragraphs above in full just just because they document Bate's sloppiness, as well as Salmon's diligence in trying to get support for the statistic.  Again, it shouldn't be our responsibility to check the numbers -- the economist should tell us where they come from, especially if he's out there doing actual studies and reporting numbers from those.

Some of the comments defend Bate as being more reasonable than the typical AEI drone.  I'm not convinced.  Again, call me paranoid, but I think the pharmaceutical companies get great value -- they can probably even quantify it -- every time an article like this, or a discussion of Bate's Phake book, hits the press.  That's what this is all about.  Trust me.

Q:  When do free marketers start advocating for market controls?

A:  When they are being paid by those who would benefit from such controls.

Artemisinin

As is often the case, one post leads to another.  I don't have time to track all of this down right now, but I looked up the "hard-to-get" drug Artemisinin mentioned by Roger Bate, and found that it's actually a natural product produced by the wormwood plant, that has been used as a remedy for malaria for millenia.  There is a touching story of a Chinese scientist who tracked down a bunch of folk remedies, including this one, and managed to get a patent on something containing it in China.  And of course, Novartis stepped in and got world-wide testing and approvals.  Oh, and good old Novartis also distributed it at cost in the third world, saving hundreds of thousands of lives.

The artemisinin-based product is called Coartem, and there's also a product called Coartem Dispersible.  All patented, but Novartis generously supplies them at cost, as above, saving many lives.  But if that's true, then why is the WHO buying it from Indian and Chinese manufacturers?  This all bears further investigation.  Interestingly, the wikipedia article on Coartem has the following legend:  "This article appears to be written like an advertisement. Please help improve it by rewriting promotional content from a neutral point of view and removing any inappropriate external links. (January 2011)"

Here's something from the wikipedia article:


The combination artemether/lumefantrine (trade names Coartem and Riamet) is a fixed-dose combination artemisinin-based combination therapy (ACT) indicated for the treatment of acute uncomplicated Plasmodium falciparum malaria.   The individual drugs were both initially developed in China. Artemether is one of the semi-synthetic derivatives of artemisinin, and lumefantrine (also known as benflumetol and CGP 56695 during development) is purely synthetic. The combination is an effective and well-tolerated malaria treatment, providing high cure rates even in areas of multi-drug resistance.


The reference to Artemether as a "semisynthetic derivative" is interesting.  I wonder what "semi-synthetic" means in this context.  An online medical dictionary gives two choices:


1. Prepared by chemical synthesis from natural materials, as of a pharmaceutical. 


2. Consisting of a mixture of natural and synthetic substances.

I'm guessing it's choice number two.  [update 8/3/12 -- a commenter who clearly knows more about this area than I do says that my choice is incorrect -- that "semi-synthetic derivative means that the starting material is natural and chemical syntheses are made from it," and that "[i]t is often used for increasing solubility or decreasing toxicity."  The commenter reports that Sanofi developed artesunate for solubility in water, since Artemisinin is insoluble in water.  Perhaps this suggests that Bate is being sloppy when he talks about the Artemisinin concentration in the supposedly-inferior Indian- and Chinese-supplied drugs.  As above, I'm still confused as to how it can be the case that Novartis is supplying coartem itself at cost, and yet WHO is still buying something with artemisinin in it from Indian and Chinese manufacturers]

Another interesting lead is this piece, in which it is claimed that artemisinin has cancer-fighting properties, but because it is so cheap to produce, the pharmaceutical companies are not interested in testing it.  Of course all that has to be taken with a grain of salt -- there are doubtless nutraceutical companies out there bottling the stuff and selling it at pharmacies and this could just be part of the campaign to persuade people that it does have cancer-fighting properties.


--


So I tried to find information about lumefantrine, and I see that it is considered an "anti-malarial drug" (by Wikipedia), but that it is never used without Artemether.  So it's really just a scam, most likely.  Let's get a patent on this combination of a well-known folk remedy plus a placebo, and see how much money (or good publicity) we can make of it.   


Hey, coartem shows up as a "USPTO Patent for Humanity" here.


And now my googling for coartem takes me full circle to this 2007 article by Bate.  I don't want to be unfair, and I need to analyze the situation more closely, but the article seems to suggest that in 2007, Coartem was the best drug for fighting malaria, and yet everyone was using cheaper drugs with less quality control and that the result was that people were dying.  My guess is that 2007 was BEFORE Novartis started providing Coartem at cost, and the result was that people were using artemisinin-based drugs that were not patented.  And of course, he says that they were also using counterfeit drugs with no therapeutic effect whatsoever.  His 2007 article is thus a pitch for people to step up and buy the brand name drug, possibly at brand name prices (there's no mention of Novartis's sell-it-at-cost program).  


So the bottom line is that Mr. Bate has been working for Novartis for quite a while now.






Counterfeit Drugs

There's no question that counterfeit drugs are a problem, are killing people, and are resulting in the creation of more resistant strains of bacteria.  That's the theme of Roger Bate's book "Phake" as well as his recent op-ed in the Washington Post, "Medicine that is more placebo than cure".

Bates (who is with the American Enterprise Institute),


"purchased, off the shelf from local pharmacies, about 2,600 drugs to treat malaria, tuberculosis and bacterial infections in low- and middle-income countries, including Ghana, Nigeria, Turkey, India and China. We then tested these drugs to see how much active pharmaceutical ingredient — the chemical that performs the drug’s lifesaving function — they contained."


Sounds reasonable. He reports that:


"Drugs made by Chinese and, to a lesser extent, Indian manufacturers performed quite badly — sometimes a fifth of them failed basic quality-control tests. Most worryingly, more than 15 percent of the Chinese drugs approved by the WHO failed to include adequate amounts of active pharmaceutical ingredient."


This is an interesting blend of statistics.  All it says is that sometimes a fifth of them failed.  What does that mean for all the other times?  Why tell us that you tested 2600 drugs, without giving us some sense of how many passed overall?  Or whether there were pockets where sometimes 100% passed.  Why not tell us if some of the manufacturers were better than others?  Based on these statistics, maybe some were perfect.


More haziness:

"The Chinese and Indian manufacturers making substandard drugs are often significant producers, certainly capable of making high-quality products — they did so to obtain WHO approval. But given available, albeit limited, data, they are not doing so consistently."

So the ones making bad drugs are "often" significant producers.  To me that strongly suggests that some significant producers are NOT making bad drugs.

But this is serious:

"With little or no oversight, these companies may be cutting corners in the manufacturing process — or worse, watering down the active ingredient in their drugs, perhaps when the price of the raw material spikes and supply becomes harder to obtain. The drug most often with too low a dose in our samplings, for instance, involved the hard-to-get­ artemisinin, a key antimalarial ingredient."

Obviously, the drug companies that are profiteering by deliberately watering down drugs to save money on ingredients need to be banned from these programs.  But why not just name some names and be done with it?  How many companies out there showed proper levels of artemisinin in all the tests?

The other thing that's missing from this is a discussion of what other sources of these drugs are available and at what cost.  It looks like they are being bought through the WHO and other donor programs, which presumably make an attempt to get the best quality drugs at the lowest price -- presumably through a competitive bidding process.  My guess is that the solution to the problem is simple -- just fire the Indian and Chinese companies that are producing sub-standard drugs, and give the business to those (the vast majority, for all we know) that have consistently produced good drugs.  But that doesn't seem to be the agenda here.  If I had to guess (suspicious me!), the agenda is probably part of a much broader campaign designed to foster concern and fear about generic (or grey market, or internet-bought) drugs generally, and to steer those sales to the brand-name pharmaceutical companies.  It would be very interesting to know just who funded this work.

Ok, I saved looking him up until the very end.  He shows up on wikipedia as a free-market extremist -- pro-tobacco, anti-climate change, pro-DDT, and pro-genetically modified organisms.  Of course that doesn't mean he is wrong, and it doesn't mean he hasn't identified a real problem.  But it does suggest that he has an agenda.  And quite obviously (as I just said) that agenda is to steer more sales toward the tried and true brand name pharmaceuticals.

As always, it's quite interesting to see these "free-market" types jumping in and taking a "protectionist" approach in areas where intellectual property protection applies.  Isn't the market supposed to correct itself in situations like this -- i.e. producers won't supply bad drugs, because then they'll lose business in the long run?  

Thursday, July 12, 2012

Doctors Selling Drugs

In yesterday's NYT, Barry Meier and Katie Thomas report that doctors are increasingly setting up in-house pharmacies, and dispensing drugs to their patients at a cost of ten times that charged by pharmacies.  See Insurers Pay Big Markups as Doctors Dispense Drugs.  The problem seems to be particularly acute in the area of workers' compensation insurance, which apparently in some states contains loopholes that actually require the insurance companies to pay these marked-up prices.  It's probably a problem in other areas as well though -- there's an inherent conflict of interest in allowing a doctor to profit from his or her own prescriptions.

While ordinarily I would welcome more competition in the pharmacy market (as we've seen from the example of CVS, it's possible for a pharmacy to engage in all kinds of price gouging), this sounds doesn't seem like the kind of competition that will result in lower costs to consumers.  Quite the contrary.

I wonder if ObamaCare will fix that.

Probably not, since ObamaCare doesn't have a whole lot to do with cost control, and controlling this would distress at least one faction of health-care profiteers.

When I look at these drug prices, it just reminds me of how little it costs per pill to actually manufacture a drug compared to how much they sell for when on-patent.  While the patent system has done a decent job of getting new and useful drugs created, tested, and marketed, it has also been incredibly inefficient and costly.  And the potential for markups like these tends to create more and more pockets of inefficiency up and down the distribution chain.  There may well be a better way.