Posts Tagged ‘medicine’
“Old ways of thinking die hard, particularly when they were weaned by legally enforced monopolies”*…
According to the US Bureau of Labor Statistics, from 2000 to present, prices in the hospital industry have grown faster than prices in any other sector of the US economy. The $1.3 trillion US hospital sector accounts for 6% of US GDP, nearly a third of all health care spending (which is materially higher as a share of GDP in the U.S. than in any other country). The average price for an inpatient hospital stay is $25,000.
A new working paper from the NBER assesses the impact of these rising costs. From its abstract:
We analyze the economic consequences of rising health care prices in the US. Using exposure to price increases caused by horizontal hospital mergers as an instrument, we show that rising prices raise the cost of labor by increasing employer-sponsored health insurance premiums. A 1% increase in health care prices lowers both payroll and employment at firms outside the health sector by approximately 0.4%. At the county level, a 1% increase in health care prices reduces per capita labor income by 0.27%, increases flows into unemployment by approximately 0.1 percentage points (1%), lowers federal income tax receipts by 0.4%, and increases unemployment insurance payments by 2.5%. The increases in unemployment we observe are concentrated among workers earning between $20,000 and $100,000 annually. Finally, we estimate that a 1% increase in health care prices leads to a 1 per 100,000 population (2.7%) increase in deaths from suicides and overdoses. This implies that approximately 1 in 140 of the individuals who become fully separated from the labor market after health care prices increase die from a suicide or drug overdose.
– NBER WORKING PAPER SERIES- WHO PAYS FOR RISING HEALTH CARE PRICES? EVIDENCE FROM HOSPITAL MERGERS
Four of the authors of that paper looked more deeply into the issue, exploring why those costs are rising; they identified consolidation in the hospital sector– 90% of hospital markets are now highly concentrated, according to the thresholds set by the FTC and the U.S. Department of Justice– as a key culprit:
The study, conducted in collaboration with researchers at Harvard University, Yale University, and the University of Wisconsin-Madison, found that of 1,164 mergers among the nation’s approximately 5,000 acute-care hospitals that occurred in the United States from 2000 to 2020, the Federal Trade Commission (FTC), which is tasked with preserving competition, challenged only 13 of them — an enforcement rate of about 1%.
Meanwhile, the researchers show that the FTC, using standard screening tools available to the agency during that period, could have flagged 20% of the mergers — 238 transactions — as likely to cause reduced competition and increase prices…
Unchallenged hospital mergers should have had minimal effects on competition and prices if the FTC were optimally targeting enforcement, the researchers noted. However, using data on the prices that hospitals negotiate with private insurers, the researchers found that mergers the FTC could have challenged as predictably anti-competitive between 2010 and 2015 eventually led to price increases of 5% or more.
The researchers estimate that the 53 hospital mergers that occurred on average annually from 2010 to 2015 raised health spending on the privately insured by $204 million in the following year alone. Putting this spending increase in context, the researchers note that the FTC’s average annual budget and antitrust enforcement budget between 2010 and 2015 were $315 and $136 million, respectively…
The study found that mergers in rural regions and areas with lower incomes and higher rates of poverty generated larger average price increases, often in outpatient services. The researchers suggest this occurred because those regions — compared with higher income, urban settings—have fewer free-standing clinics that offer surgical and imaging services that compete against hospitals in the outpatient market…
Consolidation in Hospital Sector Leading to Higher Health Care Costs
As Cory Doctorow succinctly observes…
The health system is a perfect example of how monopolization drives more monopolization, and how that comes to harm the public and workers. Health consolidation began with pharma mergers, that led to pharma companies gouging hospitals. Hospitals, in turn, engaged in a nonstop orgy of mergers, which created regional monopolies that could resist the pricing power of monopoly pharma – and screw insurers. That kicked off consolidation in insurance, which is why most Americans have a “choice” of between one and three private insurers – and why health workers’ monopoly employers have eroded their wages and working conditions.
How consolidation in the hospital sector is increasing healthcare prices and creating even steeper costs more broadly in the economy. @nberpubs @AEAjournals @doctorow
* Mitch Kapor
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As we measure our blood pressure, we might send concerned birthday greetings to Janette Sherman; she was born on this date in 1930. A physician, toxicologist, author, and activist. She researched pesticides, nuclear radiation, birth defects, breast cancer, and illnesses caused by toxins in homes and was a pioneer in the field of occupational and environmental health.
Dr. Sherman served as a medical-legal expert witness in more than 5,000 workers’ compensation claims and served as an expert witness for residents in communities affected by environmental hazards, most famously the Love Canal neighborhood of Niagara Falls, N.Y. Her medical-legal files, among the largest collections of their kind in the United States, are preserved at the National Library of Medicine at the National Institutes of Health in Bethesda, Md.
“Judge me by my size, do you?”*…
A tiny variety of the fork fern seems altogether unremarkable– but has a genome that dwarfs the human genome in size. Max Kozlov explains what that might teach us…
A small, unassuming fern-like plant has something massive lurking within: the largest genome ever discovered, outstripping the human genome by more than 50 times.
The plant (Tmesipteris oblanceolata) contains a whopping 160 billion base pairs, the units that make up a strand of DNA. That’s 11 billion more than the previous record holder, the flowering plant Paris japonica, and 30 billion more than the marbled lungfish (Protopterus aethiopicus), which has the largest animal genome. The findings were published [on May 31] in iScience…
The world’s genomic champion, which is native to New Caledonia and neighbouring archipelagos in the South Pacific, is a species of plant called a fork fern. Its colossal number of base pairs raises questions as to how the plant manages its genetic material. Only a small proportion of DNA is made of protein-coding genes, leading study co-author Ilia Leitch, an evolutionary biologist at London’s Royal Botanic Gardens, Kew, to wonder how the plant’s cellular machinery accesses those bits of the genome “amongst this huge morass of DNA. It’s like trying to find a few books with the instructions for how to survive in a library of millions of books — it’s just ridiculous.”
There’s also the question of how and why an organism evolved to have so many base pairs. Generally, having more base pairs leads to higher demand for the minerals that comprise DNA and for energy to duplicate the genome with every cell division, Leitch says. But if the organism lives in a relatively stable environment with little competition, a gargantuan genome might not come with a high cost, she adds.
That could help to provide an explanation — although a rather boring one — for the fork fern’s large genome: it might be neither detrimental nor particularly helpful for the plant’s ability to survive and reproduce, so the fork fern has gone on accumulating base pairs over time, says Julie Blommaert, a genomicist at the New Zealand Institute for Plant and Food Research in Nelson.
For now, researchers can only speculate on answers to these questions. The largest genome to be sequenced and assembled belongs to the European mistletoe (Viscum album), with about 90 billion base pairs. Modern techniques might not be sufficient to do the same for the fork fern’s genome: even if it’s sequenced, there’s still the computational challenge of taking the data and “sticking them together in a way that biologically reflects what’s going on”, Leitch says.
Finding ways to analyse enormous genomes could yield crucial insights into how genome size influences where organisms can grow, how they are able to flourish in their environments and their resilience to climate change, independent of their specific DNA sequence, she adds. Pellicer says it’s remarkable that a tiny, non-flowering plant that most people “wouldn’t bother to stop and look at” could offer such important lessons. “The beauty of the plant is inside.”
“Biggest genome ever found belongs to this odd little plant,” from @maxdkozlov in @Nature.
* Yoda, “The Empire Strikes Back”
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As we rescope scale, we might send insightful birthday greetings to Phillip Allen Sharp; he was born on this date in 1944. A geneticist and molecular biologist, he co-discovered RNA splicing— for which he shared the 1993 Nobel Prize in Physiology or Medicine (with Richard J. Roberts). His work has spurred new research in evolutionary biology, and has contributed to the development of both treatments and vaccines for infectious diseases, cancer and other ailments.
“Analysis of death is not for the sake of becoming fearful but to appreciate this precious lifetime”*…
As Alex Blasdel explains, new research into the dying brain suggests the line between life and death may be less distinct than previously thought…
… For all that science has learned about the workings of life, death remains among the most intractable of mysteries. “At times I have been tempted to believe that the creator has eternally intended this department of nature to remain baffling, to prompt our curiosities and hopes and suspicions all in equal measure,” the philosopher William James wrote in 1909.
…
In 1976, the New York Times reported on the burgeoning scientific interest in “life after death” and the “emerging field of thanatology”. The following year, Moody and several fellow thanatologists founded an organisation that became the International Association for Near-Death Studies. In 1981, they printed the inaugural issue of Vital Signs, a magazine for the general reader that was largely devoted to stories of near-death experiences. The following year they began producing the field’s first peer-reviewed journal, which became the Journal of Near-Death Studies. The field was growing, and taking on the trappings of scientific respectability. Reviewing its rise in 1988, the British Journal of Psychiatry captured the field’s animating spirit: “A grand hope has been expressed that, through NDE research, new insights can be gained into the ageless mystery of human mortality and its ultimate significance, and that, for the first time, empirical perspectives on the nature of death may be achieved.”
But near-death studies was already splitting into several schools of belief, whose tensions continue to this day. One influential camp was made up of spiritualists, some of them evangelical Christians, who were convinced that near-death experiences were genuine sojourns in the land of the dead and divine. As researchers, the spiritualists’ aim was to collect as many reports of near-death experience as possible, and to proselytise society about the reality of life after death. Moody was their most important spokesman; he eventually claimed to have had multiple past lives and built a “psychomanteum” in rural Alabama where people could attempt to summon the spirits of the dead by gazing into a dimly lit mirror.
The second, and largest, faction of near-death researchers were the parapsychologists, those interested in phenomena that seemed to undermine the scientific orthodoxy that the mind could not exist independently of the brain. These researchers, who were by and large trained scientists following well established research methods, tended to believe that near-death experiences offered evidence that consciousness could persist after the death of the individual. Many of them were physicians and psychiatrists who had been deeply affected after hearing the near-death stories of patients they had treated in the ICU. Their aim was to find ways to test their theories of consciousness empirically, and to turn near-death studies into a legitimate scientific endeavour.
Finally, there emerged the smallest contingent of near-death researchers, who could be labelled the physicalists. These were scientists, many of whom studied the brain, who were committed to a strictly biological account of near-death experiences. Like dreams, the physicalists argued, near-death experiences might reveal psychological truths, but they did so through hallucinatory fictions that emerged from the workings of the body and the brain. (Indeed, many of the states reported by near-death experiencers can apparently be achieved by taking a hero’s dose of ketamine.) Their basic premise was: no functioning brain means no consciousness, and certainly no life after death. Their task, which Borjigin took up in 2015, was to discover what was happening during near-death experiences on a fundamentally physical level.
Slowly, the spiritualists left the field of research for the loftier domains of Christian talk radio, and the parapsychologists and physicalists started bringing near-death studies closer to the scientific mainstream. Between 1975, when Moody published Life After Life, and 1984, only 17 articles in the PubMed database of scientific publications mentioned near-death experiences. In the following decade, there were 62. In the most recent 10-year span, there were 221. Those articles have appeared everywhere from the Canadian Urological Association Journal to the esteemed pages of The Lancet.
Today, there is a widespread sense throughout the community of near-death researchers that we are on the verge of great discoveries…
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… Perhaps the story to be written about near-death experiences is not that they prove consciousness is radically different from what we thought it was…
… there is something that binds many of these people – the physicalists, the parapsychologists, the spiritualists – together. It is the hope that by transcending the current limits of science and of our bodies, we will achieve not a deeper understanding of death, but a longer and more profound experience of life. That, perhaps, is the real attraction of the near-death experience: it shows us what is possible not in the next world, but in this one…
Eminently worth reading in full: “The new science of death: ‘There’s something happening in the brain that makes no sense’,” from @unkowthe_again in @guardian.
* Dalai Lama
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As we ponder passages, we might send innovative (and painless) birthday greetings to Robert Andrew Hingson; he was born on this date in 1913. An anesthesiologist and inventor, he is best known for three major inventions that continue to relieve pain and suffering worldwide today. One is a very portable respirator anesthesia gas machine and resuscitator, called the Western Reserve Midget, used to deliver a short-term, general anesthetic.
The second came from extensive experiments in the use of anesthesia to prevent pain during childbirth, leading to the invention of the continuous caudal epidural anesthesia technique.
The third and best known is his “peace gun,” a pistol-shaped jet injector that enabled efficient, mass, needle-less inoculation worldwide against such diseases as small pox, measles, tuberculosis, tetanus, leprosy, polio, and influenza. It can inoculate 1,000 persons per hour with several simultaneous vaccines.
“I am now no more than a pile of blood, bone, and meat that is unhappy”*…
Most of us are familiar with the placebo effect. Dr. Michael H. Berstein explains the “nocebo”…
The term “nocebo effect” derives from the Latin word nocere, which translates roughly as “to harm” (as in the Hippocratic injunction, primum non nocere—first, do no harm). Whereas the better-known placebo effect is typically positive (the alleviation of pain or malaise through treatments that otherwise have no inherent therapeutic value); the nocebo effect is negative, often manifesting as headache, skin irritation, or nausea.
No surprise, then, that the nocebo effect has been called “the placebo effect’s evil twin.” It can be more formally summarized as “the occurrence of a harmful event that stems from conscious or subconscious expectations.” Or, more simply: When you expect to feel sick, you are more likely to feel sick.
Of course, human expectations come up in all sorts of banal, everyday contexts, such as when you tell a friend that you’re stuck in traffic and so he or she should expect your arrival in twenty minutes. But expectation is also an important term of art that academics use (sometimes interchangeably with “expectancy”), having been popularized by Dr. Irving Kirsch, who now serves as Associate Director of the Program in Placebo Studies at Harvard Medical School.
Kirsch’s work built on that of Dr. Henry Beecher, who served with the American military during World War II. While deployed in North Africa and Italy, he gave saltwater to wounded soldiers, but told them they were receiving a powerful painkiller. Beecher did not engage in this deception by choice, but by necessity: As an anesthesiologist treating a flood of battlefield injuries, he faced the difficult task of rationing his supply of morphine.
The roots of our understanding of the nocebo effect are more obscure. But we do find an early precedent involving the work of eighteenth-century German physician Franz Mesmer, best known for his interest in the eponymous proto-hypnotic therapy known as “mesmerism.” In the salons of Paris and Vienna, he promoted the idea that illnesses could be alleviated by using magnets to govern the flow of fluid in patients’ bodies. (If this sounds like obvious quackery, which it is, bear in mind that Mesmer lacked any of our modern-day tools of science. He lived in an era when bloodletting with leeches was still seen as state-of-the-art medical treatment.)
Louis XVI (yes, the French king of guillotine fame) learned of Mesmer’s claims, and (properly) regarded them with skepticism. He established a commission to investigate, led by none other than Benjamin Franklin, who was then serving as the United States Minister to France. The American polymath and Francophile performed what we would now refer to as placebo-controlled studies so as to (as the commission put it) “separate the effects of the imagination from those attributed to magnetism.”…
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… The mind’s unfortunate ability to create suffering ex nihilo can sometimes affect large groups of people though a process of social contagion (or, in the more indelicate language of the past, hysterical contagion). One such example, known as “The June Bug,” occurred in a U.S. textile mill in 1962. Many employees began to feel dizzy and nauseous. Some vomited. Rumors of a mysterious bug that was biting employees began to circulate, and eventually 62 workers became ill. Yet a subsequent Centers for Disease Control and Prevention investigation determined that no bugs could be identified. Nor could investigators find any other physical cause of the illnesses. This type of phenomenon is now referred to as psychogenic illness—sickness caused by belief.
Over the course of history, there have been countless other examples of psychogenic illness, with symptoms ranging from hysterical laughter to seizures. Aldous Huxley, the famed author of Brave New World, described one such seventeenth-century example in his lesser-known historically-based novel, The Devils of Loudun. In the 1630s, as Huxley documents, an entire convent of Ursuline nuns in the western French community of Loudun became convinced that they’d been demonically possessed (complete with convulsions, and other symptoms recognizable to any connoisseur of the modern exorcism-themed horror-movie genre) due to the unholy machinations of a (genuinely licentious) local priest named Urbain Grandier.
Could such a mass outbreak occur today, in an era when few believe in demonic spirits? Consider that during 2016 and 2017, no fewer than 21 American diplomats serving in Cuba reported a range of bizarre neurological symptoms that later came to be collectively described as “Havana Syndrome.” News of the outbreak spread globally through American diplomatic networks, and eventually more than 200 U.S. diplomats became ill. One leading theory was that the Russian government was attacking American embassies and consulates with microwaves.
To be clear: We do not yet know for certain the cause of these ailments. And it is conceivable that speculation concerning Russian involvement may prove correct (even if the microwave theory is far-fetched). That said, the possibility of psychogenic effects is obvious, and I regard it as concerning that this theory seems to have been rejected out of hand by American officials.
In 2021, in fact, a senior State Department official who’d been mandated to oversee the task force investigating Havana Syndrome was pushed out of her role when she refused to take psychogenic illness off the menu of potential causes. A former C.I.A. officer who claimed he’d been affected by Havana Syndrome while serving in Moscow declared that failing to rule out “mass hysteria” as a cause was “grotesquely insulting to victims and automatically disqualifying to lead the task force.”
I suspect that if Ben Franklin were alive today, he might take a different view…
When we experience pain, depression, or illness based on nothing more than negative expectations: “The Placebo Effect’s Evil Twin,” from @mh_bernstein in @Quillette.
Adapted, with permission, from the forthcoming book, The Nocebo Effect: When Words Make You Sick, by Michael H. Bernstein, Ph.D., Charlotte Blease, Ph.D., Cosima Locher, Ph. D., and Walter A. Brown, M.D. Published by Mayo Clinic Press.
* J.M. Coetzee, Waiting for the Barbarians
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As we adjust our attitude, we might recall that it was on this date in 1867 that Joseph Lister published the first of his series of articles in The Lancet on “The Antiseptic Principle of the Practice of Surgery.” Lister, having noticed that carbolic acid (phenol) was used to deodorize sewage, had experimented with using it to spray surgical instruments, surgical incisions, and dressings. The result, he reported, was a substantially reduced incidence of gangrene.
“Right now I’m having amnesia and déjà vu at the same time. I think I’ve forgotten this before.”*…
Our first three years are usually a blur, and we don’t remember much before age seven. Kristin Ohlson wondered why…
… Freud argued that we repress our earliest memories because of sexual trauma but, until the 1980s, most researchers assumed that we retained no memories of early childhood because we created no memories – that events took place and passed without leaving a lasting imprint on our baby brains. Then in 1987, a study by the Emory University psychologist Robyn Fivush and her colleagues dispelled that misconception for good, showing that children who were just 2.5 years old could describe events from as far as six months into their past.
But what happens to those memories? Most of us assume that we can’t recall them as adults because they’re just too far back in our past to tug into the present, but this is not the case. We lose them when we’re still children…
…
To form long-term memories, an array of biological and psychological stars must align, and most children lack the machinery for this alignment. The raw material of memory – the sights, sounds, smells, tastes and tactile sensations of our life experiences – arrive and register across the cerebral cortex, the seat of cognition. For these to become memory, they must undergo bundling in the hippocampus, a brain structure named for its supposed resemblance to a sea horse, located under the cerebral cortex. The hippocampus not only bundles multiple input from our senses together into a single new memory, it also links these sights, sounds, smells, tastes, and tactile sensations to similar ones already stored in the brain. But some parts of the hippocampus aren’t fully developed until we’re adolescents, making it hard for a child’s brain to complete this process.
‘So much has to happen biologically to store a memory,’ the psychologist Patricia Bauer of Emory University told me. There’s ‘a race to get it stabilised and consolidated before you forget it. It’s like making Jell-O: you mix the stuff up, you put it in a mould, and you put it in the refrigerator to set, but your mould has a tiny hole in it. You just hope your Jell-O – your memory – gets set before it leaks out through that tiny hole.’
In addition, young children have a tenuous grip on chronology. They are years from mastering clocks and calendars, and thus have a hard time nailing an event to a specific time and place. They also don’t have the vocabulary to describe an event, and without that vocabulary, they can’t create the kind of causal narrative that [that’s] at the root of a solid memory. And they don’t have a greatly elaborated sense of self, which would encourage them to hoard and reconsider chunks of experience as part of a growing life-narrative.
Frail as they are, children’s memories are then susceptible to a process called shredding. In our early years, we create a storm of new neurons in a part of the hippocampus called the dentate gyrus and continue to form them throughout the rest of our lives, although not at nearly the same rate. A recent study by the neuroscientists Paul Frankland and Sheena Josselyn of the Hospital for Sick Children in Toronto suggests that this process, called neurogenesis, can actually create forgetting by disrupting the circuits for existing memories.
Our memories can become distorted by other people’s memories of the same event or by new information, especially when that new information is so similar to information already in storage. For instance, you meet someone and remember their name, but later meet a second person with a similar name and become confused about the name of the first person. We can also lose our memories when the synapses that connect neurons decay from disuse. ‘If you never use that memory, those synapses can be recruited for something different,’ Bauer told me.
Memories are less vulnerable to shredding and disruptions as the child grows up. Most of the solid memories that we carry into the rest of our lives are formed during what’s called ‘the reminiscence bump’, from ages 15 to 30, when we invest a lot of energy in examining everything to try to figure out who we are. The events, culture and people of that time remain with us and can even overshadow the features of our ageing present, according to Bauer. The movies were the best back then, and so was the music, and the fashion, and the political leaders, and the friendships, and the romances. And so on…
Why we remember so little from our youngest years: “The great forgetting,” from @kristinohlson in @aeonmag.
* Steven Wright
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As we stroll down memory lane, we might spare a thought for Benjamin McLane Spock; he died on this date in 1998. The first pediatrician to study psychoanalysis to try to understand children’s needs and family dynamics, he collected his findings in a 1946 book, The Common Sense Book of Baby and Child Care, which was criticized in some academic circles as being too reliant on anecdotal evidence, and in some conservative circles for promoting (what Norman Vincent Peale and others called) “permissiveness” by parents. Despite that push-back, it became one of the best-selling volumes in history, having sold at the time of Spock’s death in 1998 over 50 million copies in 40 languages.
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