Medical

This time around, we cover the Hanson/Alexander debates on the value of medicine, and otherwise we mostly have good news.

Regeneron administers a single shot in a genetically deaf child’s ear, and they can hear after a few months, n=2 so far.

Great news: An mRNA vaccine in early human clinical trials reprograms the immune system to attack glioblastoma, the most aggressive and lethal brain tumor. It will now proceed to Phase I. In a saner world, people would be able to try this now.

More great news, we have a cancer vaccine trial in the UK.

And we’re testing personalized mRNA BioNTech canner vaccines too.

US paying Moderna $176 million to develop a pandemic vaccine against bird flu.

We also have this claim that Lorlatinib jumps cancer PFS rates from 8% to 60%.

Early results from a study show the GLP-1 drug liraglutide could reduce cravings in people with opioid use disorder by 40% compared with a placebo. This seems like a clear case where no reasonable person would wait for more than we already have? If there was someone I cared about who had an opioid problem I would do what it took to get them on a GLP-1 drug.

Rumblings that GLP-1 drugs might improve fertility?

Rumblings that GLP-1 drugs could reduce heart attack, stroke and death even if you don’t lose weight, according to a new analysis? Survey says 6% of Americans might already be on them. Weight loss in studies continues for more than a year in a majority of patients, sustained up to four years, which is what they studied so far.

The case that GLP-1s can be sued against all addictions at scale. It gives users a sense of control which reduces addictive behaviors across the board, including acting as a ‘vaccine’ against developing new addictions. It can be additive to existing treatments. More alcoholics (as an example) already take GLP-1s than existing indicated anti-addiction medications, and a study showed 50%-56% reduction in risk of new or recurring alcohol addictions, another showed 30%-50% reduction for cannabis.

How to cover this? Sigh. I do appreciate the especially clean example below.

Matthew Yglesias: Conservatives more than liberals will see the systematic negativity bias at work in coverage of GLP-agonists.

Less likely to admit that this same dynamic colors everything including coverage of crime and the economy.

The situation is that there is a new drug that is helping people without hurting anyone, so they write an article about how it is increasing ‘health disparities.’

The point is that they are writing similar things for everything else, too.

The Free Press’s Bari Weiss and Johann Hari do a second round of ‘Ozempic good or bad.’ It takes a while for Hari to get to actual potential downsides.

The first is a claimed (but highly disputed) 50%-75% increased risk of thyroid cancer. That’s not great, but clearly overwhelmed by reduced risks elsewhere.

The second is the worry of what else it is doing to your brain. Others have noticed it might be actively great here, giving people more impulse control, helping with things like smoking or gambling. Hari worries it might hurt his motivation for writing or sex. That seems like the kind of thing one can measure, both in general and in yourself. If people were losing motivation to do work, and this hurt productivity, we would know.

The main objection seems to be that obesity is a moral failure of our civilization and ourselves, so it would be wrong to fix it with a pill rather than correct the underlying issues like processed foods and lack of exercise. Why not be like Japan?

To which the most obvious response is that it is way too late for America to take that path. That does not mean that people should suffer. And if we find a way to fix the issues raised by our diets without changing (‘fixing’) our diets, that is great, not a cause for concern.

The other obvious response is: Who cares? The important thing is to fix it.

Believing he is responding to Hanson and Caplan, Scott Alexander makes the case that medicine, and more access to medicine, does indeed improve health, and that claims to the contrary are misunderstood.

Robin Hanson responds here, with lots of quotes, that he never claimed medicine was useless, rather that additional medical spending on the margin appears useless. Cut Medicine in Half, he says, not cut medicine entirely. Then Scott Alexander responded again.

Scott Alexander’s conclusion in his first post was that medicine obviously works, and the argument should be whether it is effective on the margin, or whether marginally more insurance is cost effective. Robin agrees these are the questions, and convincingly says he been asking them whole time.

The question is, are we spending too much on health care, given the costs and benefits? Robin thinks clearly yes. It seems hard to arrive at any other conclusion.

It is a useful exercise to step through Scott’s arguments. What does the case for ‘medicine does something rather than nothing’ look like?

1. Scott’s first argument is that modern medicine improves survival rates from diseases. In particular that five-year survival rates from cancer are greatly improved. The problem is that health care also greatly increases diagnosis of cancer, and the marginal diagnoses are mild cases. The same potentially applies for other conditions he mentions.

   1. I understand the desire to control for outside conditions, but you do have to pick your poison. And the need to control for outside conditions points to those conditions having at least a large share of the effects. The story of cancer rates is largely the story of smoking rates.

   2. Robin responds also: But [Scott] seems well aware that many other specialists judge differently here [versus Scott’s judgment that being healthier is only at most 20%-50% of the effect.] 

2. Scott next tackles the RAND health insurance experiment, with people getting various qualities of health coverage. He says that RAND actually found a big effect for men ‘at elevated risk’ on hypertension, that this would mean a 1.1% increased 5-year survival rate at age 50 (as in, by age 55, out of 1,000 such men, the treatment would keep an extra 11 of them alive). And yes, glasses fix vision, we agree. Scott defends the failure to accomplish anything else measured. Okay.

   1. The mortality claim is based on the blood pressure impact. So it is assuming that changing blood pressure via treatment changes mortality. I would not assume that this is true.

   2. This does not contradict Hanson’s position, which I understand to be: ‘medicine is in some ways helpful and in some ways harmful and if you exclude a few highlights like trauma care where we are confident it is helpful, the rest mostly cancels out.’

   3. If there was a large overall mortality effect (in any of these studies) I presume we would know, but Scott says the samples weren’t large enough for that.

   4. Note that this also is evidence for ‘doctor lectures do not effectively persuade people to quit smoking, lose weight or change their diets.’

3. Scott gets to the famous Oregon Health Insurance Experiment. People randomly got Medicaid or didn’t, those that did then used more health care. Were the mental improvements from this primarily a placebo plus an income effect, especially since a lot of it happened right away before any treatments? Were there physical effects?

   1. Once again Scott is focusing on ‘gave people with hypertension medication to lower blood pressure’ as his example of medicine working, which he essentially asserts based on the knowledge that the medication does this. He is saying that the medication works because we know the medication works, and the treatment group got more of the medication, so medicine works. Which does not seem like it meaningfully answers the claims.

   2. Scott argues that the study lacked power to pick up on the physical impacts of medicine. This seems like a stronger rebuttal, at least to individual null results like the hypertension effect.

4. Scott next goes to the Karnataka Health Insurance Experiment in India.

   1. He basically dismisses this one as having too little power, because the people who got insurance did not know what it was and did not consume much care.

   2. This seems like a reasonable take here when looking for smaller effects. But Robin points out that there was substantial utilization change, and relatively large changes can be ruled out, although for smaller ones the likelihood ratio here is not so large.

5. Putting it all together, Scott claims that the studies mostly are vastly underpowered, except the Oregon self-reported impacts which he admits could be (a still effective, it counts) placebo.

6. Scott then points to other more recent studies he says are more positive.

   1. We do get an all-cause mortality impact, Goldin, Lurie, and McCubbin claim 56-64 year-olds had one fewer death per 1,648 individuals who got a letter to get insurance, over the following two years, p = 0.01. They were 1.1% more likely to buy insurance. They go back and forth on this one a lot, link includes responses by Dr. Goldin. I think the Lindley’s Paradox argument here is actually pretty strong and Dr. Goldin’s response to it is weak, despite Scott thinking it looks strong – you have to focus on likelihood ratios.

   2. But this effect is completely physically impossible if you attribute it to people buying insurance, because it would be larger than the size of the total death rate, and presumably no one thinks medicine is that good. Perhaps this explains why Robin dismisses this as noise.

   3. Robin has different calculations, but he also comes up with absurd answers that imply ludicrous amounts of impact on all-cause mortality.

   4. Then there are three more studies. States expanding Medicaid had lower mortality, as did Massachusetts after the similar Romneycare, and Medicaid availability lowered child mortality. Low p-values.

   5. I basically buy that there is an all-cause mortality effect here, but how do we differentiate the stories here? Story one is that medicine mostly works. Story two is that trauma care, vaccines, antibiotics and a handful of other things clearly work, and the rest is a mixed bag that mostly cancels out. We also need to worry about wealth effects.

I agree with Scott that there is a clear distinction between ‘core care’ and ‘extra care.’ It is not a boolean, but we all know those times that no really, we need to go to the doctor, which in turn splits into ‘I need to see a doctor’ versus ‘no really I might die if I don’t see a doctor,’ versus those times we might want to go.

In Scott’s follow-up post, he sees Hanson as being unable to decide whether or not we can tell which parts of medicine work, sees Hanson being far too willing to cut essentially at random, and proposes a trilemma.

1. If we can’t distinguish good and bad medical interventions, we shouldn’t cut medicine, because medicine is net positive now.

2. Or if we can’t distinguish, but the average intervention is net negative if you include costs, you should cut everything.

3. Or if we can distinguish, then we should… pay a lot of attention to getting that right?

Before reading Hanson’s reply, here would be my response:

1. There are some things we know work or have high confidence work, in ways that have very good cost-benefit.

2. There are then a lot of other things, where we don’t know how much or if they work, or whether they are worth it. And also some where we actually know they aren’t worth it or don’t work, but we’re currently stuck with them.

3. If we were forced to cut medicine by half, no we would not do that by only treating half of trauma patients and only giving half of people antibiotics. People would make reasonably good decisions.

4. When Robin Hanson says trying to figure out what treatments work so we cut only the things that don’t work is a ‘monkey trap,’ what he means is that you say cut medicine by half, they say they will appoint a committee to do a study to figure out how to figure out which ones don’t work, there are a bunch of big endless fights and accusations and a lot of lobbying and you don’t cut anything.

5. Scott wants to argue about cutting entire categories of care. Does cancer care work? If so, don’t cut it. But I would hope we all agree that at current knowledge levels the right amount of cancer care is more than zero and less than what we do now, at least for those Americans with good insurance. If we cut cancer care costs by half the doctors would mostly do a rather good job identifying which half to keep.

6. We can largely do this by shifting more of the costs for marginal care onto the patients. They will mostly make reasonable decisions on which things to keep.

7. And come on, we all basically know all this.

Also, to nitpick a bit because of who is writing this, when Scott uses the example of asking whether guns kill people, and how you might study this by giving people vouchers to buy guns and seeing if they get convicted of murder more people than a control group, I notice this seems terrible even if you ignore the ethical problems. This is so obviously a no good, very bad, terrible way to test the question of ‘does shooting someone with a gun kill them?’ because this is asking a completely different question. It is not merely about whether the impact is statistically significant or not. Whereas yes, we do seem to have records of how much more money was spent on healthcare in the studies this is supposed to be a metaphor for?

And then Scott basically… says Hanson is wrong about the strength of his evidence but is probably mostly right about the underlying questions?

Scott Alexander: In case my own position isn’t clear: I think lots of medicine is useless, and that most doctors would agree with this. We over-order tests when we don’t need them, we do a lot of ineffective stuff to please patients (starting with antibiotics for viral illnesses, but sometimes going up to surgeries that have only placebo value), and we do lots of treatments that we know fail >90% of the time, like certain kinds of rehab for drug addiction (we tell ourselves we’re doing it because the tiny number of people who do benefit deserve a chance, but a rational health bureaucrat who wants to save money might not see it that way).

Does all this add up to half? I’m not sure. But I think we can work on cutting back on this stuff without saying things like “maybe medicine is just about signaling” or “how do we know if any of it works?” or “you can’t trust clinical trials because they’re all biased”, and that it very very much matters which parts of medicine we cut.

(something like this has to be true, because eg Britain spends only half as much per person as the US on healthcare, and Brits have approximately as good health outcomes. This isn’t because medicine, in the sense of specific treatments for specific diseases, works any better or worse in Britain – it’s for the same reasons that colleges have ballooned in cost without educating people much better.)

It wouldn’t surprise me if expensive insurance doesn’t have much marginal mortality benefit over cheap insurance, although it might still be worth it on a personal level (because it gets you faster care, kinder doctors, fancier hospital rooms, etc).

So yes, our spending double what the UK spends on medicine is probably buying us very little additional health or longevity.

Hanson’s second response mostly says ‘I keep saying that we should cut medicine by having people pay out of their own pockets, and you should cut your own consumption by asking if you would have paid the sticker price for it.’ And he proposes or reminds us of other methods of differentiating good versus bad care.

Hanson also emphasizes that a lot of this is paying more for fancier versions of the same treatments, or more expensive treatment options, and you can usually get most or all of the benefits without paying more.

Certainly I have witnessed this, where the cost difference of what different treatment providers bill is rather stunning. Yes, the more expensive is better, but wow is the marginal benefit not worth the marginal cost.

John Mandrola especially endorses Hanson’s advice for finding low-value care.

1. Ask about a treatment’s Cochrane Review rating.

2. Ask if a treatment is done in low spending geographic regions.

3. Ask if treatments are done in small hospitals.

4. Ask your doctor how strongly they recommend a particular treatment; decline if recommendation is weak. (I’ve done this.)

5. Ask yourself and associates if you would be willing to pay for them out of your own pocket, if insurance did not cover them.

I agree that these recommendations seem excellent, in cases where you are unsure. Scott Alexander thinks they are pretty good too. And again I would emphasize that your instincts on this are probably pretty good no matter how you get them.

In the end, it sounds like Robin and Scott (and I) are not that far apart on the actual physical question of what actions cause or don’t cause health outcomes to improve. All three of us mostly agree on the ground truth that America spends a lot of money that is wasted, as the result of signaling and regulatory capture and various toxic dynamics, and we should work to spend a lot less.

The real fight here, I think, is mostly that Robin Hanson wants to or at least is down to lower the status of medicine and doctors, and to make it not a sacred value. Scott Alexander wants to not do that and defend medicine and doctors, and keep medicine sacred.

One way to spend too much on healthcare is to write checks that are the wrong size.

Your periodic reminder that pharmaceutical pricing is crazy town, with rampant price discrimination, and you can and should game the hell out of it.

Alex Tabarrok: The joys of pharmaceutical pricing.

Picking up a Rx at Walmart. I say $150? that seems high. The cashier responds do you have the GoodRx app? I download the free app and sign up while standing in line. New price $8.

Gwern on how much credence to give new causal claims in epidemiology or nutrition, especially claims something is a ‘subtle poison.’ I agree with the conclusion that ignoring such claims entirely unless there is a unique reason is at worst a small mistake, and doing otherwise risks much larger mistakes than that.

The shortage of Adderall is not only flat out sabotage, it is stupider-than-you-could-put-into-a-work-of-fiction level stupid sabotage by the DEA.

Inside Ascent’s 320,000-square-foot factory in Central Islip, a labyrinth of sterile white hallways connects 105 manufacturing rooms, some of them containing large, intricate machines capable of producing 400,000 tablets per hour. In one of these rooms, Ascent’s founder and CEO — Sudhakar Vidiyala, Meghana’s father — points to a hulking unit that he says is worth $1.5 million. It’s used to produce time-release Concerta tablets with three colored layers, each dispensing the drug’s active ingredient at a different point in the tablet’s journey through the body. “About 25 percent of the generic market would pass through this machine,” he says. “But we didn’t make a single pill in 2023.”

… the company has acknowledged that it committed infractions. For example, orders struck from 222s must be crossed out with a line and the word cancel written next to them. Investigators found two instances in which Ascent employees had drawn the line but failed to write the word.

So for that style of failure, they shut down the entire factory.

We need to take this authority away from the DEA. The DEA should deal with illegal drugs and only illegal drugs. Regulation of legal drugs should for now go to the FDA. Of course, FDA Delenda Est for other reasons, but you do what you can.

The FDA often gets in the way. It would be easy to think that the FDA’s failures would be illustrated by the rejection of MDMA for post-traumatic stress disorder.

In some ways, it was. The logic on the rejection was in part that you should keep your intervention safe in the lab until it is perfect, and until then ban it, rather than allowing learning and iteration and helping people. And that’s really dumb.

They also objected that the studies were effectively unblinded (because if you take MDMA you would know) and some people had previously taken MDMA. To which we all reply, it’s MDMA, what would you have the experimenters do? What is your proposed active placebo here? I don’t think this is avoidable.

The FDA also said they did not sufficiently study ‘the known cardiovascular effects,’ wait aren’t they known? To be fair to the FDA they raised these crazy objections in advance and Lykos proceeded with the study without listening, which is kind of (also) on them at that point. The study did not do its job, which was to follow FDA instructions.

But also it turns out the study was horrible in other ways. Not merely horrible ‘they didn’t follow the instructed procedure’ type of ways, although there was that too. Horrible in the ‘experimenters asked patients to give higher ratings to help get the drug approved’ and ‘experimenters having sex with the patients while the patients were high’ kinds of ways.

Yeah, well, whoops.

Doing a study on MDMA is hard. Blinding it is almost impossible. The FDA is not inclined to help you. That does not excuse falling down on the job.

The FDA is considering black octagon warning labels on the front of packages of foods to warn of things like ‘excess’ fat, sodium, sugar or calories. So judgemental.

The first thing I notice is these labels are less obnoxious than I expected, but they are still ugly, and rather large on small items. The second is that if you are going to do this, you would want better differentiation between the different warnings. Shouldn’t they be different colors or shapes or something? The whole point is to make it easy.

I am very much in favor of the existing nutrition labels, which are highly informative. I would be in favor of extending them a bit to make them easier to quickly scan for the things people most care about. My initial reaction is that this new proposal is obnoxious, and it goes too far in telling people what they should care about and putting it constantly in their face. However, in Chile, they say that sugar consumption dropped 10% after the labels were used. That is a big win, if people are responding to superior information rather than having their preferences overridden. So if we gather the data and see that the shift is voluntary and this large, then I can see it.

How about instead the FDA do what should be its job, and offer reciprocity with sister agencies like the European Medicines Agency or at least fast tracking for things those agencies have approved. The example here is there is a drug called ambroxol that helps with coughs and colds, in wide use since 1979, and in America you can’t have it.

An example of FDA trying to do its job: They are including more regulatory feedback earlier in the clinical trial process, based on lessons from Operation Warp Speed.

How terrible are bioethicists anyway, by their own admission?

Bryan Caplan: Someone smart told me bioethicists weren’t so bad, and actually supported Human Challenge Trials.

But I’m sticking with my adage that “Bioethics is to ethics as astrology is to astronomy.”

Leah Pierson: Our article ($53?!), Bioethicists Today: Results of the Views in Bioethics Survey (VIBeS), is now out in AJOB! We surveyed 824 US bioethicists on:

1. Major issues in bioethics, like medical aid in dying, paying organ donors, abortion, and many others

2. Their backgrounds

…

There’s consensus on certain issues: For instance, most bioethicists think it’s ethically permissible to:

– Select embryos based on medical traits, but not based on non-medical traits

– Pay blood donors, but not organ donors

…

Bioethicists’ normative commitments also predict their views:

For instance, consequentialist bioethicists are more likely to believe that medical aid in dying is morally permissible (82% of consequentialists vs. 57% of deontologists and 38% of virtue ethicists).

The hidden champion here is ‘allocate resources based on past decisions.’ Do you support the idea that people should be able to enter into and honor agreements, make commitments or own property? Or is all of that old and busted?

It seems ~75% of ‘bioethicists’ think that abiding by agreements because you agreed is not usually ethically permissible. About 20% think it is almost never permissible. It has been pointed out to me that no, what this presumably means is the past decisions of the patients. Except when smokers get first crack at the Covid vaccine. So yeah.

These same people also think abortion is more ethically permissible than choosing embryos on the basis of ‘medical’ traits, and are highly against the idea that you might choose an otherwise better embryo rather than a worse one.

So in conclusion, no, I do not think it is fair to say that bioethicists are to ethics what astrologists are to astronomy. Astrologists do not actively try to damage the sky.

Scott Sumner on the Scott Alexander analysis of Covid origins. He is with Scott Alexander on 90% zoonosis, and says ‘good for me’ and others like me, who have decided not to dive deeply into this issue and retain odds closer to 50/50.

Paper on the cost of mask mandates (paper). Tyler Cowen raises the question of willingness to pay (to be exempt) versus willingness to be paid, which is often much higher. Mostly I believe willingness to pay, and treat willingness to be paid as a paranoid upper bound combined with people hating markets. Also if you ask willingness to pay (or be paid) to be exempt form the mandate, you should also ask the same question about imposing the mandate around you. If the average person was willing to pay $525 to be exempt, how much would they have paid or need to be paid to allow everyone around them to be exempt but not them? Or everyone together?

For a fun look at how deep people can go in the most nonsensical rabbit holes, Jonathan Engler explains that the “covid” narrative is fake and there was no pandemic. I always love true refuge in audacity.

Your periodic reminder that we went fast when we created the Covid vaccines, but could have gone much faster.

Sam D’Amico: The entire discussion around this is still cursed but has anyone done a postmortem on how fast we could have YOLO’d out the mRNA vaccines if we manufactured at risk and skipped the clinical trials.

Josie Zayner: Myself and two other Biohackers created and tested a DNA based COVID vaccine on ourselves before Fall 2020, before any vaccine was available, and we moved slow so we could livestream the whole design and testing process. I was banned for life from YouTube for doing this.

Scott Alexander reviews the book The Others Within Us, about Internal Family Systems and the fact that occasionally it discovers what the book’s author thinks are literal demons. Here Disfigured Praise offers a few additional thoughts. I did experiment a little with IFS once so I have some experience with the baseline case. You are told to go into a form of trance and think you have an amazing core self, and also these other ‘parts’ that are functionally other people inside you, that you created for some purpose, but that are often misaligned. Then you talk to and negotiate with those parts until they agree to stop doing the misaligned things. In this theory, there is (almost) always a path to doing this if you are patient and understanding, whereas hostility doesn’t work.

This is often effective at causing change, for reasons that should be obvious. It is also highly dangerous to ask people to imagine parts of them that are actively interfering, because you can incept that happening. The parallel to multiple personality syndrome is obvious, and Scott points it out. This is not ‘safe’ therapy. But the self being supposedly good and in charge, and there (almost) always being a way to solve any problem, means that if the therapist knows what they are doing this is plausibly a worthwhile thing to do sometimes.

As Scott says, we use the cultural models of the brain we have lying around. It makes sense that one could engineer a version of this that, inside our cultural context, gives you maximum opportunity to do well while minimizing downside risk. I am reasonably confident that a well-iterated, well-taught version of this, implemented with empathy and dedication, would often be a good idea.

That does not mean that what is on offer in any given situation qualifies for those adjectives. In practice, I would stay away from IFS unless I had very high confidence of a high quality therapist, and also a situation with enough upside to roll those dice.

The catch discussed here is that every so often, less than 1% of the time, patients insist one or more of their parts are not part of them, and instead are literal demons. The therapists try really hard to convince the patient that they’re normal parts, and the patients sometimes are having none of it. At which point there is another procedure to get the ‘demon’ to leave on its own or if necessary cast it out.

Which, yeah, of course that is sometimes where a patient’s mind is going to go on this. All the descriptions make perfect sense. And it makes sense to meet those patients where they are, with a procedure that tells them the demons are pretty easy to cast out via an hour of talking in a chair and doing guided imagery. Great response. It sounds like it often does great work, you give the patient the opportunity to decide something awful is distinct from them and give them a way to get rid of it. No latin or levitation or hostility required. Love it.

The problem is that author Robert Falconer rejects this very obvious explanation, instead saying yep, the demons must be literal demons. Whoops. And as Scott notes, if your group starts actually believing in literal demons, you start getting iatrogenic demons, which does not sound like a great thing to be conjuring into existence. So if everyone involved can’t get on the same page of ‘this is a metaphor that you never encourage or bring up first but that you sometimes encounter and here’s how to deal with it’ maybe forget the whole thing.

Mental health problems are only somewhat correlated between generations.

We estimate health associations across generations and dynasties using information on healthcare visits from administrative data for the entire Norwegian population. A parental mental health diagnosis is associated with a 9.3 percentage point (40%) higher probability of a mental health diagnosis of their adolescent child. Intensive margin physical and mental health associations are similar, and dynastic estimates account for about 40% of the intergenerational persistence. We also show that a policy targeting additional health resources for the young children of adults diagnosed with mental health conditions reduced the parent-child mental health association by about 40%.

I am surprised this is so low, since it is the combination of three correlations:

1. Genetic

2. Cultural and Behavioral Patterns

3. Diagnosis

Whereas this is only a 40% difference: 15.5% versus 24.8%, after combining all three. A concentration of extra resources reducing the correlation does not tell us if this concentration is efficient, nor does it tell us the composition of the causes involved, given the diagnosis concern (including treatment’s impact on diagnosis) we cannot even measure how much actual mental illness is being prevented by shifting resources around. So it feels like a deeply wrong question.

My first move would be to attempt a study that tried to control for diagnosis, by using objective measures, ideally including new evaluations. Then try to control for genetic factors using the usual twin study and adaption paper techniques.

Previously: #1

It feels so long ago that Covid and health were my beat, and what everyone often thought about all day, rather than AI. Yet the beat goes on. With Scott Alexander at long last giving us what I expect to be effectively the semi-final words on the Rootclaim debate, it seemed time to do this again.

I know no methodical way to find a good, let alone great, therapist.

Cate Hall: One reason it’s so hard to find a good therapist is that all the elite ones market themselves as coaches.

As a commentor points out, therapists who can’t make it also market as coaches or similar, so even if Cate’s claim is true then it is tough.

My actual impression is that the elite therapists largely do not market themselves at all. They instead work on referrals and reputation. So you have to know someone who knows. They used to market, then they filled up and did not have to, so they stopped. Even if they do some marketing, seeing the marketing copy won’t easily differentiate them from other therapists. There are many reasons why our usual internet approach of reviews is mostly useless here. Even with AI, I am guessing we currently lack enough data to give you good recommendations from feedback alone.

American life expectancy rising again, was 77.5 years (+1.1) in 2022.

Bryan Johnson, whose slogan is ‘Don’t Die,’ continues his quest for eternal youth, seen here trying to restore his joints. Mike Solana interviews Bryan Johnson about his efforts here more generally. The plan is to not die via two hours of being studied every day, what he finds is ideal diet, exercise and sleep, and other techniques and therapies including bursts of light and a few supplements.

I wish this man the best of luck. I hope he finds the answers and does not die, and that this helps the rest of us also not die.

Alas, I am not expecting much. His concept of ‘rate of aging’ does not strike me as how any of this is likely to work, nor does addressing joint health seem likely to much extend life or generalize. His techniques do not target any of the terminal aging issues. A lot of it seems clearly aimed at being healthy now, feeling and looking younger now. Which is great, but I do not expect it to buy much in the longer term.

Also one must note that the accusations in the responses to the above-linked thread about his personal actions are not great. But I would not let that sully his efforts to not die or help others not die.

I can’t help but notice the parallel to AI safety. I see Johnson as doing lots of mundane health work, to make himself healthier now. Which is great, although if that’s all it is then the full routine is obviously a bit much. Most people should do more of such things. The problem is that Johnson is expecting this to translate into defeating aging, which I very much do not expect.

Gene therapy cures first case of congenital deafness. Woo-hoo! Imagine what else we could do with gene therapies if we were ‘ethically’ allowed to do so. It is a sign of the times that I expected much reaction to this to be hostile both on the ‘how dare you mess with genetics’ front and also the ‘how dare you make someone not deaf’ front.

A ‘vaccine-like’ version of Wegovy is on the drawing board at Novo Nordisk (Stat+). If you are convinced you need this permanently it would be a lot cheaper and easier in this form, but this is the kind of thing you want to be able to reverse, especially as technology improves. Consider as parallel, an IUD is great technology but would be much worse if you could not later remove it.

The battle can be won, also Tracy Morgan really was playing Tracy Morgan when he played Tracy Morgan.

Page Six: Tracy Morgan says he ‘gained 40 pounds’ on weight-loss drugs: I can ‘out-eat Ozempic’

“It cuts my appetite in half,” the 55-year-old told Hoda Kotb and Jenna Bush Hager on the “Today” show in August 2023.

We used to eat a lot more, including more starch and sugar, without becoming obese, including people who did limited physical activity. According to these statistics, quite a lot more. Yes, we eat some new unhealthy things, but when people cut those things out without cutting calories, they do not typically lose dramatic amounts of weight.

All right, why do the studies find ice cream is good for you, again? As a reminder the Atlantic dug into this a year ago, and now Manifold gives us some options, will resolve by subjective weighing of factors.

My money continues to be on substitution effects, with a side of several of the other things. Ice cream lets you buy joy, and buy having had dessert, at very little cost in calories, nutrition or health. No, it’s not great for you, but it’s not in the same category as other desserts like cake or cookies, and it substitutes for them while reducing caloric intake.

I am not about to short a 13% for five years, but I very much expect this result to continue to replicate. And I do think that this is one of the easier ways to improve your diet, to substitute ice cream for other desserts.

The NIH is spending $189 million dollars to do a detailed 10,000 person study to figure out what you should eat.

Andrea Peterson (WSJ): Scientists agree broadly on what constitutes a healthy diet—heavy on veggies, fruit, whole grains and lean protein—but more research is showing that different people respond differently to the same foods, such as bread or bananas. 

I would instead claim we have broad agreement as to what things we socially label as ‘healthy’ versus ‘unhealthy,’ with little if any actual understanding of what is actually healthy or unhealthy, and the broad expectation among the wise that the answers vary greatly between individuals.

Elizabeth and his fellow participants spend two weeks each on three different diets. One is high fat and low carb; another is low on added sugars and heavy on vegetables, along with fruit, fish, poultry, eggs and dairy; a third is high in ultra-processed foods and added sugars. 

This at best lets us compare those three options to each other under highly unnatural conditions, where the scientists apply great pressure to ensure everyone eats exactly the right things, and that have to severely alter people’s physical activity levels. A lot of why some diets succeed and others fail is how people actually act in practice, including impact on exercise. Knowing what set of foods in exactly what quantities and consumption patterns would be good if someone theoretically ate exactly that way is nice, but of not so much practical value.

Also, they are going to put each person on each diet for only two weeks? What is even the point? Yes, they draw blood a lot, measure heart rates, take other measures. Those are highly noisy metrics at best, that tell us little about long term impacts.

This does not seem like $189 million well spent. I cannot imagine a result that would cause me to change my consumption or much update my beliefs, in any direction.

This both is and is not how all of this works:

Keto Carnivore: [losing weight] not hard compared to being fat, in pain, chronically fatigued, or anxious/depressed/psychotic. Those things are extremely motivating. It’s only hard if it doesn’t work, or the body is fighting it (like caloric restriction without satiation, or constant cravings).

exfatloss: Can💯confirm. Do you know how much willpower I need to do a pretty strict ketogenic diet?

0. Because the alternative is not having a career/life and feeling like shit all the time from sleep deprivation.

When it obviously works, motivation is not an issue.

To clarify, I have a very rare and specific circadian rhythm disorder that therapeutic keto fixes. 99.99% of people don’t have this issue and therefore won’t get the same benefits I do.

Motivation is not an issue for me, in the sense that I have no doubt that I will continue to do what it takes to keep the weight off.

That does not mean it is easy. It is not easy. It is hard. Not every day. Not every hour. But often, yes, it is hard, the road is long. But yeah, the alternative is so obviously worse that I know I will do whatever it takes, if it looks like I might slip.

‘‘What we wish we knew entering the aging field.’ I hear optimistic things that we will start to see the first real progress soon, but it is not clear people wouldn’t say those things anyway. It certainly seems plausible we could start making rapid progress soon. Aging is a disease. Cure it.

Ken Griffin donates $400 million to cancer hospital Sloan Kettering. Not the most effective altruism available, but still, what a mensch.

Sulfur dioxide in particular is a huge deal. The estimate here is that a 1 ppb drop in levels, a 10% decline in pollution, would increase life expectancy by a whopping 1.2 years. Huge if even partially true, I have not looked into the science.

Someone should buy 23AndMe purely to safeguard its data. Cost is already down to roughly $20 per person’s data.

Yes, Schizophrenia is mostly genetic.

HIPPA in practice is a really dumb law, a relic of a time when digital communications did not exist. The benefits of being able to email and text doctors vastly exceed the costs, and obviously so. Other places like the UK don’t have it and it’s much better.

The story of PEPFAR, and how it turned out to be dramatically effective to do HIV treatment instead of HIV prevention, against the advice of economists. Back then there were no EAs, but the economists were making remarkably EA-like arguments, while making classic errors like citing studies showing very low cost estimates per life saved for prevention that failed to replicate, including ignoring existing failed replications. And they failed to understand that the moral case for treatment allowed expansion of the budget and also that treatment halted transmission, and thus was also prevention.

In many senses, it is clear that Bush ‘got lucky’ here, with the transmission effect and adherence rates exceeding any reasonable expectations, while prevention via traditional methods seems to have proven even less effective than we might have expected. If I had to take away three key lessons, they would be that you need to do larger scale empiricism to see what works and not count on small studies, and that you should care a lot about making the moral or obvious case for what you are doing, because budgets for good causes are never fixed. People adjust them based on how excited they are to participate. And I do not think this is stupid behavior on anyone’s part, focusing on things where you score clear visible wins guards against a lot of failure modes, even at potential large efficiency costs, while usually still being more than efficient enough to be worth doing on its own merits.

Say it with me, the phrase is catching on, except looks like this was eventually approved anyway?

Henry: TIL there was a company that sold a baby sock with an spo2 monitor that sent a push notification if your baby stopped breathing until the FDA forced them to stop selling them because only doctors should be able to see a blood oxygen number.

> The FDA objection was based on the fact that the wearable had the capacity to relay a live display of a baby’s heart rate and oxygen levels, which is critical data that a doctor should interpret, especially in vulnerable populations.

FDA delenda est.

If I try, yes, I can tell a story where people think ‘oh I do not have to check on my baby anymore because if something goes wrong the sock will tell me’ and this ends up being a bad thing. You can also tell that story about almost anything else.

Some very silly people argue that it is not preventing schizophrenia unless you do so in a particular individual, if you do it via polygenic selection then it is ‘replacement.’ Scott Alexander does his standard way overthinking it via excruciating detail method of showing why this is rather dumb.

90% of junior doctors in South Korea strike to protest against doctors. Specially, against admitting 2,000 more students each year to medical schools. One can say ‘in-group loyalty’ or ‘enlightened self-interest’ if one wants. Or realize this is straight up mafia or cartel behavior, and make it 5,000.

Brian Patrick Moore: Good thing we don’t have some crazy thing like this in the US

Of all the low hanging fruits in health care, ‘lots of capable people want to be doctors and we should train more of them to be doctors’ has to be the lowest hanging of all.

Vaccine mandates for health care workers worsened worker shortages on net, the ‘I don’t want to get vaccinated or told what to do’ effect was bigger than the ‘I am safer now’ effect, claiming a 6% decline in healthcare employment. Marginal Revolution summarized this as the mandate backfiring. We do see that a cost was paid here. It is not obvious the cost is not worthwhile, and also if someone in healthcare would quit rather than be vaccinated one questions whether you wanted them working that job.

Katelyn Jetelina asks Kelley Krohnert why science lost public trust during the pandemic. The default is still ‘a fair amount’ of trust but the decline is clear especially among Republicans.

Here are the core answers given:

Everything sounds like a sales pitch

From Paxlovid to vaccines to masks to ventilation. Public health sounded (and still sounds like) a used car salesman for many different reasons: 

1. Data seems crafted to feed the pitch rather than the pitch crafted by data. Overly optimistic claims weren’t well-supported by data, risks of Covid were communicated uniformly which meant the risks to young people were exaggerated, and potential vaccine harms were dismissed. Later, when it was time to pitch boosters, public health pivoted on a dime to tell us vaccine protection wanes quickly. How did we get here?

2. Data mistakes …

3. Messaging inaccuracies. …

4. Mixing advocacy with scientific communication … The latest example was a long Covid discussion at a recent congressional hearing, and one of the top long Covid doctors saying, “The burden of disease from long Covid is on par with the burden of cancer and heart disease.”

I would give people more credit. Focusing on what things ‘sound like’ was a lot of what got us into this mess.

The issue wasn’t that everything ‘sounded’ like a sales pitch.

The problem was that everything was a sales pitch.

People are not scientific experts, but they can recognize a sales pitch.

The polite way to describe what happened was ‘scientists and doctors from Fauci on down decided to primarily operate as Simulacra Level 2 operators who said what they thought would cause the behaviors they wanted. They did not care whether their statements matched the truth of the physical world, except insofar as this would cause people to react badly.

As for this last item, I mean, there is a lot of selection bias in who becomes a ‘top long Covid doctor’ so it is no surprise that he was up there testifying (in a mask in 2024) that long Covid is on par with the burden of cancer and heart disease, a comment that makes absolutely zero sense.

Indeed, statements like that are not ‘mixing advocacy with scientific communication.’ My term for them is Obvious Nonsense, and the impolite word would be ‘lying.’

Information that would have been helpful was never provided

Indeed, ‘ethicists’ and other experts worked hard to ensure that we never found out much key information, and that we failed to communicate other highly useful informat we did know or damn well have enough to take a guess about, in ways that ordinary people found infuriating and could not help but notice was intentional.

This has been going on forever in medicine, better to tell you nothing than information ‘experts’ worry you won’t interpret or react to ‘properly,’ and better not to gather information if there is a local ethical concern no matter the cost of ignorance, such as months (or in other cases years) without a vaccine.

A disconnect between what I experienced on the ground and the narrative I was hearing

As in, Covid-19 in most cases wasn’t that scary in practice, and people noticed. I do think this one was difficult to handle. You have something that is 95%-99% to be essentially fine (depending on your threshold for fine) but will sometimes kill you. People’s heuristics are not equipped to handle it.

She concludes that some things are improving. But it is too little, too late. Damage is mostly done, and no one is paying attention anymore, and also they are still pushing more boosters. But this is at least the start of a real reckoning.

As an example of this all continuing: I have been told that The New York Times fact checks its editorials, and when I wrote an editorial I felt fact checked, but clearly it does not insist on those checks in any meaningful sense, since they published an op-ed claiming the Covid vaccine saved 3 million lives in America in its first two years. That makes zero sense. America has only 331.9 million people, and the IFR for Covid-19 on first infection is well under 1% even for the unvaccinated. The vaccines were amazing and saved a lot of lives. Making grandiose false claims does not help convince people of that.

Matt Yglesias has thoughts about Covid four years after.

He is still presenting More Lockdowns as something that would have been wise?

If the Australian right could implement hard lockdowns to control the virus, I believe the American right could have as well. This probably would have saved a ton of lives. Australia and other countries with tougher lockdown policies saw dramatically lower mortality.

Or maybe not?

Even a really successful lockdown regime couldn’t be sustained forever, and there was a price to pay in Australia and Finland and everywhere else once you opened up.

I mean, yes those other countries had lower mortality, but did America have the prerequisites to make such policies sustainable, where they work well enough you can loosen them and they still work and so on? I think very clearly no. Trying to lock down harder here would have been a deeply bad idea, because for better and also for worse we lacked the state and civilizational capacity to pull it off.

Then we have these two points, which seem directly contradictory? I think the second one is right and the first is wrong. The hypocrisy was a really huge deal.

I think the specific hypocrisy of some progressive public health figures endorsing the Floyd protests is somewhat overblown.

…

After Floyd, it became completely inconceivable that any liberal jurisdiction in America would actually enforce any kind of tough Covid rules.

He makes this good note.

Speaking of drift, I think an under-discussed aspect of the Biden administration is they initiated a bunch of rules right when they took office and vaccine distribution was just starting and had no plan to phase them out, seemingly ever. When they got sued over the airplane mask mandate, they fought in court to maintain it.

At minimum this was a missed opportunity to show reasonableness and competence. At worst, this was a true-colors moment for many people, who remember even if they don’t realize they remember.

Matt also points out that there has been no reckoning for our failures. America utterly failed to make tests available in reasonable fashion. Everyone agrees on this, and no one is trying to address the reasons that happened. The whole series of disingenuous mask policies and communications also has had no reckoning. And while Democrats had an advantage on Covid in 2020, their later policies did not make sense, pissed people off and destroyed that advantage.

Scott Alexander posted an extensive transcript and thoughts on the Rootclaim debate over Covid origins. The natural origin side won decisively, and Scott was convinced. That does not mean there are not ongoing attempts to challenge the result, such as these. An hours-long detailed debate is so much better than not having one, but the result is still highly correlated with the skills and knowledge and strategies of the two debaters, so in a sense it is only one data point unless you actually go over the arguments and facts and check everything. Which I am not going to be doing.

(I mean, I could of course be hired to do so, but I advise you strongly not to do that.)

To illustrate how bad an idea that would be, Scott Alexander offers us the highlights from the comments and deals with various additional arguments. It ends with, essentially, Rootclaim saying that Scott Alexander did not invest enough time in the process and does not know how to do probability theory, and oh this would all be sorted out otherwise. Whether or not they are right, that is about as big a ‘there be dragons and also tsuris’ sign as I’ve ever seen.

The one note I will make, but hold weakly, is that it seems like people could do a much better job of accounting for correlated errors, model uncertainty or meta uncertainty in their probability calculations.

As in, rather than pick one odds ratio for the location of the outbreak being at the wet market, one should have a distribution over possible correct odds ratios, and then see how much those correlate with correct odds ratios in other places. Not only am I not sure what to make of this one rather central piece of offered evidence, who is right about the right way to treat that claim would move me a lot on who is right about the right way to treat a lot of other claims, as well. The practical takeaway is that, without any desire to wade into the question of who is right about any particular details or overall, it seems like everyone (even when not trolling) is acting too confident based on what they think about the component arguments, including Scott’s 90% zoonosis.

My actual core thinking is still that either zoonosis or a lab leak could counterfactually have quite easily caused a pandemic that looks like Covid-19, our current ongoing practices at labs like Wuhan put as at substantial risk for lab leaks that cause pandemics that could easily be far worse than Covid-19.

I do not see any good arguments that a lab leak or zoonosis couldn’t both cause similar pandemics, everyone is merely arguing over which caused the Covid-19 pandemic in particular. And I claim that this fact is much more important than whether Covid-19 in particular was a lab leak.

‘I’m 28. And I’m scheduled to die in May.’

Rupa Subramanya (The Free Press): Zoraya ter Beek, 28, expects to be euthanized in early May. 

Her plan, she said, is to be cremated.

“I did not want to burden my partner with having to keep the grave tidy,” ter Beek texted me. “We have not picked an urn yet, but that will be my new house!” 

She added an urn emoji after “house!”

Ter Beek, who lives in a little Dutch town near the German border, once had ambitions to become a psychiatrist, but she was never able to muster the will to finish school or start a career. She said she was hobbled by her depression and autism and borderline personality disorder. Now she was tired of living—despite, she said, being in love with her boyfriend, a 40-year-old IT programmer, and living in a nice house with their two cats. 

She recalled her psychiatrist telling her that they had tried everything, that “there’s nothing more we can do for you. It’s never gonna get any better.” 

At that point, she said, she decided to die. “I was always very clear that if it doesn’t get better, I can’t do this anymore.”

…

“I’m seeing euthanasia as some sort of acceptable option brought to the table by physicians, by psychiatrists, when previously it was the ultimate last resort,” Stef Groenewoud, a healthcare ethicist at Theological University Kampen, in the Netherlands, told me. “I see the phenomenon especially in people with psychiatric diseases, and especially young people with psychiatric disorders, where the healthcare professional seems to give up on them more easily than before.”

Theo Boer, a healthcare ethics professor at Protestant Theological University in Groningen, served for a decade on a euthanasia review board in the Netherlands. “I entered the review committee in 2005, and I was there until 2014,” Boer told me. “In those years, I saw the Dutch euthanasia practice evolve from death being a last resort to death being a default option.” He ultimately resigned. 

Once again, we seem unable to be able to reach a compromise between ‘this is not allowed’ and ‘this is fully fine and often actively encouraged.’

This is especially true when anything in-between would be locally short-term worse for those directly involved, no matter what the longer-term or broader implications.

We have now run the experiment on euthanasia far enough to observe (still preliminary, but also reasonably conclusive) results on what happens when you fully accept option two. I am ready to go ahead and say that, if we have to choose one extreme or the other, I choose ‘this is not allowed.’

Ideally I would not go with the extreme. I would instead choose a relatively light ‘this is not allowed’ where in practice we mostly look the other way. But assisting you would still be taking on real legal risk if others decided you did something wrong, and that risk would increase if you were sufficiently brazen that your actions weakened the norms against suicide or you were seen as in any way applying pressure.

However, I worry that if the norms are insufficiently strong, they fail to be an equilibrium, and we end up with de facto suicide booths and medical professionals suggesting euthanasia to free up their budgets and relatives trying to get you out of the way or who want their inheritance early, a lot of ‘oh then kill yourself’ as if that is a reasonable thing to do, and life being cheap.

New world’s most expensive drug costs $4.25 million dollars. It is a one-off treatment for metachromatic leukodystrophy.

Saloni: Fascinating read about the world’s newest most expensive drug ($4M)

A one-off treatment for metachromatic leukodystrophy, a rare genetic condition where kids develop motor & neurological disease, and most die in childhood.

42% of untreated died before 6 yo versus 0% of treated.

Kelsey Piper: $4M is of course an eye-popping amount of money, but this is apparently 1/40,000 US births. Would you pay $100 to guarantee that, if your baby is one of them, they will likely be healthy and live a normal life instead of dying a slow horrible death over several years? I would!

So it’s worth it at $4M, and also the price will come down, and also lots of other people will benefit from the medical developments that come with it. What a win.

Dave Karsten: This just feels straightforward reasonable give usual costing for regulatory interventions if it’s a “saves 0.58 human lifetimes per dose” price (Yes obvi other hazards await any patient in the future and maybe you should NPV the value also, but you get my point).

The disease is progressive. The 58% of children who live to age 6 are not going to get anything like full quality of life, with declining function over time.

So yes, assuming this is a full cure then this does seem worth it for America, on the principle that a life saved is worth about $10 million. In theory we should be willing to pay at least $5 million for this drug, possibly up to $10 million, before it would cost more than it is worth.

Thus, one could say this is priced roughly correctly. Why shouldn’t a monopolist be charing roughly half of consumer surplus, especially if we want to incentivize creating more such products? Seems like about the right reward.

(Obviously, one could say EA-style things about how that money might be better spent. I am confident telling those people they are thinking on the wrong margin.)

Saving up medical and health related stories from several months allowed for much better organizing of them, so I am happy I split these off. I will still post anything more urgent on a faster basis. There’s lots of things here that are fascinating and potentially very important, but I’ve had to prioritize and focus elsewhere, so I hope others pick up various torches.

We have a new malaria vaccine. That’s great. WHO thinks this is not an especially urgent opportunity, or any kind of ‘emergency’ and so wants to wait for months before actually putting shots into arms. So what if we also see reports like ‘cuts infant deaths by 13%’? WHO doing WHO things, WHO Delenda Est and all that. What can we do about this?

Also, EA and everyone else who works in global health needs to do a complete post-mortem of how this was allowed to take so long, and why they couldn’t or didn’t do more to speed things along. There are in particular claims that the 2015-2019 delay was due to lack of funding, despite a malaria vaccine being an Open Phil priority. Saloni Dattani, Rachel Glennerster and Siddhartha Haria write about the long road for Works in Progress. They recommend future use of advance market commitments, which seems like a no brainer first step.

We also have an FDA approved vaccine for chikungunya.

Oh, and also we invented a vaccine for cancer, a huge boost to melanoma treatment.

Katalin Kariko and Drew Weissman win the Nobel Prize for mRNA vaccine technology. Rarely are such decisions this easy. Worth remembering that, in addition to denying me admission despite my status as a legacy, the University of Pennsylvania also refused to allow Kariko a tenure track position, calling her ‘not of faculty quality,’ and laughed at her leaving for BioNTech, especially when they refer to this as ‘Penn’s historic research team.’

Did you also know that Katalin’s advisor threatened to have her deported if she switched labs, and attempted to follow through on that threat?

I also need to note the deep disappointment in Elon Musk, who even a few months ago was continuing to throw shade on the Covid vaccines.

And what do we do more generally about the fact that there are quite a lot of takes that one has reason to be nervous to say out loud, seem likely to be true, and also are endorsed by the majority of the population?

When we discovered all the vaccines. Progress continues. We need to go faster.

Reflections on what happened with medical start-up Alvea. They proved you could move much faster on vaccine development than anyone would admit, but then found that there was insufficient commercial or philanthropic demand for doing so to make it worth everyone’s time, so they wound down. As an individual and as a civilization, you get what you pay for.

Researchers discover what they call an on/off switch for breast cancer. Not clear yet how to use this to help patients.

London hospital uses competent execution on basic 1950s operations management, increases surgical efficiency by a factor of about five. Teams similar to a Formula 1 pit crew cut sterilization times from 40 minutes to 2. One room does anesthesia on the next patient while the other operates on the current one. There seems to be no reason this could not be implemented everywhere, other than lack of will?

Dementia rates down 13% over the past 25 years, for unclear reasons.

Sarah Constantin explores possibilities for cognitive enhancement. We have not yet tried many of the things one would try.

We found a way to suppress specific immune reactions, rather than having to suppress immune reactions in general, opening up the way to potentially fully curing a whole host of autoimmune disorders. Yes, in mice, of course it’s in mice, so don’t get overexcited.

From Sarah Constantin, The Enchippening of Medical Imaging. We are getting increasingly good not only at imaging, but imaging with smaller and more mobile and cheaper devices, opening up lots of new potential applications. An exciting time. As Sarah notes more broadly to open the series, making cheaper and better chips is the core tech behind pretty much everything getting continuously cheaper and better, and you should expect continuously cheaper and better from anything that relies on chips.

She also notes that Ultrasound Neuromodulation is potentially very exciting, especially if it can be put into a wearable. We could gain control over our mental state.

Claim that Viagra was significantly associated with a 69% reduced risk of Alzheimer’s Disease. Nice. There are supposed mechanisms involved and everything, the theory being direct brain health effects and reductions in toxic proteins that cause dementia. As opposed to the obvious interaction that Viagra users have more sex than non-users, which might protect against and definitely indicates against dementia.

Experts are, and I quote, warning us ‘not to get our hopes up yet.’

Amazon is now offering medical services, at very low prices. No insurance accepted.

Emily Porter, M.D.: Amazon is now offering chat medical visits (not even video) with physicians and NPs for $35 cash if you think you have COVID. Or a yeast infection. Or need birth control. How is this even considered healthcare? And why is it less expensive than my copay for my $700/mo BCBS PPO?

I want to jump in and say that I actually believe birth control should be OTC (plenty of my past tweets support that). But asthmatics, thyroid patients, those with high blood pressure, etc that Amazon is treating deserve affordable, accessible in-person care. This is suboptimal.

Armand Domalewski: Being able to chat with a doctor within 15 minutes for $30 is amazing. If you had told me this would be possible ten years ago I would’ve been blown away.

Seems great to me. Yes, if your only optimization target is optimal care and presume that everyone would otherwise get the full product, you will favor vastly more doctor attention, at vastly greater expense. However, if you instead realize that people’s time and money are things that matter to them and to society generally, which also means they will forgo medical consultations and treatments that cost too much of them. And also that we only have so many doctors (thanks AMA!) and thus only so many doctor hours to allocate, so if you waste them where they’re not valuable then someone else misses out, and that we do a lot of that allocation via time rather than price which is even worse. This is all very practical, a lot of people in the spots Amazon is offering a consult would instead have chosen no care at all under our existing system.

Health care would work so much better if we treated it as less sacred and more like Amazon treats its other products.

Economist reports (HT MR) that health insurance providers have a cap on direct profits, so they are buying health providers in order to steer customers to them, then paying those providers arbitrary prices. The incentives were already a nightmare, this makes them that much worse.

An interesting note is that Matthew Yglesias says he thought that this position was the consensus. It is simultaneously the consensus in the sense that people believe it, and also contrarian in the sense that the establishment and public health plan to do it all over again to the maximal extent possible and often act, like they and other cultural would-be authorities do on many things, as if anyone who defies the minority opinion they endorse too loudly is dangerous and terrible.

American Hearth Association releases new clinical tool that removes race as a factor in predicting who will have heart attacks or strokes. They decided that this is not a form of evidence they are willing to use, even though African-Americans suffer more heart attacks and strokes even when you control for everything else we know to measure. Not factoring this in means they will get less care. That doesn’t seem great.

Dylan Matthews makes a convincing case that while deaths of despair and overdose deaths have increased, the bulk of the decline in American life expectancy so far has been due to problems with cardiovascular disease. It is also noted that the decline is focused on the worst-off locations and among high school dropouts, as opposed to being about whether you go to college.

So what matters is whether something in one’s early life is going very wrong. When that happens, we are letting such people down in many ways.

Not that the overdoses don’t matter. We have a rapidly growing, out of control problem with overdose deaths, and it is already having a real impact on life expectancy, and if it continues growing exponentially it will soon be far worse. It is scary as hell.

The right question to ask, as is often the case, is: Is this an ongoing exponential?

It looks exponential. It would be scary anyway since it is already almost 3% of deaths in 2021. What happens if it doubles again in the next decade?

My mind still boggles that asking questions with the intent to learn or prove something requires ‘ethical’ clearance and worries about ‘potential harm’, and people keep endorsing this on reflection, burn it all to the ground.

Keller Scholl: The idea that asking people questions requires approval by an ethics board is a position unique to science/health. A YouTuber can do this and nobody bats an eyelash! But the moment you say you’re trying to do something other than entertain and profit, the “ethics people” arrive.

I want to differentiate them sharply from people who care about ethics, people who do serious ethical reasoning, etc. Primary marker is a bias towards inaction that is stronger when activity is for human advancement. Unlikely to be kidney donors personally.

amolitor.dolt: you kinda want *somethingthough. anyone should check that you’re literally just asking questions and not “while giving them electric shocks” or whatever. scientists get up to some shit if you don’t keep an eye on them.

Keller Scholl: “Asking people questions is fine. If you want to stick needles in them or lock them up, now you need approval from a peer committee with one or two outside voices” is a reasonable standard.

Yes. A simple safe harbor. If all you are doing is talking to people, or ideally also if you are otherwise doing things humans are allowed to do to other humans without any paperwork or checking for ‘informed consent’ then you don’t need any approvals. Even if you have the federal funding. Ask your questions.

A continuous problem is that the world desperately needs more common sense ethics and well-considered ethical considerations, and also that anyone who uses the word ‘ethics’ almost ever has anything to do with either of these things.

United Health pushed employees to follow an algorithm to cut off Medicare patients’ rehab benefits, says StatNews, to the tune of our way or the highway. If you want a ‘human in the loop’ the human needs to be able to determine the outcome of the loop. Here, it seems, they did not.

Yes, a lot of the reason Canadian health care is cheaper is that they sometimes tell you they’re not going to give you the surgery and instead suggest you consider assisted dying instead, whereas in America they will operate on you.

Tyler Cowen makes the case for a big push for hospital pricing transparency. As in, we need to insist on this like we insisted on ending the Vietnam War. The current situation is rather dire, as in things like this:

Recent research shows it is hard to even get a single consistent answer from a single provider. For instance, prices posted online and prices quoted over the telephone do not correlate very closely. For 41% of hospitals, the price difference was 50% or more. Clearly, suppliers aren’t really trying.

…

There is also a bipartisan health-care price transparency bill that was introduced last summer. President Joe Biden’s administration is proposing additional rule changes to further health care price transparency. Both are positive steps.

If all this sounds like too much government intervention, keep in mind the current non-transparent system is very much the product of ill-conceived government intervention, including regulations, entry barriers and trillions of dollars of public money. Most of those policies are not going away, so addressing these problems is going to involve some positive use of government. At the same time, a broader cultural revolution will be necessary.

Quite right on all counts. Government has decided for various reasons to intervene massively in the health care payments system, which is a central reason we lack price transparency. We need to use government to fix this, even if we do not use the first best solution of ‘get out of the way,’ and the benefits would be massive if we did fix it.

Paper claims working from home has negative mental health effects versus a workplace arrangement, although neither a big effect not anything like not working.

When considering all three dimensions of mental health together, WFH causes a 0.087 standard deviation increase in the overall measure of mental health deterioration compared to WP. Conversely, when compared to the NW option, WFH leads to a 0.174 standard deviation decrease in the overall measure of mental health deterioration.

In the context of a pandemic, working from home was probably relatively worse. My model is that the problem comes from isolation. If work was your only contact with the outside world you needed that. If not, you don’t.

Expiration dates are only, like, suggestions, man.

Kevin Kosar: News you can use: “Ah, but these food-safety regulations keep us safe, you might say. In almost all cases, there is no regulation and the dates do nothing to keep us safe.”

Scott Lincicome: An excellent @JoshZumbrun dive [in WSJ] into what I’ve been preaching for years now: so-called “expiration” dates are costly scam.

It took me blindly eating 5-month old yogurt live on camera (and lots of yelling) to do it, but I think I can finally now say it: I won.

The expiration dates are mandated only for infant formula. That does not mean they are useless, not net useful, or not protective of your health. Expiration dates are highly useful as they mark the relative freshness and remaining time of your items, and they provide reasonable approximations on how long various items can remain edible. Does that make them reliable markers of either spoilage or safety? No. It is a problem when sticklers treat them as gospel, again in either or both directions. I’m still glad they are there.

Scott Alexander notes that fully abolishing the FDA would require additional adjustments in the system. How would we deal with liability? What if doctors are stupid or fooled by advertising? How would prescriptions work or not work? How would insurance work? He comes down suggesting the FDA have a safety-only pathway for making drugs allowed, and legalization of artificial supplements.

That would be a reasonable practical compromise, but I think you can go a lot further. All these questions have reasonable answers. Prescriptions can continue where a sufficiently high bar is met, likely with a broader range of who can prescribe (e.g. a pharmacist should be fine for many but not all of them, so you don’t need an extra visit.) The other stuff will sort itself out the way it does everywhere else. Inspection agencies, for example, will rise up that do a better job for less money. Probably we do keep an FDA-like agency around for safety certifications due to liability concerns. To the extent other things wouldn’t fix themselves, it would mostly reveal rather than create those additional problems.

Again, I’d be happy to take Scott’s or another similar compromise. I still want to recognize it is far from first best.

The alternative is not abolishing the FDA and having stories like this?

David Neary: A friend in Spain was feeling unwell and took a covid test. The good news is it’s not covid. The bad news it is the flu. The astonishing news is Spanish covid tests are dual-Covid/flu tests and why in the hell are these not available everywhere?!

Aaron: haha people might want to send home kids with the flu? lol fuck those people, right?

Medic Kim: Why don’t we have at-home antigen tests? Because the FDA panels are composed of these people:

A 2016 FDA advisory_panel, meanwhile, was split on whether the benefits of over-the-counter influenza tests outweighed the risks. Meeting transcripts show that as experts debated whether at-home tests would actually be effective at keeping people at home if they knew they or their children had the flu, one panelist joked that daycare centers might make the decision for parents if over-the- counter tests were available.

“The woman is going to want to go to work, and she wants to drop her kids off at daycare,” the panelist said. “The daycare, when they sign their contract, [could say] ‘If your kid has symptoms, we’re going to test him,” and send the child home if they tested positive.

The room laughed at the idea.

Chair: Looks like they were concerned abt the public’s inability to correctly assimilate false positive / false negative rates, resulting in harmful overconfidence in kit results.

So, yeah. I’ll take my chances with abolition.

Also, the FDA continues to move forward to regulate lab tests. As Alex Tabarrok says, it is vital that we do not let them, although by the time you read this it will be too late for public comment.

Also, why don’t your cold medicines work? Oh right.

John Arnold: Americans have been wasting billions a year on cold medicines like Sudafed & Benadryl with the active ingredient phenylephrine, despite conclusive evidence they don’t work. But a report published yesterday may finally lead to the removal of these drugs from pharmacy shelves.

FDA approval for these medicines was grandfathered without any clinical trial because the active ingredient was shown to be safe and to work if given intravenously. But, since approval, there have been 4 trials of oral form and all have shown no benefit vs placebo.

It’s a great example of the waste in the healthcare system that leads to high costs/poor outcomes. A vote next week will be a big test whether the FDA follows the science or caves to industry pressure.

The FDA has been monitoring these drugs since 2007 and finally ordered a formal review. From the report, posted yesterday: “We have now come to the initial conclusion that orally administered phenylephrine is not effective as a nasal decongestant.

The reviewers note the harms of continued sales:

– Unnecessary patient & total healthcare costs

– Delay in care

– Potential allergic reactions

– Overdosing given no response to recommended dosage

– Risk of use by children

– Missed opportunity for more effective treatment.

An advisory committee will vote next week whether to recommend removal of the drug from OTC use. If successful, it would go to the full FDA. Patients depend on the FDA to conduct rigorous analysis as to the efficacy of drugs. Let’s hope they correct this mistake.

Baron St. Rev Dr. von Rev: Reminder that fedgov allowed drug makers to substitute phenylephrine (which is useless) for pseudoephedrine in order to hamstring public opposition to their crackdown on the latter. It wasn’t a mistake, it was a con-job.

Will they finally fix it? I am not optimistic. They did vote 16-0 that there is no evidence that phenylephrine does not work.

If the system were otherwise sane, I would have zero problem with people selling a medicine that does not work. People could make their own choices. Alas, given the say the rest of the system works, permission, like retweets, here is an endorsement, and results in this preventing other actually effective treatment.

As Nate Silver reminds us, the Covid vaccine was the one thing that we know worked to prevent Covid deaths. Red states had 35% higher death rates than blue states once the vaccine was available, but had similar death rates before that despite less stringent countermeasures, so the effectiveness of all other measures remains unclear.

Former NIH director Francis Collins says the quiet parts out loud (1: 18 video, worth watching) regarding Covid policy and the public health mindset. They don’t think about the impact on the lives of ordinary people. They don’t do trade-offs or think about cost-benefit. They care only about lives saved, to which they attach infinite value.

I thank him for the clarity. Let this be common knowledge. Then let us never again entrust any future public health decisions to anyone with this ‘public health mindset.’

Instead, public health carries on as if they were right all along, even calling for us to mask up again every so often, and we sometimes see cases such as this one: San Diego State University to require Covid boosters in order to attend. Our colleges never learn, yet we expect them to teach us. What will we do about it?

Some good news on Covid is new claims that vaccination before first infection greatly.

Another good news note that hasn’t been noticed enough:

Steve Sailer: Here’s one observation about the contentious history of the pandemic I’ve never seen anywhere: Hospital managers turned out to be better at juggling their resources to keep their facilities from being overwhelmed than anybody had expected them to be.

This was the dog that did not bark. By all accounts, hospitals should have been far more overwhelmed, in ways that caused a lot more degradations in care and many excess deaths. Indeed, health care workers were constantly reporting hellish conditions, being put under unbearable pressures. Yet in the end, at least after the very early days, the center almost entirely held. We never properly thanked or honored those who pulled this off, in any form. Nor have we updated our future anticipations.

House passes ban on toddler mask mandates without a vote after opposition fails to provide any evidence whatsoever that masking toddlers is helpful. Took long enough. Turns out people say things are evidence-based without, ya know, evidence.

Several Republican Congressmen including Rubio told Biden on December 1 to ban travel from China to prevent mystery illness spread. And of course the person posting this was claiming there is no difference between this and lockdowns and this makes Republicans hypocrites. It doesn’t. It does make them wrong, in the sense that such a rule would have accomplished nothing even if the mystery illness had mattered – it is difficult imagine the world where such a ban stops the spread that would have otherwise happened. Luckily, we didn’t ban travel and everything is fine.

Nate Silver continues to be loud about the ‘Proximal Origins’ paper, the damage it and related efforts to convince us we could assume natural origins of Covid have done to trust in science, and in particular the lack of willingness to admit and call out what happened. He links to this post about it. Things do not look better over time:

Paul Thacker (from a larger thread): @USRightToKnow released documents showing virologists & Wuhan researchers attempted to mislead on a DARPA grant–they hid that they would do some dangerous virus research in Wuhan. Right where the pandemic started.

Nate Silver: This is quite bad. A group of virologists wanted to do gain-of-function research on COVID viruses in Wuhan in ways that closely matched the SARS-CoV-2 virus that’s killed 8+ million, but tried to hide the Wuhan linkages and got a lot of help in doing so from science journalists.

…

Idk COVID killed 8m people officially and tens of millions unofficially (based on excess deaths) and also profoundly disrupted nearly everyone’s well-being for 6-18 months, seems like a pretty important one compared to all the dumb shit people usually argue about.

The responses attempting to defend natural origin are all essentially ad hominem attacks at this point. The wrong person is advocating, why are you amplifying this bad person and bad theory, you do not know what you are talking about. Never arguments about the facts.

Here is a thread summarizing many pieces of evidence in favor of a lab leak.

If you want to engage with the debate, well, good news, it seems there is an 18 hour recorded debate, a third of which is published, six figures at stake on the outcome and a prediction market on the outcome.

Daniel Filan: One thing I’d like to emphasize: I think this is the best debate I have seen in my life. Object level informative, and worth wondering how to emulate. I genuinely wish political debates had this format.

I still am not about to watch hours of that.

The prior should not be low:

William Eden: The prior on lab leaks happening IS NOT LOW. It does NOT require extraordinary evidence for a lab leak being a source of an outbreak. This is always a reasonable hypothesis and *must be investigated*

Ian Birrell: New study reports 309 lab acquired infections and 16 pathogen lab escapes between 2000 and 2021

If we have almost one confirmed lab leak per year, and given the other circumstances, it would almost be surprising if Covid-19 wasn’t a lab leak.

Was Covid a lab leak? We don’t know. At this point it seems more likely than not.

That statement should drive huge changes in policy. A lot of people should be rethinking quite a lot of things. That is true even if (as I expect) we never know the answer for sure. This is very similar to the question of existential risk from AI. Any reasonable person, given the evidence, should say the lab leak has substantial probability, as does natural origin. Once you think the number is substantial, it does not much matter if your probability of the lab leak is 30%, 50%, 70% or 90%. They should drive most of the same changes in policy, and the same reflections. They won’t.

Imagine how we and you would have reacted if we had known, back in February 2020, that this virus had escaped from a lab. Then ask which parts of that reaction you would endorse on reflection, and which you do would not. Then act accordingly.

The good news is that it likely has succeeded in at least cancelling Deep VZN.

Jonatan Pallesen: The lab leak discourse has probably already succeeded in cancelling Deep VZN. An absurdly dangerous project where they would go and seek out the viruses most able to cause pandemics in humans. This alone makes it a debate that has achieved more than most others.

You think this is the worst that can happen? Well, remember that time Australian researchers were actively trying to create a ‘contraceptive mouse virus’ for pest control, which is totally not how any science fiction dystopia stories start, and they instead accidentally created a modified mousepox virus with 100% mortality? Check the linked thread out, because it keeps… getting… worse.

House unanimously votes to defund gain-of-function experiments with potential pandemic pathogens. I would prefer a ban, but unanimous support for at least not paying for it is a great start. Why am I worried this will still not get implemented?

Reducing third world lead poisoning continues to be a plausible high-value cause area.

Nathan Young: For a lack of, lets say, $1bn, half the children in poor countries have lead poisoning.

Jesse Copelyn in The Guardian: An estimated $350m in targeted aid from 2024 to 2030 would be enough to dramatically reduce lead exposure in lower-income countries, provided there is enough engagement from political leaders, according to the CGD. Funding requirements include donations for lead-testing equipment, support with advocacy and awareness campaigns, and technical assistance with drafting and enforcing regulations.

Statements like Nathan’s require caution and careful calibration. I very much doubt a billion dollars would put a stop to all the lead poisoning. How much would it reduce such lead poisoning for how many children, with how much impact? I have no idea. I find it likely that $1 billion well-spent on this would be a good use of funds. I also can think of ways one could plausibly spend that money badly, and it ends up wasted or even making things worse.

Seriously, let’s buy out the patent rights and offer these drugs for free to anyone who wants them, what are we waiting for. New EA cause area.

Belarusian comedian hits it big with comedy routine (YouTube, 1: 04: 00) in which he complains he will die of old age and calls upon everyone to focus on maybe stopping this from happening.

Robert Wiblin: Paying people in exchange for their blood is very bad — but saying misleading things so they’ll give you their blood for free is very good.

The expected QALYs from you donating blood is more like 0.01 rather than the 200 which they’re suggesting. Still a good thing to do but you can’t save 3 lives in an hour.

Excellent, I don’t remember seeing a good estimate before, 0.01 seems highly sane. So that’s about three days of life. A very good thing to do, definitely donate blood. Very, very different from three lives in an hour, not even the most outlandish EA earning-to-give and cost-per-life-saved statistics claim anything close to that.

Rob Bensinger: Seems like one of the more important facts about our civilization — we live in the world where paying people is seen as taking advantage of them, while lying to people is seen as normal and OK. (In a surprisingly large number of cases.)

I think a lot of what’s going on is that “was money exchanged?” is a relatively discrete and legible question, whereas “was a falsehood stated?” is often a lot fuzzier, depending on how vague language is interpreted, and on where you draw various lines.

An eight year old watching a webcam feed can tell with confidence whether money was exchanged, typically.

Whereas the entire Earth’s resources, science, and technology can’t necessarily reach a confident verdict about whether Alice’s “I’m fine” statement is strictly true. (Even Alice may not be confident!)

So bureaucracies have a much easier type setting actionable policies about money than about truthfulness. And individual humans have a far easier time rationalizing their preferred conclusion about “was X true?” than about “was Y paid?”.

The end result being that bureaucracies end up with all sorts of wacky rules about money, because humans have emotional hang-ups about Everything and money is an easy thing to regulate.

Whereas even the most scrupulous bureaucracy will tend to lie a lot, because this is harder to regulate and incentive gradients toward lying abound: you fudge the truth a tiny bit and it helps, then you fudge it slightly more…

I doubt anyone in the bureaucracy ever had the conscious thought “it’s OK to fudge the truth and deceive people, but not OK to pay them”. Lying and paying people are just very standard human behaviors, and of those “paying people” is a lot easier to regulate.

Want to get more people to donate? Yes, you could and should pay them. There is some price at which you’ll get plenty of donations, it will be cheap versus health gains, and those that get the money will be better off.

But also I once again iterate to those in charge of blood donations: By requiring appointments, you are greatly raising the effective cost of donations. If you could take walk-ins, even confirmed right beforehand on the web, I would happy do this much more often. If I have to block out an appointment time days in advance, that’s so much harder.

That change fits well within the ‘ethics’ requirements. All you have to do is provide a place I can walk in on a whim and donate, or go when there is urgent need. I’ll do it.

You know who else you should pay? The head of UK pandemic preparedness.

Alex Tabarrok: What’s the chance it could happen twice? ¯_(ツ)_/¯

Wegovy (a GLP-1 antagonist) cut the rate of major heart problems in a 17k patient trial – heart attack, stroke, or cardiovascular-related death by 20%. It also cut all-cause mortality by 19%, which I would have led with, with no major side effect issues. Wow.

Market Monetarist thinks GLP-1s are a huge economic deal.

Obesity, particularly severe obesity, involves enormous healthcare costs. In the United States, the rate of obesity has increased markedly since the 1980s. Now, approximately 40% of the population is obese, leading to stagnation in average life expectancy and making obesity-related diseases like diabetes and heart disease among the leading causes of death.

A Danish study from 2021 showed that healthcare costs for obese individuals are double those for individuals of normal weight, significantly contributing to the national healthcare burden in Denmark. The reduction of severe obesity through medications like Ozempic and Wegovy could provide a substantial economic boost.

America spends more than 17% of GDP on health care. If GLP-1s reliably cure obesity, and obesity doubles health care costs, and 42% of Americans are obese, the math says that you could in theory reduce health care costs by almost 30%, saving almost 6% of GDP.

That is a huge game, if and only if that spending does not then get reallocated to providing more care to others. If our health spending is determined more by wealth than medical need, as it seems largely to be, most of that would be wasted on additional marginal care of little value.

The actual health benefits, of course, would be very real, including productivity.

Obese individuals are also less productive, more likely to be unemployed, and earn lower wages. This translates into substantial economic impacts, such as higher rates of work absenteeism among severely obese workers compared to their normal-weight counterparts.

A reduction in obesity in the U.S. could lead to an improvement in the economy. Halving the number of obese individuals could result in a 2% increase in overall wages and a significant rise in GDP if we assume as numerous studies shows that obese women have salaries 10% lower than normal weight women (corrected to age, education and experience).

I would be cautious attributing too much of the earnings differential to productivity. The beauty premium is real, discrimination against ugly or fat people is rampant, and these are likely to largely be positional effects.

Still, there are obviously large real productivity gains to better health.

There are also big productivity gains to general impulse control. GLP-1 inhibitors help with a wide variety of addictive and unproductive behaviors. My presumption is you would see substantial productivity gains.

How best to think about what Ozempic (another GLP-1 antagonist) does?

Cate Hall: Ozempic doesn’t provide willpower; it eliminates the need for it. These might sound like similar things but the internal experience is wildly different, as any addict can tell you.

Andy Jung: Translation: it doesn’t give you the willpower to overcome unhealthy urges. It eliminates the urges. Really interesting…powerful, but ultimately a shortcut.

Cate Hall: Hell yeah, we love shortcuts!

Emmett Shear: Will power basically doesn’t exist as far as I can tell?

Cate Hall: I think that’s a defensible position. It’s certainly at least a confused concept. I would probably say willpower in the sense of gritty determination exists, but in application doesn’t look anything like what “alcoholism is just poor willpower” folks think.

I think this is one of those places where willpower is a confused concept when you look at it too carefully, but acting like it does not exist or is not important will only leave you far more confused. I find it wise to treat willpower as if it is real.

How much adaptation will we see? It is easy to do the math on every obese person taking Ozempic. It is a lot harder to get that to happen, or anything approaching that.

Ozempic might be driving a selloff in candy and beer stocks, with the caveat that of course one must never reason from a price change.

Genevieve Roch-Decter: Weight loss drug Ozempic causing selloff in candy and beer stocks, per Bloomberg. Walmart said it’s already seeing an impact on shopping demand from people taking Ozempic. That sent shares of food and beverage companies sliding, some to multiyear lows. Crazy.

This is super exciting. As with AI, this part of the future remains highly unevenly distributed, and is orders of magnitude more expensive than it will be soon.

Tenobrus: it turns out ozempic is also the cure for doomscrolling and tiktok

Ava: something amazing about the fact that we invented things we’re incapable of consuming in moderation and then invented something that removes our ability to enjoy them.

It looks like GLP-1s reduce alcoholism, which on its own is a huge freaking deal.

Does… this… work? Issue hasn’t come up for me in a while:

Iva Dixit: Constantly stupefied at how if I google a medication name with the word “coupon” and show the pharmacist the first result from a shady looking spammy site — 90% of the time it works and the medicine’s price goes from $283 to $31.

I have just been told that if I get this medicine delivered via their home delivery program it’s $60 and if I want to come pick it up myself then it’s $142 ………………. big pharma are you guys ok.

I mean, I googled ‘Ozempic coupon’ as a test – note that these are very much the opposite of verified – Henry Meds claims to be selling a GLP-1 antagonist at $300/month, Calibrate claims even less, GoodRx has modest (~10%) discounts off the bat.

Also does this work? A public service announcement blast from the past.

Karandeep Singh: The more friction that exists in US healthcare, the more that innovation ends up looking like this 👇

Matt Yglesias shares his experience losing weight via bariatric surgery. He found it easy to lose weight up to a point, but that past that point he continued to struggle with the same urges to eat more and eat unhealthy and not be active. He’s excited for the GLP-1 inhibitors. One worthy note he makes is that if you have an unhealthy relationship to food, fixing it is (usually, for most people, myself included) not a matter of ‘eat like a healthy person,’ the same way an alcoholic can’t drink like a normal person. You have to do something far more intentional and deliberate, more absolute, more costly, and do it constantly forever. The other is that he sees anticipation that doctors will lecture fat people that they should lose weight as a big barrier to them effectively getting any other treatment for problems their weight makes worse – not only don’t they want to hear it, the doctors often refuse to offer alternative help. Which is terrible, and doctors should of course stop it, especially the not helping with alternatives. Yet we also would be wise to find ways not to generally fool ourselves into thinking that unhealthy weights are healthy.

An epic and righteous rant about how much people obsess over vegetables and what is rightfully called morality-based dietary planning. Eigenrobot’s 100-year-old grandfather is literally starving to death because his grandmother keeps insisting on these elaborate ‘healthy’ meal plans that took him hours to consume, when instead it turns out you can just feed the guy stuff like ice cream and he can get it down fine, and obviously that is what any sane person would do in this spot.

My model is that we know four things about nutrition with any certainty:

1. Different people work very, very differently here.

2. There are things you need, often but not always your body lets you know.

3. Vegetables good.

4. Sugar bad.

How important are rules two and three? Great question. We don’t know that.

I’ve been unable to eat fruits or vegetables in most forms for my whole life, unless they are very tiny or heavily processed. My body does not believe they are food and I will literally gag and choke on them. The few ways I can sometimes eat one almost never bring me any joy, only melancholy and sorrow. People constantly worried about this for a long time, and I haven’t been able to fix it. I don’t worry much about this anymore, and you know what? It’s fine.

On rule three, my revealed preference is ‘enough to eat less sugar than I otherwise would, not enough to not eat a lot of sugar anyway.’ I endorse this on reflection.

What are the returns to exercise? Roger Silk does some math, attempting to think like an economist.

His basic model is to assume that we value 16 waking hours per day only, exercise costs time now, and it pays off with additional time in the future. He then asks, if a program of 9 hours gives a 50-year-old the chance to live to 88 instead of 80, what is the rate of return? He finds 5.8%, with returns up to 6.5% for smaller investments, so the marginal return on the final hours is likely more like 4%.

Is that a good investment? As Roger points out, there is no inflation in years. If all things were fully equal, and all that mattered was my personal time discounting, and I thought I ‘lived in normal times’ so to speak so postponing my actions didn’t impact the world nor would the world much change, I would take essentially any positive return.

What key considerations are being ignored in the calculation here?

1. Correlation is not causation. Exercise is claimed to be ‘associated’ with 8 extra years of life. But it is trivial to see why this is almost certainly an overstatement of the causal effect of choosing more exercise. Choosing to do more and better exercise is associated with good health through direct causation, and also associated with most other good habits and attributes. A brief look at the study indicates no effort to account to properly control for these problems.

2. Exercise has major positive impacts other than lifespan. This is the reason why I am able to motivate myself to exercise. If it was purely lifespan, I would not trust that the rate of return was positive. But when I exercise, I have more energy, I feel better, I look better, I can eat more, life is good. That is a huge deal.

3. Exercise can be good or bad in many other ways. Are you using up willpower or generating more? Learning to form good habits, or using up your habit budget? Does this make you more interesting and confident, or less interesting and overconfident? Do you start loving life, or start hating life? Different people get different results, on top of the considerations I mentioned earlier.

4. As is noted, what kind of years are you getting? Are you getting extra healthy years, extra aged years on the end, or a slowing of the aging process? How exactly does this all supposedly work? You are investing your best remaining years now (at least if we are assuming you are at least 25 now), in terms of health, to get years later. If the average future year quality doesn’t change, you are downgrading quite a bit on health. You could make some of it up with wisdom and wealth.

5. You could also make up for it via future technology. If you expect technology to extend our lifespans over time, then buying time becomes more valuable. If you expect escape velocity, expected returns could suddenly look very, very good. Same if you think that new tech will make life a lot better in at least some worlds. If I am alive in 2054, then chances are some really awesome tech is available.

6. The time you spend exercising is not worth zero. If you hate it, it could be strongly negative. If you find something you like, or a way to like it, it can be substantially positive. I have yet to find exercise I actively enjoy that I can sustain (I started to like running then my knees gave out), but I have at times found exercise where the net experience is positive due to ability to watch television or listen to podcasts while doing it, or to chat with my trainer.

7. We do not have 16 flexible, valuable hours to spend each day. There are a lot of fixed costs beyond sleeping that eat into our time. Where is your exercise time going to come from? The more your joy is contained in your copious free time, and the more of that this would eat, the higher the effective price. When I was working at Jane Street, it was a relatively high effective cost in time to work out, whereas now as a writer it is relatively less.

8. Risk of injury is a real thing, with exercise both causing it directly and preventing it indirectly. I recently took out my back for a few weeks while doing squats in the wrong way, that is important lost time.

Also, the real story of people not exercising is pretty damn simple. Mostly true story.

Afro—Arakkii Leo Says Resist: most people don’t exercise because it’s fucking boring dude. That’s it. It’s literally boring as hell. Especially things like weightlifting, which is 9/10 times just grinding for vanity reasons. And people are always going to be iffy about it until we normalize play as exercise.

Most people don’t want to just go to some sweaty building and hate their bodies into something society deems acceptable like you know what would be great for heart health? Tag. We should all go to the park and play tag.

But i’m so sick of gym bros shitting on people for not wanting to exercise like bro….this shit isn’t natural. Picking heavy things up over and over again to look bigger is something we just made up! And it’s not even fun!

I would take the under on 90% vanity. A lot of working out is for the right reasons. But yes, working out is mostly unpleasant and boring as hell as we conceive of it and we need to stop pretending otherwise. Once we agree that most exercise mostly bores most people who try it out of their minds, we can work on not doing that.

Well, maybe. From a certain point of view.

Matthew Yglesias takes a stand against dentistry. Well, maybe not quite against dentistry writ large, but against the current regime of dentists being a cartel taking a large cut of every cleaning, not letting others diagnose conditions, and the only insurance available being a product that does not insure one against large dental bills, while not providing evidence for its interventions working.

Studies show, he says, that letting dental hygienists work on their own improves dental health, in addition to improving equality and lowering costs. The mechanism is that if routine dental services cost more, you will consume less of them.

The insurance thing is its own complaint and also pretty weird every time I think about it. In medicine you want to buy medical catastrophic insurance and are forced to also buy coverage on pain of them charging you artificially high prices to punish you. In dentistry, you cannot buy the insurance at all even together with the coverage, only partial coverage of routine costs.

Most interesting is the claim that dentistry is not evidence based.

Matthew Yglesias: Dental medicine is practiced with almost no scientific evidence, making it a huge field of opportunity for grifts and scams.

The Matthew Principle (no relation I think): I’ve had similar experiences: went to a dentist once and was told I had seven (!) cavities. Went to another and was told there were just two.

Adrienne: This happened to my mom. Went to a new dentist and was told she needed about $7,000 of work. Got a second opinion, and nothing was wrong.

Alicia Smith: Friend of mine went to the dentists and was told she had 3 cavities since her last visit a year ago. She went and got a 2nd opinion before getting these cavities filled, and was told she has no cavities at all.

[comments full of people who don’t trust dentists not to defraud them.]

Matt Yglesias (in his post): Some people, of course, are not that ethical. And even those who are ethical are naturally going to find themselves inclined in the direction of self-interest when dealing with an evidentiary void. William Ecenbarger did a great investigative report for Readers’ Digest years ago where he visited dentists in different cities and asked for their recommendations and got prescribed courses of treatment ranging from $500 to $25,000. One outfit in Philadelphia diagnosed him this way: “Tell me what your insurance limits are, and we’ll proceed from there.”

Back at Vox, I used to work with Joey Stromberg (whose dad is a dentist), who wrote a piece about how “while seeing other dentists, my brother has been told he needed six fillings that turned out to be totally unnecessary (based on my dad’s look at his X-rays) and I’ve been pressured to buy prescription toothpaste and other products I didn’t need.” Aspen Dental appears to have built a whole corporate dental chain around the observation that you can attract patients with low prices and then make it up in volume by prescribing unnecessary treatments.

Yglesias also quotes Ferris Jabr in the Atlantic here:

The Cochrane organization, a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of oral-health studies since 1999. In these reviews, researchers analyze the scientific literature on a particular dental intervention, focusing on the most rigorous and well-designed studies. In some cases, the findings clearly justify a given procedure. For example, dental sealants—liquid plastics painted onto the pits and grooves of teeth like nail polish—reduce tooth decay in children and have no known risks. (Despite this, they are not widely used, possibly because they are too simple and inexpensive to earn dentists much money.) But most of the Cochrane reviews reach one of two disheartening conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there is simply not enough research to say anything substantive one way or another.

And perhaps it gets worse? Here’s MF Bloom quoting the AP saying there is no evidence that flossing works. The government seems to have agreed that no one has ever properly researched the question. The AP looked and its findings where that the evidence is “weak, very unreliable” and of “very low” quality. Ouch.

Does flossing do something? It is a physical action, so we can tell that it does literally do something. But does that something translate into better dental health? We do not know. It would be unsurprising to me either way. I can also see why there could be no one party with the incentive to study this properly and find out.