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Moral Hazard: biomedical epilogue

Blog entry posted by anciendaze, Aug 29, 2011.

Humans are the only known species which will not simply guard members who are injured or sick, but actively feed and care for them. Likewise, we have an apparently unique ability to subordinate individual differences during struggles with forces of nature which endanger all. We forget these are not natural laws, but social norms. When events like recent ones in Tripoli, Libya or Monterrey, Mexico violate these norms we react with horror. We may talk about 'failed states', but this goes beyond government to the core of what it means to be human social animals. If those characteristics which distinguish us from beasts are absent, what are we?

Previously, I've talked about the consequences of financial defaults, which can be serious, but they pale in comparison to more serious defaults. A sinking ship without enough lifeboats is doomed to something worse than seven years of bad credit. Do we have enough for everyone?

There is a fairly esoteric debate about the future solvency of the Social Security System. A sizable chunk of the backing involves specialized debt instruments passed between different parts of government. There are always some insisting that the free market will do better. This is not necessarily my contention. I wonder about any security which is not traded on a general market. How am I to evaluate these?

At worst this could be a special-purpose fiat currency denominated in dollars, another fiat currency. If backed by the full faith of the federal government, it could be based on nothing more than a willingness to tax or ability to borrow. A future taxpayer revolt has become a real possibility, thanks in part to those who say they are trying to prevent catastrophe. Demographic trends show fewer paying in, and more drawing out. At what point will healthy young people decide to default on obligations to people now old and/or sick?

An argument I've made earlier is that ordinary supply and demand could send costs for medical care past any ceiling if we don't have the trained people required. Current efforts at limiting costs show great promise in providing jobs for clerks, bureaucrats and attorneys, while shifting medical thinking from long-term to short-term. Effective medical treatment keeps taking longer, and getting more expensive. This parallels the general economic trends which landed us in our present sorry state.

It is possible to do better, and U.S. history can illustrate this.

The Spanish-American War was not our best moment as a nation. I won't even try to defend a great deal of the foolishness of the period. However, one small episode deserves to be better known.

When the U.S. occupied Cuba there was little required of the U.S. Army at first. This began to change with the summer outbreak of yellow fever. Soldiers who had no immunity started dropping like flies. At the time, the cause was heatedly debated. One Cuban doctor, Carlos Finlay, insisted the disease was transmitted by mosquitoes. Unfortunately, he got a great many things wrong, and few believed him. General opinion of U.S. officers was that the disease could be prevented by good hygiene. Some of their measures struck experienced Cubans as funny.

Finally, an Army doctor, Captain Walter Reed, was given the go ahead to solve the problem. Some of his subordinates experimented on themselves, allowing mosquitoes which had fed on people with yellow fever to bite them. Considering the horror of the disease, and a complete lack of effective treatment, this goes beyond ordinary heroism. James Carroll and Jesse Lazear came down with the disease. Lazear died; Carroll was never entirely healthy again.

There were anomalies. Lazear and A. S. Pinto had previously allowed mosquitoes which had fed on yellow fever patients to bite them, without falling ill. Lazear had later been bitten by an insect he did not control while collecting a mosquito which had bitten a patient. He did not even know what kind it was.

A prevailing theory by Giuseppe Sanarelli claimed the disease was caused by bacillus icteroides. Early reports of Army experiments in Cuba based on the mosquito hypothesis were dismissed as "silly beyond compare" in an editorial in the Washington Post.

In the end they found the disease was transmitted by female aedes aegyti (there are many kinds of mosquito, but this one is common) which fed on an infected person several days after they fell ill then waited 12 days to feed on a person without immunity. The cause was not bacterial or parasitic, it was a virus, which was not understood at all well.

They had not cured the disease, but the path to prevention was clear: stop mosquitoes from breeding, use mosquito nets, quarantine active cases. (Earlier attempts at quarantine of goods or baggage from infected areas had been useless, the disease was not transmitted by "fomites".) This incomplete solution was enough to virtually rid Cuba of the disease, and later allow completion of the Panama Canal, where an earlier attempt had failed disastrously. The economic consequences were enormous. The Army had put $10,000 into the project, with a promise of another $10,000, "if needed", beyond the salaries of doctors already serving in Cuba.

Today, a replica of Camp Lazear, where the definitive experiments were carried out, is maintained by the Cuban government, despite political differences with the U.S.

Another disease allows comparison between American and European experience. Tuberculosis (TB) is a chronic disease which, untreated, might take 20 years to kill, or might not kill at all. Koch established the infectious agent as mycobacterium tuberculosis, with a very similar bacterium causing bovine tuberculosis. More work showed cows could carry both infections, and these could be transmitted by milk. Humans could also be infected with bovine tuberculosis. Pasteur showed that bacteria in milk or wine could be destroyed by heating below the boiling point.

Koch's attempt to find a vaccine for TB produced tuberculin. This provoked too violent a reaction to be used for safe treatment, though it took many years for this to be accepted by some doctors. (Patients paid the price.) At the time, Arthur Conan Doyle, then working as a medical reporter, suggested in print that tuberculin might be used as a test for TB infection.

Here we run into some national rivalries. The governments and medical establishments of England, France and Germany failed to put all these together. In America all such discoveries were equally foreign. The U.S. began testing cattle with tuberculin, removing those with infections, and Pasteurizing milk. This meant the economic burden of chronic TB was lower in the U.S. than in most of Britain or Europe. I don't know that anyone has ever put a number to these savings. Prevention was far less expensive than the preferred treatment in sanatoria.

Even so, there was a missed opportunity. A French bacteriologist, Albert Calmette, and a veterinarian, Camille Guerin, set out to deliberately breed weakened bacteria so distantly related to mycobacterium tuberculosis that they would not quickly revert to their lethal ancestors. By 1921 they felt they had succeeded. This was used in a vaccine called BCG. It was not a complete preventative, but when large scale tests were eventually done, it proved to cut the incidence of TB to 1/4th that of an un-immunized population. The reduction of cases with severe complications was even more dramatic. Had this been used effectively it could have reduced the economic burden of TB by a factor of 5 to 10 -- twenty years before the discovery of streptomycin.

There is another side to this story. In those countries I've mentioned, public health decisions were regularly based on a consensus of medical opinions. Doctors weren't entirely wrong, but the consensus was more often wrong than right. Remarkably few pieces of conventional medical wisdom were ever subjected to rigorous clinical trials. When medical treatment is largely ineffective, the most nearly correct view is typically held by only a small minority of experts. Consensus will predictably favor those treatments producing current income streams -- irrespective of benefits to patients.

At this point we should remember that those doctors who formed the majority opinion were not being paid for cures, there were none; they were being paid for treatment. Should we be surprised that medical opinion favored the most expensive options, like alpine sanatoria? This doesn't mean all these people, or even most of them, were cynical charlatans. It is easy to become self-deceived.

Consider a tale of two doctors: one is an honest practitioner who hands his patients a printed flyer with the few suggestions known to make a difference, and carefully answers questions; the other confidently proclaims that his sanatorium in Davos is the best answer known to medical science. To raise funds for building and maintaining the sanatorium, he must travel and speak to a variety of people with money. If he exhibits doubt, his fund raising will fail. If he succeeds, the resulting income, and the prestige of being director of the famous sanatorium where all the rich go, will validate his approach in his own mind. All the funding will be directed toward immediate goals in treatment. None is likely to be expended on research hypotheses that undermine the notion of sanatorium treatment. Even the possibility of telling all those rich and powerful patients you know so well that you were wrong rapidly recedes into the mental distance.

Now shift forward to the present, where doctors are paid strictly for treatment, and admitted experimentation on patients results in legal action. Does a doctor who treats an upper respiratory infection with the same antibiotic every year, when the same patient shows up with the same thing, lose money? Suppose he/she is wrong about curing the infection. Does the resulting resistant infection come back to haunt the doctor or the patient? The patient ends up in a hospital quarantined in a negative-pressure room where he is treated by a different team of specialists. If the doctor who caused the problem is even consulted he/she will insist the patient must not have taken all the prescribed antibiotic. (This is indeed possible. It is also never checked.) The doctors and hospital will make money from efforts at difficult treatment even if they bag the patient. The scope of the entire interaction with modern medicine has expanded to the point much is over the horizon of daily concerns of any of the professionals involved. Nobody has the big picture.

Does a standard EKG predict heart disease? I contend it merely reports damage after it has occurred. A patient isn't sent to a cardiologist until after heart disease has become established. This specialist is like the man with a hammer to whom everything looks like a nail. It is an expensive hammer.

An ordinary physician merely checks some numbers from the lab report, and advises a patient that his LDLs are too high, or his LDL/HDL ratio bad, or his triglycerides too high. What practical advice does he give? Eat right, lose weight, exercise regularly, try not to worry.

Now, here's a kicker. Correlations between individuals who either know each other or do not reveals a curious pattern. Obesity behaves like a contagious disease. If your friends gain weight, you are distinctly more likely to gain weight. Psychosocial models have an immediate explanation: people with bad habits transmit these to associates.

People with unhealthy low weight also show this pattern. Should we drop the weight hypothesis in favor of a 'death wish'?

What about health, is that contagious? Not nearly as strongly. The obvious explanation for experienced hypothesis wranglers is that bad habits are more contagious than good ones. This ignores the desirable features of health, including life itself, the cultural emphasis on fitness and diet, and the natural motivation to be sexy. A casual survey of advertising material will reveal an overwhelming bias in this direction.

Could there be chronic infectious disease behind this epidemic of obesity or unwillingness to exercise? It is a legitimate question. Short term increases or decreases in weight are classic signs of undetected disease. What about long term changes? It appears we don't do long term thinking about medical problems. In many parts of the U.S. you may have trouble obtaining records of a patient's condition and treatment 20 years ago.

There is a problem in estimating savings due to things which did not happen. (Dilbert's coworker Wally once claimed to have saved the company one billion dollars in a month. He didn't spend one billion dollars.) How do we tell if medicine is really preventing or curing disease? My answer is decreasing incidence. Whether you are preventing a disease in the first place, or curing it when it arises, the end result is decreased incidence of the disease.

There is no question the incidence of TB has dropped in the developed world. Exactly how the healthcare system brings this about may not be clear, but the end result stands out. Had there been a plan in 1925 to address the health problems of 1950, treatment of TB would have been a major concern. Preferred treatment options would have suggested buying land at high elevations for sanatoria, and raising a great deal of funding to build and support them. Some organizations actually did this.

Likewise, if you had planned for the healthcare of 2000 back in 1950, there would have been a substantial investment in 'iron lungs'. Prevention of poliomyelitis changed the picture dramatically within 5 years.

Now, let's take a look at conditions which have not responded. Obesity is commonly held to cause many long-term health problems. Prevailing opinions blame it on either bad genes or bad habits. Has this had any measurable effect? Perhaps it is time to consider other causes.

Cancer remains high on the list of causes of death and disability. Cancer treatment is a huge expense. You can blame some increases in rates on an aging population, but you can't blame aging for increased rates of rare cancers in young people. We now know many cancers develop over decades. Every week I see new links between cancer and infectious disease. Shouldn't we be looking for chronic infectious causes? Do we have to wait until every link in the chain is solid to begin taking action?

Added: By coincidence, today's news has an estimate that one person in three in Scotland will develop cancer. I was struck by the sentence on cancer risk related to obesity. Why should such a linkage exist? An infectious cause would make sense.

I debated stopping at this point. Instead I'm going to rush in where angels fear to tread. The models of either bad genes or bad habits have been used to explain mental illness for about a century. Has this had any effect on rising incidence?

(After reading about a spectacular chase in local news, and the number of people involved, I wondered aloud when the number of remaining sane people would be insufficient to fit the confirmed crazies with straitjackets. It took a moment for listeners to realize I was joking.)

Not only do those associated with the mentally ill have increased risk themselves, a pattern like the one for obesity, those who work in facilities for treatment of the mentally ill are well aware that their patients suffer from higher rates of physical disease. There have also been documented outbreaks of physical illness among staffs of mental institutions. Considering the negligible effect of enormous time and effort on incidence isn't it time to reconsider hypotheses that mental illness might be precipitated by chronic infectious disease?

What I've outlined above are a number of potential opportunities for major reductions in healthcare costs over the long term. With the current system of incentives, either in government or private research, this is not likely to happen. In broad terms the best current predictor of future funding for biomedical research is previous success in obtaining funding, not results which lower incidence of disease. Current emphasis on short-term costs are actually an impediment to progress.

The examples used above are all imperfect solutions within the grasp of the technology of the time. Nobody could meaningfully say, "go out and discover streptomycin!" There is another aspect of these solutions which gets into serious concerns about biomedical ethics. I won't dodge that either.

Both finding the cause of yellow fever and testing the BCG vaccine required experimentation on humans. The general statement that doctors do not experiment on patients should be laughable, considering the level of ignorance and confusion about many subjects. Treating mental illness, in particular, is largely a matter of uncontrolled experiments on subjects who may not be qualified to give informed consent.

In addition to the heroic doctors mentioned, the experiments which established the cause of yellow fever used non-medical volunteers. Some were military personnel, like Pvt. John E. Kissinger or John J. Moran. They had not been asked to volunteer, because they were subordinates who might be subject to pressure from superiors. They came forward anyway.

Others were recent immigrants to Cuba who had never been exposed to yellow fever, and thus should not have acquired immunity. These were paid $100 in gold, in addition to getting free food and medical care during the experiment. The statement they were given is worth reading:

Several reported they were better fed, and treated better, during the experiment than at any prior time in their life. Nobody had previously shown much interest in their health. Fortunately, none of them died.

Outside the experiment the number of reported deaths due to yellow fever among U.S. military personnel was roughly equivalent to all combat deaths in the conflict. Those who participated were taking a chance, but it was a rational choice. The end result stopped centuries of epidemics.

Some of those who participated did not believe the mosquitoes caused yellow fever. Some did. Either way they were playing a role in ending the debate which none of those who previously published opinions had come close to doing. They were no longer passive participants in a lethal lottery.

Patients were taking an active role in defeating a dreaded disease, and this gave their lives added meaning. Denying them this option in a situation of high risk and expert confusion would have been the ultimate medical hubris. This is still very much in evidence today.

Confused about the relation of this post to others in this series? I'll make one last try at explaining. When markets work, they allocate resources and provide information through a robust process with multiple sources of feedback. The economic crisis came about when this process was subverted. For far too long we rewarded people and organizations who undermined the system by hiding or distorting information on which rational decisions could be made. This has direct parallels with our problems in healthcare.

Hiding liabilities or risk is equivalent to printing money. If people could resist the temptation to print money the U.S. would not need the Treasury's Secret Service. The financial problem could have been averted if people had compared the valuations based on opinions with so-called economic fundamentals. Some valuations didn't have any reasonable explanation. Risks were assumed to have vanished.

Instead the opinions of experts who claimed to understand a complex and confusing class of financial products replaced those of most investors. Connections between these financial products and individual mortgages, bank accounts and insurance were obscure. Risks disappeared from balance sheets. Few people thought about the possibility those experts might not be unbiased and objective. It turned out they had a large stake in the game. The results were predictable.

Liabilities connected with healthcare are now major items in both corporate and federal accounting. Many of these are not explicitly on the balance sheet. Some reputable estimates put unfunded liabilities at about four times explicit national debt. Some suggestions for reducing these amount to violating the social contract under which many have labored for their entire career. The prospect of a social default on obligations should be more frightening than the scare we have had over financial default.

Where we talk about financial fundamentals we lack a corresponding term for medicine. I'm proposing reduced incidence of disease as one such measure of medical success. Too often leaders have equated effort expended with assumed results based on little or no objective data. In the special case that brings people to this forum, we have the common experience of misrepresented incidence and liability. This badly distorts measures of medical effectiveness.

I don't have an answer to questions about exactly how much who should pay for what, or the extent of public and private responsibilities. In the end all of us will pay, one way or another. It is likely most present experts will be wrong. Whatever process emerges, I'm calling for fixing the broken feedback, and giving those most concerned some meaningful degree of participation in decisions directly and intimately affecting their lives.

(Steps down off soapbox.)
anciendaze

About the Author

As the name suggests, I am old and dazed. The avatar illustrates my rule of thumb: "Hang on! This ride isn't over."
  1. anciendaze
    Above, I mentioned news concerning increasing cancer risks. Since then another story has appeared warning of a 20% jump in global cancer rates. This is again considered preventable because it is tied to obesity, exercise and diet. The assumption here is that people all over the world are catching the bad habits of those in developed countries.

    The difference between correlation and causation should be common knowledge. It is easy to show correlation between ice cream sales in New York, New York and epidemics in Kolkata (Calcutta). Should we ban ice cream in New York?

    The two observations are linked to a common cause, seasonal variations in climate. Neither fact causes the other.

    Considering the enormous effort put into exhorting people to live healthy lives the results are pitiful. Shouldn't we at least test our assumption that there is no common infectious cause?
  2. anciendaze
    ...On the other hand, when it comes to trauma, they can fix almost anything. So why is there such dramatically different outcomes for trauma vs. chronic illness?Check the history of surgery. Trauma treatment for people who had been healthy, until minutes before, was essential for military purposes. Napoleon's success with conscript armies depended not only on God being on the side "with the most cannon", but also the side which could throw in the largest number of soldiers. Ignoring the plight of the wounded would cause mass desertion. Thus, the problems of major trauma got the attention of military and political leaders, added resources followed.
    Reading the history of TB clinics, I couldn't help but think of Cort's excellent analysis of Dr Cheney's cardiac theories. After reading all that stuff several times, I still don't have any idea what to think of his theories. There is just too much mush between the ears.Paul Cheney has often been thinking three or four steps ahead of others. Sometimes he is right, sometimes wrong. He has been less successful at communication with other doctors. He keeps forgetting most doctors don't have a PhD. in nuclear physics, as he does. What he has said about ejection fraction and Q make sense to me, but violate beliefs of most cardiologists, who think you can ignore things that don't result in immediate problems. By the measures he uses we are not in heart failure, but right near the threshold.
    But I do have a question, maybe someone can answer? If we have a big problem with cardiac output, why don't we have edema? Part of the answer is that we generally have hypovolemia, low volume of blood. Another aspect is that we don't have a big problem while lying down. Our problem only turns up in responding to changing demands. Exactly which things are causes, and which effects of attempts at compensation still needs to be hashed out. Our bodies are functioning, but only by invoking emergency operating procedures.
  3. jimells
    It strikes me that the history of western medicine can be summarized are follows:

    "If we don't understand your illness, then it's your fault your sick".

    On the other hand, when it comes to trauma, they can fix almost anything. So why is there such dramatically different outcomes for trauma vs. chronic illness?

    Reading the history of TB clinics, I couldn't help but think of Cort's excellent analysis of Dr Cheney's cardiac theories. After reading all that stuff several times, I still don't have any idea what to think of his theories. There is just too much mush between the ears.

    But I do have a question, maybe someone can answer? If we have a big problem with cardiac output, why don't we have edema?
  4. Merry
    No, I shouldn't underestimate the effort you put into writing. But I'm impressed with the results. Thanks, aciendaze.

    I certainly agree with your statement "throwing up your hands, and blaming patients for things they do not control, should be an obvious dead end."
  5. anciendaze
    ...Since you quite obviously have brains to spare, can I have some? Fooled you! If you had seen the entire edit history, including the part that took place before I put anything on-line, you would know that organizing my thoughts is like herding gerbils. I start with gibberish, and edit prose into existence through unnatural selection.

    Some flotsam I just grabbed as it floated by does serve to illustrate that there is far more potential for improved health than general medicine acknowledges. Stroke and Parkinson's disease are major causes of disability said to be due to aging. This may not be so. Here is an opportunity to not only reduce the named diseases, but also many ill-defined problems said to be concomitants of aging. Preventing problems which haven't even been given clear diagnostic categories is one way to score major gains in public health. The opposite approach of simply throwing up your hands, and blaming patients for things they do not control, should be an obvious dead end. I keep waiting for people to catch on.

    Added: Today's news includes more on stroke, which I linked above as an opportunity for improving public health through prevention. It seems the risk is rising -- even in children. This doesn't fit several theories of causation, but does fit a model with infectious disease.
  6. Merry
    "(Steps down off soapbox.)"

    (Applause.)

    Since you quite obviously have brains to spare, can I have some?
  7. anciendaze
    Not sure these two claims are true, especially the first. Fine, I'm not looking for consensus. Just name me a species which feeds and cares for sick or injured members.
  8. Sean
    Some thought provoking stuff there, AD. Thanks for that.

    Humans are the only known species which will not simply guard members who are injured or sick, but actively feed and care for them. Likewise, we have an apparently unique ability to subordinate individual differences during struggles with forces of nature which endanger all.

    Not sure these two claims are true, especially the first.
  9. alex3619
    Hi anciendaze, while I am not qualified to comment on much of the historical analysis you go into, I can comment on specific issues that I agree with. I write it as a quote and comment.

    "Consensus will predictably favor those treatments producing current income streams -- irrespective of benefits to patients."

    The outcome of any judgement depends on the criteria used. When multiple criteria are in conflict such as patient care and cost saving it is particularly susceptible to manipulation by those with one agenda or another. With respect to government and insurance agencies, cost saving or profit making are often the dominant motive.

    Governments should be making the strategic decisions - but they are locked into short term thinking by regular election cycles. This in turn is reinforced by the way media reviews political events. This is NOT the fault of the insurance industry, it is doing what it is mandated to do. This is the fault of government which is failing the role of doing whatever business can't do but is still necessary.

    "Consider a tale of two doctors: one is an honest practitioner who hands his patients a printed flyer with the few suggestions known to make a difference, and carefully answers questions; the other confidently proclaims that his sanatorium in Davos is the best answer known to medical science. To raise funds for building and maintaining the sanatorium, he must travel and speak to a variety of people with money. If he exhibits doubt, his fund raising will fail. If he succeeds, the resulting income, and the prestige of being director of the famous sanatorium where all the rich go, will validate his approach in his own mind. All the funding will be directed toward immediate goals in treatment. None is likely to be expended on research hypotheses that undermine the notion of sanatorium treatment. Even the possibility of telling all those rich and powerful patients you know so well that you were wrong rapidly recedes into the mental distance."

    See my Doggy Treat Theory - its the same issue.

    "The scope of the entire interaction with modern medicine has expanded to the point much is over the horizon of daily concerns of any of the professionals involved. Nobody has the big picture."

    Yes, local feedback, global ignorance. There is no big picture. Institutes and government need to get good strategic analyses, but if these analyses are limited in scope to narrow concerns it is more tactical than strategic. Any government that does this can potentially win every battle but lose the war - and it looks like most if not all governments are doing this.

    "What I've outlined above are a number of potential opportunities for major reductions in healthcare costs over the long term. With the current system of incentives, either in government or private research, this is not likely to happen. In broad terms the best current predictor of future funding for biomedical research is previous success in obtaining funding, not results which lower incidence of disease. Current emphasis on short-term costs are actually an impediment to progress."

    Completely agree with you here anciendaze. It is the entire cultural and institutional support to the this failed approach that needs to be changed.

    "I don't have an answer to questions about exactly how much who should pay for what, or the extent of public and private responsibilities. In the end all of us will pay, one way or another. It is likely most present experts will be wrong. Whatever process emerges, I'm calling for fixing the broken feedback, and giving those most concerned some meaningful degree of participation in decisions directly and intimately affecting their lives."

    Government practice has failed on strategic issues. Government representatives are great at short term tactical management of political issues, though not without their faults, but there is no long term analysis or vision.

    One thing I do disagree with is that ignoring the health care crisis is not like printing money. I liken it to borrowing money to balance the budget while ignoring future increases in debt, including compound interest. Compound interest will crash the economic system in time if it is not addressed. The only difference on health issues is that most pathogens have limits to growth, but this is not true with respect to environmental toxicity. There is no upper bound.

    Bye
    Alex