Black infant mortality

The NYT writes: 

Precisely why the black infant mortality rate is so high is a mystery that has eluded researchers even as the racial disparity continues to grow in cities like Pittsburgh, Los Angeles and Boston. 

In Pittsburgh, where the unemployment rate is well below the national average, the infant mortality rate for black residents of Allegheny County was 20.7 in 2009, a slight decrease from 21 in 2000 but still worse than the rates in China or Mexico. In the same period the rate among whites in the county decreased to 4 from 5.6 — well below the national average, according to state statistics. ...

And the article goes on, in the standard fashion, to talk about the black-white gap from various perspectives. 

Recent studies have shown that poverty, education, access to prenatal care, smoking and even low birth weight do not alone explain the racial gap in infant mortality, and that even black women with graduate degrees are more likely to lose a child in its first year than are white women who did not finish high school. Research is now focusing on stress as a factor and whether black women have shorter birth canals.

My guess would be that the differences would be part nature, part nurture. The nature side looks to me like at base, an r-K differential. The nurture side, however, needs investigating because matters could be improved. For example, what is the role of STDs?

The problem with most conventional thinking about racial differences is what I call the midget-giant gestalt issue, after the time when I was at UCLA and I saw a midget talking to a normal sized guy. But then a second midget walked up and I suddenly realized the midgets were six-footers and the normal sized guy was 7'-4" 290 pound basketball player Mark Eaton. 

Similarly, American race discourse is obsessed with black-white comparisons, which often don't get very far for lack of a third party to provide perspective. 

Thus, a table accompanying the article shows that the infant mortality rate among Hispanics is slightly lower than among whites, much less among blacks. (Click on the table above to see more columns.) That poor Hispanics have much, much lower infant mortality than poor blacks is not a new development.  I noticed that back in the early 1990s. But there is no reference in this 2011 article to Hispanics. You would think that this would be a key avenue of research because Hispanics have, evidently, found cheap ways to have healthy babies.

There are now 50,000,000+ Hispanics in the U.S. We're not supposed to notice their failures. Can we at least notice their successes? 

My old articles are archived at iSteve.com -- Steve Sailer

Race and Medicine, Part LXXV

This Washington Post article illustrates that the widespread conceptual confusion over what race is can be bad for health care:

Race reemerges in debate over ‘personalized medicine’ 

By Rob Stein 

Federal examiners have rejected patents for genetic screening tests because the applicants did not explore their effectiveness for different races, adding to the debate about whether race has scientific validity in modern DNA-based medicine. 

Presumably, Patent Office staffers got a memo encouraging them to make sure that genetic tests work on minorities and aren't just being optimized for whites. But this upsets the Race Does Not Exist crowd.

Some geneticists, sociologists and bioethicists argue that “black,” “white,” “Asian” and “Hispanic” are antiquated categories that threaten to revive prejudices. Others, however, say that meaningful DNA variations can track racial lines and that ignoring them could deny many benefits of “personalized medicine,” which aims to develop tests and treatments tailored to a person’s genetic makeup. ...

Jonathan Kahn, a law professor at Hamline University in St. Paul, Minn., discovered the patent rejections when he began sifting through applications, prompted by a 2008 patent office presentation that raised the race issue. 

“Constructions of race as genetic are not only scientifically flawed, they are socially dangerous, opening the door to new forms of discrimination or the misallocation of scarce resources needed to address real health disparities,” Kahn wrote in a report in the journal Nature Biotechnology in May. ...

Similarly, in 2009, an examiner rejected a patent for a test for a propensity for prostate cancer because it did not specify the risk the variation posed among different races, Kahn found.
And in 2010, an examiner denied a patent for a test for a genetic marker for asthma and eczema because it was vetted only in whites and Asians. 

The prostate cancer and asthma rulings were reversed on appeal. But the colorectal cancer applicant narrowed the application to win approval. 

“There’s no telling how many people will just give in and use race in a way that the scientists clearly do not think is an appropriate way to use race,” Kahn said. 

Just the fact that patent applications are including such information is disturbing, he and other critics say. 

“This gives almost scientific legitimacy to the false categories of race — that somehow being white or being European is a strong category you can use in research,” said Troy Duster, who studies the racial implications of scientific research at New York University. 

For decades, demagogues — and even some scientists — argued that racial groups were genetically distinct and, in some ways, biologically inferior or superior, justifying laws barring interracial marriage and other discriminatory practices. 

Genetic predispositions — such as for sickle cell anemia, which occurs more frequently among African Americans, and Tay-Sachs disease, which is found more often in descendants of Ashkenazi Jews — clearly can pass down through generations. But as scientists developed modern tools of molecular biology, they produced ever more convincing evidence that genes vary as much among people who identify themselves as the same race as among groups segregated along traditional racial lines.

Except that they don't. Statistically, genes vary a lot within races, just as they vary a fair amount among siblings within a nuclear family, but they vary even more among individuals across races.

“What we are learning is that ancestry is really the key here,” said Charles N. Rotimi, director of the center for research on genomics and global health at the National Human Genome Research Institute.

Because ancestry and race don't have much to do with each other, I guess.

“The labels for race, at least as we currently use them, distort some of the things we want to understand in terms of ancestry.” 

Then perhaps we need for doctors to use more accurate terms. For example, Professor Kahn is up in arms about a Patent staffer who supposedly treated "Hispanic" as a racial group. This suggests that the medical profession ought to revive more genetically useful terms such as "mestizo" and "mulatto." Doctors use technical terms for lots of things that are considered inappropriate to mention in polite society, so why shouldn't they use "mestizo" and "mulatto?" It's their job, after all.

For example, although sickle cell anemia is more common among African Americans, the blood disorder is also rare in some parts of Africa and common in some predominantly Caucasian populations.

This is the kind of race-does-not-exist talking point that's more likely to confuse nonspecialist doctors than to help them make more accurate diagnoses. For the purposes of figuring out which tests to run on sick African American children, it doesn't particularly matter that sickle cell anemia "is rare in some parts of Africa" because traditional African-Americans (i.e., the descendants of American slaves) are a blended population with no ability to accurately tell a doctor something like, "My baby can't have sickle cell anemia because all 512 of my great-great-great-great-great-great-great-grandparents were from parts of Africa where sickle cell anemia is rare." The point is that if your baby is African-American, sickle cell anemia should be a concern for your pediatrician. Now, if you and your spouse just got off the plane from, say, the highlands of Ethiopia, well, maybe not, but you are the exception.

Likewise, it would be good for doctors to know that if your baby is, say, 100% Sicilian, then there's a small chance of sickle cell anemia because there was some falciparum malaria in Sicily.

The ultimate goal of genetic-based personalized medicine is to match care to each patient’s genetic makeup, Rotimi and others say. 

“You are truly going to be looking at that individual, whether black, white or Asian. It’s the individual’s genome that becomes important to their disease risk as opposed to their socially identified race or ethnicity,” said Vence L. Bonham Jr., an associate investigator at the institute, which is part of the National Institutes of Health.

But in the mean time ... Look, this individualized medical genomics thing hasn't working out as fast as people thought it would. What is progressing fast is racial genomics. Scientists are getting very good at figuring out people's racial backgrounds from their DNA.

Injecting race back into the mix carries myriad dangers, critics say. On a practical level, it may result in doctors using tests or treatments on one ethnic group and not another, denying people care based on the color of their skin.

Because less information is better when making diagnoses.

... On a more disturbing level, it could fuel racism. 

“It has the social consequence of making it seem that differences among groups are fundamentally biological,” said Barbara A. Koenig, a medical ethicist and anthropologist at the Mayo Clinic in Minnesota. “Inevitably, in our history, that leads back to the idea that one race is better than another.” 

But others say that although race is far from perfect, some genetic variations with meaningful implications for health can be much more common among certain groups. 

For example, the anti-seizure drug Tegretol produces a life-threatening skin rash more frequently among certain Asians than others; the best dose of the common blood thinner Warfarin varies by race and African Americans appear to be at an increased risk for kidney failure because they more often carry certain mutations. 

“I don’t think race/ethnicity and personalized medicine are mutually exclusive,” said Neil Risch, a professor of human genetics and epidemiology at the University of California at San Francisco. “You can call it sociological, cultural — whatever. It’s all of the above. That doesn’t mean it’s devoid of genetic meaning.”

In other words, racial medicine doesn't work in theory, but it does work with human beings. That suggests that we need a better theory.

In fact, recent analyses have indicated that many common diseases probably are caused by genetic variations in different populations, making it crucial to assemble diverse databases, researchers said in an article published online July 13 by the journal Nature. 

Two large genetic analyses published July 20 by the journals Nature and Nature Genetics found hundreds of genetic discrepancies between people of African American and European descent. And two papers published online Sunday by Nature Genetics found four unique genetic variations associated with asthma in people in Japan and people of African ancestry. Until scientists learn more about individual genetic predisposition, race provides a useful proxy, some say. 

“I think there’s a healthy debate right now about the role of race in medicine,” said Noah A. Rosenberg, a professor of biology at Stanford University.

One of the reasons that this debate has dragged on in a confused fashion for so many years, probably killing a few patients along the way, is that doctors aren't given a solid concept of race. Doctors are busy, practical people. They need the conceptual heavy lifting to be done by intellectuals, but the intellectual class has overwhelmingly failed when it comes to understanding what race is.

The problem is that because it's easy to poke holes in the crudest forms of old-fashioned American racial concepts, such as the one-drop rule, that means you can jump all the way to Race Does Not Exist, which is even cruder and stupider. What we need instead is a more sophisticated way for doctors to think about race. Fortunately, I invented* that way back in the 1990s: a racial group can most profitably be thought of as an extended family that is partly inbred. This is very close to being tautological, and, not surprisingly, lots of recent genetic data supports this insight.

The good news is that doctors shouldn't have too much trouble grasping my concept because it fits nicely as an extension of a concept they use all the time: the family medical history. The Surgeon General, AMA and the Mayo Clinic advocate that patients draw up a family medical history for themselves.

Race fits into the notion of a family medical history by allowing your family medical history to be extended beyond relatives whose medical histories you happen to know. Thinking of race as a partly inbred extended family means implies that statistical tendencies should also be garnered from large numbers of members of your more extended families.

The bad news is that almost nobody is explaining this concept to doctors. Thus, we see confused and confusing articles like this one.

----------------------

* I'm sure lots of other people invented it before me.

My old articles are archived at iSteve.com -- Steve Sailer

New autism findings

From the NYT:

New Study Implicates Environmental Factors in Autism 

By LAURIE TARKAN 

A new study of twins suggests that environmental factors, including conditions in the womb, may be at least as important as genes in causing autism. 

The researchers did not say which environmental influences might be at work. But other experts said the new study, released online on Monday, marked an important shift in thinking about the causes of autism, which is now thought to affect at least 1 percent of the population in the developed world. 

“This is a very significant study because it confirms that genetic factors are involved in the cause of the disorder,” said Dr. Peter Szatmari, a leading autism researcher who is the head of child psychiatry and behavioral neuroscience at McMaster University in Ontario. “But it shifts the focus to the possibility that environmental factors could also be really important.” 

... Other experts have cited factors like parental age, multiple pregnancies, low birth weight and exposure to medications or maternal infection during pregnancy. 

... In the new study, the largest of its kind among twins, researchers looked at 192 pairs of identical and fraternal twins whose cases were drawn from California databases. At least one twin in each pair had the classic form of autism, which is marked by extreme social withdrawal, communication problems and repetitive behaviors. In many cases, the other twin also had classic autism or a milder “autism spectrum” disorder like Asperger’s syndrome. 

Identical twins share 100 percent of their genes; fraternal twins share 50 percent of their genes. So comparing autism rates in both types of twins can enable researchers to measure the importance of genes versus shared environment. 

The study found that autism or autism spectrum disorders occurred in both twins in 77 percent of males and 50 percent of females. As expected, the rates among fraternal twins were lower: 31 percent of males and 36 percent of females. 

But surprisingly, mathematical modeling suggested that only 38 percent of the cases could be attributed to genetic factors, compared with the 90 percent suggested by previous studies.
And more surprising still, shared environmental factors appeared to be at work in 58 percent of the cases. 

“We, like everyone else, were very surprised because we didn’t expect it to be that high,” said a senior author of the study, Neil Risch, a geneticist and epidemiologist at the University of California, San Francisco. 

In siblings who are not twins, the rate of autism is much lower, suggesting that the conditions the twins shared in the womb, rather than what they were exposed to after birth, contributed to the development of autism. 

A second article in the same journal found an elevated risk of autism in children whose mothers took a popular type of antidepressant during the year before delivery. But the authors reassured women taking these drugs — so-called S.S.R.I.’s like Prozac, Zoloft, Celexa and Lexapro — that the risk was still quite low: 2.1 percent in children whose mothers used them in the year before delivery, and 2.3 percent in the first trimester of pregnancy.

Autism is another one of those medical syndromes, like schizophrenia, that seems implausible to explain wholly genetically, since full-blown autistics don't have many children, so why wouldn't it die out?

You could make the argument that autism might be like sickle cell anemia, a hereditary disease that is fatal without medical care in people with two copies of the gene, but one copy makes you more likely to survive the most lethal form of malaria. 

Nerds are more functional versions of autistics, and nerds are more likely to invent the weapons and other technology that help one tribe conquer another. But then you get into the usual problems with trying to argue the logic of group selection. I'm not saying it can't be done, but it's not easy. 

This article should be commended for at least mentioning the word "infections" as an example of potential environmental influences. I'm not saying that germs contribute to autism or schizophrenia but that there's no reason not to mention it as a possibility. Similarly, the genetic contributions to these kind of syndromes might not be so much positive as negative -- i.e., it might be that your genes less make you autistic or schizophrenic as that your particular genes give you less defense against whatever it is in the environment that causes autism or schizophrenia. Or, autism could be an occasional cost of a defense system, like sickle cell anemia. 

We need a consciousness-raising campaign that infections can possibly be a cause of long term medical problems.

My old articles are archived at iSteve.com -- Steve Sailer

Stress and schizophrenia

From Nature News

City Living Marks the Brain: 

Epidemiologists showed decades ago that people raised in cities are more prone to mental disorders than those raised in the countryside. But neuroscientists have avoided studying the connection, preferring to leave the disorderly realm of the social environment to social scientists. A paper in this issue of Nature represents a pioneering foray across that divide. 

Using functional brain imaging, a group led by Andreas Meyer-Lindenberg of the University of Heidelberg's Central Institute of Mental Health in Mannheim, Germany, showed that specific brain structures in people from the city and the countryside respond differently to social stress (see pages 452 and 498). Stress is a major factor in precipitating psychotic disorders such as schizophrenia. 

The work is a first step towards defining how urban life can affect brain biology in a way that has a potentially major impact on society — schizophrenia affects one in 100 people. It may also open the way for greater cooperation between neuroscientists and social scientists. "There has been a long history of mutual antipathy, particularly in psychiatry," says sociologist Craig Morgan at the Institute of Psychiatry in London. "But this is the sort of study that can prove to both sides that they can gain from each others' insights." 

Meyer-Lindenberg works on risk mechanisms in schizophrenia, and previously focused on the role of genes. But although a dozen or so genes have been linked to the disorder, "even the most powerful of these genes conveys only a 20% increased risk", he says. Yet schizophrenia is twice as common in those who are city-born and raised as in those from the countryside, and the bigger the city, the higher the risk (see 'Dose response?').

The article goes on to describe some brain scan experiment in which a lovely young science lady with lots of dark hair and dark eyes "scolds" subjects while they do arithmetic, which sounds like something out of an Austin Powers movie. I can no more make sense of brain scan experiments than I can make sense of recipes so I won't comment on the experiment.

But, there are a few problems with attributing schizophrenia to "stress." The first is that "stress," while it definitely exists, can be used as one of those all-purpose hand-waving explanations. That doesn't mean that it's wrong, but I tend to have a prejudice against it.

The second is that schizophrenia is so catastrophic from a Darwinian point of view -- it ruins the lives of roughly 1% of the population, but generally not until after their families have almost fully invested in their upbringing -- that it deserves some careful explanation.

Third, it's not at all clear to me that we stress out more over stuff that wasn't around during the evolutionary past. Lots of people stress out over snakes and spiders, but people seem to get fairly used to, say, driving 75 mph on the Ventura Freeway. A few weeks ago, I got a cell phone call from some family friends who had a flat tire on the freeway, so I drove over to stand upstream from them and glare at drivers while they were changing it by the side of the freeway. From that perspective, a few feet from cars roaring past, the entire idea of driving on the freeway seems like utter madness. I drove home very slowly on surface streets. But the next day I was driving 75 mph down the Ventura Freeway with no more thought in my head than: "How come I didn't like Led Zep as much in the 1970s as I do now? Black Dog is awesome!"

Fourth, if city life correlates with schizophrenia, why stress instead of infection as a potential cause? Disease burden was such a problem for city dwellers until quite recently that, for example, sub-Saharan Africa had very few cities. People in Africa had to live spread out in small villages or they'd get sick and die.

My old articles are archived at iSteve.com -- Steve Sailer

Heart disease and IQ

From Reuters:

Low intelligence among top heart health risks

LONDON (Reuters) - Intelligence comes second only to smoking as a predictor of heart disease, scientists said on Wednesday, suggesting public health campaigns may need to be designed for people with lower IQs if they are to work.

This works both ways: sickly people tend to less smart in the first place (maybe some have lower IQs because their heart and circulatory system don't deliver enough blood to the brain?), and being sick and/or old cuts your IQ. So, it is the duty of smart people in the medical industry to think hard about to make everything simpler for patients. Instead, a lot of practices in medicine (like those pages of tiny type in magazine ads for prescription drugs listing side effects) are done to appease smart lawyers rather than to make life better for baffled patients.

Similarly, as the recent cases of patients being fried by overly large doses of radiation therapy and scanners show, programmers need to build in safety measures to keep low IQ and/or sleep deprived medical personnel from messing up.

Research by Britain's Medical Research Council (MRC) found that lower intelligence quotient (IQ) scores were associated with higher rates of heart disease and death, and were more important indicators than any other risk factors except smoking.

Heart disease is the leading killer of men and women Europe, the United States and most industrialised countries.

According to the World Health Organisation, cardiovascular diseases and diabetes accounted for 32 percent of all deaths around the world in 2005.

It is well known that people with poorer education and lower incomes often face higher risks of ill health and a range of diseases. Studies have pointed to many likely reasons, including limited access to healthcare and other resources, poorer living conditions, chronic stress and higher rates of lifestyle risk factors like smoking.

The MRC study, which analysed data from 1,145 men and women aged around 55 and followed up for 20 years, rated the top five heart disease risk factors as cigarette smoking, IQ, low income, high blood pressure, and low physical activity.

The researchers, led by David Batty of the MRC and Social and Public Health Science Unit in Glasgow, Scotland, said there were "a number of plausible mechanisms" which might explain why lower IQ scores could raise the risk of heart disease -- in particular a person's approach to "healthy behaviour."

Judging by the number of people I see jogging in the most expensive parts of town, versus the few joggers in the rest of town, I often wonder whether "energy" -- both physical and mental -- has a sizable general factor.

My published articles are archived at iSteve.com -- Steve Sailer

Illegal Aliens, Health Care and Amnesty: Medical costs are just a fraction of the issue

This happens every single day right now: an illegal immigrant roofer falls off a roof and is hurt. He doesn't have health insurance. Is he denied health care?

Of course not. America is a civilized country and we won't let suffering people within our borders go untreated. So, an ambulance rushes him to a hospital emergency room and he spends as many nights in the hospital as it takes to treat him. He pays nothing because he has no money. The roofing contractor doesn't pay either (his motto: privatize profits, socialize costs). The illegal alien's cost is simply added to the bills paid by people with insurance.

No, the big issues about illegal aliens, health care, and amnesty revolve around the indirect effects on the birthrate that nobody is supposed to think about in modern America.

If the roofer eventually goes home to Latin America because there is no construction work anymore in America without fathering any children in the U.S., then the costs he imposes on us are finite. If, however, he fathers a number of anchor babies within the U.S., then the costs become long term and difficult to fully foresee.

Clearly, one reason for Obama's repeated announcements that he's going to push through "comprehensive immigration reform" Real Soon Now is to dissuade unemployed illegal immigrants from going home: Sure, it's cheaper to be unemployed back home in Mexico than in LA, but you'll miss out on the amnesty if you leave now.

Add to that Obama's message to the Congressional Hispanic Caucus Institute on Wednesday that the 12-million (or whatever) illegal aliens he intends to amnesty in 2010 would benefit from his subsidized health insurance, and you have another inducement for them to stay here, or to rush on in, even though there aren't jobs, so they'll be on the amnesty list next year.

A massive question that nobody thinks about other than Democratic political strategists is whether the synergy of Obama health and amnesty plan attracts maternal-minded women from Mexico. Maternal-minded women tend to be more cautious than men about crossing the border illegally and living without health insurance for their children. Plenty of them do sneak in anyway and have babies (according to the Public Policy Institute of California, the 2005 total fertility rate for foreign-born Latinas in California was 3.7 babies per lifetime, versus 1.6 for American-born whites and 1.4 for American-born Asians, and about 2.4 in Mexico itself -- the U.S. is attracting Mexican women who can't afford to have as many children as they want in their own country).

But think about what's coming if we have another amnesty and we have subsidized health insurance.

We know that the 1986 illegal alien amnesty, even without health insurance, brought in a flood of women from south of the border, who then had an extraordinary number of children in California over the next eight or so years. Demographer Hans P. Johnson of the Public Policy Institute of California wrote:

“Between 1987 and 1991, total fertility rates for foreign-born Hispanics [in California] increased from 3.2 to 4.4 [expected babies per woman over her lifetime]. ...

“Why did total fertility rates increase so dramatically for Hispanic immigrants? First, the composition of the Hispanic immigrant population in California changed as a result of the Immigration Reform and Control Act (IRCA) of 1986. In California alone, 1.6 million unauthorized immigrants applied for amnesty (legal immigrant status) under this act. The vast majority were young men, and many were agricultural workers who settled permanently in the United States. Previous research indicates that many of those granted amnesty were joined later by spouses and relatives in the United States... As a result, many young adult Hispanic women came to California during the late 1980s. We also know that unauthorized immigrants tend to have less education than other immigrants and that they are more likely to come from rural areas. Both characteristics are associated with high levels of fertility. As a result, changes in the composition of the Hispanic immigration population probably increased fertility rates.

This post 1986 amnesty-induced Latino Baby Boom is one of the sizable events in recent American social history and a major contributor to California's current dire financial straits, yet it simply is off the media map as if it never happened. I've been whooping about it for seven years, but I don't recall anybody else ever mentioning it. The national Baby Boom of 1946-1964 is rehashed endlessly, but this more recent and more relevant Baby Boom is utterly unknown.

When it comes to health insurance by itself, I don't have a strong opinion. The current system of employer-provided insurance, which is a byproduct of a loophole in WWII wage controls, is ridiculous. If this was Finland, with negligible immigration and a broadly skilled and healthy population, I'd probably be fine with the government-dominated health insurance system they have there. But, we're not Finland. As Milton Friedman said at the 1999 World Libertarian Conference: "You cannot simultaneously have free immigration and a welfare state."

Many have commented on the craziness of trying to hold a debate over health insurance, when there are multiple plans floating around, each 800 pages long. Worse, though, we're not supposed to publicly debate (or even think about) the most important impact of these bills: the long-term impact on the population.

My published articles are archived at iSteve.com -- Steve Sailer

"Sicko"

My review from the July 30, 2007 issue of The American Conservative:

Michael Moore's comic polemical documentaries have done more for his net worth than for his political causes. He attacked greedy CEOs sending American factory jobs abroad in 1989's "Roger & Me," gun sales in 2002's "Bowling for Columbine," and President Bush's war in Iraq in 2004's "Fahrenheit 9/11," leaving him 0-for-3.

In "Sicko," he has his ripest target yet, America's ramshackle health care finance system. Having come down with lymphatic cancer in 1996, I am sympathetic to Moore's bias against for-profit health insurance. I may still be here only because I had the kind of generous insurance that few employers provide these days.

Moore's centerpiece example is a young man battling cancer (at the same age as me) whose request for an expensive bone marrow transplant was denied. He died three weeks later. Moore blames his death on insurance company greed (although that brief interval suggests his condition was hopeless). If I'd needed a bone marrow transplant, I'd have wanted the law to align incentives by requiring my employer to buy both my health and life insurance from the same firm. The insurer would then have had to choose between paying my clinic or paying my widow.

Strangely, "Sicko" misses much of our expensive but stressful system's black comedy, such as medical providers mailing out heart-attack inducing bills demanding we pay their zany list prices, apparently in the hope that an occasional senile patient might dutifully ante up rather than forward it to his insurer. For instance, after a two night hospital stay costing $2,000 (according to the rate my insurance company had already negotiated), the hospital billed me for $34,000.

Unfortunately, Moore's self-promotion, disingenuousness, and leftist ideology leave his event movies being more about Moore than about their ostensible subjects. "Sicko's" underlying goal appears to be to use our absurd health payment system to persuade us that socialism in general is superior to capitalism, that innately evil tumor on humanity. That's not a debate he's going to win, so he's distracting from the reality that medical insurance is a big exception to the rule that the profit motive works best.

Moreover, Moore's faux populism gives him an excuse to dumb down "Sicko" and not bother to explain why the competitive enterprise system that's good at providing us with, say, life insurance is bad at medical insurance.

In truth, our dysfunctional tradition of employer-provided health insurance isn't a result of the free market. Instead, it emerged during WWII as companies slid past wage-price controls by offering free fringe benefits to attract workers. In other words, it began as corporate liberality evading government-mandated stinginess. Of course, you won't learn that from "Sicko."

The documentary's lack of economic sophistication could be tolerated if his audience really was as uneducated as Moore implies. Yet, despite his trademark obesity and bad clothes, Moore's blue-collar Joe shtick is just an act, as he showed in his gun control movie "Bowling for Dollars." Moore's fans -- urban white liberals -- want gun control to disarm the minority criminals who threaten them, but they aren't going to admit that, so Moore concocted a fantasy for them about how dangerous those heavily armed rural rednecks are.

Similarly, Moore lovingly shows us in "Sicko" that the French upper middle class live more stylishly than us American slobs. And he seems most at home chatting with another pseudo-prole, the grand old man of English leftism, Tony Benn, who used to be Anthony Wedgwood Benn, the 2nd Viscount Stansgate.

When Moore ventures abroad to tells us about the wonderfulness of the government-paid systems in Canada, Britain, France, and, yes, Cuba, his satirical eye deserts him as he descends into complete credulity: It's free! Unlimited care, free!

Sadly, nothing can be unlimited. When I had cancer, I made my insurance pay for second, third, and fourth opinions. I hired an oncologist as my consultant to help me evaluate the clinical trials offered by three top lymphoma specialists. With his aid, I became the first patient with intermediate-grade non-Hodgkins lymphoma to be treated with a radical new monoclonal antibody that has since become a multi-billion dollar per year drug. I've been fine for the decade since.

Today, I suspect, few HMO's -- or, contra Moore, governments -- would pay for such a lavish (but effective) plan of attack.

Still, despite Moore's miscues, health insurance is the best domestic issue the Democrats possess. Why let them have it?

Rated PG-13 for brief strong language.

My published articles are archived at iSteve.com -- Steve Sailer

Why I hired an oncologist as my private consultant when I had cancer

Back in February, 1997, I was, I believe, the first person in the world with intermediate grade non-Hodgkins lymphoma to be treated with what's now the world's biggest selling cancer drug, Rituxan, a monoclonal antibody that inspires your own immune system to target cancer cells, like a smart bomb goes right to the enemy headquarters, while traditional therapies like chemotherapy are like carpet bombing. (Ritxuan had already been proved to be safe and effective in treating people with "indolent" lymphatic cancer, so it didn't take any courage on my part to choose this drug.) So, I'm a big fan of market forces on the supply side of medicine.

On the demand side, I'm not so sure. One issue that's seldom talked about is that people trust their doctors too much and don't realize that their doctors may have different interests than they do.

Here's a NYT article about two even newer drugs that I had heard about in 1997 as the next generation of NHL treatments after Rituxan. Because lymphatic cancer is so diffused throughout your body, you can't use radiation therapy because you'd fry much of your body. So, Bexxar and Zevalin cause your immune system to deliver tiny bits of radioactive material directly to the cancer cells.

Market Forces Cited in Lymphoma Drugs’ Disuse
By ALEX BERENSON

The patients’ stories sound nearly impossible.

After an hourlong infusion, Linda Stephens, 58, has been cancer-free for seven years. Dan Wheeler, three years. Betsy de Parry, five years. Before treatment, all three had late-stage non-Hodgkin’s lymphoma, a cancer of the immune system, and a grim prognosis.

All three recovered after a single dose of Bexxar or Zevalin, both federally approved drugs for lymphoma. And all three can count themselves as lucky.

Not just because their cancers responded so well. But because they got the treatment at all.

Non-Hodgkin’s lymphoma is the fifth most common cancer in the United States, with 60,000 new cases and almost 20,000 deaths a year. But fewer than 2,000 patients received Bexxar or Zevalin last year, only about 10 percent of those who are suitable candidates for the drugs.

“Both Zevalin and Bexxar are very good products,” said Dr. Oliver W. Press, a professor at the University of Washington and chairman of the scientific advisory board of the Lymphoma Research Foundation. “It is astounding and disappointing” that they are used so little. The reasons that more patients don’t get these drugs reflect the market-driven forces that can distort medical decisions, Dr. Press and other experts on lymphoma treatment say. A result can be high costs but not necessarily the best care.

The drugs have not been clinically proven to prolong survival, compared with other therapies. But patients are more likely to respond to them than standard treatments, and trials to test whether the drugs do have a survival benefit are nearly complete.

Other, more thoroughly tested lymphoma drugs are preferred as first-line treatments. But doctors often repeatedly prescribe such drugs even after they have lost their effectiveness — and when Bexxar and Zevalin might work better.

One reason is that cancer doctors, or oncologists, have financial incentives to use drugs other than Bexxar and Zevalin, which they are not paid to administer. In addition, using either drug usually requires oncologists to coordinate treatment with academic hospitals, whom the doctors may view as competitors.

As a result, many doctors prescribe Bexxar and Zevalin only as a last resort, when they are unlikely to succeed because the cancer has advanced. “Oncologists use everything in their cupboard before they refer,” Dr. Press said. “At least half the patients who get referred to me have had at least 10 courses of treatment.”

While Bexxar and Zevalin help many patients, only a minority become cancer-free for many years. But clinical trials indicate that they are as good as or better than other treatments. When the drugs were approved, analysts expected they would be used widely.

But the drugs have run into an obstacle that so far has been impassable. Because they are radioactive, they are almost always administered in hospitals, not doctors’ offices. As a result, doctors are not paid by Medicare and private insurers for prescribing them, as they are when they give patients a more common treatment, chemotherapy.

In addition, most oncologists outside academic hospitals treat many different cancers and may be only vaguely familiar with the drugs, said Dr. Andrew D. Zelenetz, chief of the lymphoma service at Memorial Sloan-Kettering Cancer Center. “There are a number of barriers,” Dr. Zelenetz said.

Dr. Press and Dr. Zelenetz acknowledge that they have their own financial incentives to support the drugs. Dr. Press has been paid to speak at medical education seminars sponsored by the makers of the drugs. Dr. Zelenetz has been paid when the companies sponsor clinical trials at Memorial Sloan-Kettering. But both said the money was a small part of their total income and had not colored their views.

Some patients say they would not have received Bexxar and Zevalin if they had not demanded them. Mr. Wheeler of Kalamazoo, Mich., said he received Bexxar in April 2004 only after insisting on it when his lymphoma recurred. “I told my local oncologist, I want Bexxar, you give me a referral,” Mr. Wheeler said. “I’ve been a real pain.” ...

Both drugs are very expensive, costing about $25,000 per treatment. But one dose is usually enough. The cost of the drugs is similar to a full four-month regimen of chemotherapy and Rituxan, another lymphoma treatment. ...

Because lymphoma is relatively common, and Rituxan costs $20,000 for a typical course of treatment, it is the top-selling cancer drug worldwide, with sales in 2006 of $4 billion.

Doctors agree that Rituxan is an excellent drug with only minor side effects for most patients.

Still, the few head-to-head clinical trials that have been conducted show that Bexxar and Zevalin are as effective as Rituxan, if not better. ...

Advocates for the drugs worry the companies may stop making them. Biogen Idec said in October that it might shed Zevalin. Although the company continues to manufacture the drug, it no longer actively promotes it. [More]

One problem with the current system is that seems to be considered vaguely
"unethical" by the medical profession for a patient to pay one doctor to be his consultant and help him choose among other doctors. That's just nuts. If you are a corporate executive assigned some complex once-a-decade task, such as choosing a new email system for the company, it is standard practice to hire a consultant to help you decide among competitive offerings. But not for cancer patients, who suddenly find themselves besieged with novel technical information about potential treatments. You are supposed to trust your doctor to refer you to an oncologist, and take it on faith.

Fortunately, when I was diagnosed with non-Hodgkins lymphoma in 1996, a computer consultant at my marketing research whose wife was battling cancer gave me the name of a suburban Chicago general oncologist who was willing to be employed as a consultant to help me choose among the clinical trials offered by the three top lymphoma specialists in Chicago. After each of my appointments with a specialist, I'd call my consultant and we'd review what the expert had to offer me. (Also, unusually for a doctor, he'd charge me for our phone discussions. For some reason, it's traditional among American doctors to provide phone calls for free, which is a reason they always insist you come in for a visit -- they can charge for that. But it was a three hour round trip to his suburban office, so he agreed to charge me by the hour for phone calls, which was a huge convenience.)

My consultant helped me pick out the absolute state-of-the-art clinical trial, the only one featuring Rituxan. That may well be why I've been in remission for 10 years and one month -- i.e., why I'm still here. (By the way, once you are past five years in remission with NHL, the chance of a relapse is no higher than a random person who never had NHL developing it in the first place.)

I doubt that many employer insurance plans would pay for my expensive four opinion plan of attack these days. But, I also doubt that many governments, not even Michael Moore's sainted Cuban regime, would pay either.

My published articles are archived at iSteve.com -- Steve Sailer

"Sicko"

From my upcoming movie review in The American Conservative:

Michael Moore's comic polemical documentaries have done more for his net worth than for his political causes. He attacked greedy CEOs sending American factory jobs abroad in 1989's "Roger & Me," gun sales in 2002's "Bowling for Columbine," and President Bush's war in Iraq in 2004's "Fahrenheit 9/11," leaving him 0-for-3.

In "Sicko," he has his ripest target yet, America's ramshackle health care finance system. Having come down with lymphatic cancer in 1996, I am sympathetic to Moore's bias against for-profit health insurance. I may still be here only because I had the kind of generous insurance that few employers provide these days.

Moore's centerpiece example is a young man battling cancer (at the same age as me) whose request for an expensive bone marrow transplant was denied. He died three weeks later. Moore blames his death on insurance company greed (although that brief interval suggests his condition was hopeless). If I'd needed a bone marrow transplant, I'd have wanted the law to align incentives by requiring my employer to buy both my health and life insurance from the same firm. The insurer would then have had to choose between paying my clinic or paying my widow.

Strangely, "Sicko" misses much of our expensive but stressful system's black comedy, such as medical providers mailing out heart-attack inducing bills demanding we pay their zany list prices, apparently in the hope that an occasional senile patient might dutifully ante up rather than forward it to his insurer. For instance, after a two night hospital stay costing $2,000 (according to the rate my insurance company had already negotiated), the hospital billed me for $34,000.

Unfortunately, Moore's self-promotion, disingenuousness, and leftist ideology leave his event movies being more about Moore than about their ostensible subjects. "Sicko's" underlying goal appears to be to use our absurd health payment system to persuade us that socialism in general is superior to capitalism, that innately evil tumor on humanity. That's not a debate he's going to win, so he's distracting from the reality that medical insurance is a big exception to the rule that the profit motive works best.

My published articles are archived at iSteve.com -- Steve Sailer

The French secret

Why does the French health care system provide at least as good value at a cheaper price than ours? A big part of the answer appears to be that they just pay their doctors less:

To make all this affordable, France reimburses its doctors at a far lower rate than U.S. physicians would accept. ... Specialists who have spent at least four years practicing in a hospital are free to charge what they want, and some charge upwards of $675 for a single consultation. But American-style compensation is rare. "There is an unspoken and undefined limit to what you can charge," says Dr. Paul Benfredj, a gastroenterologist in Paris.

Like soldiers, you reward them with glory (or at least respect) instead of money. That can work for for a long awhile, but if you let the genie out of the bottle (as the U.S. did many years ago with doctors and is probably doing with soldiers today by employing Blackwater mercenaries in Iraq at five times what they were making in the Army), it's awfully hard to start all over again.

My published articles are archived at iSteve.com -- Steve Sailer

Presidential candidates with cancer

We have so many candidates for President, declared and undeclared, that they follow fairly conventional distributions on many traits. For example, how many have had cancer? Sen. John McCain was diagnosed with malignant melanoma in 2000 (Celtic ancestry and Arizona sunshine can be a bad combination).

Actor and undeclared candidate Fred Thompson has a (currently) incurable form of slow-acting (or "indolent") lymphoma (cancer of the lymphatic system), in contrast to the more aggressive lymphomas which offer more of a high stakes gamble -- they can kill you quick or be cured. (I was treated for intermediate grade lymphoma in 1997.)

When a tumor showed up under his jaw in 2004, Thompson had it treated first with radiation, which often doesn't work as well with lymphoma as with other cancers because lymphoma tends to be diffused rather than just in one place where you can zap it.

Then he was treated with Rituxan, a monoclonal antibody that inspires the body's own immune system to target the cancer cells. It's often compared to smart bombs, while standard chemotherapy is compared to Dresden-style carpet bombing in which you try to kill everything that's growing in you in the hope that you can kill the cancer before you kill yourself.

(In 1997, I was, I believe, the first person in the world with intermediate-grade [moderately fast growing] lymphoma to be treated with Rituxan. I'm still here and Rituxan had sales of $1.6 billion in 2004 in the U.S. alone. The standard treatment for aggressive lymphoma is today CHOP chemotherapy and Rituxan, which I was fortunate enough to get a decade ago. I'm now almost ten years out, so the odds of avoiding a relapse look good for me, knock on wood.)

Thompson is currently in remission. Many people his age, 64, will die of old age before his slow-acting kind of lymphoma kills them. He is fairly likely to relapse, however, if he otherwise stays in good health. He claims that another round of treatment, if it became necessary, wouldn't be "debilitating."

Oncologists are fairly open-minded about how to treat relapsed indolent lymphoma, with options ranging from (not a comprehensive list):

- doing nothing until the pain gets bad (watch-and-wait)

- to radiation therapy

- to more Rituxan, which doesn't have many side effects

- to the two second-generation monoclonal antibodies for lymphoma, Zevalin and Bexxar, that come loaded with radioactive substances to deliver radiation right to the cancer cells. These have more side effects, but still aren't as bad as chemotherapy.

- to traditional chemotherapy (which many people, including me, find debilitating -- I didn't suffer much nausea, but slept 12 hours per day during my 18 weeks of treatment and suffered anemia for about a year afterwards)

- to intensive chemotherapy, which is usually called a stem-cell transplant or bone marrow transplant. It's no fun.

It would be useful if an oncologist would calculate the odds for us that Thompson could get through both one and two four-year terms as President without having to resort to debilitating treatments for relapses. I would guess that he'd probably get through a single term okay, but I wouldn't begin to guess about two terms. And don't listen to me, anyway.

In general, the U.S. has been lucky with the health of its Presidents, even though the press wasn't very responsible about reporting the facts to voters. FDR managed to survive long enough until Harry Truman had replaced Stalin-fan Henry Wallace as Vice-President, and Reagan's old-age deterioration didn't come with major costs. Oddly, the most nearly disastrous health problems were those of the youngest elected President, JFK, who was in a lot of pain much of his life. He was so pilled-up and unimpressive when he first met Khrushchev in Vienna in 1961 that the Soviet supremo thought he could push the playboy around over missiles in Cuba.

My published articles are archived at iSteve.com -- Steve Sailer