Sunday night & medical cannibalism

Western civilised countries routinely used human body parts in pharmaceutical preparations up to the end of the 18th century.  The practise was widespread. Blood, meat the lot was tried with varying success. The potions didn't always work:

"In 1492, when Pope Innocent VIII was on his deathbed, his doctors bled three boys and had the pope drink their blood. The boys died, and so did the pope".

Not quite the flesh and blood of Jesus but I guess it was tasty enough.

Pity about those boys though. The pope was a slave trader, an adultera and a strong supporter of the Spanish Inquisition.  On the basis of that last sin the world was a better place with him dead.

HT John S.

Radon & lung cancer

This is the first of several posts that I will make on lung cancer. They are related to my work on cigarette smoking.

I am interested in the fact that the incidence of lung cancer was very low prior to cigarette smoking but that, these days, around 10-15% of lung cancers seem to be unrelated to cigarette smoking. What is the source of these new lung cancers*? In part the finding could be related to early non-recognition of lung cancers but other factors seem to bear on the higher incidence of non-smoking related cancers that has emerged recently.

In the US the second largest cause of lung cancer is exposure to the element radon – most usually as it seeps through the floor of the family home. Radon kills 15,000-22,000 people in the US annually and is responsible for 12% of all lung cancer deaths. Services are available for testing and reducing radon levels in the family home . There is concern if radon levels exceed 4 pico Curies per litre (4pCi/L).

Puzzling recent findings suggest that radon at low concentrations in the home is hermetic for lung cancer – at low enough dosage levels radiation might help repair damaged DNA. These claims don’t challenge the 4pCi/L standard but the fact is that most households are below that level in any event.

By the way, radon concentrations in Australian homes are low – for most households they are marginally above concentrations in the atmosphere. There is however evidence of heightened health risks from radon in the Australian uranium mining industry.

*Of course passive smoking, asbestos and air pollution also cause lung cancers but their effects seem less important than radon exposure. Smoking and radon exposure are however probably synergistic in promoting lung cancers.

ADHD & treatments using drugs

Your children have Attention Deficit Hyperactivity Disorder (ADHD)? In the long-term they will be no better off using dangerous drugs like Ritalin or Concerta than behavioral therapies according to a study of 600 ADHD sufferers in the UK.

ADHD medications are widely prescribed in Australia - for some reason rates of prescription are 5X the average in WA. I agree with Dr. Aitkins - parents whose children have ADHD should monitor their sugar consumption.

Update: This report from today's New York Times suggests that kids with ADHD and other behavioral disorders suffer a lag in their development not a permanent impairment. Give them help but, most of all, give them time.

The PBS & mesothelioma drug treatment

The Age runs its normal pre-election, anti-Liberal Party line – this time Mr Howard (with all those budget surpluses) won’t interfere to ensure the PBS spend money to provide the drug Alimta, on a subsidised basis under a PBS listing, to unfortunate sufferers of mesothelioma. An editorial repeats these charges.

Drug firms seek to have their high-priced drug products listed under the PBS to sell them using public monies to meet required subsidies. Hence the PBS - not Mr Howard - screens drugs for effectiveness and value for money. The general idea is to maximisde health benefits per buck spent. Their assessment is that Alimta does not provide value for money and may not increase lifespan. The drug costs $20,000 per year of treatment and, acoording to one US study, can increase life expectancy by at most 3 months. It can also have adverse side effects. The detailed reason for the PBS’s Pharmaceutical Benefits Advisory Committee decision to not list Alimta is here. It has been put forward by its manufacturer (Eli Lily) 3 times for listing and is to be put forward again this November.

The scientific evidence discussed in the PBAC report is complicated. But none of this evidence is discussed in The Age’s article. The implication is that John Howard is just a cold-hearted bastard who won’t help those suffering from this awful disease. This is gutter journalism at its worst. As I have said before The Age is becoming one of the worst newspapers in Australia.

Mr Bernie Banton is a tragic sufferer of mesothelioma and a co-supporter with Eli Lily of listing Alimta under the PBS. He is a very brave man - and a battler who has universal public support and affection. He has done a lot to publicise the lot of those suffering from asbestos-related diseases and in dealing with the company, James Hardie, that inflicted this damage. Of course suffering from a disease does not make one an expert in evaluating treatments.

The Age should provide evidence that Alimta has health advantages that the PBAC has overlooked and which exceed the benefits from spending comparable amounts of money on the treatment of other diseases. Otherwise it should butt out and leave the cheap populism to nasty left-wing blogs.

A nation in pain

This article in The Age reports on an explosion of addictive painkiller use in the US. It fails to mention that a significant degree of this abuse is due to prescription and illegally-diverted prescription use by those addicted to these drugs. Oxycodone is the drug most responsible for the increased use of painkillers – it is an opiate with similar effects to heroin.

According to The Age:

AMERICANS took more than 90,000 kilograms of painkillers in 2005, with sales of five major painkillers almost doubling between 1997 and 2005.

The dramatic increase has been attributed to the ageing population and aggressive marketing by pharmaceutical companies. (my bold)

According to analysis by the Associated Press of figures from the Drug Enforcement Administration, more than 91,000 kilo-grams of codeine, morphine, oxycodone, hydrocodone, and meperidine were purchased in 2005, the most recent year of the data. This equates to 300 milligrams of painkillers for every person in the country.
The main increase was in the sale of oxycodone, the chemical used in OxyContin, which increased sixfold…….

AP found that the reason for the increases was that the population of the US was getting older, with the number of Americans aged over 65 expected to reach 65 million by 2020 — almost double the 35 million over-65s in 2000.

But it also said that drug manufacturers had embarked on unprecedented marketing campaigns, with spending on drug marketing almost trebling from $11
billion in 1997 to nearly $30 billion in 2005.

Big pharma (a clone of big tobacco) is cashing in on the legal opiate addiction business for killing pain just as they are with methadone and buprenorphine that are used as ‘maintenance drugs’ for heroin addicts. In fact the effects of all these drugs are pharmacologically similar - they are all opiates.

These drugs are ideal products to market. Just like nicotine once you are addicted to any of them it is something you do for life – providing a lifelong stream of income to those supplying them. Indeed in many cases you can get the taxpayer to subsidise the cost of providing these drugs on the grounds that you are treating pain or treating heroin addiction among 'disadvantaged' groups.

Many in the medical profession promote methadone and buprenorphine as ways of practising harm minimisation with respect to heroin users. This is assisted by professional medical groups such as APSAD (Australian Professional Society on Alcohol and Other Drugs) who hold staged promotional sessions for drugs such as buprenorphine at their annual conference meetings. I have attended the last two myself.

Dare to question the case for substituting dependence on one addictive opiate for another and you will get a blasting. Addictive drug use is purely a medical issue and other views are not tolerated.

By the way how are so many drug users gaining access to prescription painkillers which they abuse are prescribed these painkillers by doctors? My assumption is that most are. In this sense the problem of painkiller abuse is a medical problem. It stems from selfish, inept and perhaps lazy doctors who do not do their proper duty with respect to those they are supposed to exercise a duty of care toward.

I'll try to get some data together on the extent of the painkiller issue in Australia. I know it is bad here but not quite as bad as for the US.

Facts on smoking - incidence & health issues

This post contained some data errors. I have reposed the whole thing with corrections here.

Financial incentives to induce healthy behavior

An insidious externality in our comprehensive health cover system is that poor health risks, even if induced by negligent individual behavior, are borne as costs by the community rather than those who create them. This is moral hazard. Consumers have inadequate incentives to look after their health since their health costs are partly borne by others.

Business Week’s Get Healthy - or Else shows how private profit incentives in the US can improve health outcomes – health insurance costs can be reduced and health outcomes improved. The same incentives will work with our private health schemes in Australia.

Firms in the US often pay a proportion of their employee health care costs. As health is expensive this is a rising cost and firms have encouraged employees to bear a wider range of costs themselves through higher premiums and co-payments. This doesn’t work well because health costs are still shared threough pooling of health risks. Hence firms are starting to force employees to take preventative measures to improve their health and even firing them if they don’t. Firms provide discounts on health club memberships, free weight-loss and smoking-cessation programs, gratis gym memberships, counselling for emotional problems and prizes for health achievements like vacations or points that can be redeemed for gifts. These schemes prevent employees from driving up costs simply because they are unwilling to address their health problems. The schemes save firms money and employees who respond to such incentives get healthier. It is a good deal all round and should be duplicated here in Australia where health insurance firms and the State, rather than private firms, provide most health cover.

It should be possible to lower health care costs in Australia by encouraging consumers to signal to private health funds and to Medibank that they are taking measures to improve their health or to prevent its deterioration. This is not the same thing as offering reduced premiums to those with good health – I am not suggesting free competition for clients and indeed, I favour the current universal health care system. What I am proposing is that individuals be offered incentives to encourage them to take care of their health.

For example many chronic conditions such as Type 2 diabetes can be largely self-regulated by controlling diet and by exercising. One way of encouraging self-regulation is to first help people understand that they have the condition – screening is very inexpensive requiring only a glucose tolerance test. The main costs associated with the condition are associated with not dealing with it, rather than treating it, and thereby incurring catastrophic conditions such as blindness, limb amputations, heart attacks or strokes. As I have previously reported:

‘Average annual health costs/per person of the disease (diabetes) were $5360 in direct costs. Health care costs contributed 79% of costs with medications accounting for only 30%. The complications mentioned, which occur only in a relatively small number of DM sufferers, were the main driver of diabetes costs. Annual costs without complications were $4025, $7025 for those with only microvascular complications, $9055 with macrovascular complications and $9645 for those with both.’

It would be sensible for the Australian private health funds and perhaps for Medibank to subsidise testing for such conditions and, where relevant, to offer health insurance rebates to those who do successfully manage the condition by regulating diet and by taking exercise. It would be a sound investment that would encourage better health care practices and reduce our health bills. Moreover, this would in no way threaten the system of universal cover for health costs that we enjoy.

I have taken the chronic Type 2 diabetes condition as an example but the general approach would apply to other conditions such as obesity. Private health schemes should be able to provide financial rewards to those who take care of themselves and offer subsidies for screening abnd other forms of treatment where such incentives reduce health insurance costs and improve health outcomes.

Placebos

I am interested in the idea of placebos and of specific social beliefs – such as religion – which operate as placebos. But the most interesting modern placebos are associated with medicine. Despite the obvious huge advances of modern medicine, like most people, I am skeptical of its claimed powers. So too is psychiatrist Patrick Lemoine.

He claims that 35-40% of prescriptions are impure placebos – placebos with a tiny amount of some active ingredient that is insufficient to have any clinical effect. Use of impure placebos is what remains of the witchdoctor’s craft. And good witchdoctors need to sell a patient on a placebo cure – a white coat and a mysterious unintelligible script handed to a pharmacist (also wearing a white coat) can help.

You must know the idea - magnesium for nervousness, antibiotics for viruses and so on. It often seems impossible for a general practitioner to send a patient away without a prescription – and dangerous to prescribe such drugs as antidepressants for mild depressions because of their side-effects – a placebo does less harm and may help.

Of course we should be rational enough to understand that there are various paths for healing. Sport or romance might be more helpful than pills and potions. Or going to Holy Communion and doing the cannibal bit.

What makes us fat?

The standard answer, consistent with the first law of thermodynamics, is that we intake too many calories as food or we expend insufficient calories because of our sedentary lifestyle. We either eat too much or are slobs. There’s evidence that these factors alone however cannot explain it all – see here. New Scientist sets out 10 possible reasons for the obesity epidemic - the following is a summary of their discussion.

1. Not enough sleep. Several studies suggest people who sleep less than 7 hours a night have a higher body mass index (BMI) than people who sleep more. Obesity impairs sleep, so perhaps people get fat first and sleep less afterwards but it is also known that sleep loss may cause weight gain. Sleep deprivation alters metabolism because leptin, the hormone that signals satiety, falls while ghrelin, which signals hunger, rises.

We really are sleeping less. In 1960 people in the US slept an average of 8.5 hours per night. A 2002 poll by the National Sleep Foundation suggests that the average has fallen to under 7 hours.

2. Climate control. Humans like to keep our core body temperatures pretty constant regardless of what's going on in the world. We do this by shivering or sweating. Keeping warm and staying cool take energy unless we are in the ‘thermoneutral zone’ of around 27 °C for a naked body - increasingly where we choose to live and work.

Ambient temperatures have changed in the past few decades. Between 1970 and 2000, the average British home warmed from a chilly 13 °C to 18 °C. In the US, the changes have been at the other end of the thermometer as the proportion of homes with air conditioning rose from 23 to 47% from 1978 to 1997. In the southern states - where obesity is highest - the houses with air con has shot up to 70% from 37% in 1978.

Studies of people in respiration chambers show that, in comfortable temperatures, we use less energy. In one study of women exposed to 27 °C versus 22 °C, it amounted to a difference of about a megajoule (239 kilocalories) a day. That's the amount of energy in 27 grams of body fat.
Sweating burns up energy, however, and there's good evidence that high temperatures reduce the amount people eat. Whether these factors significantly alter energy balance is not clear, but it's got to be worth investigating.

3. Less smoking. Smokers are thinner than the rest of us, and quitting packs on the pounds probably because nicotine is an appetite suppressant that ups your metabolic rate.
Between 1978 and 1990, the prevalence of obesity in the US increased by 9% . About a fifth of this increase can be attributed to people giving up smoking. That's not to say that quitting smoking is a threat to public health - far from it. Smoking is so dangerous that you'd have to gain about 45 kilograms to justify continuing.

4. Prenatal effects. Your chances of becoming fat may be set before you are even born. Children of obese mothers - especially those who develop gestational diabetes - are much more likely to become obese themselves. While this may be partly down to genetics, there is also some ‘intrauterine programming’.

Offspring of mice fed a high-fat diet during pregnancy are much more likely to become fat than the offspring of identical mice fed a normal diet. Intriguingly, the effect persists for two or three generations. Grandchildren of mice fed a high-fat diet grow up fat even if their own mother is fed normally - so your fate may have been sealed even before you were conceived.
At the other extreme, energy restriction in the womb can lead to obesity later in life. This is likely if there is a period of rapid catch-up growth in the first 2 years of life. In the prosperous west, that might seem of little relevance, yet in the US the incidence of low birth-weight is now at its highest level for 30 years.

5 Fat equals fecund. Heavier people have more children. One study suggests women of normal weight or below had 3.2 children, while overweight or obese women had 3.5 children.
Does having more children make women gain weight, or does being overweight cause women to have more children? Having lots of kids can increase the chances of getting fat - if for no other reason than poor sleep as above. But people's BMI before they become parents is associated with the number of children they eventually have.

Explanations vary. Extreme thinness impairs fertility. Extreme obesity does too, but the effect is probably stronger at the thin end. Also, obesity can lower socioeconomic status, which in turn is associated with having more children.

This is relevant to the epidemic because obesity is heritable - twin studies indicate it's about 65% genetic so a tendency for this to be associated with having a large family will cause the proportion of overweight people to go up.

6. Aging. Adults aged 40 to 79 are around 3X as likely to be obese as younger people. Non-white females fall at the plumper end of the spectrum: Mexican-American women are 30% more likely than white women to be obese, and black women have twice the risk. In the US, these groups account for an increasing percentage of the population. Between 1970 and 2000 the chunk of the US population aged 35 to 44 grew by 43%. The proportion of Hispanic-Americans also grew, from under 5 to 12.5% of the population, while the proportion of black Americans increased from 11 to 12.3%. These demographic shifts may account in part for the increased prevalence of obesity.

7. More drugs. In the 1970s new antipsychotic medications (neuroleptics) came on the market, and millions of people worldwide now take these drugs. Alongside their undoubted success in treating psychosis, neuroleptics have a drawback: users typically gain 4 kilograms in the first 10 weeks, and another 4 or 5 kg in the year that follows. Furthermore, anticonvulsants to treat epilepsy, antihypertensives for high blood pressure, protease inhibitors to treat HIV and diabetes medications, including insulin, are associated with weight gain. Beta blockers add 1.2 kg to people using them, and taking contraceptive pills for 2 years will add an extra 5 kg. Even antihistamines can fatten you.

8. Pollution. People are exposed to thousands of industrial chemicals: pesticides, dyes, flavorings, perfumes, plastics, resins and solvents, to name but a few. There is evidence low levels of these chemicals can lead to weight gain. Mice given small amounts of the dieldrin, more than doubled their body fat. Hexachlorobenzene, another pesticide, caused rats to gain significantly more than controls, despite eating half as much. Studies of humans exposed to PCBs by eating fish caught in North America's Great Lakes have found similar associations: the more the toxic load, the greater the body weight.

Some of these chemicals interfere with hormones such as oestrogen. Numerous animal and human studies suggest that when oestrogen is not functioning properly, adiposity increases. Our exposure to such chemicals is on the rise: one study found that the concentration of PBDE (polybrominated diphenyl ether, a now-banned fire retardant) in breast milk doubled every 5 years between 1972 and 1998.

9. Mature mums. Mothers are getting older. Mean age at first birth in the US has increased from 21.4 in 1970 to 24.9 in 2000. But having an older mother is an independent risk factor for obesity. The odds of a child being obese increase 14% for every 5 years of their mother's age.

Also first-born offspring have more fat than younger siblings. As family size decreases, firstborns account for a greater share of the population. In 1964, the British woman had 2.95 children; by 2005 that figure had fallen to 1.79. In the US in 1976, 9.6% of women in their 40s had had only one child; in 2004 it was 17.4%. This combination of older mothers and more single children could contribute to obesity.

10. Like marrying like. Just as people pair off according to looks, so they do for size. Lean people marry lean and fat marry fat. Hence there is a correlation between spouses of both BMI and ‘skinfold’ measures of flabbiness that can’t be accounted for by the fact that they live together.

On its own, this cannot account for increased obesity. But combined with the fact that obesity is partly genetic and that heavier people have more children - it amplifies the increase from other causes.

Vaccines for nicotine addiction & lung cancer

An interesting range of vaccines are being developed to deal with nicotine addiction. They prevent nicotine from activating pleasure centers in the brain.

If you are a smoker but don’t get to use this vaccine all is not lost. Scientists are also developing a vaccine for preventing smoking-induced lung cancer. So far experiments have been carried out on mice.

One wonders if the latter innovation will increase the demand for cigarettes by reducing the user costs of smoking. An earlier post that I made on the related issue of advertising cigarette cures suggests it might.

Passive smoking causes harm

Most people know that smoking is the largest preventable cause of death in the world today. Smoking is the only legal product which kills people when it is consumed as intended. A recent report claims smoking kills half the people who regularly smoke.

Defenders of smoking and opponents of smoking bans however claim that, if smokers internalize the risks of smoking, and are fully informed of its effects, that it unnecessary to target smoking with public policy. They argue the externalities caused by the effects of secondary smoke are so small that they can be ignored. The specific claim is that only 1% of the toxins in cigarette smoke are inhaled by passive smokers an amount so small that it is irrelevant.

But there are plenty of US studies that refute this optimistic picture. Indeed the earliest study (in 1981) of Japanese non-smoking women married to smokers found their lung cancer risks were raised 20-30% and their risk of heart disease by 23%. Recently, I found this interesting excerpt from a recent ABS publication. It further buries the myth that passive smoking is a beat-up by the moral police:

• The breathing in of tobacco smoke by non-smokers can lead to harmful health effects in the unborn child, and middle ear infections and bronchitis, pneumonia, asthma and other chest conditions in children. It is also linked to sudden infant death syndrome (SIDS).
• In adults, passive smoking can increase the risk of heart disease, lung cancer and other chronic lung diseases (Queensland Health 2006).
• 37% of children aged 0-14 years live in households with one or more regular smokers, while 10% of children 0-14 years live in households where there is at least one regular smoker who smokes indoors.

The Queensland Health report cited is of interest. It states that passive smoking is a proven health hazard. Over 600 medical reports have been published linking passive smoking to diseases. In 1999-2001, in Queensland, exposure to passive smoking caused an estimated 21 deaths per year in children aged newborn to 4 years.

Libertarians who see smoking only as a ‘freedom of choice’ issue and who suppress the role of smoking’s health costs on both smokers and non-smokers alike are missing these points. There are significant external costs of smoking that need to be considered by those adopting the daft position of supporting smoking on the grounds that people have the right to kill themselves.

If you do choose to kill yourself you probably do have that right - though the death will inflict misery on your friends and family. But you definitely have no right to inflict smoke-induced health costs on co-workers, bar attendants and your children. As high taxes on cigarettes are regressive in their income-distributional impact, have low impacts on those hhighly addicted and because most people initiate smoking as immature youth, smoking bans as well as high cigarette taxes make good sense.

Non-smoking wives of smokers can of course walk-out of the marriage or force their spouse to smoke outside and should be encouraged to do so should they value their health.

But a good question is how to stop parents breathing carcinogens over 'their' children. Do they have the 'right' to do this in their 'own home' or their 'own car'? Smoking could be made illegal in cars with non-smoking passengers with hefty fines on those offending but in the home I can't think of a practical policy for limiting smoking that goes beyond providing information about its health consequences. The hope then is that idiot parents will act with consideration towards other non-smoking residents. Of course in schools children should be warned at a young age against inhaling secondary cigarette smoke, to encourage parents who must smoke to do so in a way that prevents secondary smoke from being inhaled by them. The suggestion of giving children the right to sue parents for health damages that can be attributed to passive smoking is an inviting one but there are manifest practical issues of establishing causation.

The main secondary consequence of being a child in a family that does smoke is that there is an increased probability of acquiring the smoking habit yourself.