September 2024 – Page 2 – artdiamondblog.com

Black Physician Wants to “Play Fair” and Be Judged on Merit

(p. A17) Do I deserve to jump the line? If I say yes, I may play a leading role in ending the scourge of atherosclerosis—also known as hardening of the arteries. If I play fair, I may lose the opportunity to save people around the world from heart attacks and strokes. I’m angry at the National Institutes of Health for putting me in this position. I’m even angrier it has done so in the name of racial equity.

My quandary comes down to whether I should “check the box” on an upcoming NIH grant application attesting to my recent African heritage. Since at least 2015, the NIH has asserted its belief in the intrinsic superiority of racially diverse research teams, all but stating that such diversity influences funding decisions. My family’s origins qualify me under the federal definition of African-American. Yet I feel it’s immoral and narcissistic to use race to gain an advantage over other applicants. All that should matter is the merit of my application and the body of my work, which is generally accepted as foundational in atherosclerosis research.

. . .

If I refuse to identify myself as African-American, our application is more likely to lose on “diversity” grounds. It’s a double wrong. Not only is the system rigged based on nonscientific—and possibly illegal—criteria; it encourages me to join in the rigging.

Truth be told, I made my decision years ago. When my study team files our application, it won’t note my West African origins. If we don’t get the grant, so be it. I refuse to engage in a moral wrong in pursuit of a moral good—even one as important as saving lives from the leading killer on earth. My father, who struggled against racism to achieve so much on the merits of his own work, would never forgive me for “checking the box” to grab a race-based advantage.

And no matter what happens, I can never forgive the National Institutes of Health for reinjecting racism into medical research.

For the full commentary see:

Kevin Jon Williams. “Why I’m Saying No to NIH’s Racial Preferences.” The Wall Street Journal (Thursday, March 28, 2024): A17.

(Note: ellipsis added.)

(Note: the online version of the commentary has the date March 27, 2024, and has the same title as the print version.)

The “Innovative Approach” of the Dog Aging Project May Have Hurt Its Odds for Renewed Funding

Veterinary medicine is less regulated than human medicine, and so trial and error experiments may allow faster innovation that would benefit both dogs and humans.

(p. D3) In late 2019, scientists began searching for 10,000 Americans willing to enroll their pets in an ambitious new study of health and longevity in dogs. The researchers planned to track the dogs over the course of their lives, collecting detailed information about their bodies, lifestyles and home environments. Over time, the scientists hoped to identify the biological and environmental factors that kept some dogs healthy in their golden years — and uncover insights about aging that could help both dogs and humans lead longer, healthier lives.

Today, the Dog Aging Project has enrolled 47,000 canines and counting, and the data are starting to stream in. The scientists say that they are just getting started.

“We think of the Dog Aging Project as a forever project, so recruitment is ongoing,” said Daniel Promislow, a biogerontologist at the University of Washington and a co-director of the project. “There will always be new questions to ask. We want to always have dogs of all ages participating.”

But Dr. Promislow and his colleagues are now facing the prospect that the Dog Aging Project might have its own life cut short. About 90 percent of the study’s funding comes from the National Institute on Aging, a part of the National Institutes of Health, which has provided more than $28 million since 2018. But that money will run out in June, and the institute does not seem likely to approve the researchers’ recent application for a five-year grant renewal, the scientists say.

“We have been told informally that the grant is not going to be funded,” said Matt Kaeberlein, the other director of the Dog Aging Project and a former biogerontology researcher at the University of Washington. (Dr. Kaeberlein is now the chief executive of Optispan, a health technology company.)

. . .

Steven Austad, a biogerontologist at the University of Alabama at Birmingham who is not part of the research team, said he was surprised that the researchers’ grant might not be renewed. “The importance of the things they publish and the depth of detail will increase over time, but I thought they got off to a really good start,” he said. “A large study like this really deserves a chance to mature.”

Dr. Austad’s miniature dachshund, Emmylou, is enrolled in the Dog Aging Project. But at 2 years old, he noted, Emmylou is “not going to teach them a lot about aging for a long time yet.”

The project’s innovative approach might have worked against it, Dr. Austad added. Reviewers accustomed to evaluating short-term research on lab mice and long-term studies of humans may not have known what to make of an enormous epidemiological study of pet dogs.

Whatever the reason, the refusal to commit to more funding is “wrong,” Dr. Kaeberlein said. “It’s just really, really difficult to justify this decision, if you look at the productivity and the impact of the project.”

That impact extends beyond the findings themselves, he added. “This project has engaged almost 50,000 Americans in biomedical scientific research.”

Over the last few years, Shelley Carpenter, of Gulfport, Miss., has provided the researchers with regular updates on and medical records for her Pembroke Welsh corgi, Murfee. (She also collected a cheek swab for genomic sequencing.) Ms. Carpenter, whose previous corgi died from a neurodegenerative disease similar to A.L.S., hoped that the project might produce new medical knowledge that could help both dogs and people.

For the full story see:

Emily Anthes. “Scientists Scramble to Keep Dog Aging Project Alive.” The New York Times (Tuesday, January 16, 2024): D3.

(Note: ellipses added.)

(Note: the online version of the story has the date Jan. 11, 2024, and has the same title as the print version.)

Sweden’s Restraint in Mandating Covid Lockdowns Resulted in Much Lower Excess Mortality Than the U.S. Suffered

(p. A17) The best measure of health performance during the pandemic is all-cause excess mortality, which captures the overall number of deaths relative to the expected level, encompassing Covid and lockdown-related deaths. On this measure Sweden—which kept most schools open and avoided strict lockdown orders—outperformed nearly every country in the world.

A recent study published in the Proceedings of the National Academy of Sciences found that the U.S. “would have had 1.60 million fewer deaths if it had the performance of Sweden, 1.07 million fewer deaths if it had the performance of Finland, and 0.91 million fewer deaths if it had the performance of France.” In America, states that imposed prolonged lockdowns had no better health outcomes when measured by all-cause excess mortality than those that stayed open. While no quantifiable relationship between lockdown severity and a reduction in Covid health harms has been found, states with severe lockdowns suffered significantly worse economic outcomes.

. . .

The economic costs of lockdowns were also staggering. According to the Bureau of Labor Statistics, as many as 49 million Americans were out of work in May 2020. This shock had health consequences. A National Bureau of Economic Research study found that the lockdown unemployment shock is projected to result in 840,000 to 1.22 million excess deaths over the next 15 to 20 years, disproportionately killing women and minorities.

For the full commentary see:

Scott W. Atlas and Steve H. Hanke. “Covid Lessons Learned, Four Years Later.” The Wall Street Journal (Tuesday, March 19, 2024): A17.

(Note: ellipsis added.)

(Note: the online version of the commentary has the date March 18, 2024, and has the same title as the print version.)

The “recent study” mentioned above is:

Ioannidis, John P. A., Francesco Zonta, and Michael Levitt. “Variability in Excess Deaths across Countries with Different Vulnerability During 2020–2023.” Proceedings of the National Academy of Sciences 120, no. 49 (Dec. 5, 2023): e2309557120.

The published version of the National Bureau of Economic Research study mentioned above is:

Bianchi, Francesco, Giada Bianchi, and Dongho Song. “The Long-Term Impact of the Covid-19 Unemployment Shock on Life Expectancy and Mortality Rates.” Journal of Economic Dynamics and Control 146 (Jan. 2023): 104581.

Fingarette Provoked Thought on Alcohol and Death

When I was a graduate student in the late 1970s I attended a small seminar in Santa Barbara presented by Henry Fingarette on his thoughts on alcoholism. I do not know if I agree with those thoughts, or his thoughts on death, mentioned in the obituary quoted below. But I enjoyed his non-politically-correct seminar and still find his thoughts on both topics to be worth pondering. [I participated in the seminar as part of a month or two residency in Santa Barbara organized by the philosopher Tibor Machan and funded by the Reason Foundation. Other participants included David Levy, Doug Rasmussen, and Doug Den Uyl. Gary Becker told me that it was a mistake for me to attend; he said those weeks would be better spent staying in Chicago and improving my math skills. Becker’s advice was sincere and well-intentioned, but even now I am conflicted on whether I should have followed his advice.]

(p. 26) Herbert Fingarette, a contrarian philosopher who, while plumbing the perplexities of personal responsibility, defined heavy drinking as willful behavior rather than as a potential disease, died on Nov. 2 at his home in Berkeley, Calif. He was 97.

. . .

In “Heavy Drinking: The Myth of Alcoholism as a Disease” (1988), Professor Fingarette all but accused the treatment industry of conspiring to profit from the conventional theory that alcoholism is a disease. He maintained that heavy use of alcohol is a “way of life,” that many heavy drinkers can choose to reduce their drinking to moderate levels, and that most definitions of the word “alcoholic” are phony.

“Some people can drink very heavily and get into no trouble whatsoever,” he told The New York Times in 1989.

. . .

At his death, he was completing an essay on how the dead continue to shape the lives of the living, a topic he had written about in “Death: Philosophical Soundings” (1996). . . .

“Never in my life will I experience death,” he wrote. “I will never know an end to my life, this life of mine right here on earth.” He added: “People hope never to know the end of consciousness. But why merely hope? It’s a certainty. They never will!”

For the full obituary, see:

Sam Roberts. “Herbert Fingarette, 97, Contrarian on Alcoholism.” The New York Times, First Section (Sunday, November 18, 2018 [sic]): 26.

(Note: ellipses added.)

(Note: the online version of the obituary has the date Nov. 15, 2018 [sic], and has the title “Herbert Fingarette, Contrarian Philosopher on Alcoholism, Dies at 97.”)

Fingarette’s book on alcoholism, mentioned above, is:

Fingarette, Herbert. Heavy Drinking: The Myth of Alcoholism as a Disease. Berkeley, CA: University of California Press, 1989.

Fingarette’s book on death, mentioned above, is:

Fingarette, Herbert. Death: Philosophical Soundings. Chicago: Open Court, 1999.

When Medical Insurers Own Doctor Practices, Medicare Advantage Creates “Conflicts of Interest and Opportunities to Game the System”

Through its Optum division health insurer UnitedHealth has 90,000 affiliated doctors. Under the federal government’s Medicare Advantage program, UnitedHealth received higher payments from the federal government for its customers who have more dire diagnoses. This creates an incentive for UnitedHealth to pressure its affiliated doctors to code their patients with dire diagnoses.

(p. A3) UnitedHealth has built a sprawling health services company that shows no sign of slowing down. With annual revenue of $372 billion in 2023, it ranks among the five largest companies in the U.S. on that measure. Its stock, meanwhile, has returned more than 600% in the past decade.

UnitedHealth’s success has been fueled by its expansion beyond insurance as its care delivery and solutions unit Optum steadily acquires a vast array of health services companies, from a pharmacy-benefits manager to specialty pharmacies to doctor groups and surgical centers. Over the past two decades, Optum has spent about $82 billion on nearly 100 acquisitions, according to a tally by Raymond James analysts.

Much like the rest of the U.S. economy, America’s healthcare system has consolidated in recent decades, creating giant hospital systems, chain-owned medical practices and vertically integrated insurance conglomerates. Immense scale can drive efficiencies and reduce the cost of care. But in the highly complex and opaque world of U.S. healthcare, where giant companies always seem to be a step ahead of regulators, it also raises potential conflicts of interest and opportunities to game the system. The benefits of size often flow to those companies, not patients or the employers and taxpayers footing much of the bill.

. . .

A key growth driver for UnitedHealth is Optum’s steady acquisitions of doctor practices. Optum now has ties with 90,000 doctors—about 10% of the country’s physician workforce.

. . .

Much of the vertical integration in the industry has focused on the Medicare Advantage business, the sector’s golden goose. These are the private plans in which the government pays insurers a fixed rate to manage the care of seniors. The sicker the patient, the more the government pays.

In recent years, some insurers’ acquisitions seem targeted at controlling the Medicare coding apparatus. If you control the doctors who code patients, you control how much you get paid, explains Loren Adler, a fellow at the Center on Health Policy at the Brookings Institution, a nonprofit research organization. UnitedHealth and other insurers argue that they are simply coding patients according to their risk profile and that they comply with Centers for Medicare and Medicaid Services rules.

But they have been accused of abusing the system by coding patients too aggressively. An investigation by the Office of Inspector General of the Department of Health and Human Services found that Medicare insurers received $9 billion in questionable payments in a single year.

For the full commentary see:

David Wainer. “Insurers as Healthcare Providers Risk Conflict of Interest.” The Wall Street Journal (Friday, June 14, 2024): B10.

(Note: ellipses added.)

(Note: the online version of the commentary has the date June 13, 2024, and has the title “What Happens When Your Insurer Is Also Your Doctor and Your Pharmacist.”)

“Hamas Knew” It Was “Starting a Devastating War” With “Heavy Civilian Casualties” Among Gazans

(p. 1) On Oct. 7 [2023], as the Hamas-led attack on Israel was unfolding, many Palestinians took to the streets of Gaza to celebrate what they likened to a prison break and saw as the sudden humiliation of an occupier.

But it was just a temporary boost for Hamas, whose support among Gazans has been low for some time. And as the Israeli onslaught has brought widespread devastation and tens of thousands of deaths, the group and its leaders have remained broadly unpopular in the enclave. More Gazans have even been willing to speak out against Hamas, risking retribution.

In interviews with nearly a dozen Gaza residents in recent months, a number of them said they held Hamas responsible for starting the war and helping to bring death and destruction upon them, even as they blame Israel first and foremost.

. . .

Some of the Gazans who spoke to The New York Times said that Hamas knew it would be starting a devastating war with Israel that would cause heavy civilian casualties, but that it did not provide any food, water or shelter to help people survive it. Hamas leaders (p. 9) have said they wanted to ignite a permanent state of war with Israel on all fronts as a way to revive the Palestinian cause and knew that the Israeli response would be big.

Throughout the war, hints of dissent have broken through, sometimes even as Gazans were mourning loved ones killed by Israeli attacks. Others waited until they left the enclave to condemn Hamas — and even then were at times reluctant in case the group survives the war and continues to govern Gaza.

In March [2024], the well-known Gaza photojournalist Motaz Azaiza caused a brief social media firestorm when he obliquely criticized Hamas after he left the territory. He was one of a handful of young local journalists who rose to international prominence early in the war for documenting the death and destruction on social media.

“If the death and hunger of their people do not make any difference to them,” he wrote in an apparent reference to Hamas, “they do not need to make any difference to us. Cursed be everyone who trafficked in our blood, burned our hearts and homes, and ruined our lives.”

. . .

Gauging public opinion in Gaza was difficult even before the war began. For one, Hamas, which long controlled territory, perpetuated a culture of fear with its oppressive system of governance and exacted retribution against those who criticized it.

. . .

One Gaza resident who in recent months fled to Egypt with her family said that she hears regularly from friends and family that they do not want the war to end before Hamas is defeated in Gaza. She said Hamas had prioritized its own aims over the well-being of the Palestinians they purport to defend and represent.

“They could have surrendered a long time ago and saved us from all this suffering,” said the woman, who asked not to be named for fear of possible retribution if her criticism were made public.

For the full story see:

Raja Abdulrahim and Iyad Abuheweila. “Gazans Voice Their Distress Under Hamas.” The New York Times, First Section (Sunday, June 16, 2024): 1 & 9.

(Note: ellipses, and bracketed years, added.)

(Note: the online version of the story has the date June 15, 2024, and has the title “As War Drags On, Gazans More Willing to Speak Out Against Hamas.”)

Older Americans, Most at Risk from Covid-19, Were Often Excluded from Mandated Clinical Trials of Therapies and Vaccines

Mandating randomized double-blind clinical trials for Covid-19 candidate therapies or vaccines slowed down the ability of citizens to choose those therapies or vaccines in 2020. Arguably those most hurt by the delay were older Americans age 65 and older, who had the greatest risk of death from Covid-19. The mandated trials slowed availability, but did they at least provide older Americans more and better information about the safety and efficacy of the therapies and vaccines? Not as much as you might suppose. The clinical trials often excluded older Americans because their participation would make the trials more expensive, slower, and less likely to prove safety and efficacy at levels that would result in FDA approval.

(p. D3) “Ideally, the patients enrolled in a randomized clinical trial reflect the demographics of the disease,” said Dr. Mark Sloan, a hematologist leading a Covid-19 drug study at Boston Medical Center, in an email. “Unfortunately, this is seldom the case.”

Now, Dr. Sharon K. Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, is sounding an alarm. She points out that in the race to find drugs and vaccines to fight the pandemic — in which 80 percent of American deaths have occurred in people over age 65 — a substantial proportion of studies may be excluding older subjects, purposely or inadvertently.

“A year from now, when these trials are published, I don’t want to see that there’s no one in them over 75,” she said. “If they create a drug that works really well in healthy 50- and 60-year-olds, they’ve missed the boat.”

She and her team have reviewed 241 interventional Covid-19 studies undertaken in the United States and listed on clinicaltrials.gov, a site maintained by a division of the National Institutes of Health.

They found that 37 of these trials — testing drugs, vaccines and devices — set specific age limits and would not enroll participants older than 75, 80 or 85. A few even excluded those over 65.

. . .

Overall, when Dr. Inouye compiled preliminary results, which have not yet been published, she found that about one-quarter of interventional trials in the United States could exclude or underrepresent older adults.

“To have them be this gravely impacted and not include them is immoral,” said Dr. Louise Aronson, the author of the best-selling book “Elderhood” and a geriatrician at the University of California, San Francisco. “It seems crazy.”

. . .

In clinical trials, “you want to control as many factors as possible,” Dr. Aronson said. Most older adults have other illnesses and take multiple medications, so-called confounding variables that make it difficult to distinguish the effects of the drug or vaccine being studied.

Older people also suffer more side effects. “Nearly all drugs are less toxic when given to younger, healthier people,” Dr. Sloan said in an email. Focusing on them produces fewer adverse effects that must be reported, “and thereby improves chances for F.D.A. approval.”

Physical disabilities, which make it harder for seniors to reach study sites, or hearing and vision impairments requiring large-print forms or audio amplification, can further decrease participation. Investigators may need to take the extra step of obtaining family consent if a patient is incapacitated.