January 2025 – artdiamondblog.com

The Lovable, Frustrating, Vulnerable “Big Easy”

Our daughter is a loyal Notre Dame graduate, so we went to New Orleans for the Sugar Bowl game, scheduled for January 1, but ultimately played on January 2. The day before the scheduled game, we were in Jackson Square on New Year’s Eve for the countdown to 2025. For us a little partying goes a long way, so we headed back to the Marriott about 12:30. About two and a half hours later, a couple of blocks from where we had been, the terrorist plowed his truck through the crowd, killing 14, and seriously injuring many more.

They call New Orleans “the Big Easy.” I appreciate its joy, its spontaneity, its libertarian tolerance. But I can only visit New Orleans, I cannot live there.

When I arrive in a hotel I want a glass of ice water. In our two most recent visits to Marriott hotels in New Orleans, the ice machines on our floor did not at first work. It never worked during our stay at the first hotel and worked only occasionally at the second hotel. When I complained at the first hotel, I got a joyful grin and a shrug–the ice machine had been that way for several days and who knows when or if it would be fixed? It’s “easy” to celebrate; it’s hard to fix ice machines and keep them running.

There were barriers on Bourbon Street that could have kept the terrorist from killing 14. But it has come out that they were not working and it was not “easy” to fix them. (There were also supposed to be levies that could have reduced the damage from Hurricane Katrina, but it was not “easy” to fix them either.)

I like visiting New Orleans. I like its joyful spontaneity. But what makes New Orleans “the Big Easy” also makes it “the Big Frustrating” and “the Big Vulnerable.” I like visiting New Orleans but I want to live in a city where type-A personalities do what is hard: build, fix, and protect.

The Second Arthur Mansfield Diamond Would Be 100 Today

Happy Birthday Dad! He was the second Arthur Mansfield Diamond and would be 100 today.

I think if we adopt the right policies, many of us could live to 100. Too late for Dad, and almost certainly for me.

The first Arthur Mansfield Diamond died in 1933, I think. I was told he played the piano by ear and I saw an article saying that when he was a young man he briefly was a book-keeper for the family vaudeville activities. He looked dapper in a straw hat and knew Knute Rockne of Notre Dame. My Dad was eight when cancer took the first Arthur Mansfield Diamond. My Grandma, with no college degree, raised four children during the Great Depression. Cabbage was nutritious and cheap, so Grandma served a lot of sauerkraut. As an adult Dad hated sauerkraut.

Dad was always reading. He is the only person I ever met who read all three volumes of Solzhenitsyn’s Gulag Archipelago. And he read a conservative reader’s digest weekly (or monthly?) newspaper called Human Events. He was a Republican lawyer in an overwhelmingly Democratic county.

When my brothers and I were young he read aloud to us most of the Oz books, and other books including Atlas Shrugged. Thank you Dad, especially for that.

I wish I had finished my book before he died–he would have read it, argued with me about parts of it, but I think mostly liked it.

Dad was active in Toastmasters, a self-help organization for those who want to improve their public speaking. He rose to become the International President. Their headquarters is near Disneyland. When Dad first joined the Toastmasters board, he spent some time in the park. When he returned from that first trip, I remember his excitement at the then-new attraction, the Tiki Room–seeing what was possible in audio animatronics. Mom and Dad took us to Disneyland and on road trips to most of the U.S.

I remember Dad telling me in his last year that one of his regrets is that he won’t know how things turn out.

Dad was not perfect; neither am I. But I miss him and wish I could still talk with him, and thank him for his wit, his curiosity, and his courage in holding unpopular views when he thought they were right.

To End Drug Shortages Make Healthcare a Free Market

Drug shortages are sometimes blamed on the free market. A bum rap. In a free market when supply declines or demand increases, prices rise, and the increase in price incentivizes a greater quantity supplied, eventually ending a short-run period where quantity demanded at the going price exceeds quantity supplied at the going price (in other words, a shortage). But healthcare in America is far from a free market. Every aspect is highly regulated. Prices are negotiated, often by middlemen called (Pharmacy Benefit Managers, aka PBMs), entry is not free, and the demanders (patients) often do not know (or care) about the prices, since they are paid by a third party (insurers, employers, or the government). Perverse incentives abound.

(p. A26) There’s been a bombardment of bad news for drug supplies. The American Society of Health-System Pharmacists found this summer that nearly all of the members it surveyed were experiencing drug shortages, which generally affect half a million Americans. Cancer patients have scrambled as supplies of chemotherapy drugs dwindle. Other shortages include antibiotics for treatable diseases, such as the only drug recommended for use during pregnancy to prevent congenital syphilis (a disease that is 11 times more common today than a decade ago), and A.D.H.D. medications, without which people struggle to function in their day-to-day lives. The toll on Americans is heavy.

Over half of the shortages documented this summer by health consulting firm IQVIA had persisted for more than two years. But even though drug shortages affect millions of Americans, policymakers and industry leaders have provided little to no long-term relief for people in need.

Shortages have occurred regularly since at least the early 2000s, when national tracking began. Hundreds of drugs, in every major therapeutic category, have been unavailable for some period. The average drug shortage lasts about 1.5 years. Even when substitute medications are available, they may be suboptimal (for example, deaths by septic shock rose by 10 percent during a 2011 shortage of the first-line medication, norepinephrine) or have spillover effects (such as possibly increasing the risk of antimicrobial resistance). In addition to harming patients, shortages have cost health systems billions of dollars in increased labor and substitute medications.

. . .

Large hospital chains can readily monitor shortage risks and preemptively place large orders. This panic buying can wipe out inventory, and leave hospitals with fewer resources strapped since they may get notice of a drug shortage only when it’s too late. There is little penalty for over-ordering because unused drugs can often be returned.

. . .

Addressing the underlying fragility of our essential drug supply will take structural change and investments. While all industries must grapple with how to build resilient supply chains, the pharmaceutical industry is unique. The people who are most affected by supply chain vulnerabilities — patients — are also those with least say in the choice to buy from reliable manufacturers. When people buy cars, they may pay more based on company reputation, ratings by outside testers and reviews from other customers. In contrast, patients bear the harm of drug shortages, yet they cannot choose the manufacturers of their essential drugs nor evaluate their reliability.

For the full commentary see:

Emily Tucker. “We’re Stuck in a Constant Cycle of Drug Shortages.” The New York Times (Thursday, December 7, 2023 [sic]): A26.

(Note: ellipses added.)

(Note: the online version of the commentary has the date Dec. 6, 2023 [sic], and has the title “America Is Having Yet Another Drug Shortage. Here’s Why It Keeps Happening.”)

F.D.A. Should Allow Physicians and Parents the Freedom to Give Preterm Infants Probiotics

Substantial observational evidence shows that the status of a person’s microbiome can have a large effect on the person’s health. We still have a lot to learn about which bacteria are helpful and the details of how they help. But patients must act under uncertainty, or in the case of the preterm infants dicussed in the passages quoted below, physicians and parents must act under uncertainty. Given the current evidence and the uncertainty, the F.D.A. is arrogantly wrong to ban probiotics.

(p. A5) For years, hospitals around the world have tried to protect prematurely born babies from life-threatening gut disease by giving them probiotics. Then . . . [in Oct. 2023], American hospitals stopped.

The Food and Drug Administration had linked an infant’s recent death to one of the products. It warned doctors about using them in preterm infants without getting agency permission first, and pushed Abbott Laboratories and another major manufacturer, Infinant Health, to stop selling them.

. . .

Neonatologists in the U.S. and other developed countries have learned to help smaller and smaller babies stay alive. As they treat tinier babies, the medical challenges mount, including a swift-onset disease known as necrotizing enterocolitis, or NEC.

. . .

To help prevent NEC, nearly all neonatal units in Australia and New Zealand give probiotics, as do a majority in several European countries. About 40% in the U.S. did before the FDA’s actions, according to recent surveys and neonatologists’ estimates.

Nearly all of the products consist of live bacteria intended to help create a healthy community of microbes in the gut. Scientists don’t know exactly how they work, but suspect they prevent harmful bacteria from overwhelming the bowels.

. . .

Neonatal units across the U.S. halted use of the probiotics because popular versions were no longer available and the FDA warned doctors against using probiotics for preterm babies outside of clinical trials.

“I was stunned,” said Jennifer Canvasser, who started a NEC patient advocacy group after her infant son died 10 years ago, weakened by the disease. “To think about families having one potential less way to prevent this devastating disease is just concerning.”

Probiotics supporters say the FDA disregarded the evidence favoring probiotics for preterm babies, saying that they likely save hundreds of infants for every one probiotic-caused infection, which can be treated with antibiotics.

An analysis of more than 100 studies involving more than 25,000 premature infants, published . . . [in Oct. 2023] in the journal JAMA Pediatrics, found that probiotics containing multiple strains of bacteria were associated with reduced deaths and NEC.

For the full story see:

Liz Essley Whyte. “Discord Arises Over Treating Preemie Babies.” The Wall Street Journal (Saturday, Nov. 17, 2023 [sic]): A5.

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

(Note: the online version of the story was updated Nov. 16, 2023 [sic], and has the title “Doctors, FDA Fight Over Giving Probiotics to Premature Babies.” The passages quoted above omit the subheadings that appear in the print, but not the online, version of the story.)

The analysis published in JAMA Pediatrics and mentioned above is:

Wang, Yuting, Ivan D. Florez, Rebecca L. Morgan, Farid Foroutan, Yaping Chang, Holly N. Crandon, Dena Zeraatkar, Malgorzata M. Bala, Randi Q. Mao, Brendan Tao, Shaneela Shahid, Xiaoqin Wang, Joseph Beyene, Martin Offringa, Philip M. Sherman, Enas El Gouhary, Gordon H. Guyatt, and Behnam Sadeghirad. “Probiotics, Prebiotics, Lactoferrin, and Combination Products for Prevention of Mortality and Morbidity in Preterm Infants: A Systematic Review and Network Meta-Analysis.” JAMA Pediatrics 177, no. 11 (2023): 1158-67.

For a useful discussion of how current medical protocols, especially the over-prescription of antibiotics, harm the microbiome, see chapter 3 of:

Makary, Marty. Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health. New York: Bloomsbury Publishing, 2024.