Category: Health

Philosopher Argues That Human Flourishing Has Grown With “Access to Fossil Fuels”

(p. C13) The brilliance of Alex Epstein’s recent “Fossil Future” is that he writes not as a scientific expert but as a philosopher.

. . .

What is the best course of action to improve human flourishing? His answer is clear and unapologetic: more plentiful, reliable, abundant access to fossil fuels. The climate-disaster-related death rate, he points out, is 98% lower today than it was just a century ago—largely owing to innovations powered by fossil fuels. The right way to handle climate change isn’t to reverse it but to master its effects—a thesis that is as provocative as it is intuitive.

For the full review, see:

Vivek Ramaswamy. “12 Months of Reading; Vivek Ramaswamy.” The Wall Street Journal (Saturday, Dec. 10, 2021): C13.

(Note: ellipsis added.)

(Note: the online version of the review has the date December 8, 2022, and has the title “Who Read What in 2022: Thinkers and Tastemakers.”)

The book praised by Vivek Ramaswamy is:

Epstein, Alex. Fossil Future: Why Global Human Flourishing Requires More Oil, Coal, and Natural Gas–Not Less. New York: Portfolio, 2022..

Heat Deaths Rise Mostly Due to Rise in Fragile Aging Population

(p. A17) One recent and much-cited Lancet report appears deliberately deceptive.

The study offers a frightening statistic: Rapidly rising temperatures have increased annual global heat deaths among older people by 68% in less than two decades. That stark figure has been cited all over, from the BBC and Time to the Washington Post and the Times of India, the world’s largest-selling English-language daily.

. . .

Annual heat deaths have increased significantly among people 65 and older world-wide. The average deaths per year increased 68% from the early 2000s to the late 2010s. But that is almost entirely because there are so many more older people today than there were 20 years ago, in no small part thanks to medical innovations that keep us alive longer. Measured across the same time span the Lancet maps heat deaths, the number of people 65 and older has risen by 60%, or almost as much as heat deaths. When the increase in heat mortality is adjusted for this population growth, the actual rise that can be attributed to rising temperatures is only 5%.

It is hard not to see the Lancet study’s failure to adjust this figure as a deliberate act of deception.

For the full commentary, see:

Bjorn Lomborg. “The Lancet’s ‘Heat Death’ Deception.” The Wall Street Journal (Saturday, November 5, 2022): A17.

(Note: ellipsis added.)

(Note: the online version of the commentary has the date November 4, 2022, and has the title “Climate Change and the Lancet’s ‘Heat Death’ Deception.”)

Share of Insulin Revenues Going to Middlemen Pharmacy Benefit Managers (PBMs) Increased by 155%

(p. B12) Pharmacy-benefit managers, or PBMs, have captured a growing slice of America’s world-leading drug spending during the past decade. The spotlight could soon shift to them.

. . .

While the three largest manufacturers of insulin—Eli Lilly, Novo Nordisk and Sanofi—charge more for their products in the U.S. than they do elsewhere, their take of overall spending has been decreasing in recent years as the relative power of middlemen has grown. PBMs have steadily gained negotiating clout by consolidating and merging with large insurance companies. The three largest PBMs are owned by CVS Health Corp. (which owns insurer Aetna), UnitedHealth Group Inc. and Cigna Corp.

. . .

. . . increases in recent years have mostly been passed on to PBMs in the form of heavy discounts that are hidden from public view.

A recent study by University of Southern California scholars showed that, between 2014 and 2018, the share of a hypothetical $100 insulin expenditure accruing to manufacturers decreased by 33%. During that same period, total U.S. spending on insulin hasn’t budged, but the share of insulin expenditures retained by PBMs has increased by 155%.

. . .

“What’s happening in this market is that the middlemen are making more and more money,” said University of Southern California professor Neeraj Sood, one of the authors of the study who has previously done consulting work for drug companies.

Yet the drug-pricing provisions in the recently passed Inflation Reduction Act singularly focused on what manufacturers charge while ignoring other players that take a slice of profits farther down the chain.

For the full commentary, see:

David Wainer. “HEARD ON THE STREET; Sanders, Musk Miss the Mark on Insulin.” The Wall Street Journal (Tuesday, November 22, 2022): B12.

(Note: ellipses added.)

(Note: the online version of the commentary has the date November 21, 2022, and has the title “HEARD ON THE STREET; Elon Musk, Bernie Sanders and Others Miss the Mark Over Pricey Insulin.”)

The academic study co-authored by Sood, and mentioned above, is:

Van Nuys, Karen, Rocio Ribero, Martha Ryan, and Neeraj Sood. “Estimation of the Share of Net Expenditures on Insulin Captured by Us Manufacturers, Wholesalers, Pharmacy Benefit Managers, Pharmacies, and Health Plans from 2014 to 2018.” JAMA Health Forum 2, no. 11 (2021), doi:10.1001/jamahealthforum.2021.3409.

Nonprofit Hospitals Get $60 Billion in Annual Tax Breaks in Order to Aid the Poor, but Often Use High-Pressure Opaque Tactics to Collect Full Payment

(p. A1) Nonprofit hospitals must have financial-assistance policies for needy patients, under federal requirements tied to an estimated $60 billion in annual tax breaks.

They often make that aid hard to get. Hospitals put up obstacles, delay checking eligibility and sometimes press for payments that aren’t refunded even if a patient eventually gets qualified for assistance.

That is according to a Wall Street Journal analysis of thousands of nonprofit hospital policies in filings to the Internal Revenue Service and posted by hospitals, as well as thousands of pages of internal documents from government hospitals obtained through public-record requests and the experiences of dozens of advocates and patients who have (p. A9) applied for aid.

. . .

An earlier Journal analysis of Medicare filings highlighted how little of nonprofit hospitals’ billions in revenue goes toward financial help for low-income patients. The new analysis uncovered the barriers many hospitals place in the way of patients who should qualify for assistance—even under the hospitals’ own criteria.

Under tax laws, nonprofit hospitals are set up to function as charities benefiting their communities. Government facilities, whose policies the Journal also looked at, are also intended to serve the public, though they aren’t subject to all the same IRS requirements as private nonprofits. The Journal found that many of these hospitals act like for-profit businesses in their efforts to get paid, even by those who can’t afford it.

. . .

Separate from the analysis of nonprofit hospitals’ IRS documents, the Journal also obtained internal documents on patient-billing procedures from large state and local government hospitals, including academic medical centers, through public-records requests. These hospitals share a similar mission with private nonprofits to serve communities.

The thousands of pages of procedures, scripts and other training material for hospital staff give an inside look at how some hospitals routinely push patients toward payment, including through installment plans that may come with interest. The guidelines often play down or don’t raise the option of financial assistance. Adding to the pressure, these tactics are often deployed before the patient gets care.

In a document titled “Collections Scripting for Non-Emergent Visits,” used by Georgia-based Augusta University Health System, staffers are supposed to start by requesting the entire amount due from the patient, saying, “How would you like to take care of that today?”

For the full story, see:

Anna Wilde Mathews, Andrea Fuller and Melanie Evans. “Some Hospitals Skimp on Aid.” The Wall Street Journal (Friday, Nov. 18, 2022): A1 & A9.

(Note: ellipses added.)

(Note: the online version of the story has the date November 17, 2022, and has the title “Hospitals Often Don’t Help Needy Patients, Even Those Who Qualify.”)

Cardiologist Braunwald Transformed Treatment of Heart Attacks

The book praised by Collison is about one of the founders of modern cardiology. David McCullough praised the book as “splendid.” Others did too.

(p. C6) We recently started Arc, a new biomedical research organization, and I’ve been digging into the early days of other institutions. Thomas Lee’s “Eugene Braunwald and the Rise of Modern Medi-(p. C7)cine” stood out.

For the full review, see:

Patrick Collison. “12 Months of Reading; Patrick Collison.” The Wall Street Journal (Saturday, Dec. 10, 2021): C6-C7.

(Note: the online version of the review has the date December 8, 2022, and has the title “Who Read What in 2022: Political and Business Leaders.”)

The book praised by Patrick Collison is:

Lee, Thomas H. Eugene Braunwald and the Rise of Modern Medicine. Cambridge, MA: Harvard University Press, 2013.

Regulations Block CRISPR Cures

(p. 6) Scientists like me can now visualize an ideal scenario for the future of CRISPR medicines: When a 3-month-old starts to develop antibiotic-resistant infections, her primary care doctor orders a DNA test, and 48 hours later, ‌‌the faulty gene that is preventing the development of a normal immune system is identified. “Not a problem. We will refer your child for corrective CRISPR therapy,” says the physician to the devastated parents.

. . .

(p. 7) ‌To make CRISPR cures a reality, the biomedical community needs to start with regulation. For treatments developed for genetic diseases that affect tens of thousands of people (or, say, if a company tries to take on heart disease, which affects millions), the Food and Drug Administration has a well-established, yearslong review process. But the F.D.A. needs to consider a new regulatory process that could create a more streamlined path for bringing much-needed CRISPR medicine tailored to patients with a one-of-a-kind genetic typo. There is precedent for this: Starting in the late 1990s, the F.D.A. facilitated regulatory pathways for innovation of a then-new class of genomic medicines for cancer — CAR-T therapy — which is now widely used clinically. The same can be done for CRISPR.

For the full commentary, see:

Fyodor Urnov. “We Can Edit A Person’s DNA. So Why Don’t We?” The New York Times, SundayOpinion Section (Sunday, December 11, 2022): 6-7.

(Note: ellipsis added.)

(Note: the online version of the commentary has the date Dec. 9, 2022, and has the title “We Can Cure Disease by Editing a Person’s DNA. Why Aren’t We?”)

So-Called “Inflation Reduction Act” Reduces Incentive for Pharma Firms to Seek Approval for New Uses of Drugs


(p. A17) It may take years before we can fully appreciate the impact of the Inflation Reduction Act on the pharmaceutical industry, but we’re already getting signs of the damage. While Democrats boast that they’ve given Medicare the power to “negotiate” drug prices, the effect has been to saddle manufacturers with a complex and ill-conceived price-setting scheme. In response, many have canceled drug-development programs, resulting in an unfortunate but predictable loss for patients nationwide.

One poorly crafted provision is driving companies away from research into treating rare diseases. In its Oct. 27 earnings statement, Alnylam announced it is suspending development of a treatment for Stargardt disease, a rare eye disorder, because of the company’s need “to evaluate impact of the Inflation Reduction Act.” Alnylam’s decision turns on a provision in the Democrats’ bill that exempts from price-setting negotiations drugs that treat only one rare disease. The company’s drug is currently marketed as treating only amyloidosis, and thus is exempt from Medicare’s price setting. If Alnylam proceeded with research into treating Stargardt, it would lose its exemption.

That disincentive might be most pronounced in cancer treatments. On Tuesday [Nov. 1, 2022], Eli Lilly announced it is canceling work on a drug that had been undergoing studies for certain blood cancers. “In light of the Inflation Reduction Act,” the company wrote to Endpoints News, “this program no longer met our threshold for continued investment.”

. . .

Nearly 60% of oncology medications approved a decade ago received additional approvals in later years. The new law eliminates the incentive to conduct additional research, because its price-setting mechanisms kick in after nine years for small-molecule drugs and 13 years for biologics, regardless of how much research companies conduct after the drug’s initial approval.

For the full commentary, see:

Joe Grogan. “The Inflation Reduction Act Is Already Killing Potential Cures.” The Wall Street Journal (Saturday, Nov. 4, 2022): A17.

(Note: ellipsis, and bracketed date, added.)

(Note: the online version of the commentary has the date November 3, 2022, and has the same title as the print version.)

Dogs Can Accurately Know by Smell When a Human Is Stressed


(p. C4) Dogs are champion sniffers, equipped with 100 to 300 million olfactory receptors in their noses—compared with a mere 6 million in our own—and an olfactory cortex 40 times as large as ours. They can be trained to detect disease in human beings, including cancer cells, a latent epileptic seizure, or a Covid infection, just by sniffing—no blood samples, biopsies, MRIs, antigen or PCR tests required.

. . .

In a study published in September in the journal PLoS One, Ms. Wilson and colleagues tested whether dogs can read and respond to our emotional states, without the benefit of facial expression, tone of voice, or social context. The researchers trained four dogs to detect and react to the smell of human stress, depending on their sense of smell alone to distinguish between a person’s baseline scent and the unique cocktail of volatile organic compounds (VOCs) in their sweat and breath when they’re feeling stressed out.

. . .

The results offered overwhelming confirmation that dogs can smell psychological states as well as physical ones. On average, the four dogs picked out the stress sample 94% of the time, with individual dogs ranging between 90% and 97% accuracy. “There’s a smell to stress,” Ms. Wilson concludes. “If we can add it to the dog’s repertoire, we can use it to identify anxiety and panic attacks before they occur.”

For the full commentary, see:

Susan Pinker. “MIND AND MATTER; Dogs Can Sniff Out When a Human Is Stressed.” The Wall Street Journal (Saturday, Oct. 22, 2022): C4.

(Note: ellipses added.)

(Note: the online version of the commentary has the date October 20, 2022, and has the title “MIND AND MATTER; Dogs Can Sniff Out Human Stress.”)

Pharmacy Benefit Managers (PBMs) Create Incentives to Reduce Hiring and Pay of Pharmacists

(p. A1) If any group of workers might have expected their pay to rise last year, it would arguably have been pharmacists. With many drugstores dispensing coronavirus tests and vaccines while filling hundreds of prescriptions each day, working as a pharmacist became a sleep-deprived, lunch-skipping frenzy — one in which ornery customers did not hesitate to vent their frustrations over the inevitable backups and bottlenecks.

“I was stressed all day long about giving immunizations,” said Amanda Poole, who left her job as a pharmacist at a CVS in Tuscaloosa, Ala., in June. “I’d look at patients and say to them, ‘I’d love to fill your prescriptions today, but there’s no way I can.’”

Yet pay for pharmacists, who typically spend six or seven years after high school working toward their professional degree, fell nearly 5 percent last year after adjusting for inflation. Dr. Poole said her pay, about $65 per hour, did not increase in more than four years — first at an independent pharmacy, then at CVS.

For many Americans, one of the pandemic’s few bright spots has been wage growth, with pay rising rapidly for those near the bottom and those at the top. But a broad swath of workers in between has lagged behind.

. . .

(p. A16) Pharmacies also faced external challenges. To hold down the cost of prescription drugs, insurance companies and employers rely on so-called pharmacy benefit managers to negotiate discounts with drugmakers and pharmacies. Consolidation among benefit managers gave them more leverage over pharmacies to drive prices lower. (CVS merged with a large benefits manager in 2007.)

Big drugstore chains often responded by trying to rein in labor costs, according to William Doucette, a professor of pharmacy practice at the University of Iowa. Several pharmacists who worked at Walgreens and CVS said the formulas their companies used to allocate labor resulted in low levels of staffing that were extremely difficult to increase.

According to documents provided by a former CVS pharmacist, managers are motivated by bonuses to stay within these aggressive targets.

. . .

In most cases, an industry without enough workers to meet customer demand would simply hire more, or at least raise wages to attract them.

Yet, according to the Bureau of Labor Statistics, neither of those things happened last year. The number of pharmacists employed in the United States dropped about 1 percent from 2020 to 2021. On balance, employers did not raise wages — in fact, median pay fell slightly, even without adjusting for inflation.

. . .

Several pharmacists said they were especially concerned that understaffing had put patients at risk, given the potentially deadly consequences of mix-ups. “It was so mentally taxing,” said Dr. Poole, the Tuscaloosa pharmacist. “Every day, I was like: I hope I don’t kill anyone.”

. . .

Asked about safety and staffing, CVS and Walgreens said they had made changes, like automating routine tasks, to help pharmacists focus on the most important aspects of their jobs.

Many pharmacists contacted for this article quit rather than face this persistent dread, often taking lower-paying positions.

Still, none had regrets about the decision to leave. “I was 4,000 pounds lighter the moment I sent my resignation email in,” said Dr. Wommack, who left the company in May 2021 and now works at a small community hospital.

As for the medication she had taken for depression and anxiety while at Walgreens, she said, “Shortly after I stopped working there, I stopped taking those pills.”

For the full story, see:

Noam Scheiber. “Why Working At Pharmacies Lost Its Luster.” The New York Times (Tuesday, September 13, 2022): A1 & A16.

(Note: ellipses added.)

(Note: the online version of the story has the same date as the print version, and has the title “How Pharmacy Work Stopped Being So Great.”)

Federal Government Botches Distribution of Monkeypox Vaccine

“A protest outside the San Francisco Federal Building . . .” Source of photo and caption: online version of the article quoted and cited below. (The wording of the caption is different in the online and print versions.)

(p. A1) Roughly 5,000 doses of monkeypox vaccine intended for Fort Lauderdale, Fla., left the national stockpile’s warehouse in Olive Branch, Miss., on July 19 [2022]. They somehow ended up in Oklahoma.

Then Tennessee. Then Mississippi again. Then, finally, Florida.

In Idaho, a shipment of 60 vaccine doses disappeared and showed up six days later, refrigerated rather than frozen, as needed. Another 800 doses sent to Minnesota — a significant portion of the state’s total allotment — were unusable because the shipment was lost in transit for longer than the 96-hour “viability window.”

The federal government’s distribution of monkeypox vaccine has been blemished by missteps and confusion, burdening local officials and slowing the pace of immunizations even as the virus spreads, according to interviews with state health officials and documents obtained by The New York Times.

Officials in at least 20 states and jurisdictions have complained about the delivery of the vaccine, called Jynneos. (More than half are led by Democrats, including California, Washington, Connecticut and Michigan, suggesting that their grievances are not politically motivated.)

“This is happening everywhere,” said Claire Hannan, exec-(p. A17)utive director of the Association of Immunization Managers, a nonprofit group that represents state, local and territorial officials.

“Our response is completely inefficient and breaking the back of state and local responders,” she added. Ms. Hannan said she had never “seen this level of frustration and stress.”

. . .

. . . Jynneos is being disbursed from the National Strategic Stockpile by a different government agency under the Department of Health and Human Services. That agency was never set up to take ongoing orders, arrange deliveries from the stockpile, track shipments or integrate with state systems.

Instead, the stockpile was designed to deliver massive amounts of vaccine to each state in response to a catastrophic event, according to a federal official with knowledge of the stockpile’s operations.

For the full story, see:

Apoorva Mandavilli. “States Blame Federal Mix-Ups As Monkeypox Shots Are Lost.” The New York Times (Tuesday, August 16, 2022): A1 & A17.

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

(Note: the online version of the story has the date Aug. 15, 2022, and has the title “‘Frustration and Stress’: State Officials Fault Rollout of Monkeypox Vaccine.”)

“Advances in Gene Sequencing” Have Not “Unlocked the Key to Cures for Cancer”

(p. 10) In his new book, “The Song of the Cell,” Siddhartha Mukherjee has taken on a subject that is enormous and minuscule at once. Even though cells are typically so tiny that you need a microscope to see them, they also happen to be implicated in almost anything to do with medicine — and therefore almost anything to do with life.

. . .

If Mukherjee were another kind of storyteller — tidier, if less honest — he could have showcased a more linear narrative, emphasizing how developments in cell research have yielded some truly amazing possibilities. He himself has been collaborating on a project to engineer certain cells in the immune system so that they eat tumors without stirring up an indiscriminate inflammatory response.

But as a practicing physician, he has seen too much suffering and death to succumb to an easy triumphalism. He recalls the “exuberance” of the mid-2000s, when spectacular advances in gene sequencing had made it appear as if “we had unlocked the key to cures for cancer.” Such exuberance turned out to be fleeting; the data from clinical trials were “sobering.”

Many medical mysteries remain unsolved. If the book’s protagonist — our understanding of cell biology — seemed to be riding high again on new advances in immunology, such “self-assuredness” was laid low by the Covid-19 pandemic. Mukherjee presents a string of questions that are still unsettled. “The monotony of answers is humbling, maddening,” he writes. “We don’t know. We don’t know. We don’t know.”

For the full review, see:

Jennifer Szalai. “Building Blocks.” The New York Times Book Review (Sunday, November 13, 2022): 10.

(Note: ellipsis added.)

(Note: the online version of the review was updated Nov. 2, 2022, and has the title “Siddhartha Mukherjee Finds Medical Mystery — and Metaphor — in the Tiny Cell.”)

The book under review is:

Mukherjee, Siddhartha. The Song of the Cell: An Exploration of Medicine and the New Human. New York: Scribner, 2022.