30 April 2011

Unhealthful News 120 - Banning use of food stamps for soda - can all of the arguments on both sides be wrong?

The New York Times ran an exclusive article about the New York mayor's proposal to forbid the use of food stamps for purchasing sugar sweetened beverages (soda and such).  The story read like a trial balloon to test out the arguments for and against (i.e., it looks like it was planted with a pet reporter or newspaper by a politico – presumably Bloomberg's office – to see how people would react before moving forward).  The funny thing is that pretty much none of the arguments presented in that article on either side of the issue seems valid.
 “This initiative will give New York families more money to spend on foods and drinks that provide real nourishment,” Mr. Bloomberg said in seeking federal approval.
Um, no.  It is not possible for a rule that only prevents someone from doing something to "give" them something.  If Bloomberg wants to make the argument that it forces people to spend more money on other products (or, more diplomatically, leaves them no choice but to spend more money on those products), then fine.  But if he has to claim that it gives people something he is (a) dishonest and (b) not very confident that the truth will win the day.
Food stamp benefits are paid for entirely by the federal government, and the city is seeking permission from the Agriculture Department to test its proposal in a two-year project. Because the proposal would define “food” more narrowly than federal law and regulations, food industry groups have unleashed a barrage against it.
Again, no.  Whatever happens, it will not change anyone's definition of food.  Opponents do not like the law because it would directly cut into sales of their products a bit and would probably set precedents for other actions that would cut a lot more.
President Obama, whose position on the New York plan is unclear, is in an awkward situation. The Agriculture Department, historically averse to restricting the use of food stamps, has said, “There are no bad foods, only bad diets.” ….  But Mr. Obama has set a goal “to solve the problem of childhood obesity within a generation,” and his wife, Michelle, is waging a high-profile campaign to promote healthy eating. The Web site of Mrs. Obama’s childhood obesity initiative even urges Americans to “drink less soda or sugar-sweetened drinks.”
Really?  Obama is going to personally intervene in this matter?  He does not have time to fight for a stimulus plan to help tens of millions of suffering Americans, or to figure out how to have a more enlightened way to deal with innocent (they have not been proven guilty) prisoners at Guantanamo, or even to provide a decent health financing plan, but he is going to get so involved in this that he cannot distance himself from it.  Just great.

And what about this list of facts makes it awkward?  It is common knowledge that the USDA says "there are no bad foods" because their primary constituents include the meat and corn industries, makers of bad foods, and not consumers.  There is no reason the President needs to yield to this conflict of interest if he does not want to.  As for the website recommendation, there are a lot of things that are recommended for health that are in no way enforced by government action.  Where is the awkwardness in leaving this one of them?
Opponents say that many factors, besides soft drinks, contribute to obesity.
You would think that the opponents of this could muster some good arguments.  But if this article is to be believed then this is their lead argument.  The logic is equivalent to saying, "many factors besides sleeping air traffic controllers contribute to plane crashes, so let's not do anything about it."
Moreover, they say, imposing restrictions on food stamps would require retailers to reprogram computers and embarrass some customers at the checkout counter.
I suspect there is not a food-stamp-accepting store in existence that does not sell some items that are not eligible for food stamps, so they are already asking for some cash from food stamp customers.  Even if customers feel bad about using food stamps or somehow feel bad about being asked for cash, these do not change, so where is the new embarrassment?  As for reprogramming, if anyone is using a cash register computer system that cannot be changed to handle this using one data upload that presumably the government could provide (the SKUs or other identifying series information of all the products included in the change), then I would guess that they are already committing food stamp fraud (at least unintentionally), so probably would not care too much. 

I cannot fathom how these pass for the arguments against the policy.  My only theory is that these are the fake arguments cooked up by the policy proponents to make the opponents look like they have no valid arguments.  As I said, the article does read like a planted trial balloon, and so is probably testing arguments Bloomberg is worried about, not the best arguments that could be made.  One more source of disinformation for serious readers of the health news to beware of.
Eighteen members of the Congressional Black Caucus recently urged the Obama administration to reject New York’s proposal. The plan is unfair to food stamp recipients because it treats them differently from other customers, they said in a letter to Agriculture Secretary Tom Vilsack.
Still not even making a close pass near reality.  This rule would actually treat food stamp recipients slightly more similarly to other customers, requiring them to pay cash for something that everyone else is already paying for.  Is the Black Caucus's reasoning that if food stamps can buy anything then it is unfair for them to not buy everything?  If so, why are they not protesting the fact that they cannot be used to buy prepared deli foods, beer, or greeting cards?

The article goes on to offer and answer:
While Coca-Cola and PepsiCo are among the largest contributors to the nonpartisan Congressional Black Caucus Foundation, a research and education institute, caucus members say their positions are not influenced by such contributions.

Not much face validity in that claim.  On the other hand, the fact that it showed up in the article again reads like a plant, with the planters trying to preemptively discredit what could be phrased as a legitimate concern.  The legitimate version appears below, which the previous version might have been intentionally made to sound dumb.

One public health professor type was quoted as saying,
the government spends hundreds of millions of dollars a year buying beverages that have been linked to risks for obesity and diabetes. These conditions cost the government and taxpayers billions of dollars a year in costs paid by Medicaid and Medicare.
The article still lacks a legitimate argument for a policy change.  Even if the "costing taxpayers" claims that are made so casually turn out to be completely true (as opposed to the claims about the health effects of smoking causing a net cost for the government which are false), this still does not justify the policy.  Show of hands out there – who wants to live in a country where "it saves the government money" is considered a sufficient justification for a restrictive policy decision?

Also interesting is that the San Francisco Chronicle runs a "ask Marion Nestle" column, which just happened to address the question of food stamps and soda on the same day as the NYT trial balloon story.  Coincidence?  It seems unlikely.  But then again, why would the people planting the NYT story set it up so that someone else's brief column could present the issue and the best real arguments on both sides better than their story (please read it if you are interested in the topic).  I can only guess there was a leak about the story and she took the opportunity to preempt it.

Nestle is an academic and probably the most well-known critic of U.S. food business and nutrition policies (or at least the most well known honest, intelligent and respectable critic – there are a few just science aficionados who are better self-promoters than she is, although she is pretty good).  She happens to be one of the authors I referred to in yesterday's UN who wrote the call for papers for article about how to change the behavior of the food industry.  But do not mistake her for the typical "health promotion" or anti-tobacco academic; she has worldly political views, but she is honest and does good analysis, not junk science.  Nestle manages to make a better case than the Black Caucus did (or at least were reported to have done), explicitly noting that the restriction could be seen as condescending to the poor.  In light of that she admits ambivalence about the Bloomberg proposal, but has come to support it.

Unfortunately, her articulate and though-out arguments strike me as dangerously close to invoking the "denormalization" concept from anti-tobacco.  That was the campaign that started out as "let's get people to stop thinking that smoking is an inevitable part of social interaction and getting through the day" and morphed into "let's convince everyone that smokers are evil and that seeing smoking should be as socially unacceptable as seeing someone get raped".  Nestle makes a good case, but a good policy that flirts with a proven-dangerous process is seldom a good idea.  This might be what some of the opponents are trying to say, but not doing a very good job of getting it into the papers.

The best part of the whole story, though, was the reader question that Nestle was answering in her column.  It read:
Q: When I see people in grocery stores using food stamp benefits to buy sodas, I get upset. Why does the government allow this?
It is just so sad that she did not answer the question as asked with:  "Because the government has no magic power to keep people like you from getting upset when your urge to force others to live how you want them to creates emotional turmoil.  Perhaps you should see a counsellor about that."

29 April 2011

Unhealthful News 119 - Adamance and conflict of interest (part 1)

It is a bad day for news, thanks to the oh so pretty wedding of the heir to the system that made Old Europe the source of most of the worst bloodshed the world experienced for about half a millennium.  (For anyone who is interested in my further anti-royalist snark – not that you should be – see my comment on this post.)  So, lacking news, today I will do a meta – instead of writing about health research and reporting, I am writing about something that affects health research and reporting.  It is something that comes up so often, and is pretty clearly even less well understood than confounding.  Several commentaries that bring up the concept of highly adamant opinions and how they relate to conflict of interest have crossed my screen this week, so I will concentrate on those.  I have written a lot on this topic, so I am picking just a few themes, continuing this post in UN121, and planning to revisit the topic later series.

The most important thing to understand is that the phrase "conflict of interest" is not just jargon.  It has its natural language meaning:  Someone has two different interests and they create conflicting motives.  One interest is about worldly outcomes, and is venal or is a narrow special interest that is not universally shared, and the other is the ideal of presenting disinterested and dispassionate scientific analysis.  It is actually often the case that someone is not really motivated by the latter of these at all, feeling no hesitation to unabashedly serve their worldly goals, in which case the phrase refers to the conflict between their actual interest and the interest they are supposed to have.

So, someone doing a study to figure out whether "Big Food" is really causing children to eat badly has an obligation to try to report what the data shows, shooting for the ideal of being a disinterested scientist.  (The term "objective" often gets used, but that is actually a very bad choice of words – objective science cannot exist, while disinterested science is rare in worldly sciences, but theoretically possible.)  But if a researcher is a dedicated activist against Big Food, already convinced that there is problem, it will be quite the challenge to not let that influence the interpretation.  Even when someone in that situation does their best to be unbiased there are blind spots (to borrow a phrase from this recent NYT op-ed that looked at ethical questions related to COI).

On the other hand, not every adamant opinion leads to a conflict of interest.  Jacob Sullum just posted this observation about how two anti-Big Food activist academics published a call-for-papers at a journal, looking for "articles considering how to change the behavior of the food industry".  Sullum slams the authors for portraying their particular personal morality on this controversial topic as if it were a matter of science or the only possible view of the public interest.  At this point, it might be tempting to accuse such advocates-cum-scientists of having a COI, as some authors (not Sullum) have done.  But I would argue that they neither exhibit much COI nor are creating it with their call for papers.  They are not calling for studies that support the claim that the food industry's behavior should be changed – that would clearly create a terrible COI (of the type that is typical in anti-tobacco and other areas that are more politicized than food).  Rather, they lead with their goal and look for support for how to pursue that change; so long as their premises, motives, and goal are not secret (it would be hard for them to avoid disclosing those even if they wanted to), there is no COI or disclosure problem.  The legitimate criticism, then, takes forms like Sullum's, about the adamance itself and how it is directing the science priorities, not that it is corrupting the science.

Being an advocate for a particular worldly goal and writing an advocacy piece in favor of it is not a conflict of interest.  It is a perfect alignment of interests – no conflict there.  Moreover, being a paid advocate for a particular position is no more a conflict of interest than is being an unpaid advocate.  Why would it matter?  In theory, a paid advocate might not really believe in the cause they are advocating, unlike an unpaid advocate, but it is difficult to see why this would matter when interpreting their claims.  A conflict does arise if, instead of trying to make the case for one's side of an argument, an advocate-author claims to be presenting a balanced analysis of the dispute or claims to be speaking for the "public" or the only possible goal someone could have. 

Money matters occasionally, and under a few circumstances is arguably the strongest source of COI, though it is not the most common source as is generally implied.  Money is primarily a problem when someone is employed by an entity with a particular position.  A rarer but potentially far more problematic case is when someone has a major financial investment (e.g., owning relevant intellectual property) that is affected by the outcome of a study.  In both of these cases, it is difficult to imagine the author being able to completely overcome the COI if writing about whether a particular scientific conclusion or view (the one that they are employed to support, or stand to make a lot of money from) is justified.  If they were studying something based on the assumption that their preferred view is true (e.g., why it is true; how to act, given that it is true, as in the case of the food advocates; etc.), then they should be fine.  Someone who is employed in "tobacco control" can be trusted to make the best arguments in favor of more tobacco control policies (more's the pity that the published arguments are so lame).  But vanishingly few tobacco control advocates have the intellectual discipline and honesty to analyze whether, all things considered, tobacco control efforts are improving the world (I cannot recall ever seeing a respectable example of that).

Anti-tobacco activists recently became agitated upon learning that British American Tobacco quietly provided financial support for UK retailers' campaign to fight the proposed ban on all in-store displays of tobacco products.  But for activists to portray this as some improper "conflict of interest" debases the term, changing its meaning to simply "there is financial support for a position I and my friends personally disagree with".   If a tobacco company (or an anti-tobacco advocacy group, private or governmental; or a retail lobbying group) expends resources to support a particular goal, they are simply acting in their interests – no conflict.  It is only COI if they claim to be acting for the common good or disinterested science that they start promising scientific disinterestedness.  If BAT, hypothetically, commissioned a study about the effects of display bans, there would be a challenging COI to deal with.  Similarly, when activists who are intent on demonizing tobacco use claim there is scientific support that display bans have a public health benefit, their obvious COI must be considered in interpreting their claims (and their persistent failure to disclose that COI needs to be recognized as reflecting their overall level of honesty).  Their interest in the demonization creates the incentive for them to misrepresent the health science.

In short, adamantly believing in a position, for whatever reason, whether one's salary depends on it or not, does not create a COI for many analyses related to the position, and certainly not with explicit advocacy for the position.  However, the COI is a challenge for analyses of whether the position is valid.  Interestingly, the adamance itself may create more credibility problems for honest readers than the COI.  I will take that up in Part 2.

28 April 2011

Unhealthful News 118 - How to take an unconfounded result and introduce confounding

Thanks to a tweet from @cjsnowdon I found this study in which the researcher showed a month-of-birth effect for anorexia risk (high if born in March-June, low if September-October).  The results were pretty strong and cannot be explained by confounding, and measurement bias seems extremely unlikely.  So as odd as it might seem, the effect seems to be real.

Highly technical point:  The test statistics they report are probably wrong (in the sense of being dishonest, though probably out of ignorance of honest methodology rather than lying) because they pretty clearly fished around to pick the most extreme time period.  Notice that Mar-Jun is four months but Sep-Oct is two, and you can be sure they did not specify their protocol to be "we will pick which of the four month periods, running Mar-Jun, Jul-Oct, or Nov-Feb, has the highest rate and which two month period, starting with Jan-Feb, has the lowest.  But I am sure they calculated their error statistics based on the assumption that they did exactly that.  So their results are biased upward a bit and their confidence intervals are too narrow.  I will make it a project to try to write up a version of this that fills in some details but is still widely understandable – I will post it when I manage.

Because the most sensible claim is basically "something about being born in a particular month" has an effect, there is literally no way for there to be confounding or reverse causation.  It cannot be that some unknown factor is causing both the ostensible cause and the observed effect (the most common source of confounding) because the "something about" conceptualization means that whatever that unknown factor is, it is actually captured in the broad phrasing of the causal factor.  Also, it is obviously impossible for someone's characteristics later in life to go back and affect their birth month.  So, in the spirit of yesterday's UN and my efforts to explain that there is no rigid hierarchy of study types, this correlation must be causation.  When people say that randomized trials (RCTs) are always better than any other study design, they are saying (though they often do even not understand enough to know this is what they are saying) that any systematic confounding is replaced by random confounding.  But the birth-month study is actually better than a RCT even for this one thing that favors RCTs:  There is no confounding, random or systematic.  Thus, the relationship must be causal.

Ah, but the tricky part is figuring out the causal pathway.  Unfortunately, the researchers did not seem to understand that this is a challenge and simply declared,
These results indicate that environmental risk factor(s) are operative during gestation or immediately after birth and their identification will be important for disease prevention strategies.
Really?  They apparently did not understand the "something about being born in a particular month" concept and managed to re-introduce confounding where none existed before by restricting the causal claim to "the physical act of coming to term in particular months and being a newborn in particular months" causes anorexia.  Unlike the claim that just trusts in what the data actually shows and must be right, this one makes huge assumptions and therefore is reasonably likely to be wrong.  If, for example, being conceived in a particular month is the actual cause of anorexia (maybe it is related to birth order, for example, or parents' SES), then under the authors' claim the result is actually due to confounding:  both the ostensible cause (being a newborn in a particular month) and the effect would be caused by an underlying common cause, and not otherwise related to each other.

The funniest part of all of this – at least to me – that in the BBC article about this, one of the authors declared,
However, our study only provides evidence of an association. Now we need more research to identify which factors are putting people at particular risk.
Allow me to just say, nonononononono NO NO NO!  Come on people, this is really not that difficult.  While it is never possible to prove than an association is causal, this study provides overwhelming evidence of causation (so long as you do not gratuitously introduce claims about why and stick with the "something about" that the data actually supports), not "only association".  There is almost no conceivable epidemiologic study that could provide better evidence of causation.  Now you need to figure out why there is causation.  The situation does not warrant some weaselly "more research blah blah which factors blah blah" that might be at home in some other study like the one I looked at yesterday.  I am somehow reminded of barely-literate star athletes awkwardly reciting the interview script after a game: "it was a team effort", "I could not have done it without….", and "the fans have been great".  You would like to think that someone working at a research university could do better than than reciting a pretend self-deprecating script while parading in front of the admiring national news rreporters. 

(And why did this highly technical study produce news coverage like scoring the winning goal? It is not as if the result is big enough to change anyone's behavior.  I guess that is a topic for another day.)

Of course, we do want to know why birth month is causing anorexia.  Thus we would not fault the researchers for positing a theory.  But that is not what they did.  They not only declared what particular aspect of birth month was causing the outcome, but they absurdly claimed "these results indicate".  But the results they report absolutely do not indicate that.  The results indicate what I wrote ("something about…"), but not the specific causal mechanism.  Other information would be needed to support their claim.  The BBC interview provided better support than their results.  The author noted that other very different psychological diseases have similar birth-month patterns, which tends to support the biological claim.  Nevertheless, I would wager on a social theory rather than a biological one.

My conception-date hypothetical may seem a little far-fetched but there are lots of alternatives.  The more promising ones to explore have to do with who is a bit older and younger when they first enter a school grade where the social pressures that cause anorexia start to manifest.  Keep in mind that anorexia undoubtedly has biological causal factors, but it is predominantly a social phenomenon.  Surely everyone has read the example, popularized by Malcolm Gladwell in Outliers, that professional hockey players who grew up in Canada are much more likely to have been born early in the year.  The explanation is that youth leagues form based on calendar-year birth cohorts, so the kids born in January are older, stronger, and more practiced than their contemporaries.  This would not matter by the time someone got to the NHL except for the fact that it matters a lot when someone is six years old, and the better players get more attention, and so become even better, and so play in better leagues as they move up the ladder, which makes them a bit better still, and so on.  Such a positive feedback loop seems less likely for anorexia, so the results would not be as dramatic.  But some story like that seems at least as plausible as a biological factor resulting from being a newborn in summer rather than winter manifests in a socially-constructed behavioral disorder. 

And surely the researchers must have read Outliers.  Even if you see that book, as some critics do, as just-so stories that rip off the clever ideas of other researchers without giving them due credit, it is still a must-read.  Kind of like The Spirit Level.  (That link is a plug for Snowdon's takedown of that book as a s/o for giving me this great example.)

27 April 2011

Unhealthful News 117 - Exercise is good for six-year-olds, but not because of this study result

A new study had researchers looking into the back of the eyeballs of over a thousand Australian six-year-olds and found that those who watch more television or engage in less outdoor sports have narrower capillaries there.  The alarming conclusion that was reported is that since narrower blood vessels are associated with cardiovascular disease in adults, that this means that watching more TV or doing less exercise for six-year-olds means that they will be at greater CVD risk.

If the conclusion is simply that less exercise and more television viewing are probably associated with poorer cardiovascular health, then it is undoubtedly right.  But we kinda knew that already.  If the conclusion is something more specific about the meaning of this particular study, then we have a really serious problem of epistemology.

I will set aside the question of how well habits of six-year-olds predict future behavior and focus on some other problems with the reasoning of the study authors and the reporters who blindly transcribed their claims.  The most important of these is that correlation does not necessarily mean causation.

You have no doubt read that observation before.  Unfortunately, most of the time you read it, it is just being used as weasel words by someone who does not like what a study suggests about causation (e.g., cigarette companies forty years ago protesting that the overwhelming correlation between smoking and lung cancer, which was pretty obviously causal, does not mean that smoking causes cancer because it is just correlation).  Occasionally the statement is used by a study's authors themselves if they are looking for an excuse to not really stand up for what their study shows.  Other times it is used by observers who are not intent on discrediting the study, but are trying to make themselves seem like knowledgeable reviewers of the science by pretending there is some simplistic bright-line hierarchy of study types such that "more research of the right type is needed" to show causation (regular readers will be aware of the fact that this mostly just shows their lack of knowledge).

But correct statements are not made incorrect because the ignorant or venal misinterpret them.  In many cases we observe correlations and have good reason to believe they are causal, and absent the presentation of any affirmative reason to believe otherwise, the causal conclusion is warranted.  In other cases, there are so many other compelling explanations for the correlation that a causal conclusion without further information is foolish.  Sometimes we are somewhere in between.  For example, if we observe that roofers have an elevated risk for skin cancer, it seems safe to conclude it is causal (with a causal pathway that passes through sun exposure).  If they have a very elevated rate of liver cancer, it is plausibly causal, and we should look into chemicals they are using.  If they have a higher rate of diabetes, we might consider looking at their dietary patterns or ethnicity.

The implicit causal claim in the present case is: (a) the behaviors cause narrow capillaries; (b) that narrowness is associated with CVD in adults so either (b1) the narrowing causes the CVD or (b2) whatever is causing it causes CVD and that "whatever" is being caused by the six-year-olds' behaviors (and is, in turn, causing the narrowing that we observe).  I can think of twenty different stories that explain the observations without supporting that full causal pathway.  E.g., adult narrowing of blood vessels is caused by CVD, not the other way around; narrow blood vessels in adults cause CVD, but children who use their eyes on televisions just have effects in their eyes that  do not affect this; physically unhealthily people (or even just children) have narrower blood vessels and also eschew outdoor sports, which causes CVD via some other pathway; and so on.

The headlines mindlessly repeated the causal claims even though the same reporters would probably have mindlessly reported the claim "oh, but this is just correlation, not causation" in some other case where causation is the only compelling explanation.  USA Today reported "Couch-potato kids could be risking their hearts", the New York Times reported it in their "Risks" series, and some more sensationalistic sources included the whole causal claim in their headline, like "TV Causes Heart Risks in Children".  Funnier were the ones who reported headlines that told us nothing that was not already obvious, but still managed to imply the study showed results that it did not, like "Watching Television Could Be Harmful for Kids".  That is just about as simultaneously obvious and misleading as the usual stating that correlation is not necessarily causation.

To further put the study's naive claims in perspective, here is a pretty good analogy in terms of the many flaws in the causal conclusion:  Having darker skin is associated with an increased chance of imprisonment.  Kids who spend lots of hours in front of screen have lighter skin, while those who do more outdoor exercise have darker skin. 

Let's break down the implications of the analogy:  There is no reason to assume that the mechanism that causes narrowing/darkening among screen users is the same one that causes the association with CVD/imprisonment.  Darkening from tanning has no relationship with the association of race and imprisonment; it is a completely different phenomenon though it still involves darker skin.  Even when race is a step along the causal pathway (or a proxy for one) between screen and outdoor activity and health outcomes – e.g., kids in poor urban neighborhoods have no place to safely play outdoors – the implied causal path is still wrong.

The point is, when causation seems like the only plausible explanation for a correlation, it is a reasonable conclusion.  When other explanations seem comparably compelling, it is not.  Instead, efforts should be made to identify the other explanations (well-educated epidemiologists know how to do this; >95% of those publishing epidemiology do not) and test them in ways that discriminate the different explanations (which is something that scientists know how to do).

There are a few obvious questions to ask.  Is there something special about looking at TV (the study looked at other screen use but did not find such interesting results) or do bookish six-year-olds have the same narrowing?  If the type of sedentary activity matters, the implications are different.  Similarly, does indoor exercise have the same effect as playing outdoors.  We are talking about activities that directly affect the eyes, after all, and a measurement in the eyes.  Maybe there is nothing important about that confluence and it is all about overall vascular health, but maybe not.  Do we even know if narrow blood vessels in kids predicts adult CVD?  In a field that was more serious than epidemiology or health reporting, these questions would have been at least mentioned.

In fairness to the professor who is the senior author of the study, he was quoted in the NYT as being cautious about interpreting the results.  Apparently he has not taught this wisdom to his student / advisee / employee who was the first author of the paper, though, who was quoted in the USA Today article basically making the full causal claim.

Finally, as a subtle technical point, one that I could pick up even without doing a careful analysis of the study, I noticed that the authors chose to divide the kids into thirds based on level of outdoor sporting activity, comparing the top third to the bottom, while they divided the TV watching into quarters, again comparing the top to the bottom.  This is always a sketchy methodology, since the extreme groups in population studies like this pick up all the extreme people (e.g., the kids who hardly ever go outside and watch TV all day, perhaps causing huge genuine health problems that only exist at the extreme, or perhaps caused by major non-lifestyle health problems that keep them from being able to play outside).  But even beyond that standard error(!), the change of what fraction the group was divided into is very suspicious and suggests that they made choices that gave them more dramatic results.  If this is really the case then something is very wrong since the less extreme comparison (top third to bottom third) would produce a less dramatic result than the more extreme (top quarter to bottom) if there were really a trend.  If the comparison that should produce a larger contrast does not, then we should be very suspicious of even the claimed correlation.

In summary, there is no doubt that exercise is better for cardiovascular health than being sedentary.  It is plausible that this manifests in vascular size in adults, though it is not clear to me that we know how way the causation runs (though it might be clear to those who both understand causal inference and are expert in the subject matter).  That the same thing happens in six-year-olds is plausible, though far from obviously true, and the new study might be seen as lending a bit of support to that claim though it has major limitations.  As for whether this effect in kids has any bearing on adult health, this is purely speculative at this point.

So exercise – both your body and your reasoning ability.

26 April 2011

Unhealthful News 116 - Yesterday's non-news about e-cigarettes

I found a great UN example today, but it was a bad health and productivity day, so writing this post for the THR blog was most of my productivity for the day.  So just a few words now about the news reporting that relates to that one, and I will save the more interesting one tomorrow.

The quick background is that the US FDA announced yesterday that it would regulate electronic cigarettes according the rules used for tobacco products instead of the rules for medicines, as they had wanted.  The latter would have effectively banned e-cigarettes, but manufacturers took them to court, and the court required they do what they just announced they are doing.  For a bit more background, you can read my other post at the link, and for more background still, you can follow the links from that.

Every reporter seemed to have either missed or ignored the fact that this was not a choice by FDA, but something the court had required, and that there was really no information provided about what the critical implementation details will be.  It was kind of an inkblot test for the reader, with e-cigarette supporters typically reading in better news than can be assumed.  Despite that, the Associated Press story by Michael Felberbaum did a nice job of explaining the matter.  Covering the pertinent facts for someone to basically understand the matter, without hype, too much hyperbole, or too many unsubstantiated scientific claims.  It was one of the better short health news stories I have read in a while. 

Extra credit goes to the Philadelphia Inquirer, whose version of the AP story left out the flawed attempt to explain why e-cigarettes are much less harmful than smoking, because they do not contain "the more than 4,000 chemicals found in cigarettes".  You get used to seeing nonsense like that from anti-tobacco propaganda, but it is pretty lame when news reporters decide to gratuitously throw it into stories.  Here is a hint about counting chemicals:  There are pretty much as many of them as you want to count, if you keep looking hard enough, in most any complex natural substances like tobacco, kale, salmon, children, etc.  Also, the counts of thousands of measured and named chemicals refer to the smoke, which has different properties from the cigarettes themselves.  The New York Times version cut out much of the useful material and left that in.

The Los Angeles Times made the mistake of writing their own story, and dredged up the discredited attacks on e-cigarettes that FDA launched as part of their legal strategy.  The Winston-Salem Journal, which often delves more deeply into tobacco-related stories than any other paper, focused on the reactions of various partisans in a way that was probably cryptic to anyone unfamiliar with the topic.  Most of the television news reports cut for length by leaving out the fact that this was fait accompli, implying it was a policy-changing decision.  This is actually what a lot of my expert colleagues did also, interestingly enough.

As far as I could find, no reporter seems aware of how little the FDA announcement told us about what will really happen (see my THR post for my take on that), other than there will be no immediate ban.  But I get the impression that no one they talked to made any effort to explain to them how uncertain the matter still is, so it is hard to blame them.  In this case, it is not so much that we need a more skeptical press corps, as I often scream, but that we need more skeptical pundits.  The only such analysis I noticed came from two small San Francisco newspapers which suggested (as I did) that this paves the way for treating e-cigarettes like cigarettes in all ways.  Because of recent policy debates there, they focused on including e-cigarettes in place-specific smoking bans.  While this obviously does not logically follow from the FDA policy (the rule is that e-cigarettes will be regulated as tobacco products, many of which are smokeless, not as producers of smoke) it seems like an inevitable rhetorical path.

Bottom line: It really is interesting to see so much reporting about a "groundbreaking" "decision", some of which included some genuinely good background information, without actually seeing any news reporting.

25 April 2011

Unhealthful News 115 - Goals are not predictions; sometimes they are not even goals

Numerous headlines over the past few days have reported that the US will/could/should/is expected to have inflexible indoor smoking bans everywhere in the country by 2020, or some variant on that theme (here are some examples).  The thing is that this is merely some people's goal, and contrary to many of the reports, there was no study supporting the claim.  Moreover there was not even anything "newsworthy", since there was not even any change in the arbitrary goal.

So what generated the "news"?  There was a simple matter-of-fact report in Morbidity and Mortality Weekly Report (MMWR), CDCs weekly blog.  It is actually a newsletter that predates blogging, but these days the most useful way to think of it is as a blog, to avoid confusing it with a journal or even a carefully-edited periodical.  The report was about the enactment of indoor smoking bans from 2000-2010, and it seemed to be just fine for what it was.

But it also included the tangential observation that the US government's "Healthy People 2010" goals included enacting exception-free nationwide indoor smoking bans in any space where someone is employed, which did not happen.  So the wish was just carried over to "Healthy People 2020" and the report said this "is achievable if current activity in smoke-free policy adoption is sustained nationally and intensified in certain regions, particularly the South".  Yeah, that warrants headlines about 2020 being the time to expect nationwide laws – an arbitrary date from an old list of goals combined with a report that simply recounts past events and has no forward-looking analysis.  But wait, there is a one-sentence assertion by a random group of analysts working at CDC, so stop the presses.  This is what passes for health news.

(Someone looking for a more interesting story might focus on how the US government goal was to enact these laws, but they failed and are now wondering if it can be done ten years later.  For those not familiar with the US system, the explanation is simple:  Most laws are controlled by state and local governments and not all of them share the feds' goal.  The beauty of federalism is that different states and localities can try out different policies, and if they are really important, people can vote with their feet.  Of course, the feds have a habit of thwarting this system in many cases where variety and local freedom is useful and, indeed guaranteed by the Constitution.  Perhaps the confidence in the 2020 goal should be read as the federal government hinting it will withhold funds to force all states to adopt the "right" laws, the usual tactic for ignoring the rights of the states under the Constitution.  Reporting that would be a much more interesting and genuine news story.)

That one phrase from the report that is quoted above was not all that was written.  As with many MMWR reports, the analysts' useful information is accompanied by an "Editorial Note".  This one, like many such notes in MMWR, is longer than the actual study report.  Like I said, it is a blog, not a journal or even really the technical report series it is supposed to be.  The editorial waxes about how the existing laws are "remarkable public health achievements" though the data to support that claim is pretty sketchy.  More important, the editorial makes clear that whoever was writing does not consider sufficient laws that allow for any exception whereby consenting adults can gather and smoke, and suggests that restrictions on smoking at home should be added to the goals.

I am not writing this to comment on the anti-tobacco extremists and slippery slopes – there has been plenty written about those.  Rather, this story is a reminder that for any issue with political implications, the health press often take a break from being overly-credulous science reporters and instead become typically-credulous policy reporters.  That is, they report whatever someone in a position of power asserts as if it were information, and report government goals, no matter how extremist, naive, or unpopular, as if they were god-given.  There are few Americans who would insist that if some states chose to allow well-ventilated smoking sections in bars or casinos, or refuse to force old men at the American Legion (a private club for military veterans) to relive their days in Korea by going out into the snow to smoke, that this would be a terrible thing.  And it seems like there is a good chance that some states will allow at least some such exceptions, thwarting the inflexible CDC goals, if they are not blackmailed by Washington. 

I suspect that the debate on this matter will have matured enough by in 2021, or perhaps even become largely moot, so that we will not see a spate of naive stories about how the goal will be met by 2030.  But given the anti-tobacco activist enclaves of the government and the quality of the press corps, I am not willing to rule out the possibility.

24 April 2011

Unhealthful News 114 - Krugman takes on some unhealthful news

Paul Krugman has written several posts in the last week about medical financing, including his New York Times column about how medical spending requires limits/choice/rationing and how medical patients are quite dissimilar from people in their role as consumers of ordinary goods.  He pointed out in his blog that this was basically reminding us of something the great Kenneth Arrow wrote in 1963.  I suspect that readers in most of the world understand that these points go without saying, which is why the government needs to exert substantial control over medical financing and, by extension, limits on spending.  But in the US the the debate goes on about whether or not we are going to do anything remotely rational about medical financing.  (For those interested in other recent Krugman writings on the topic, they are here, here, here, and here – I understand that links from blogspot let you into nytimes pages even if you have used up your free articles for the month.)

To summarize, the most important reason that patients do not act as normal consumers – probably obvious to anyone who thinks about it, a category that clearly does not include about half of American commentators on the subject – is that they are not paying most of the bill.  This is because if they had to do so for anything other than routine care, they would not be able to afford it, so insurance of some sort is needed, and there is no getting around how that prevents normal consumer decision making.  A second reason is that the "consumers" seldom have the knowledge and confidence to make a decision, and often are in no condition to think straight, so someone else (neither the patient nor the payer) is also making the decisions.

As for the need for some kind of rationing, it is not possible for us to provide everyone with every beneficial medical treatment, a category that includes a lot of expensive treatments that will probably fail, but might offer a little benefit.  We understand this for most goods, but the thing about medical care (this is my claim, not Krugman's) is that until recently the total cost of all beneficial treatments for anyone who might benefit from them was quite small.  Moreover, during a brief period that included the formative years of most current American pundits, we were rich enough to afford all of those treatments for everyone in rich countries.  That odd situation has changed.  But our usual method for rationing consumer goods – making people choose what they want, constrained by what they can afford – does not work, so someone has to make the decision.  It can be private insurers who are looking for any excuse to not pay for something, or it can be – gulp! – government.

Rationing is tough, but it would be better if we acted like adults and recognized that it was necessary, and best to do it in some sensible way.  I had a conversation this morning with someone who is on Medicare (for those who do not know, that is America's efficient, popular, tax-funded socialized medicine, available to everyone assuming they survive their lack of health insurance and reach age 65).  She told me about how she and her husband were constantly getting calls from companies trying to sell them (which means deliver for free and bill Medicare) motorized wheelchairs, anti-sleep-apnea machines, and various other boondoggles.  She also recounted tales of oncologists making a fortune by selling the in-office chemotherapy delivery that they themselves chose to recommend over other options.  I was aware of the latter of these but had not realized how bad the former had gotten.

Anyway, the point is not that much of American medical care is making a few people rich at the expense of people who just need basic care – that is not a very impressive insight.  What Krugman's posts and that conversation got me thinking about is how badly backwards the entire system is when people are allowed to buy, at the expense of their insurance (government provided or otherwise), an electric scooter if they can get some scamming medic to declare that they have a medical need, but they cannot buy (to pick just three examples I have written about recently) soda in various public buildings, or caffeinated alcoholic drinks, or electronic cigarettes if the FDA has its way.  The latter are legitimate consumer decisions where someone can understand the ramifications and make a choice about how to expend their money (and time and perhaps their thin waist or even a few hours of long-term memory if they so choose).  We would not all make the same choices, but that is the beauty of functioning free markets:  we do not have to agree and no one has to understand why.  The same is not true for medical care, where someone often has to figure out how to choose for everyone.

The point is that it is not just offensive to liberty that "health promotion" busybodies (not to be confused with real public health advocates) try to restrict consumer choices about food, drugs, etc. and bastardize the epidemiologic science in the process.  But since they often do so in the name of reducing medical expenditures, it is downright insulting (and bastardizes the economic science).  People are told they must not smoke or otherwise enjoy nicotine because the resulting health costs increase government expenditures (which is not actually true, but let's run with it for now).  But the aforementioned medical device companies and oncologists cost the system orders of magnitude more, but are allowed to keep acting the way they do.  The burden is put upon the rest of us, and the victims are blamed.

Krugman waxes about how, because of the aspects of the relationship that are simply beyond the standard merchant-consumer interaction, medical providers have to be something more that just profitable producers, how they have to have super-human ethics and heroism.  But, you know, I am not seeing that happening anytime soon after a few decades of this "consumer" attitude.  The wheelchair makers are certainly not headed in that direction, and the millionaire oncologists probably did not choose that specialty because all the positions as a desperately-needed general practitioner in an under-served rural area were taken.  So the only hope for reigning in these costs is – again, gasp! – aggressive government intervention.  But this does not make it all right for the government to intervene to alter people's private possibly-health-affecting choices via any method other than education, suggestion, and perhaps a bit of nudging.  More pointedly, the embarrassment of those in power over the government's failure to have enough ...um... let's say fortitude to stand up those who are getting rich providing needlessly expensive medical care – let alone the embarrassment of those who are providing that needlessly expensive medical care – is a pathetic motive (though one with understandable self-interested as well as pscyhological motives) for blaming consumers for the uncontrolled costs.

23 April 2011

Unhealthful News 113 - Dishonest time-series analysis (more interesting than it sounds)

It was suggested to me that I write about this story in which the UK Office for National Statistics released an incorrect report that said that the rate of heavy drinking among women had increased by about 20% over a decade.  The problem was that the methodology for measuring how much wine is in "one glass" changed in 2006, to reflect a belated recognition that the average serving of wine had, for a while, been larger than it was being counted as in the statistics.  It turns out that this adjustment – such that someone who says "I drink two glasses of wine per day" is now counted as consuming more total alcohol than someone giving the same answer in 2005 – accounts for more than the entire supposed increase.  That is, the real trend has been downward, but the recorded data shows the inevitable huge artificial jump for women (who drink a much larger portion of their alcohol in the form of wine) at the time of the adjustment.

I was not going to write about this because others covered it very nicely and my first thought was that I had little to add to what had been written (this one is particularly good and is at a great blog about beer, and it links to the two other good ones).  These other bloggers noted in particular that the ONS had previously attached a note to their own statistics reminding users/readers that the adjustment in 2006 needed to be considered when analyzing the data, and that when the new report was aggressively challenged, they appended a retraction of the erroneous claim and apology.  But, the bloggers also note, as far as they could find, none of the press outlets that breathlessly reported the original claim have printed a retraction.

The reason I decided to write about this was that I read about another possible example to watch out for;  I was sure there would be a third if I waited a few more days, but not so far, so I decided to run with the two.  The other example, reported by the CAGE blog, starts with the observation that in 2008 India adjusted their body mass index cutpoint between "normal" and "overweight" down from 25 to 23.  Just to put that in perspective, many Western countries adjusted "normal" down to 25 earlier in the decade, where it remains; even this is so low as to be meaningless, roughly translating into a reasonably muscular man of average height being "overweight" if he is carrying only about six or eight kilograms more fat than someone who would be described as skinny or is at body-sculpting levels of fat.  CAGE predicted in 2008 that this would lead to the claim that there is an increase in obesity in India and are now saying that this has happened.  They did not actually find a smoking-gun report of a time series that ignored the adjustment like the ONS case, but they reported news that hints that people are making that mistake less formally.

Unlike the British cutpoint for women drinking too much alcohol, which at least is just (just!) into the range that is believed to start to be harmful, the BMI cutpoint of 25, let alone 23, is well below the start of the range that has been shown to be unhealthy.  The measure just makes no sense at all.  It was interesting that the Times of India article CAGE linked to in their 2008 post said, "Doctors say these guidelines are the need of the hour since the number of those suffering from obesity and related problems is on a rise," (as if the bizarre definition change would somehow help people who were actually obese) and made various hand-waving statements about Indians being somehow different from other H.sapiens.  While there is no direct connection, this strikes me as strangely similar to the reports of India trying to ban their incredibly popular dip products (oral smokeless tobacco and non-tobacco products) that I have written about over the last few weeks.  It is hard not to get the impression that the elites in India think that because of their unusual history and head count that they can just decide their part of the world works differently than the rest of it.

(Yes, I know, it is pretty rich for an American to be chiding someone else for practicing nationalistic exceptionalism.  The only defense I can offer is that most of those who make claims about American exceptionalism seem not to suggest that the rules of economics or biology affect us differently, but rather stick to claims about exceptionalism in ethics and socio-political matters, which are at least theoretically defensible though are quit dubious in practice.)

Anyway, the take-away points about these statistical adjustments are the following:  Changes in definitions like this occur all the time, and they are not difficult to deal with.  The two examples presented here are utterly trivial to deal with since they are just a change in labeling; someone doing a time series analysis today can just convert pre-change statistics to post-change ones (or vice versa) and report a consistent number.  That is, if someone wants to report the time trend in British drinking that runs through 2006 all they have to do is recalculate the pre-2006 quantities based on the post-2006 definition of "a glass".  If they want to measure the increase in "overweight" in India, it is easy to apply the silly new definition to old BMI measures.  In other cases there is a shock to the data that is not just an arbitrary change in how to label the data, such as when the phrasing of a standard survey question changes in a way that gets radically different answers, often because no one realized the change would matter (e.g., if the "same" survey changes from asking men "did you have gay sex in the last year" to asking "did you had sex (including oral) with a man in the last year", there will be a huge jump that cannot be corrected in the same way as a changed interpretation of the data).  In that case, the standard approach is to put in a variable that is whether an observation came before and after the change, which basically means assuming the time trend is continuous and that the jump that year is an artifact.  The same method can be used for a case like the wine or BMI if you only have the definition (you have the label "overweight" or "normal", but not the actual BMI number), though in that case if you are doing a study and sending out a press release (as ONS did), there is no excuse for not going back and looking at the raw numerical data.

Given how simple this is, and that it is probably taught in the second or maybe even first semester of any decent applied statistics program, there is no excuse for the British study.  This is not something that an even slightly competent researcher could possibly fail to notice in the data even if they somehow overlooked the information about how the definition changed ("hmm, lets' look at the trend from year to year: down a bit, down a bit, same, down a bit, huge increase, down a bit, down a bit – yup, it sure looks like an upward tend to me").  Either someone was intentionally trying to mislead their audience or they were in so far over their heads – and by this I mean they knew absolutely nothing about analyzing statistics, but did so anyway – that they had no excuse for claiming their analysis was worth anything.  Either way, it is important to recognize the difference between honest disagreement (which this obviously was not, since the ONS retracted it), honest mistakes (which this was not because the mistake is too glaring to make honestly), and dishonesty (either in the form of lying about the world or about one's qualifications).

The jury is still out on India about that point.  I will wait to see if I or CAGE can find a case where someone explicitly and quantitatively mis-reports the time trend.  Perhaps, notwithstanding the doubts I have about Indian government wisdom, such a technical error is less likely to happen.  After all, judging from the floods of impressive-seeming Indian applications to graduate school I have seen, there must be approximately one million people who have been educated in health statisticians in India.  (Interesting trivia:  That was at University of Texas.  At the University of Alberta School of Public Health we got very few applications from math-whiz Indians, who seemed to set their standards higher, and instead got floods of applications from unqualified Africans.)

So, though I had little more to add to what others had already written about these, there was a lesson that I will try to keep in mind:  Most newspaper readers, upon seeing the retraction of the ONS claim (if, hypothetically, they saw it), probably could not recognize that this was not some super-complicated mistake that a competent and honest group of researchers might occasionally make.  Therefore, it is important for those of us who recognize the difference – between subtle and possibly honest mistakes and the glaring dishonest ones – to point it out, and to not mince words about it.  Perhaps the credibility of political  factions who traffic in junk science would start to crumble if people could be shown how so many of the "little errors" they made were not mistakes that anyone could honestly make.

22 April 2011

Unhealthful News 112 - New official guide to masturbatory fantasies

Ethicists Update List Of Acceptable Things To Masturbate To
Unveiling what may be the most comprehensive guide to socially responsible self-pleasure ever published, a group of leading ethicists released Monday its list of things that are acceptable to masturbate to.  The 2011 edition of the Standards and Values in Autoerotic Practices is the first revision in 17 years of the venerable reference used to determine what images and thoughts are appropriate stimuli for bringing oneself to orgasm.
Just to avoid any confusion, that story was from The Onion.  But as with most of their best satires, the humor is based on calling attention to something that is quite absurd, but that we usually let pass without notice.  No, I am not talking about masturbation.  Although...  ...no, I don't think I can pull off that kind of humor.  What I am talking about are committees that form to make a bright-line declaration about something that has no bright lines, sometimes self-appointed and sometimes appointed by officials who also have no particular claim on the matter.

The observation (from Moynihan) that everyone is entitled to his own opinion, but not his own facts, has gotten quite a lot of play in recent American political debates (Google finds almost 300 hits in blogs from this month).  It usually shows up in the context of criticizing right-wing economic plans that not only represent goals that most Americans do not support, but also are based on assumptions that defy both simple facts and economic theory.  That is, people who are exercising their right to their opinion about what society's goals should be, generally an opinion that would be unpopular if they admitted to the details and all they imply, try to make up facts that make the implications of their goals more palatable, seem less costly, have miraculous benefits, etc.  A rather similar pattern can be found in some politicized areas of health science.  The most obvious are claims that public place smoking bans have miraculous health benefits; someone can believe that the bans are justified, but there is no justification for making scientifically nonsense claims (and if they feel those claims are necessary, it means they think that their opinion is not widely supported on its merits).

But the Onion story picks up on a different side of that truism:  Matters that are ultimately a matter of opinion cannot be turned into facts by convening a panel that gives us their opinions on the matter.  An expert panel certainly can help sort out scientific and technical ethical points, but ultimately their opinions that explicitly or implicitly use the word "should" are not facts.  So when a panel convenes to address whether we should maintain an aggressive military posture or whether e-cigarettes should be banned, or what is allowable when masturbating, it is possible that their opinions will be given the force of law, but they will never be facts.  (Note that this is separate from the question of whether such panels are good at answering purely scientific questions, which I will not address today.)

The Onion reports, "one of our top priorities this time was to eliminate all bias against homosexual impulses".  This might be a subtle reference to the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association's pronouncement about what constitutes psychological illness, in which homosexuality was officially considered a mental illness as recently as the 1970s.  Was this a fact?  Obviously not.  Is it a fact now that homosexuality is not a disorder?  Well, no, actually.  It might be a fact that it is inborn and irreversible in most cases, but the question of whether it is something wrong is a matter of opinion, and is not up to the APA to decide.  Unfortunately, when society reaches a rough consensus on such matters the result is sometimes quite disturbing.  But that cannot mean that some group of scientists, medics, or philosophers can assume the right to form society's opinion.  In the case the DSM and homosexuality, the changing of the official condemnation of homosexuality in 1974 lagged the enlightenment already shown by educated engaged members of society, and even by the government.

If it was at all controversial that,
 For the 23rd consecutive edition [of the Standards and Values in Autoerotic Practices], masturbating to a litter of newborn puppies is classified as "wrong, wrong, wrong.",
then the declaration of the fictional ethicists would have no merit.  What makes the declaration reasonable (and funny) is how obvious it is.  However, it would be nice if the experts would offer some explanation as to why it is wrong (which might be the same as "why society thinks it is wrong").  That was missing form the satire just as it is missing from most real Official Pronouncements.

Even ethicists, let alone psychiatrists or other physicians, have no special claim on what is ultimately good and right.  What they can offer is some insight into how to sort an analyze opinions.  So, to draw on extreme versions of the present example (might as well run with it), there is a tough question about the ethics of getting off from looking at a photograph of something such that (a) it would be unethical to take the photograph or distribute a photograph of (say, a surreptitious photo of someone through her window, though there are much worse example) or cause the event to happen, but (b) the ogler had nothing to do with any of those and just found the photo on the web.  This is akin the question of what to do with the medical knowledge the Nazis acquired by basically torturing innocent people to death.  There is a similar question about an image that pretends to be something unethical, like a photo of a young-looking 18-year-old woman posing to give the illusion that it is kiddie porn, or even just imagining the unethical with no intention of ever acting on it.  The ethicist can aid in sorting out these questions (e.g., to separate consequentialist points from symbolic issues) and there are also questions at the border of science and ethics that might be answerable (e.g., how the decision might create incentives for future behavior).  The value of that type of analysis should not be underestimated.  Unfortunately, when the panel's opinion is reported in the news, it is simplistic and inappropriate conclusory statements that are reported, not useful analysis.

Consider a case of doing it right:  The FDA scientific advisory committee on tobacco formed an opinion about whether menthol in cigarettes causes disease.  Notwithstanding the criticisms of the committee for their political biases, they seem to have gotten the answer right.  But they annoyed some commentators by not stating their opinion about whether menthol should be banned.  However, they get credit for getting that bit right too.  After laying out the costs and benefits as best they could, their opinion about what to do would add no further information.  Perhaps they are a dozen of the ten thousand people in the world who have done the most intelligent, insightful, and educated thinking about the question, but they are certainly nothing more.

Additionally, the conclusions sections of research papers act quite similarly.  Insofar as the conclusions relate to interpreting the results themselves, they have a bit of value.  Just a bit though – I have a friend who has done lots of systematic reviews, and he told me he never once paid any attention at all to what the authors concluded that their results meant.  The authors' opinion about what we should think about the world, let alone should do, is worth about as much as a Twitter post.  An analytic paper that argues or analyzes how to think about a normative question can come to legitimate conclusions about how the world is or what should be done.  But adding such a conclusion to the statistical analysis of one dataset provide no more backing or context than a tweet.  And yet it is that tweet that is typically featured in the news reports about the study, panel, or whatever.

The Onion story is funny because of all the popular human endeavors, masturbatory fantasies might be the one that is least vulnerable to control by Big Brother.  Even people in Saudi, Zimbabwe, or Bhutan can think about puppies if they really want to (though we can still hope that none of them actually do).  But the concept of having a panel deciding about allowable fantasies is remarkably similar to a committee deciding whether smoking or addiction is officially a disease, or how many weeks of gestation makes inducing abortion unethical, or whether there is such thing as autism spectrum disorder.  These can be legal questions, so some legal rule might be needed for practical purposes, but these are not factual questions, and so the right to have an opinion is not removed due to the pronouncement of an panel.  The panel's opinion is no more immune to counter-argument than anyone else's opinion, and obviously should never be cited as anything more than the opinion of a short list of fallible humans.

Finally, to end with a bit of a plot twist, I am going to offer a one paragraph argument that not everyone is really entitled to their own opinion.  Everyone gets a vote – that is a practical matter of law.  But if there actually is a body of scientific evidence and a careful analysis about how to think about the ethical aspects for some question, then you really should understand those before forming an opinion.  Failing that, you are not entitled to the opinion.  It is not ok to say "we should ban all public smoking" because you believe that passing exposure to second-hand smoke is substantially harmful (which would be a case of having your facts wrong) and because you have a vague notion that it endorses immoral behavior (though you have no idea what that even means and have never considered a careful analysis of the point).  You have the opinion, but it is not worth any more than your opinion about how to build a particle accelerator or the when humans first settled Hawaii, and your "entitlement" is rather shaky.  While you may have the legal right to espouse and even promote that opinion, you are on very shaky moral ground in doing so.

21 April 2011

Unhealthful News 111 - Black markets are just markets

This is mostly background, with just a bit of news.  It is relevant to yesterday's UN110 and an entry in our weekly reading list about THR, but did not really fit in either.

India recently banned the selling of "dip" products (sometimes incorrectly referred to as smokeless tobacco, but most of them are predominantly other plant matter, like betel nut, and other chemicals, rather than tobacco) in plastic pouches.  These single-serving products sold for the equivalent of a penny or two and seemed to be available on every block.  This odd new restriction could have been justified as a way to reduce litter, since those billions of little non-degradable wind-blown plastic pouches do make quite a mess.  But as I noted in UN64, proponents made it quite clear that this was a way to increase the cost of manufacturing and thus make these products too expensive for the "common people" (their phrase, not mine).  It is the Indian equivalent of location-specific smoking bans that supposedly have something to do with protecting nonsmokers, but are really just about making being a smoker less pleasant.

Like any supply-side intervention designed to reduce consumption, the plastic ban created a tension in the marketplace between the incentive to manufacture a desired product in the most efficient way, selling it for maximal profit in a free market, and obeying the rule.  The same principle actually applies to any regulation of a producer, such as pollution limits or rules against keeping employees chained to their work stations.  Purely from the perspective of making and consuming the good in question, it is more efficient for the manufacturer to ignore the rules.  The resulting efficiency gain from breaking the rules is split between the consumer (lower price) and producer (greater profit) in a proportion that is determined by some technical issues known as price elasticity, as well as whether others are obeying the rules.  I mention that last just to throw in an argument against those who suggest that producers decide how much profit they are going to make at consumers' expense; it is more accurate to say they take the best they can get, which is based on forces beyond their control.

Anyway, the most efficient way to impose a supply-side intervention to lower consumption is taxes, but it is not the only way.  Anything that raises the cost of supply, such as requiring expensive packaging or periodically imprisoning people in the supply chain, has a similar effect on price and thus demand, but at a much higher social cost.  If you impose a tax, the price increase is an efficient transfer – that is, everything that the consumer loses the government gains – so there is no net loss to total social wealth.  Whereas if you raise real production costs then the extra price paid by consumers is just burned up in by the higher costs, lost to the world.  Or to put in terms that would be better understood by a government official, taxes not only raise the price, but provide more money for the government, so are win-win (assuming raising the price really is a win, of course).

So why a ban on plastic packages?  Presumably the brains(?) behind the plastic package ban must have decided that imposing an equivalent tax would not work because the Indian government was not functional enough to enforce collection.  So, the fact that they chose to forgo taxation suggests they did not think they could enforce it, due to inefficiency, corruption, etc.  In some sense it is a clever solution:  It is quite difficult to figure out if taxes have been paid on a particular unit of product or if they are being collected at point of sale, but very easy to see if the cheaper plastic is being used.

But if that is the explanation, why, oh why, did they think that they could prevent some kind of black market from emerging?

Alternative markets are ways of taking advantage of the aforementioned tension and gap between the efficiency of unregulated competitive market and obeying all the rules.  The bigger the tension/gap, the more profitable and successful will be the black market in the absence of really intense enforcement efforts.  So since cannabis cannot be sold in stores, alternative supply chains spring up, with the higher-than-free-market prices reflecting the cost of occasionally being arrested or shot at, though the fact that prices are remarkably low means that enforcement is pretty ineffective.  High cigarette taxes create a enough of a gap between the free market and paying full price that there is room for both profit for the smugglers/counterfeiters and lower prices for consumers even though the illegal supply chain is much less efficient than those of the major legal manufacturers.  And even something as unexciting as taking Coke out of the vending machines in the city office buildings in Boston will inevitably result in some bored cubicle workers supplementing their income and helping out their neighbors by bringing in a cooler full to sell every day.

Anyway, my motivation for writing this explanation of markets in the face of prohibitions and partial prohibitions was just to give an excuse to quote this passage from The Times of India about how, sure enough, a black market in plastic packaged dip appeared almost immediately:
MUMBAI: The racket, involving the smuggling of gutka pouches into Maharashtra from neighbouring states like Gujarat to be sold here at thrice the actual price [emphasis added], continues unabated in the thriving black market.  The blackmarketeers are making huge profits by selling the banned gutka and pan masala sachets by charging three times the actual prices. One popular brand of gutka, whose MRP is Rs 4, is being sold for Rs 13, and another brand, whose MRP is Rs 7, is sold for Rs 20.
The rather vital fact that the reporter seems to not understand is that the actual price of something is whatever it is sold and bought for.  (Am I the only one who laughed out loud at that?  I am a bit afraid that I might have been.)  Yes, obviously we can just substitute "MSRP" or the "former price" for what he called actual price.  But I think there is more to this misunderstanding than mere incorrect wording in the national paper of record.  Factions in India keep talking about expanding the plastic ban to a complete ban on the products, thinking that would work out well.  But this story demonstrates that consumers are willing to pay at least triple the competitive market price for the product and, in a country with a lot of under-employed labor, that is undoubtedly enough of a gap to support a very nice black market.  A government that decided that it could not enforce a tax increase seems unlikely to be able to stop it.

There is nothing exotic or remarkable about this.  If those who have control over a market supply a lousy product or charge too much for it, or refuse to supply it at all, someone will step in.  That is the story of the market that gives us e-cigarettes (because pharma companies refused to produce a good cheap nicotine product), Firefox (because Internet Explorer was so lame), and crystal meth (because importing cocaine was made difficult).  You really have to wonder if the Indian government thinks it can succeed where Glaxo, McNeil, Microsoft, and the U.S. government failed.

[Coda: The examples in the last paragraph were chosen because they were cases where the previous products were creating huge fortunes while the entrepreneurs offering the alternatives have done ok, but have mostly earned only a workaday modest living through their efforts.  Market innovations like these often create a lot more surplus for consumer than for producers, Facebook and the question of whether meth is really good for anyone notwithstanding.]

20 April 2011

Unhealthful News 110 - NYT manages to report about overdoses without reporting on drug use

To clarify that title, this New York Times article described some of the damage that recreational use of prescription painkillers is causing, focusing on the Appalachian population in the state of Ohio (my own ancestral culture and home state).  The report includes the observation that overdoses have surpassed auto accidents as the leading cause of accidental death in Ohio, a staggering statistic that I had not heard before, but that seems plausible.  But somehow the authors of this and a related piece, also in todays NYT, seem remarkably uncurious about why people are willing to create such risks for themselves and harm to others in order to use OxyContin and such.  And, no, the substitution of the phrase "drug addiction" for "drug use" does not count.

(Aside:  That word substitution is not only knee-jerk rhetoric, but is also a pretty silly non-equivalence.  "Addiction" is a vaguely-defined existential state, not an action.  This makes it rather embarrassing that a reporter, presumably someone trained in proper use of language, would write that people "died from addiction" rather than from overdose or long-term use, but she did.)

The related article was a story about how the Obama administration has introduced a plan to try to further restrict the supply of these drugs.  Isn't it funny how the NYT runs a non-timely feature story about the effects of prescription painkillers on an Ohio community on the same day it reports this proposal?  Well, no, it is not funny or surprising at all given that the NYT news department, along with much of the rest of the U.S. corporate media, generally tries to carry water for whoever is in power in Washington (strangely, the NYT analysts and editorial writers offer a more balanced view than the news reporters).  After all, the NYT led the war drumming and dissemination of disinformation that facilitated the Iraq War.  This does not affect most of the health news since it is not usually related to Washington power politics, but drug use is an obvious exception.

If the press merely decided to conveniently highlight a problem in order to bolster the message that government intervention is warranted, the damage would be limited to over-hyping the problem of the day.  But the reporting implicitly supports the specific policy approach, though it is hopelessly flawed.  The Obama plan is a simplistic attempt to raise the street price of the drug (which is to say, make the supply chain less efficient – they are basically the same thing) by imposing mandatory training before a medic is allowed prescribe it.  This would likely have a trivial effect, given that someone in the business of supplying these drugs for recreational use, as enough medical clinics are, is probably already quite familiar with the intended lessons on how to "unmask patients feigning pain to get drugs they then abuse".  Indeed, they probably consider such knowledge to be central to their business model.  At most, the plan would restrict supply a bit, driving up prices, and thereby creating more incentive for blatant prescription mills and the pure black market, and for the associated violence whose toll the NYT article laments.  This concern, however, was absent from both articles.

Great plan, Obama.  Great reporting, NYT.  This might seem to be surprising behavior from these particular factions, but as I have noted before, the madness of the American Drug War seems to come more from what is thought of as the political left.

Starkly absent from the discussion, as I allude to in my title, was any acknowledgment of why someone might want to use these drugs.  There was no mention of their benefits or appeal, nor even of the sense of pessimism in that community that would lead to drug use that hardly even seems beneficial.  There was no apparent awareness that serious reduction in use requires demand-side interventions.  Curtailing supply when people are willing to kill for these drugs, as the NYT report described, will lead to more acts of desperation as well as switching to equally dangerous drugs.  Of course, dealing with the big picture would require Obama or the NYT to stand up to the oligarchs and call for a serious economic stimulus plan and other interventions that would provide hope for the nation's working class.  This is just not going to happen.  Another solution to some of the problems would be to try to encourage the substitution of other drugs that offer some of the benefits but with little overdose potential and less of the behavior that is attributed to addiction.  It seems like the most promising intervention would be to shift the cultural norms from pain pills (and that other scourge of middle-American, methamphetamine) to cannabis and other low-risk drugs.  Of course, promoting sensible drug use is even less likely to happen than a stimulus plan.

Also not mentioned in the articles are the many people who "abuse" these drugs to relieve chronic pain – which is to say, they use the drugs as designed, and with good reason, but without Big Brother writing an Official Permission-Slip.  There will always be a black market for these drugs, even if the authorities shut down the gray market prescriptions, because they are so valuable to some people who cannot otherwise get them.  Most other recreational drugs, excepting heroin, are no substitute for pain killers when someone suffers terrible pain but anti-drug madness prevents them from receiving enough treatment legally.  Of course, it would be nice if someone could develop highly-effective pain killers that were not so "addictive", but something is better than nothing.

It would also be nice if we had a press corps that: would avoid writing stories about the human condition without actually communicating with the humans at the center of the story (no actual drug users were troubled with a request for a interview in the making of this article); does not assume that proposed laws are a good idea and will accomplish what is promised just because some guy who wears a suit said so (hint: if the guy in the suit reports to the person who proposed the policy, or actually is that person, then he has a bit of a conflict of interest when assessing it); and is not willing to accept that the solution to any major problem is to just tell all those clueless idiots to quit doing what they are doing (because, of course, no one would ever do anything that hurt themselves and spilled over onto others, except out of ignorance).

19 April 2011

Unhealthful News 109 - New York bans freeze tag (no, not really)

Hundreds of news outlets reported today that the state of New York has backed off on rules that were widely interpreted as declaring that such games as freeze tag and whiffle ball are unacceptably dangerous and thus need to be regulated.   I know this story sounds like it might be more at home at one of the blogs devoted to defending our liberties against the encroaching nanny state, and I suspect it will be covered there.  But I am going to go rather a different direction than you might guess, since I interpret the whole story a bit differently and contend it is actually rather more more interesting than the "evil government gone wild" story.

It is true that the government had implemented regulations that classified various low-risk childhood pickup games in the same category as archery or rock climbing.  But the category was not a restriction on individual choice, but rather a way of determining if an entity sponsoring youth recreation needs to meet the permitting and other requirements that are imposed on outdoor youth camps that provide certain hazardous activities.  The apparent concern was that some organizations that offered youth recreation (which are referred to as indoor camps in most stories, though it sounds like the rules applied to less formal operations, like community rec centers) were skirting the rules, and so there was need for a clear definition of when certain rules apply.  Put that way, it does not seem so egregious.

After all, it is reasonable to not allow a drop-in rec center to set up an archery course or teach BMX stunt riding to young children on the basis of, say, one of the 18-year-old summer employees at the facility being an aficionado of the activity and thinking he can teach it.  Yes, sure, parents need to take responsibility and all that, but I think even the libertarians among us can agree that simply forbidding kids from stumbling into certain situations are reasonable.  Parents are responsible for long-term issues like bad eating habits, but they cannot know what is happening every minute.

So some rule makes sense, and the problem came in the details of New York's regulation.  It seems quite likely that some low-level apparatchik was assigned the task of making a list of the dangerous activities that triggered the regulation, and just went in a dumb direction with it.  Then the regulatory agency was pressed to get a rule implemented in time.  It does not really have the capacity for critical pausing and reality-checks about what its employees are doing, since it has barely enough capacity to meet its various mandates in any way.  So the silly rules were implemented, only to trigger a backlash when a member of the legislature received complaints and took on the cause, resulting in the regulators belatedly realizing that someone in their house had done something really dumb, and backing off on it.  That is my theory of what happened anyway, a pretty common story.  The news reporters did not seem to have ferreted out the actual story – an activity that many of them are quite good at, by the way (as opposed to them not being good at reporting on scientific research, the usual theme of this series) – but it will probably come out sometime and get reported on page 20 of a few local newspapers. 

A closer look at some of the more in depth stories reveals more.  The impetus for the law seemed not to be any legitimate source of worry – nor even a single tragic event, the usual motivator for overly-cautious rules.  Rather, it was the cause of so much regulation:  One set of businesses is trying to use government to give them an advantage over another set of businesses.  That is, the traditional summer camp operations that offer genuinely dangerous activities were clearly subject to existing licensing and other requirements, so they lobbied that the new requirements be imposed on their competitors that run indoor day camps (which generally did not offer the same dangerous activities, but might have included some slightly hazardous outdoor play) to force them to deal with the same burdens.  Given this observation, it is possible that whoever designed the details of the regulation was not actually so stupid as to think that freeze tag and rock climbing belonged on the same list, but rather was  the pocket of Big Camp (yes, really – the new regulation was apparently pushed by the New York Camp Directors Association).

As for the activities themselves, it was an amusing list.  (Part of the amusement came from realizing that not everyone knows what all these games are, even in America.  Was mine really the last generation to play freeze tag on the playground?  How can people not know that game?!)  Some activities make sense to regulate like rock-climbing and archery.  But it is silly to lump in tag and whiffle ball (which is like baseball but with a hollow plastic bat an a lightweight plastic ball), which are probably less dangerous than kids just engaging in free-play.  (Are kids allowed to do free play anymore?)  Falling in between, though not treated any differently from freeze tag are some activities like dodge ball and red rover (the kids form a human chain, locking hands or arms, and another kid smashes into them trying to break the chain – or bones) that perhaps could use a little discouraging, if not more.  These activities are nastily violent and have as their core feature potentially damaging trauma.  American football falls into that category too.  It would be hard to argue against a regulation that actually prohibited organizing these activities for kids who are too young to make decisions about their own health.  Kickball, on the other hand, is quite tame as sports go.  And I will not go into activities that are more subtly dangerous like tug-of-war and see-saws – you get my point.

Thinking about the details a little more reveals another problem, one that picks up on the classic reasons to be suspicious of regulators as a matter of habit.  The regulation in question focused on requiring the organizations to pay a fee to the government to get a permit, which is the side of regulation that almost seems like it is designed to make people distrust and hate government.  Obviously this alone would make a minimal contribution to protecting the kiddies.  The only other requirement was having medical staff on site, which is reasonable for a summer camp with a few hundred kids in residence, and obviously prohibitive for a small-town recreation center with a $200/day budget and a few dozen kids dropping in. 

Perhaps most interesting was that the one rule that prompted the funny news reports was not really the problem; it is the entire set of regulations that is misguided.  They were not too strict nor too permissive; the were completely in the wrong direction.  Having medical staff on hand makes sense if you have the kids playing American football, but again, they really should not be doing that.  But for a rock climbing wall or archery range, what is needed is adequate supervision by adequately trained staff.  With that in place, the activity is less hazardous than basketball or just running around the neighborhood.  No medical staff boondoggle is required.  But the problem is that it is impossible to write a regulation that describes what constitutes adequate personnel, skill, and equipment for a supervised climbing wall.  Those of us familiar with the activity know it when we see it, but if government decides to write down rules, such common sense and folk knowledge gets pushed out.  Which is why the useful rules for climbing gyms were created by agreement of those who do that activity, not by outside regulators.

At the same time, a good case could be made not for just getting rid of the rules, but imposing some limits on truly dangerous activities.  For those who support the idea of libertarian paternalism, no banning would be necessary:  Perhaps we should just require parents to sign activity-specific permission slips, like they presumably do for rock climbing or football, before people supervising children can assign them to play red rover.  Yes, drawing the line is difficult.  But it already exists, so we might as well get it in roughly the right place.   Keep in mind that saying a regulation "goes too far" implies that some other regulation, rather than no regulation at all, would be just right.

To bring this back to a few general lessons about the health news, and more specifically making sense of debates about health regulations:  It is easy to think of government as being some thoughtful monolithic actor with enormous resources behind its every move.  But most of the time the details, as initially implemented, are the random result of a few people's disorganized decisions.  Mature regulations are not quite so laughable because the rules evolve by natural selection over time to get rid of the worst of the rough edges.  Many of my readers are familiar with the recent FDA decision to declare certain smokeless tobacco products to not be smokeless tobacco products, and thus not subject to FDA tobacco regulations.  There was a huge outpouring of consternation about the absurdity of this, as well as attempts to figure out its deep meaning, based on the assumption that the decision was carefully thought out, intentional in all its implications, and permanent, though it was probably none of those. 

Additionally, it is useful to realize that many proposed actions that seem absolutely silly in isolation were the product of some reasonable goal combined with someone just not having the chops to implement it well.  But that offers no excuse for them not backing off of dumb ideas once someone takes a closer look and calls them on it.  Finally, to get really cynical, most (not all) health regulations are designed to benefit an organized special interest group, not the general public.  In light of that, we should actually be pleasantly amazed that our regulatory systems turn out as good as they are, and that we have only as many unhealthful health regulations as we do.