Seth's Blog

“I can say what I really think,” said Tyler about blogging a few days ago. Not only that, (a) this truth-speaking is on a topic he cares about, (b) what he says is based on considerable knowledge (what an ignorant person “really thinks” about something isn’t helpful), and (c) a lot of people listen. This is a potent mix.

The magic of blogging is that when you start you can tell the truth because no one is listening. With zero audience, it makes sense — it feels good — to tell the truth. If you are an expert like Tyler, this sort of thing is irresistible to readers (economics confidential) so your audience grows. Now it is too late to start censoring yourself; people are reading your blog because you tell the truth.

Tyler’s blog.

Speaking of empowering patients, this is incredibly important.

He clicked on baclofen, and the Web site informed him that nearly 200 patients registered at PatientsLikeMe were taking the drug. He clicked again, and up popped a bold bar graph, sectoring those 200 across a spectrum of dosages. And there it was. Contrary to what his neurologist told him years ago, 10 milligrams wasn’t the maximum dose. In fact, it was at the low end of the scale. “They’re taking 30, 60, sometimes 80 milligrams — and they’re just fine,” Small recalls. “So it hits me: I’m not taking nearly enough of this drug.” A few days later, Small asked his neurologist to up his dosage. Now Small takes 40 milligrams of baclofen a day. His foot drop isn’t cured — there are no miracles in M.S. — but he has found that after 14 years, he can walk to his car without sinking into quicksand.

Long ago diabetics did not have access to blood-glucose meters. Doctors resisted this innovation, now considered the greatest advance in the treatment of diabetes since the discovery of insulin.

Thanks to Tyler Cowen.

I asked Bryan Caplan what effect his blogging had had. It made his first book a success, he said. Or helped make it a success. He had started blogging about two years before it appeared. Other bloggers wrote about his book as if they knew him. They knew him from his blog.

I am visiting George Mason University. Yesterday, as I was answering email, I heard a class in progress on the other side of the partition by my desk. It was Robin Hanson lecturing about the economics of health care to 20 undergraduates. It was so interesting I ended up listening to about 90 minutes of it. “Do your students know what a great class they’re getting?” I asked Robin during a break. “I don’t know myself,” Robin replied.

I have heard hundreds of professors lecture. I had never heard anything like this. It wasn’t the usual stuff. It wasn’t the usual stuff made entertaining with cartoons or demonstrations or jokes or war stories. Instead, it was a straightforward look at how the medical profession operates, and a lot of it was about how it operates to empower doctors, reduce the power of patients, and reduce health care innovation. Robin traced the history of the profession from the 1800s until today. “What separates a trade from a profession?” he asked his class. Professionals have ethics, he said. Doctors devised a code of ethics. At the top was “first, do no harm.” What does this mean in practice, he asked his class. If a patient dies, does the doctor feel shame? No. If a patient wants a medical procedure that isn’t recommended, does this mean the doctor doesn’t do it? Apparently not. In contrast to the remarkable vagueness of “first do no harm” the rest of the doctors’ ethics code was quite clear: no practice without a license, no advertising, and so on — each item with clear economic implications.

Robin also discussed how little doctors are supervised. A British doctor managed to kill over 200 people before anyone noticed; he was finally caught only because he forged a will. A nurse at a local hospital was assigned to measure how often doctors wash their hands. They’re supposed to always wash their hands but many do not. The nurse did the survey, and, as requested, correlated hand-washing compliance with death rates. It turned out that the doctor who washed his hands the least had the highest death rate. The nurse reported this. The exceptional doctor had her fired.

On and on like this. Several books cover bits of this territory. A Sacred Trust by Richard Harris, very well written, is about how the AMA fought public health legislation. Overtreated by Shannon Brownlee, which Robin assigned, is a recent overview. The nice thing about Robin’s critique is that it was very accessible and at the right level of detail — I didn’t have to spend 10 hours reading a book to learn what Robin said in 20 minutes — and it was very wide-ranging. During my last visit to GMU, Robin had told me about the RAND study that found groups with different access to health care had the same health. Uh-oh. This was a much broader, more narrative look at same thing — how well is our health care system working? — and was a kind of explanation of the results of the RAND study.

A friend living in Holland writes:

I found this word [beleg] in my Dutch/English dictionary today.

Definition 1: to declare martial law. Definition 2: sandwich filling.

huh?

Speaking of ignorance, after all this time, we don’t understand the effects of artificial sweeteners. Excellent health journalism by Jill Adams. The Shangri-La Diet shows we didn’t understand the effects of sugar. (Universally believed to be fattening, even by Gary Taubes, it turns out to be extremely slimming under some conditions.) Which we have been eating even longer.

Thanks to Dave Lull and Andy Pattantyus.

I’m impressed:

This is the story of Olivier Ameisen, a brilliant physician and cardiologist who developed a profound addiction to alcohol. He broke bones with no memory of falling. He nearly lost his kidneys; he fractured ribs and suffered a hemopneumothorax that left blood and air in the sac around his lungs. He gave up his flourishing practice and, fearing for his life, invested himself in Alcoholics Anonymous and, later, rehab. Nothing worked.

So he did the only thing he could: he took his treatment into his own hands. Searching for a cure for his deadly disease, he discovered baclofen, a muscle relaxant that had proven effective in curing rats addicted to every substance from nicotine and alcohol to cocaine and heroin. Ameisen prescribed himself the drug and, over a two-year period, experimented with the dosage until he reached a level high enough to leave him free of any craving for alcohol. That was four years ago.

Nathan Yau has posted results from the first two weeks of a self-experiment about procrastination. He tried

1. making a to-do list every evening for the next day

2. blocking the sites he wastes the most time at.

The results were not what he expected.

Understanding and investment go together: The more you understand something, the more you should invest in it. On Friday, Bear Stearns owners thought their stock was worth $30/share; they were utterly wrong, it turned out.

In this sense, self-experimentation — research so cheap it can be done as a hobby — is a statement of complete ignorance. Because it is so cheap, you can test a hundred absurd ideas. If you use more expensive research methods, you cannot afford to test ideas you think are absurd. You must search a smaller solution space. If you are not correct about where the answer to your question will be, the region of possibilities that contains it, your research will fail to find it.

My self-experimentation about why I was waking up too early revealed that I was almost completely ignorant about what I was studying. Two of the causes I found — eating breakfast and not standing enough — were not on my list of possibilities when I started. The Shangri-La Diet is outside the range of weight-loss methods that obesity researchers consider reasonable; without self-experimentation, it would never be tested.

The following letter is from a Swedish professor who was president of the European Society of Pediatric Allergy and Clinical Immunology. Background about Ranjit Chandra.

Lerum, March 16^th 2008

Dear Prof Roberts,

The correspondence/letters I have found or remembered are as follows.

1. In 1993, The European Society of Pediatric Allergy and Immunology, ESPACI) intended to publish a position paper on Cow’s milk allergy(1). In my position as secretary of ESPACI, I wrote that paper in collaboration with the authors listed. We had intense discussions on whether or not we should cite Prof Chandra, whom we all knew, but did not trust, mainly since we found his inclusion criteria and symptoms curious and not according to scientific knowledge at that time. We also opposed, since he had not performed any blinded oral provocation tests and several authors, e.g. Arne Host(2) have found that less than 50 % of those reporting symptoms at exposure had cow’s milk allergy at scheduled blinded oral provocation testing. I wrote a letter to the dean of the university of St John asking whether or not the rumors about Prof Chandra, that his nurse/secretary(?) had produced the results without the involvement of patients, were true. The reply was: ”Since the allegations against Prof. Chandra have not been proven or disproven, he is still in office”. I do not find that letter in my files.
2. In 1997 Ranjit Chandra published a 5 yrs follow up study on his cow’s milk allergic children(3). This paper included DBPCFC. Then some of my colleagues drew the conclusion that everything was in order.
3. In 1998 we published a second position paper together with the European Society on Pediatric Gastroenterology and Nutrition, ESPGAN, on cow’s milk allergy(4). At that time we accepted the Chandra paper, according to point 2.
4. In 2003 we were writing up three papers later published in PAI(5-7). These publications were based on papers read during the ESPACI/Section on Pediatrics meeting in Padua, Italy on Dietary prevention of Allergy. Since at that time I was President of ESPACI and Chairman of the Section on Pediatrics within EAACI and organizer of the meeting, I wrote (in collaboration with the speakers) paper I and II and Arne Host and Susanne Halken paper III. Since I was still skeptical of the data by Chandra, I wrote a letter on Feb 15 2003 to the dean of St John’s (enclosed), without any response. The three papers were published in 2004.
5. January 19 2006 I wrote once again to St John since I never got any response from the dean, correspondence enclosed.
6. On February 16 2006 I got a response from St John from Prof Strawbridge and responded. On February 20 2006 I got another response and again responded to Prof Strawbridge, Dean of St John, enclosed.
7. On Feb 24 I got a copy from German Friends and on March 3^rd another one from Arne Host on the (enclosed) TV series in CBC on January 29^th2006 and later

The rest you know much better than I do.

Actually, I don’t know whether my correspondence has any value on a website. But maybe you can use it for your documentation.

1. Businco L, Dreborg S, Einarsson R, Giampietro PG, Host A, Keller KM, et al. Hydrolysed cow’s milk formulae. Allergenicity and use in treatment and prevention. An ESPACI position paper. European Society of Pediatric Allergy and Clinical Immunology. Pediatr Allergy Immunol 1993 Aug;4(3):101-11.
2. Host A. Cow’s milk protein allergy and intolerance in infancy. Some clinical, epidemiological and immunological aspects. Pediatr Allergy Immunol 1994;5(5 Suppl):1-36.
3. Chandra RK. Five-year follow-up of high-risk infants with family history of allergy who were exclusively breast-fed or fed partial whey hydrolysate, soy, and conventional cow’s milk formulas. J Pediatr Gastroenterol Nutr 1997 Apr;24(4):380-8.
4. Host A, Koletzko B, Dreborg S, Muraro A, Wahn U, Aggett P, et al. Dietary products used in infants for treatment and prevention of food allergy. Joint Statement of the European Society for Paediatric Allergology and Clinical Immunology (ESPACI) Committee on Hypoallergenic Formulas and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition. Arch Dis Child 1999 Jul;81(1):80-4.
5. Muraro A, Dreborg S, Halken S, Host A, Niggemann B, Aalberse R, et al. Dietary prevention of allergic diseases in infants and small children. Part III: Critical review of published peer-reviewed observational and interventional studies and final recommendations. Pediatr Allergy Immunol 2004 Aug;15(4):291-307.
6. Muraro A, Dreborg S, Haken S, Host A, Niggemann B, Aalberse R, et al. Dietary prevention of allergic diseases in infants and small children. Part II. Evaluation of methods in allergy prevention studies and sensitization markers. Definitions and diagnostic criteria of allergic diseases. Pediatr Allergy Immunol 2004 Jun;15(3):196-205.
7. Muraro A, Dreborg S, Halken S, Host A, Niggemann B, Aalberse R, et al. Dietary prevention of allergic diseases in infants and small children. Part I: immunologic background and criteria for hypoallergenicity. Pediatr Allergy Immunol 2004 Apr;15(2):103-11.