Month: August 2009

Jane Jacobs and the Trouble with Medicine

Seth Roberts4 Comments

In Slate, Barry Schwartz and Kenneth Sharpe argue convincingly that viewing bad performance as an “incentive problem” (meaning bad financial incentives) can be a mistake. If you pay doctors per procedure, they will do more procedures (too many); if you pay them per person, they will do fewer procedures (not enough). The heart of their argument is this:

When day care centers fine parents who are late to pick up their kids, lateness increases. Why? Because the fine turns a moral obligation (come on time!) into a service for a fee (we’ll take care of the kids if you pay us more!). Another example: When Swiss citizens were offered an incentive for agreeing to have a toxic waste dump in their community, their willingness to accept it fell by half. Why? The offer of an incentive induces them to ask What’s in my interest? instead of What are my responsibilities as a citizen? And when people offer a stranger a token payment for help unloading a couch from a moving van, strangers are less likely to agree than if offered nothing. Why? Because the offer of money has turned the assistance from a favor into a job.

So far so good. At this point the authors get lost. Here’s their advice about fixing medicine:

It is tempting, in light of our argument, to ask how can we incentivize good medical practice, so that we get more of it. Our answer is simple but perhaps unsatisfying: Good medical practice should be, and can be, its own reward. Almost all doctors want to practice good medicine—at least before they get socialized by the grind of medical school, residency, student debt, malpractice premiums, and the like.

The sign of their lostness is that they have zero data to back up this idea.

In Systems of Survival, Jane Jacobs argued that we can see around us two systems of morality: a guardian system, which stresses loyalty and hierarchy, and a commercial syndrome, which stresses honesty and equality. Each is internally consistent; but they are quite different, and those familiar with one system have a hard time understanding the other. She had plenty of data supporting her points. She went on to say that when the two systems are mixed — when policemen are given ticket quotas (= when policemen are treated like salesmen), for example — things go bad.

Why two systems? Because they correspond to two broad ways of making a living: taking and trading. The systems aren’t arbitrary; they have survived because they worked.

Are doctors takers or traders? The flaw in trying to improve doctor performance by changing incentives is the balance of power: Doctors have almost all of it. Patients trust doctors. (When I asked my surgeon the basis for her judgment that I needed surgery — treating her as an equal, in other words — she must have been stunned. She certainly didn’t respond appropriately.) That’s why it’s so easy for doctors to do too much or too little. It’s the same problem with quota systems for policemen: The policemen have too much power. The current balance of power makes doctors takers rather than traders.

So the choice is: either reduce the power of doctors relative to patients or give them moral training as guardians. The first isn’t going to happen in medical schools. Jacobs would recommend, I think, that doctors should be taught that they are guardians. (She might use the example of her father, who was a doctor.) And that those interested in improving medicine should study well-functioning guardian systems to see how they work or worked — how the accompanying moral system was instilled.

Not All Probiotics are Wonderful

Seth Roberts3 Comments

From a mailing list I’m on:

Right before I left the U.S. I purchased Complete Probiotics from Dr. Mercola (online health guru). . . . I did not have the time needed to give these probiotics a good try before I left the States so I went ahead and purchased quite a bit. After arriving here in Beijing I began taking them just to find out they were not working well for me. I still think it is a good product, just not right for me.

I have 7 bottles total. 5 bottles expiration date: May 2011. 2 bottles expiration date: Dec. 2010

This batch I have has [in each capsule] 2 billion CFU [colony-forming units] and 500 mg of FOS [Fructooligosaccharides]. There are 90 V-caps per bottle. They are all completely sealed with shrink bands

Dr. Mercola’s sale price is $30 U.S.D. for a single bottle and about $25 U.S.D./each for a 3-pack. [the 3-pack costs $75]

She doesn’t say why they’re not right for her. I make kombucha for pennies per day. Homemade yogurt costs a few dimes per day. Also, they’re delicious, the kombucha is thirst-quenching, and the yogurt, as a condiment, improves many other dishes (salmon, soup, hamburger). So they’re easy to eat, whereas the vitamin pills I take I have to force myself to swallow. Because I am close to the making of the kombucha and yogurt — I sample them during brewing — I am sure that they have plenty of bacteria. With pills made in a factory, hard to be sure. And hard to know what those expiration dates mean.

Probiotics Prevent Colds

Seth Roberts3 Comments

Here’s a summary of a study that just appeared in Pediatrics:

More than 300 children between three and five years of age were randomly assigned to receive three different milk formulations: plain milk, milk plus the bacterium Lactobacillus acidophilus, or milk with Lactobacillus plus the bacterium Bifodobacterium animalis.

The group that just received Lactobacillus were half as likely to develop a cold and a fever. They also had fewer coughs and runny noses. Those that got both strains of probiotics had 72 percent fewer fevers. They were also less likely to come down with a cough or runny nose. If they did get sick, they got better significantly sooner. They also missed fewer days of daycare.

Here’s the abstract of that study:

OBJECTIVE: Probiotic consumption effects on cold and influenza-like symptom incidence and duration were evaluated in healthy children during the winter season.

METHODS: In this double-blind, placebo-controlled study, 326 eligible children (3—5 years of age) were assigned randomly to receive placebo (N = 104), Lactobacillus acidophilus NCFM (N = 110), or L acidophilus NCFM in combination with Bifidobacterium animalis subsp lactis Bi-07 (N = 112). Children were treated twice daily for 6 months.

RESULTS: Relative to the placebo group, single and combination probiotics reduced fever incidence by 53.0% (P = .0085) and 72.7% (P = .0009), coughing incidence by 41.4% (P = .027) and 62.1% (P = .005), and rhinorrhea incidence by 28.2% (P = .68) and 58.8% (P = .03), respectively. Fever, coughing, and rhinorrhea duration was decreased significantly, relative to placebo, by 32% (single strain; P = .0023) and 48% (strain combination; P < .001). Antibiotic use incidence was reduced, relative to placebo, by 68.4% (single strain; P = .0002) and 84.2% (strain combination; P < .0001). Subjects receiving probiotic products had significant reductions in days absent from group child care, by 31.8% (single strain; P = .002) and 27.7% (strain combination; P < .001), compared with subjects receiving placebo treatment.

The probiotics were given as pills. Such large safe improvements are signs of a nutritional deficiency being remedied. It would be very hard to produce a drug that worked as well.

Thanks to Tom George.

Genius of Common Sense

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From Genius of Common Sense, a new young-adult biography of Jane Jacobs by Glenna Lang and Marjory Wunsch, I learned that Jacobs was an independent-minded young girl:

When Jane’s third-grade teacher asked the class to raise their hands if they promised to brush their teeth every day for the rest of their lives, Jane refused to raise her hand and urged the other children not to raise theirs. . . Jane was expelled from school for the day.

Where have I read that before? In Chimamanda Adichie’s The Headstrong Historian:

Her teacher Sister Maureen told her that she could not refer to the call-and-response her grandmother had taught her as poetry, because primitive tribes did not have poetry. It was Grace who would laugh and laugh until Sister Maureen took her to detention.

Genius of Common Sense is plainly a labor of love, with a great selection of photographs and a belief in Jacobs’s importance that you might say “shines through the book like a watermark” (Nabokov). The subtitle is “Jane Jacobs and the story of The Death and Life of Great American Cities” but that isn’t right: It’s mostly about how Jacobs and her neighbors fended off Robert Moses to preserve Greenwich Village. Which is a lot more visual. As I read it I kept wondering what I would have thought of it had I picked it up as, say, a third grader. I read a lot of biographies for children back then. I might have been attracted by the weird title and helped along by the high ratio (1 to 1) of picture space to word space. I would have liked the underdog aspect. Would I have appreciated the humor of

Several years later the Lower Manhattan Expressway was to raise its ugly head again. “The rule of thumb is that you have to kill expressways three times before they die,” Jane quipped.

? Probably not. But maybe I would have noticed how much the authors cared about their subject.

Bacteria-Free Mice

Seth Roberts1 Comment

Bacteria-free mice have malfunctioning digestive systems and immune systems. Sarkis Mazmanian, an assistant professor at Caltech, has found that as little as one bacterial-surface molecule can make their immune systems work much better. Exposure to this molecule also protects the mice against a bacterium that would otherwise cause a mouse model of irritable bowel syndrome.

So far, so good: More evidence that we need bacteria for our digestive and immune systems to work properly. But then things get murky:

The Human Microbiome Project, an undertaking funded by the National Institutes of Health (NIH) to sequence the microbiota from hundreds of humans, has challenged itself with determining the relative quantities of all bacteria present in the human gut. With a known baseline of the bacteria present in healthy individuals, it will be much easier to understand which bacteria might be missing in diseased patients.

How we will find “healthy individuals”? I believe that almost everyone in America eats too little bacteria and has suboptimal health. Mazarian continues:

With a known baseline of the bacteria present in healthy individuals, it will be much easier to understand which bacteria might be missing in diseased patients. Hopefully, the Human Microbiome Project will lead to the discovery of other beneficial bacteria [in addition to the bacteria that Mazarian is studying].

“Much easier”? The bacteria that people need to be healthy must have been abundant in our environment long ago. We got vast amounts of bacteria from what we ate — bacteria that grew on food. To test the idea that these bacteria are beneficial you merely need to feed people bacteria-rich food (such as fermented food) and see if their health improves. This has been done hundreds of times, with highly positive results.

Bees and Kombucha

Seth Roberts9 Comments

After noticing how much it improved his own health, B Wrangler tried it on his bees:

In the early spring, I grade my hives strong, average, below average, weak. This year, I sprayed the below average hives with slightly diluted, about 30%, solution of overly ripe kombucha. It was probably about 3 weeks old.

The spraying was done incidentally, without any planning, etc., just to watch the initial reaction of the bees. After spraying, the below average hives were left alone, without any additional manipulation or observations.

The kombucha worked better than smoke for controlling the bees in a normal situation.

To evaluate the yard’s progress, I’d pop the covers off a couple of strong hives and a couple of weak hives every few weeks. Ten weeks later, I popped the covers off the below average hives and found they had a full super of honey, while all of the others, even those with larger bee populations had none. In fact, they hadn’t even entered the supers.

I was quite surprised to say the least! And I’d had forgotten about the incidental kombucha spraying until looking at my notes a week later.

This reminds me of the turning point in the discovery of Vitamin B1. Experiment 2 done by Christiaan Eijkman gave results opposite to Experiment 1. Eijkman was unaware, until he looked into it, that his chickens, the experimental subjects, had been fed different rice in the two experiments.

Thanks to Heidi.

Lucky Journalist of the Year

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John Seabrook of The New Yorker. In an article about the economics of rock concert tickets, with an emphasis on scalping, he appears to follow a New Jersey Bruce Springsteen fan who can’t get tickets to a show. All gone in 10 minutes, mostly to resellers. Later, due to government intervention, she is able to buy two, and on the day of the show wins a lottery for seats next to the stage — her dream. A surprise happy ending to the story. Like all of Seabrook’s work it was a pleasure to read but I wonder how Seabrook feels about it. Near the end it briefly mentions a new technology (paperless tickets) that makes scalping impossible. As if the problem was solved while Seabrook was writing about it.

Did Genghis Khan Read Weston Price?

Seth Roberts1 Comment

In Genghis Khan and the Making of the Modern World (2004) by Jack Weatherford, I read this (p. 87):

Compared to the Jurched [Chinese] soldiers, the Mongols were much healthier and stronger. The Mongols consumed a steady diet of meat, milk, yogurt, and other dairy products, and they fought men who lived on gruel made from various grains. The grain diet of the peasant warriors stunted their bones, rotted their teeth, and left them weak and prone to disease. In contrast, the poorest Mongol soldier ate mostly protein, thereby giving him strong teeth and bones.

To tenderize meat a Mongol would put it under his saddle while riding. I was pleased to read this because I eat a lot of meat and yogurt (but not milk). The source of this information is unclear but it’s a surprisingly modern comparison. Good Calories Bad Calories (2007) by Gary Taubes says much the same thing (minus the yogurt — the part that most interests me). Weston Price wrote many similar passages comparing people eating traditional food (= Mongols) with people eating modern food circa 1930 (= Chinese). Long ago, grain was modern food.

Thanks to Tucker Max.

Edward Jay Epstein

Seth Roberts5 Comments

Edward Jay Epstein, who was a media critic for The New Yorker in the 1970s, is a great journalist. For example, Diamonds aren’t forever? and Did Madoff act alone? Here’s something he said about the Warren Commission (to look into the assassination of JFK):

Part of the job of the Warren Commission was restoring confidence in the American government. And for this he had to pick seven very respectable men, men who would lend their name and probity to the report. The problem was, any seven men he picked of this sort, they would have very little time for the investigation.

Much later, still fresh. His personal website is the best personal website I’ve encountered. The financial crisis has given him a lot to write about. He has a new book on the movie industry (The Hollywood Economist) coming out next year.