Kevin Drum

Cheap Drugs

| Fri Aug. 27, 2010 9:15 AM EDT

Aaron Carroll writes today that we're addicted to new drugs even though older drugs are often just as good or better than the new ones. The problem is that we don't usually know this for sure since comparative studies are rare. However, a few years ago one was done for blood pressure medications:

There were so many drugs to choose from for this trial (at different costs) that the National Heart, Lung, and Blood Institute (NHLBI) primarily organized and supported a randomized, controlled trial to examine which was best. This study was enormous; it took place in 623 centers in the United States, Canada, Puerto Rico, and the U.S. Virgin Islands between 1994 and 1998, and included over 33,000 participants. Patients received one of four drugs:

  • Amlodipine, a calcium channel blocker
  • Doxazosin, an alpha-adrenergic blocker
  • Lisinopril, an angiotensin-converting enzyme inhibitor
  • Chlorthalidone, a diuretic

The last of these, the diuretic, was the oldest of the drugs, and by far the cheapest. However, at the end of the study, the results were clear. This old, cheap diuretic was significantly better at preventing at least one of the major types of cardiovascular disease when compared to the other, newer drugs. Since the diuretic was also significantly less expensive, it should be the drug of choice in initial treatment of high blood pressure. However, it usually is not.

I'm glad to hear it! My blood pressure has been slowly rising for the past few years, and last year my doctor decided I should start taking something for it. At first she recommended a beta blocker, but as we talked about it she said something that made me a little nervous (I don't remember quite what). "You know," I said, "I actually have a strong preference for the oldest, cheapest, best studied drugs around." She looked slightly surprised, but said that was perfectly reasonable and immediately prescribed a diuretic. I've been taking it ever since. (And, yes, I try to watch my sodium intake too.)

The whole post is worth reading. Sometimes new drugs are great, but I'm willing to bet that we waste upwards of a quarter to a third of the money we spend on pharmaceuticals because both doctors and patients have been brainwashed to always want the latest and greatest. But me? I like drugs that have been really well studied and are known to have infrequent and well understood interaction effects. In fact, new drugs actually make me kind of nervous. I am an insurance company's dream patient.

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A Climate Change Thought Experiment

| Fri Aug. 27, 2010 5:00 AM EDT

It's unfair to call Bjørn Lomborg a climate skeptic even if he did write a book called The Skeptical Environmentalist. He believes in global warming, after all. He just thinks it's not our biggest problem right now, and in any case, we can simply adapt to it when it happens. Here he is a couple of days ago on the possibility of a large rise in sea level over the next century:

Here are the facts. A 20-foot rise in sea levels [...] would inundate about 16,000 square miles of coastline, where more than 400 million people currently live. That’s a lot of people, to be sure, but hardly all of mankind. In fact, it amounts to less than 6% of the world’s population — which is to say that 94% of the population would not be inundated. And most of those who do live in the flood areas would never even get their feet wet.

That’s because the vast majority of those 400 million people reside within cities, where they could be protected relatively easily, as in Tokyo. As a result, only about 15 million people would have to be relocated. And that is over the course of a century. In all, according to Nicholls, Tol, and Vafeidis, the total cost of managing this “catastrophe” — if politicians do not dither and pursue smart, coordinated policies — would be about $600 billion a year, or less than 1% of global GDP.

It's a beguiling premise. Only $600 billion a year! And all it depends on is politicians pursuing smart, coordinated policies.

But there's something missing from this equation: namely that the money is largely going to have to be spent in some of the poorest countries on the planet, and it's going to have to come from the richest. But will rich countries be willing to pony up even a fraction of this $600 billion a year? Or will they take a look at each catastrophe separately and take refuge in the mantra that no individual event can be blamed on global warming?

I'd guess the latter. But if Myles Allen of the University of Oxford and some of his colleagues have their way, this excuse is going to get harder and harder to make:

In 2004, Allen and his colleagues showed to a high level of confidence that human greenhouse gas emissions had at least doubled the risk of the European heatwave of 2003 occurring....Kevin Trenberth of the National Center for Atmospheric Research in Boulder, Colorado, thinks similar analyses should be done within weeks of an event. For instance, we know that high sea-surface temperatures and large amounts of moist air over the Indian Ocean helped bring about the Pakistani floods and the heatwave in Russia. It should be possible to determine how great a role human climate change played in these events, Trenberth says.

Allen's team hasn't analyzed the Pakistani floods yet, and climate deniers will point out that Pakistan has had plenty of floods in the past. But what if Allen's models show, say, that climate change doubled the chance of this month's disaster in Pakistan? Does that mean that rich countries ought to bear half the cost of dealing with it? Probably. But just last week the UN reported that "donor fatigue" was hampering aid efforts and that they had raised only a third of the $459 million needed for initial relief. If two or three disasters in a single year makes it hard to raise even a measly half billion dollars for Pakistan's worst flooding in decades, what are the odds of rich countries coming up with anything close to $600 billion each and every year for the next century?

Slim and none. Given the political realities, adaptation is certain to be a necessary part of our strategy for dealing with climate change. But political realities — not to mention physical, chemical, and ecological ones — also make it clear that adaptation alone is a chimera. Citizens of rich countries will never be willing to spend enough on their poorer neighbors to mitigate the damage of climate change even if the necessary amount is "only" one percent of global GDP. The fact remains that the likely damage from climate change is so severe, so varied, and so unpredictable that the only sensible policy is to spend money to try to prevent it in the first place. Short of a massive technical breakthrough in clean energy production, this simply isn't likely to change. The faster we reconcile ourselves to it, the better.

Front page photo: Lui Siu Wai/

Is the Fed Sadistic?

| Thu Aug. 26, 2010 11:51 PM EDT

Arnold Kling on current Fed policy:

I call it neutron-bomb monetary policy. The banks are still standing, while the people are getting killed. I don't think that is the explicit intent of the Fed, but the structure of the organization makes it much more responsive to the thought process of bankers than to that of ordinary Americans.

Scott Sumner:

Central bankers are a bunch of well-meaning (or at worst amoral) people who act like sadists because they have the wrong model in their heads....What the Fed considers normal, I consider sadistic. Not just this Fed, but earlier Fed’s, and foreign central banks as well. If I knew there was 10% unemployment, I couldn’t sleep at night knowing the markets were predicting only 1% inflation, whereas the target was 2%. I’d keep asking myself; “Why not do more stimulus? We’d improve both the unemployment and inflation situations at the same time.”

Andy Harless:

How does the Recession allow the government to bail out banks? With the recession going on, people are afraid to do anything risky with their assets, so they keep them deposited in banks, earning no interest. Banks can then invest these deposits in Treasury notes and credit the interest on those Treasury notes to their bottom line, thus improving their balance sheets.

...Now this bailout program is not without its risks. The biggest risk is that the economy will recover, which would be a disaster for the program....So the success of this bailout program depends on avoiding recovery, avoiding increases in inflation expectations, and avoiding major declines in Treasury note yields. Now do you understand why the Federal Reserve Bank presidents — representatives of the banking sector — are the most hawkish voices at the FOMC’s policy meetings?

And of course, Paul Krugman:

Why are people who know better sugar-coating economic reality? The answer, I’m sorry to say, is that it’s all about evading responsibility.

In the case of the Fed, admitting that the economy isn’t recovering would put the institution under pressure to do more. And so far, at least, the Fed seems more afraid of the possible loss of face if it tries to help the economy and fails than it is of the costs to the American people if it does nothing, and settles for a recovery that isn’t.

The Fed has very few admirers anywhere on the ideological spectrum these days. And now there's this about tomorrow's economic report from the BEA: "The widening consensus that the U.S. economy has slowed to a crawl will be hammered home Friday with the government's expected announcement that the nation's second-quarter growth was far more anemic than previously estimated. Many economists believe the Commerce Department will revise its estimate of growth in gross domestic product to 1.3% or lower, down from 2.4% — a dismal performance, especially as the country struggles to rebound from recession." Perhaps the Fed should actually consider doing something to help?

Should Retirement Be Nasty, Brutish, and Shorter?

| Thu Aug. 26, 2010 5:12 PM EDT

Everyone's favorite method for "fixing" Social Security seems to be increasing the retirement age to 70. Can anyone explain why this has become such an article of faith?

On the right, courtesy of the Department of Health and Human Services, is a chart showing the average life expectancy of Americans at age 65. In 1970 it stood at 15.2. Since the Social Security retirement age was also 65, this means the average number of years you could expect to receive benefits after retiring was 15.2 years.

By 2005 life expectancy had gone up to 18.7 years. But full retirement age had already been increased to 67 (that happened in 1983), so in order to keep the expected years of benefits constant at 15.2 years you'd only need to increase retirement age by another year and a half, to 68.5.

Now, I'm not in favor of that. Regardless of life expectancy, I think 67 is plenty old enough to retire. If a reasonable compromise package of reforms came along that included, say, a one-year increase in the retirement age to 68, I might reluctantly go along.

But where does the preoccupation with age 70 come from? That would represent a decrease in the expected number of years of retirement since 1970, during a period in which the United States has become nearly twice as wealthy. That doesn't even begin to make sense. Sure, life expectancy may increase in the future, but if it does then we have the option of increasing the retirement age when it happens. For now, we should make policy based on current reality, and the current reality is that life expectancy at age 65 has increased only 3.5 years since 1970. There's no reason the retirement age should increase five years in response.

Why Do People Think Obama's a Muslim? Duh.

| Thu Aug. 26, 2010 2:37 PM EDT

There have been, by my unofficial count, approximately 5,487 stories written about the Pew poll showing that 18% of the country believes that Barack Obama is a Muslim, up from 11% a year ago. But why has this number gone up so much? Because Americans are dumb? Don't be silly. They aren't any dumber now than they were in March 2009.

The answer, of course, is obvious to anyone with a pulse, but since we no longer live in a country where obvious answers are good enough, we need a political scientist to provide us with some hard data. John Sides does that today, breaking down the Pew data by party affiliation and level of education. The results among Democrats are boring: belief in Obama's Muslim-osity is up only slightly, and it's up about the same among all educational cohorts. What's more, just as you'd expect, the better educated folks are more likely to have things straight. 

Results among Republicans are on the right, and they're far from boring. Here is Sides:

The growth in this perception among Republicans is more notable among those with some college education (a 19-point increase) or a college degree (15 points) than among those with a high school degree or less (9 points). In other words, better educated Republicans have changed more than the less educated Republicans.

....Obviously, we cannot draw definitive conclusions from this analysis. It does not prove that some media personalities and political leaders are responsible for the increasing perception that Obama is a Muslim. But it points in that direction.

Well, yes, the data does point in the direction of media personalities feeding the perception that Obama is a Muslim. In fact, it points to it with a gigantic, blinking red neon arrow. Of course the reason more people think Obama is a Muslim is because Fox and Rush and Drudge and all the rest keep insinuating it. And the more educated demographics, who ingest more political news, are therefore the ones most likely to change their views.

Really, it's remarkable that we all pretend to be idiots on this score. The conservative media promotes a variety of wacky memes on a 24/7 loop, their viewers eventually buy into them and pass them along to their friends, and this eventually shows up in poll results. No other explanation is even marginally credible, but in our current fantasy world we're all expected to stroke our chins and pretend that the source of these wacky memes is an open question worthy of extended discussion and multiple interpretations. Jesus.

Lather. Rinse. Repeat.

| Thu Aug. 26, 2010 2:00 PM EDT

Andrew Sabl offers an etymological eulogy: 

The “infinite loop” metaphor is dying, almost dead. At 41, I’m almost certainly one of the youngest people to use (in middle school, when it was already almost obsolete) a reel-to-reel tape player on which one could actually splice the tape containing some music or words into a loop for the machine to play ceaselessly. Granted, “infinite loop” is also programming talk for a subroutine from which there’s no exit — hence Apple Computer’s corporate address — but that’s hardly common knowledge. I suspect most younger people have no idea what an infinite loop is, nor should they.

Seriously? I've never heard of the tape-player version of "infinite loop" being used as a general conversational metaphor. Is/was that common back in the day? Granted, I'm a nerd, but it's never even occurred to me that there was ever any other origin of the phrase aside from programming lingo. That's always seemed like the "common knowledge" version to me. From old-school BASIC, for example:

10 Print "I am in an infinite loop."

20 Goto 10 offers only the programming origin, not the tape player origin. What's the deal, hive mind?

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E-Verify vs. a National ID

| Thu Aug. 26, 2010 12:46 PM EDT

MoJo's Suzy Khimm, on sabbatical over at Ezra Klein's place, has a post today that sets out the current state of play on E-Verify, an electronic system designed to prevent employers from hiring illegal aliens. The good news is that the system has gotten better over time: the initial error rate for authorized workers is now only 0.8%, and that error rate drops very close to zero when results are contested. Error rates for foreign-born workers were a bit higher, but this has also improved considerably over the past couple of years. (The full report is here.)

The bad news is that the error rate for unauthorized workers was way higher: about 54%, thanks to identity fraud. But here's what I think is interesting. Chuck Schumer is one of several senators who thinks E-Verify is flawed and needs to be overhauled completely. This is from a report last year about a hearing where Schumer explained the changes he wanted to see:

At the top of the 10-point list was the requirement that the system “must authenticate the employee’s identity by using a specific and unique biometric identifier,” such as a fingerprint. He said that giving workers PIN numbers or security codes would not suffice.

....In addition to a biometric dimension, Schumer said an effective verification system must apply to citizens and non-citizens, require minimal compliance costs for businesses and exonerate employers from liability if they use the system but severely fine or prosecute them if they knowingly hire illegal workers.

....Schumer’s focus on biometrics was endorsed by Sen. John Cornyn, R-Texas and the ranking Republican on the subcommittee. He recommended a “secure, tamper-proof and easily verifiable card” as proof of employment eligibility.

Can someone explain to me how this differs from a national identity card? Longtime readers know that I'm actually in favor of such a thing and am completely unmoved by fuzzy notions that this brings us a step closer to a fascist police state. But that puts me in a distinct minority. It hardly seems likely that Schumer and his colleagues have even a ghost of a chance of getting majority support for this.

Still, I admit that it's interesting that Cornyn, hailing from one of the states seemingly least likely to accept the idea of a national ID, is also in favor. Is it possible that anti-immigrant fervor is actually strong enough to break down traditional American fear and loathing of a national ID card? If this ever gets any real traction, the collective cognitive dissonance from the Tea Party crowd might produce enough steam to eliminate half the coal-fired electric plants in the country. Sounds like a winner!

Income Inequality and the Crash of 2008

| Thu Aug. 26, 2010 11:34 AM EDT

Some fellow named W.W. at the Economist is skeptical of the idea that rising income inequality had anything to do with precipitating our recent financial crisis. Economic historian David Moss thinks that rising inequality put too much power in the hands of Wall Street, thus allowing them to promote a wave of deregulation that put the system in jeopardy, but W.W. scoffs at that:

It's very hard to take seriously the idea as stated here. If Wall Street titans had "too much power" over policies regulating the financial industry, it's hard to see how a lower level of income inequality would have left their relative power much diminished.

Are we to imagine that somewhat less titanic Wall Street operators would have lacked sufficient motive and opportunity to rig the regulatory structure in their favour? In any case, regulatory capture is primarily an effect of asymmetrical information and the revolving door between government and business. What does the size of the gap between the first and fifth income quintile have to do with it?

This is a cramped view. Take a step back and try again. What kind of system would have produced Wall Street titans with less income and less power? Answer: a system in which there were competing power centers that prevented the rise of inequality in the first place. Those same power centers — primarily labor unions, but also public interest groups and the old non-corporate dominated Democratic Party — would almost certainly have fought a lot of the deregulation that ended up proving so dangerous. In other words, it's not inequality per se that's the problem, but the system that produced the inequality. A better system that produced wider prosperity would almost certainly have produced a better regulatory regime too.

This is, obviously, a counterfactual, and it can't be proven any more than any other counterfactual. But is it really so hard to believe? A system in which there are countervailing powers with the strength to demand that economic growth be shared broadly is also a system that fights Wall Street's efforts at deregulation. It's a system in which the rich have somewhat less vast pools of money to loan out to the working and middle classes. It's a system in which the incomes of the working and middle classes are growing faster and they have less need to borrow money in the first place. It is, in short, almost certainly a system in which the 2008 financial crisis was, at a minimum, less likely to happen.

It is also, unfortunately, not the system we have, and all the legislation of the past two years hasn't really done much to get us any closer to it. We continue to live in a world in which corporations and the rich have too much power, there's way too much stupid money sloshing around at the top of the wealth pyramid, and the middle classes continue to stagnate. It ain't healthy, folks.

Why ARRA Matters

| Thu Aug. 26, 2010 11:05 AM EDT

Jon Cohn says that if Time's Michael Grunwald is enthusiastic about the 2009 stimulus bill "then you should be, too." OK then! But why should I be so enthusiastic? Because beyond the short-term tax cuts and jobs creation in the bill, about a sixth of it is dedicated to longer-term projects:

For starters, the Recovery Act is the most ambitious energy legislation in history, converting the Energy Department into the world's largest venture-capital fund. It's pouring $90 billion into clean energy, including unprecedented investments in a smart grid; energy efficiency; electric cars; renewable power from the sun, wind and earth; cleaner coal; advanced biofuels; and factories to manufacture green stuff in the U.S.

....The stimulus is also stocked with nonenergy game changers, like a tenfold increase in funding to expand access to broadband and an effort to sequence more than 2,300 complete human genomes — when only 34 were sequenced with all previous aid. There's $8 billion for a high-speed passenger rail network, the boldest federal transportation initiative since the interstate highways. There's $4.35 billion in Race to the Top grants to promote accountability in public schools, perhaps the most significant federal education initiative ever — it's already prompted 35 states and the District of Columbia to adopt reforms to qualify for the cash. There's $20 billion to move health records into the digital age, which should reduce redundant tests, dangerous drug interactions and errors caused by doctors with chicken-scratch handwriting. Health and Human Services Secretary Kathleen Sebelius calls that initiative the foundation for Obama's health care reform and "maybe the single biggest component in improving quality and lowering costs."

The whole piece is worth a read — and worth passing along to skeptical friends. There's nothing really new in it, but it's a pretty good distillation of a lot of underreported aspects of the stimulus bill. As Grunwald says, it won't leave behind a trail of physical icons the way the New Deal did, but "it will create new icons too: solar arrays, zero-energy border stations, an eco-friendly Coast Guard headquarters, an 'advanced synchrotron light source' in a New York lab. But its main legacy will be change. The stimulus passed just a month after Obama's inauguration, but it may be his signature effort to reshape America — as well as its government."

Down the Rabbit Hole

| Thu Aug. 26, 2010 12:58 AM EDT

In the New York Times today, Timothy Egan doesn't just write about the "willful ignorance" of much of the conservative electorate, he takes the obvious next step and names the purveyors of this ignorance:

In the much-discussed Pew poll reporting the spike in ignorance, those who believe Obama to be Muslim say they got their information from the media. But no reputable news agency — that is, fact-based, one that corrects its errors quickly — has spread such inaccuracies.

So where is this “media?” Two sources, and they are — no surprise here — the usual suspects. The first, of course, is Rush Limbaugh, who claims the largest radio audience in the land among the microphone demagogues, and his word is Biblical among Republicans.

....[Second], there is Fox News, whose parent company has given $1 million to Republican causes this year but still masquerades as a legitimate source of news. Their chat and opinion programs spread innuendo daily. The founder of Politifact, another nonpartisan referee to the daily rumble, said two of the site’s five most popular items on its Truth-o-meter are corrections of Glenn Beck.

I don't really have anything original to say about this. At some point, the much maligned mainstream media is simply going to have to stop reacting to every outrage ginned up by the likes of Limbaugh and Fox as if it's a straight news story. They don't react that way to Keith Olbermann or Michael Moore, after all. But I'm not sure how to make that happen. There's really no excuse for repeatedly getting sucked down the same rabbit hole over and over and over — Megyn Kelly on the New Black Panthers, Breitbart on Shirley Sherrod, Limbaugh on Obama the Muslim, Hannity on the Park51 mosque — but they do anyway. They just can't seem to help themselves. What's the answer? As long as they play the game, is it any wonder that so many Americans are misinformed?