Posts tagged ‘AIDS’

Just How Little Does Government Trust Individuals?

From CNN via Carpe Diem

 

A 24-year scandal was quietly acknowledged last week. On July 3 the U.S. Food and Drug Administration approved the first "rapid home" test for HIV—a test that people can take in the privacy of their own homes to determine whether they have the virus that causes AIDS.

The approval is an unambiguously good thing—or so you would think. The saliva test in question, made by OraSure Technologies and known as OraQuick, costs less than $60 and takes just 20 minutes to self-administer. According to statistics an FDA advisory committee presented at a hearing in May, it holds the potential to prevent the transmission of more than 4,000 new HIV infections in its first year of use alone. That would be about 8 percent of the roughly 50,000 new infections we currently see annually in the United States. (About 1.2 million people in the U.S. are now living with HIV, according to the Centers for Disease Control and Prevention, of whom about 20 percent don't realize they have it. Since the epidemic began in the early 1980s, about 1.1 million people have been diagnosed with AIDS, and more than 619,000 have died from it.)

The scandal is that the approval of a rapid home test for HIV did not occur until last week—about 24 years after the FDA received its first application seeking permission to market one.

Apparently, for years, even decades, only tests of clinical options were allowed to proceed, basically because the government considers Americans to be infants:

There was great concern that the patient receive proper counseling, both before and after the test. The patient needed to appreciate the possibility of false positives, so he wouldn't panic unnecessarily if he got one. He needed to appreciate the danger of false negatives, so he wouldn't become reckless, endangering sexual partners. And he needed to understand the options and support groups available in the event he received a true positive. (On top of all these concerns, many AIDS activists at the time were opposed to almost any form of HIV testing out of fear that results could be used to ostracize and persecute HIV-positive people—though one hopes that public health concerns were paramount to the FDA, rather than political pressure and hysteria.)

March of the Protected Groups

From California State contract language I am reviewing:

During the performance of this Contract, Concessionaire and its employees shall not unlawfully discriminate, harass, or allow harassment against any employee, applicant for employment, or any member of the public because of sex, sexual orientation, race, color, religious creed, marital status, need for family and medical care leave, ancestry, national origin, medical condition (cancer/genetic characteristics), age (40 and above), disability (mental and physical) including HIV and AIDS, need for pregnancy disability leave, or need for reasonable accommodation.

This is at least double the length of such passages in contracts I saw 8 years ago.  I wonder what the list will look like in another 10 years?

This used to be simple -- treat everyone equally.  But this is no longer sufficient to conform.  New groups added to the list require accommodations of one sort or another.  Non-discrimination requirements have morphed for us from "treat everyone the same" to "here is a list of groups with special privileges."  Generally, it's not that hard at present to fulfill but who knows how onerous it will be in a decade or two?

Government War on Pain Medication

The first part in a three-part Radley Balko series is up at the Huffpo.  Good stuff, though hugely frustrating of course.  Watch the media for other stories on this topic -- I challenge you to find one story in the regular media that discusses pain medication that has even one interview of a pain sufferer.  This issues is treated 180 degrees differently from any other story one could imagine about victims of medical conditions being denied medication.   The part that always amazes me is how "addiction" is treated as a bad thing under all circumstances -- what does addiction even mean if the alternative is unbearable pain?  Are AIDS patients addicted to the medication that keeps them alive?

Ezra Klein, There Is A Reason You Can't Get An Answer to Your Question

Ezra Klein writes:

For a long time, I took questions about stifling innovation very seriously. So did a lot of liberals. But then I realized that the people making those arguments wanted to do things like means-test Medicare, or increase cost-sharing across the system, and generally reduce costs in this or that way, which would cut innovation in exactly the same way that single-payer would hypothetically cut innovation: by reducing profits.

I also found that I couldn't get an answer to a very simple question: What level of spending on health care was optimal for innovation? Should we double spending? Triple it? Cut it by 10 percent? Simply give a larger portion of it to drug and device manufacturers? I'd be interested in a proposal meant to maximize medical innovation. I've not yet seen one.

The reason he could not get an answer to this very simple question is that it is stupid.  It is a non-sequitur.  It is, as Ayn Rand used to warn, a statist trying to force the argument to conform to his statist assumptions.

Let's take a different example, because medicine is so screwed up by government intervention that it can be confusing.  Let's imagine ourselves in the computer market in 1974.  The market is dominated by IBM mainframes, and innovation at the time was considered to be the penetration of mini computers (not to be confused with PCs, these were really just smaller mainframes) by DEC and HP.

Let's say that for some reason the US government decides it is fed up with the IBM "monopoly" and the high cost of mainframe computing and it wants to take over.  It feels like there is a lot of waste in mainframes as some people are using them for frivolous reasons while other companies who really need them can't afford them.  They might have created review boards to make sure that they thought each dollar spent on computing hardware and software was "worth it."

So, how much spending is needed to maintain innovation?  We know in hindsight that the PC revolution is looming in the next few years.  And in that context, Klein's question is absurd.  The answer is that spending per se, and even profits, in the mainframe computing market were irrelevant to the coming series of innovations.    The necessary preconditions were that entrepreneurs saw that new technology provided potential new value to consumers, and were allowed the freedom to launch these new products in hopes that the value these new products provided would be sufficiently high that consumers would pay enough for them to return their cost of manufacture and development and return them a profit.  Some succeeded, and some failed, but entrepreneurs were allowed to try, despite most "experts" predicting the PC was a silly toy.

Note that computer innovators were not required to trundle into some government computing board to justify the PC and its price, to justify how much, as Klein would say, needed to be spent on PC's.   If in fact they were forced to do so, if Jobs and Wozniak had to fly to Washington to justify the Apple I to the Computing Spending Decisions Board, they would have almost certainly been shot down.  Or told they could sell it but only for $200 and not their initial price of $2000.  We would have never had a PC revolution in a government single payer computing world, no matter how much, as Klein asks, was "spent" by the government.   It is possible that the government might eventually have greenlighted a PC (years later) just as the increasingly bureaucratic IBM did, but can you imagine how frail the PC revolution would would be if only IBM had ever sold PCs, without the slew of competitors that emerged, and if every innovation had to pass the scrutiny of a government review board before it could be launched?   Only a tiny percentage of PC innovation and of what we think of as a PC today, mostly in the basic architecture, ever came from IBM.

The very problem is that when government runs computers or health care, innovation is seen as a cost.  Klein, by asking the question in this way, is betraying exactly what is fundamentally wrong with a single-payer system.  The single-payer tends to think in terms of trying to deliver the current value proposition (ie the 2009 level of health care technology) as cheaply as possible.  The problem is that in 2039, it will still be focused on delivering the 2009 level of health care technology.  For the government -- a new drug, a new procedure, a new test -- these are all incremental costs, to be avoided.  Klein just wants a number he can plug into budget projections to say, "see, innovation is covered."  Its like Wesley Mouch asking John Galt near the end of Atlas Shrugged to tell him what orders to give.

I wrote about it just the other day.  You can see it in everything the Left writes -- increased spending is equated with increased costs which are therefore bad.  They all say that America's health care spending is rising and our per capita spending is higher than other nations and that this rising spending is somehow a problem to be fixed.  But there is a value side of the equation.  What are we getting from the spending?  When you leave out things the health care system can't do anything about (homicides and fatal accidents) Americans have the longest life expectancy in the world.  We are getting something for that extra money.  It is not just "cost" to be contained.  Is a year of life worth an extra $100,000 spending?  Everyone has a different answer, which is why we typically let each individual make these tradeoffs, and why people are uncomfortable having someone in the Post Office make the tradeoff for them.

But, the left will say, we will put really smart people on this board, who are angels of public service, who will make perfect decisions on the price-value tradeoffs of innovation (have you noticed that all their programs seem dependent on this assumption?)  Back to our computer example, these guys, they would argue, would have been smart enough to have given Jobs and Wozniak the green light.  This is a fantasy.  It never happens.  No matter how good the people, every such government entity is driven by its incentives, and this group's incentives will be to cut spending.  Innovations that result in a net total increase in spending are not going to be well-received.

Further, these boards get politicized, always.  Companies will quickly learn they have a better chance, say, of getting a new breast cancer treatment rather than a new prostrate cancer treatment past the board because the current administration is closely tied to women's groups.  Just look at current government R&D spending, this already happens.  AIDS was under-funded given its mortality because Conservative administrations thought it a disease mainly of groups it found distasteful; today, women's cancers get far more funding than men's due to the strong political activism of women's groups and the success of the pink ribbon campaign.  Drug companies will learn that the quickest way to board approval may not be winning over the board, but getting certain interest groups to lobby the board, or maybe lobby Congress to override the board.  Just look at the promise not to politicize ownership of GM -- that lasted about 2 days before Congress was passing legislation reversing internal GM decisions and GM was making plant closures based on political rather than economic concerns.

But even beyond these problems, there are Hayekian ones as well.  In the mid-seventies, there might have been only a few thousand people who were excited enough to buy an early microcomputer and see its potential.  What are the odds that one of those folks would be on the government review board, particularly since few of them were in the mainstream establishment of the computing field (heck, few of them were over 19 years old).  And even if one were on the board, would they have approved a technology with only a few initial adherents?  The fact is innovation often requires adoption of bleeding edge risk-takers who are willing to try a new technology and iron out its kinks before the mainstream catches on.   The iPod was not the first music player -- a few of us struggled for years before the iPod with large and sometimes hard to use early mp3 players  -- but if these early MP3 players had not existed, the iPod would not exist.

Perhaps most importantly, everyone makes different tradeoffs.  It may make perfect sense for some person in Washington that a biopsy is not required for certain kind of positive cancer test results.  This may make perfect price-value sense to the beauracrat, but I know a number of people who would lose months or years of their life to worry -- worry that could be short-circuited with an inexpensive biopsy.   Or consider a new cancer treatment -- is a year of life worth an extra $100,000 spending?  Would I prefer to extend my life through chemo or increase the quality of life of the time I have left by avoiding chemo?   Everyone has a different answer, which is why we typically let each individual make these tradeoffs, and why people are uncomfortable having someone in the Post Office make the decision for them.

One could say that all of this does not answer Klein's question.  That is because his question, built on the wrong premise, is unanswerable.  I suspect he knows this and is, as Brad Warbiany posited in the link above, just setting up a straw man.  All I can do is try to give a feel what what innovation does require, and help folks to understand that it has little if anything to do with Klein's question.

So, if I had to come up with a pithy one sentence answer, here it would be:

Klein:  What level of spending on health care is optimal for innovation?

Me:  The very fact that you intend to control spending centrally, at any level high or low, is what kills innovation.

Postscript: For a totally different reason, I was reading this article on the Russian T-34 tank, probably the best all-around tank for its time ever made when considering its production volume (the Panther was theoretically a better tank but volume production of the scale of the T-34, not to mention mechanical reliability, eluded the Germans).  Apropos of government boards and innovation was this:

The L-11 gun did not live up to expectations, so the Grabin design bureau at Gorky Factory No. 92 designed a superior F-34 76.2 mm gun. No bureaucrat would approve production, but Gorky and KhPZ started producing the gun anyway; official permission only came from Stalin's State Defense Committee after troops in the field sent back praise for the gun's performance.

Chicken Contact Lenses

Jane Galt makes a case against industrial animal husbandry, a position which she argues is not inconsistent with being a libertarian or classical liberal.  While I don't get as worked up about such practices as cruel, I don't think it is inconsistent for a libertarian to be so concerned.  And I don't rule out that I would be just as worked up if I were more informed about what was going on.

However, what really caught me eye was this:

This is an approximate description of what happens to industrially
farmed chickens . . . lifted, mind you, from a business school case
aimed at helping industrial farms be more efficient, by using rose
coloured chicken contact lenses to cut down on the need for debeaking
'em.

I can attest that this was indeed a real case that we studied at Harvard Business School*.  In fact, it so freaked me out at the time as a concept that I included it in my most recent novel.  From BMOC [warning, profanity lurks ahead]:

Poor, boring, earnest Julian
was always prepared, because he was always terrified, scared to death
that one night slacking off might somehow destroy his future Career
(always with a capital-C), and therefore future Life, much like the
fear of catching AIDS from a one night stand.  Julian participated
(unfortunately) all too much in class, droning on in that irritating
voice of his, advocating positions as spectacularly expected as
Susan's were non-conformist.

Julian,
therefore, was not really a candidate to get cold-called to open the
class discussion, particularly this late in the year.  However, it
was clear to everyone in the room, particularly the professor, that
Julian longed to open a case.  Every day Julian would look at
the professor with this hopelessly wistful expression, only to be
followed by a look of desolation when someone else was chosen.

So
today, letting Julian open was in the same spirit as the homecoming
queen giving a pity-fuck on the last day of high school to the geek
who has been mooning and sighing over her for four years.  And right
at this
moment, Julian had the same surprised and ecstatic look on his face
that the geek would have.

But it was not just the site of
Julian creaming all over himself at his chance to open that had Susan
longing for the piranha button.  Some satanic twist of fate had
Julian Rogers earnestly and painstakingly laying out a strategy and
plan for the new product roll out of ... contact lenses for chickens.
Contact fucking lenses for Christ-sake chickens.  Right this very
second he was outlining his sales pitch to chicken farmers,
explaining how putting contacts in chicken's eyes will somehow
reduce the number of chickens that have to have their beak cut off.
Did she hear that right?  This had to be a joke "“ but no,
everyone seemed to be taking it seriously, and certainly Julian was
taking it deadly seriously.

* I know those anti-capitalists out there will be using this as evidence that business school is crafted to keep us cold and heartless.  HBS consisted of studying 2-3 cases per day for about 200 days a year, which means that over two years one might read a thousand business cases.  This case was more in the spirit of breaking the monotony of yet another case on brass vs. plastic water meters rather than part of a consistent attempt to make us cold and heartless.

Global Warming Detente?

Though Cathy Young's article has the opposite title, I actually think that the global warming debate is cooling off a bit, with a bit more reason creeping into a debate so far dominated by ideologies as much as science.  More and more voices like this one are starting to be heard:

Mark Kleiman, a professor of public policy studies at UCLA and a
self-identified liberal, noted this recently on his blog. Writes
Kleiman, "To those who dislike a social system based on high and
growing consumption and the economic activity that supports high and
growing consumption and maintains high and growing demand (a dislike
with which I have considerable sympathy), to those who think that the
market needs more regulation by the state, to those who think that
international institutions ought to be strengthened . . . global
warming is a Gaia-send" -- since it justifies drastic worldwide public
action to curb production and consumption. (Gaia, the ancient Greek
goddess of the earth, is a term used by many ecologists to refer to the
earth as a living entity.) While Kleiman sympathizes with
environmentalists, he notes that "their eagerness to believe the worst"
-- for instance, in Al Gore's documentary, "An Inconvenient Truth" --
"is just as evident as the right wing's denialism."

As an
analogy, Kleiman cites many social conservatives' attitude toward the
AIDS epidemic, which has been used to portray sex outside monogamous
heterosexual marriage as fraught with deadly peril and to preach the
message of premarital abstinence. (Kleiman doesn't explicitly say this,
but his comments hint at another abuse of science: Many conservatives
and gay rights activists, for different motives, have exaggerated the
fairly tiny risk of HIV infection from heterosexual sex.)

The
analogy between AIDS and global warming also extends to attitudes
toward ways to remedy the problem. The religious right, Kleiman points
out, pooh-poohs condoms as a way to reduce the spread of sexually
transmitted diseases because the effectiveness of such a remedy would
undermine the abstinence message. Similarly, those on the left who
embrace environmentalism as their substitute religion don't want to
hear about scientific and technological solutions to climate change --
from nuclear power to geoengineering, the artificial manipulation of
the global environment -- that do not include stepping up regulation
and curbing consumption.

There is a growing number of voices in
the scientific community that reject both denialism and alarmism on
global warming. Roger Pielke, an environmental science professor at the
University of Colorado, calls such people "nonskeptical heretics" --
those who believe that human-caused global warming is a real problem,
but one that can be met in part with technological management and
adaptation. Mooney has come to embrace such a viewpoint as well.

The NY Times actually chimed in on this same topic.  And I for a while have been promoting a skeptical middle ground in the global warming debate.

Update: Increasingly, folks seem to want to equate "skeptic"
with "denier."  If so, I will have to change my terminology.  However,
that would be sad, as "skeptic" is a pretty good word**.  I accept there
is some CO2 caused warming, but I am skeptical that the warming and its
effects are as bad as folks like Al Gore make it out to be (explanation here), and I am
skeptical that the costs of an immediate lock-down on CO2 production
will outweigh the benefits.  That is why I call myself a skeptic.  If
that is now a bad term, someone needs to suggest a new one.

**Though I can't help but be reminded of the great Tonya Harding interview on the Dan Patrick Show, where the famous hubcap-wielder and kneecap-breaker said  "I'm not going to make a skeptical of my boxing career."

Horrible Verdict

In what we may look back on as one of the worst and most destructive jury verdicts of the decade, three paint makers were found guilty of selling lead paint back when it was, well, legal:

A Rhode Island jury today found Sherwin-Williams Co. and two other
paintmakers guilty of creating a 'public nuisance' by manufacturing
lead paint after it was found to be dangerous." If upheld, the verdict
will force the companies to contribute millions toward abatement of
existing paint; a judge will also consider demands for punitive
damages. The ruling, the first of its kind, is also expected to
encourage the filing of more suits against the industry

As Walter Olson points out, the suit was dreamed up by veteran law firms from tobacco and asbestos lawsuits, using bits of both litigation models:

The verdict is an unfortunate confirmation that the "tobacco model" of
mass tort litigation remains alive and well. In particular,
contingency-fee private counsel have once again managed to 1) dream up
a novel idea for litigation based on the idea that some category of
public expenditure is really blameable on long-ago sales of a product;
2) sell the idea of suing to public officials who agree to front the
action, and who thus provide (along with advocacy groups) a suitably
public face for the lawsuit; and 3) manage to get liability attributed
retroactively to businesses whose actions decades ago were plainly
lawful under the standards of that time.

The firm Ness Motley who is RI's partner in this, is, surprise surprise, the largest single political donor in the state.

The WSJ($) has more thoughts today about why this verdict is so bad:

There are so many screwy aspects to this case that
it's hard to know where to begin. The jurors heard no evidence about an
injured party, nor were they informed of any specific house or building
that constituted the "nuisance." As for the defendants, Judge Michael
Silverstein instructed the jury that it wasn't necessary to find that
Sherwin-Williams, NL Industries and Millennium Holdings had actually
manufactured the paint present in Rhode Island or that they had even
sold it there.

Oh, and did we mention that at the time the companies
may or may not have sold lead paint in Rhode Island it was an entirely
lawful product? "The fact that the conduct that caused the nuisance is
lawful does not preclude liability," Judge Silverstein said. Lead paint
was banned for residential use in 1978.

So why is this such a big deal?  One only has to look at the situation in asbestos to see the potential ramifications.  The asbestos mess began, sensibly enough I guess, with lawyers suing makers and heavy users of asbestos products into bankruptcy for the benefit of people seriously ill (though one can argue that most of these cases belonged in the workers comp. system, but workers comp. doesn't allow those juicy punitive damage payments that pay the fuel bills for the lawyers' Gulfstream V's).  Eventually, the asbestos mass tort morphed into lawyers suing any company with deep pockets that had even heard of the word asbestos for the benefit of tens of thousands of people who had never been harmed but only claimed to have been present in the same zip code as asbestos. 

Here is the problem with the potential lead paint mass tort:  It has skipped right to the asbestos end-game, bypassing the "helping people who were seriously harmed" stage and jumping right to the settlements for billions without proof of any related injury.  And for all the ubiquity of asbestos, lead paint was even more prevalent in its day.  Will Sears be bankrupted for selling lead paint?  Will auto-makers and homebuilders be bankrupted for using it?   And, separately, will any of the settlement money that flows to states really go to lead paint abatement, or will most go to general revenue, as it did with tobacco?

OK, so its clear why those of use who care about stuff like property rights and individual responsibility might be appalled at this decision, but you progressive public policy types should be appalled as well.  If this thing gets rolling, the country will end up diverting hundreds of billions of dollars to a problem, mainly childhood lead poisoning, that while not solved has really been greatly reduced over the past few years.  Just to get a sense of scale, for example, we are talking about far more money potentially focused on lead paint than the total spent today publicly and privately on AIDS and cancer research combined.  Totally insane.

Libertarians Adrift

While it comes as no surprise to me, Republicans are making it official:  After dallying with small government notions in the eighties and nineties, under George Bush they are refocusing themselves on statism.  Going forward, Republicans see themselves locked in an arms race with Democrats over who can spend more and advocate more statist controls.

This news comes to us via conservative David Brooks, via Volokh:

[Brooks] rejects Bartlett's charge that Bush has betrayed conservatism. According to
Brooks, "Bush hasn't abandoned conservatism; he's modernized and saved it." As
Brooks tells the story, "conservatism was adrift and bereft of ideas" until
President Bush came along.

Almost single-handedly, Bush reconnected with the positive and
idealistic instincts of middle-class Americans. He did it by recasting
conservatism more significantly than anyone had since Ronald Reagan. He rejected
the prejudice that the private sector is good and the public sector is bad, and
he tried to use government to encourage responsible citizenship and community
service. He sought to mobilize government so the children of prisoners can build
their lives, so parents can get data to measure their school's performance, so
millions of AIDS victims in Africa can live another day, so people around the
world can dream of freedom.

"Government should help people improve their lives, not run their lives,"
Bush said. This is not the Government-Is-the-Problem philosophy of the mid-'90s,
but the philosophy of a governing majority party in a country where people look
to government to play a positive but not overbearing role in their lives.

Barf.  The last sentence contains a pure contradiction:  There is no way for government to play any role, positive or negative, without being overbearing, at least to some.  There is no way for the government to improve some lives without running others.

Despite what politicians may argue, the government has only one unique quality no one else can match.  They are not uniquely smart, or uniquely capable, or uniquely compassionate, or uniquely efficient, or even uniquely able to run large organizations.  Their only unique capability is to deal with people by force, and to use force and the threat of force and imprisonment to compel individuals to do things they would no choose to do themselves.

This unique ability to use force is necessary to the government in fulfilling its core roles of protecting us from the use of force from outside our borders (military) and protecting its citizens from the use of force or fraud by other citizens (police and courts).  When the government uses its unique ability to coerce in other spheres, there are always winners and losers.  That is because by definition the government is using force to cause an outcome or a decision that people would not have made on their own, based on their own self-interest and of their own free will.  So when politicians blithely say things like "help people improve their lives", what they ALWAYS mean is using force to compel someone to do something they would not have to do in a free society.   

For this reason, there is no such thing as having the government "play a positive but not overbearing role in their lives".  The best you can hope for with such an activist government system is to hope that the government plays a net-positive role in your life, while being overbearing to others.  Which pretty much sums up why politics are so high stakes today - if government is about sacrificing one group to another, I want my guy in there so he can be overbearing to some other group for the benefit of mine.

I dealt with these same themes a couple of days ago in this post, where I said "the entire Republican and Democratic platform each boil down to 'we
support government intervention except where our major donors oppose
it'".  My summary statement on the full range of government interference with free individual decision-making is here.

Update:  While Marginal Revolution is still optomistic for libertarians, they point out that "progressives" see the opportunity now for real expansion of socialism in this country

Democrat Matt
Yglesias writes
:

If you did have a progressive president, there's no longer a
particularly large amount of popular resistance to expanding the activist state.
Even most Republicans don't especially care about small government.