(2024-07-09) ZviM Medical Roundup 3

Zvi Mowshowitz: Medical Roundup #3. This time around, we cover the Hanson/Alexander debates on the value of medicine, and otherwise we mostly have good news.

Technology Advances

Great news: An mRNA vaccine in early human clinical trials reprograms the immune system to attack glioblastoma, the most aggressive and lethal brain tumor. It will now proceed to Phase I. In a saner world, people would be able to try this now.

And we’re testing personalized mRNA BioNTech cancer vaccines too.

The GLP-1 Revolution

Early results from a study show the GLP-1 drug liraglutide could reduce cravings in people with opioid use disorder by 40% compared with a placebo

Rumblings that GLP-1 drugs could reduce heart attack, stroke and death even if you don’t lose weight, according to a new analysis

The case that GLP-1s can be sued against all addictions at scale. It gives users a sense of control which reduces addictive behaviors across the board, including acting as a ‘vaccine’ against developing new addictions.

How to cover this? Sigh... The situation is that there is a new drug that is helping people without hurting anyone, so they write an article about how it is increasing ‘health disparities.’ The point is that they are writing similar things for everything else, too.

Claims About Hansoninan Medicine

Believing he is responding to Robin Hanson and Bryan Caplan, Scott Alexander makes the case that medicine, and more access to medicine, does indeed improve health, and that claims to the contrary are misunderstood. Robin Hanson responds here, with lots of quotes, that he never claimed medicine was useless, rather that additional medical spending on the margin appears useless. Cut Medicine in Half, he says, not cut medicine entirely. Then Scott Alexander responded again. (cf Overtreated, Life Expectancy)

The question is, are we spending too much on health care, given the costs and benefits? Robin thinks clearly yes. It seems hard to arrive at any other conclusion.

It is a useful exercise to step through Scott’s arguments. What does the case for ‘medicine does something rather than nothing’ look like?

Story one is that medicine mostly works. Story two is that trauma care, vaccines, antibiotics and a handful of other things clearly work, and the rest is a mixed bag that mostly cancels out. We also need to worry about wealth effects.

I would hope we all agree that at current knowledge levels the right amount of cancer care is more than zero and less than what we do now, at least for those Americans with good insurance. If we cut cancer care costs by half the doctors would mostly do a rather good job identifying which half to keep.

We can largely do this by shifting more of the costs for marginal care onto the patients. They will mostly make reasonable decisions on which things to keep.

Hanson also emphasizes that a lot of this is paying more for fancier versions of the same treatments, or more expensive treatment options, and you can usually get most or all of the benefits without paying more.

Ask about a treatment’s Cochrane Collaboration Review rating.
Ask if a treatment is done in low spending geographic regions.

All three of us mostly agree on the ground truth that America spends a lot of money that is wasted, as the result of signaling and regulatory capture and various toxic dynamics, and we should work to spend a lot less.

The real fight here, I think, is mostly that Robin Hanson wants to or at least is down to lower the status of medicine and doctors, and to make it not a sacred value. Scott Alexander wants to not do that and defend medicine and doctors, and keep medicine sacred.

Pricing

Your periodic reminder that pharmaceutical pricing is crazy town, with rampant price discrimination, and you can and should game the hell out of it.

Epistemics

Gwern on how much credence to give new causal claims in epidemiology or nutrition, especially claims something is a ‘subtle poison.’ I agree with the conclusion that ignoring such claims entirely unless there is a unique reason is at worst a small mistake, and doing otherwise risks much larger mistakes than that.

DEA Worse Than FDA

The shortage of Adderall is not only flat out sabotage, it is stupider-than-you-could-put-into-a-work-of-fiction level stupid sabotage by the DEA.

We need to take this authority away from the DEA. The DEA should deal with illegal drugs and only illegal drugs. Regulation of legal drugs should for now go to the FDA. Of course, FDA Delenda Est for other reasons, but you do what you can.

Study Harder

The FDA often gets in the way. It would be easy to think that the FDA’s failures would be illustrated by the rejection of MDMA for post-traumatic stress disorder.

But also it turns out the study was horrible in other ways. Not merely horrible ‘they didn’t follow the instructed procedure’ type of ways, although there was that too. Horrible in the ‘experimenters asked patients to give higher ratings to help get the drug approved’ and ‘experimenters having sex with the patients while the patients were high’ kinds of ways.

FDA Delenda Est

The FDA is considering black octagon warning labels on the front of packages of foods to warn of things like ‘excess’ fat, sodium, sugar or calories. So judgemental

I am very much in favor of the existing nutrition labels, which are highly informative

in Chile, they say that sugar consumption dropped 10% after the labels were used. That is a big win, if people are responding to superior information rather than having their preferences overridden.

Bioethics

Covid-19

Scott Sumner on the Scott Alexander analysis of Covid origins. He is with Scott Alexander on 90% zoonosis, and says ‘good for me’ and others like me, who have decided not to dive deeply into this issue and retain odds closer to 50/50

Paper on the cost of filter mask mandates (paper). Tyler Cowen raises the question of willingness to pay (to be exempt) versus willingness to be paid, which is often much higher. Mostly I believe willingness to pay

Your periodic reminder that we went fast when we created the Covid vaccines, but could have gone much faster: Josie Zayner: Myself and two other Biohackers created and tested a DNA based COVID vaccine on ourselves before Fall 2020, before any vaccine was available, and we moved slow so we could livestream the whole design and testing process. I was banned for life from YouTube for doing this

Demons

Scott Alexander reviews the book The Others Within Us, about Internal Family Systems and the fact that occasionally it discovers what the book’s author thinks are literal demons.

I did experiment a little with IFS once so I have some experience with the baseline case

This is often effective at causing change, for reasons that should be obvious. It is also highly dangerous to ask people to imagine parts of them that are actively interfering, because you can incept that happening. The parallel to multiple personality syndrome is obvious, and Scott points it out. This is not ‘safe’ therapy. But the self being supposedly good and in charge, and there (almost) always being a way to solve any problem, means that if the therapist knows what they are doing this is plausibly a worthwhile thing to do sometimes.

I am reasonably confident that a well-iterated, well-taught version of this, implemented with empathy and dedication, would often be a good idea. That does not mean that what is on offer in any given situation qualifies for those adjectives. In practice, I would stay away from IFS unless I had very high confidence of a high quality therapist, and also a situation with enough upside to roll those dice.