The land of giants

As promised, here’s a look at Patagonian Chile.

Chileans are, for the most part, warm and friendly. Our flight from Atlanta arrived in Santiago about 3 hours late. Standing in line waiting is one of the popular national activities in Chile, and we had to cut a few lines to make the next flight. Although we could not apologize in Spanish, people were kind, smiled, and let us hurry along.

The road trip photos demonstrate the huge civil engineering task the Chileans face, first in completing the task of constructing and paving the Carretera Austral, and second, of driving on it in with the local cows enjoying a break.

One of the great joys of fly fishing is the travel to spectacular places. The mountains and forests form “the wilderness without teeth.” It’s wild country, but with very few large animals. Patagonia just does not have the large top-of-the-food-chain carnivores (i.e., bears) that we do in North America. The sound and fury of the primaries did not make the faintest echo in the mountains.

Europeans introduced trout into South American waters around the beginning of the twentieth century, and the fish have thrived. They grow fat and strong in the clear, cold water of the rivers that run down out of the hills toward the Pacific. Patagonian Base Camp sits on the banks of the Rio Palena, and provides opportunities to visit many of the nearby streams.

Next week, I’ll return to more serious subjects. For now, have a look at the photos, imagine the stars of the Southern Hemisphere spread out in a moonless sky a hundred kilometers or more from the nearest town, and imagine the sound of Rio Palena hurrying past. What a wonderful trip!



Last night, as my wife and I watched the early minutes of the Republican debate, she commented on how strange it was that Dr. Ben Carson, a physician, could hold such an unscientific view as belief in creationism.

I responded, “A great sculptor does not have to be a geologist, nor does a talented woodcarver have to have studied forestry.”

She felt this was a bit obscure, and requested a further explanation. That explanation took me far beyond Ben Carson.

My point was that a medical doctor, physician or surgeon, is a craftsman, not a scientist. You can certainly turn the proposition around if you like. Finding a great geologist who is also a talented sculptor is also unlikely. Either way works.

The actual “doing” of medicine does not involve scientific methods, but rather the skillful use of tools. For the surgeon, the tools are the familiar instruments of the operating room. For non-surgeons, the vast majority of our proven effective tools are drugs. As time goes by, we medical doctors become fond of our tools, the drugs we use frequently. We get to know them, to feel comfortable with them, and to have a sense of how we can use them most creatively.

How strange, it  seems to me, that we seem to have developed a love-hate relationship with the pharmaceutical industry that provides us these tools. Isn’t it appropriate for the tool-makers to want to share best practices and new information with us? Don’t we want the tool-makers to make improvements so that we have new and better tools to use? And isn’t it reasonable for the tool-makers to want to make a living by charging for the products they make?

The problem is the patient. Unlike the sculptor’s stone or the woodcarver’s log, the patient has a deep sentient and personal involvement in the outcome of the doctor’s craft. In many cases, the patient and/or his agents are also involved in paying for the tools. Now the issue of “value” enters the discussion. Are the tools worth the cost? How do we know? And why advertise the tools to the patients?

In this week’s New England Journal of Medicine, two PhDs from Harvard and Chicago have written an editorial piece titled, “Pharmaceutical policy reform – balancing affordability with incentives for innovation.” They suggest that “our laissez-faire system may not be achieving the balance [between] affordability and incentives for innovation that Americans want.” That’s a difficult point to argue.

In the last few years, the toolmakers have put powerful, effective new tools at our disposal. A “system,” such as it is, that could manage the distribution of sulfa drugs, small molecule anti-hypertensives, and first-generation antibiotics has been overwhelmed by biotechnological synthetics, by monoclonal antibodies, and by novel anti-neoplastic agents. A woodcarver who can handle a good set of chisels, may be somewhat challenged by a 3-D printer.

As I see it, the critical issue for all of us as we struggle toward a new way of making, distributing, and consuming medicine is to maintain our respect for the other participants in the process. The craftsman has to care for his tools and has to have profound respect for his materials. The toolmaker has to feel proud of his role in a creative, life-sustaining activity. And all of us must earn the patient’s trust.

Off to the land of giants…

Magellan reportedly named Patagonia as such because of the height (very tall) of the natives. “Patagons” or “giants” by not too literal translation. I’ve always felt that perhaps they just had large feet.  Anyway…

The point is that that the Weekly Packet is going to be pursuing the wily trout in the land of giants for a few days. No thoughtful posting on big problems, small problems, or just ruminations on life. That’s the nice thing about fly fishing. It is a discipline that requires attention to process and detail, and if done correctly results in …sometimes…a fish. Or maybe not.

At any rate, I promise that the next post will include some visuals from “the land of giants.”

The “drug cost crisis.”

During my relatively brief tenure on the faculty of the University of Kentucky College of Medicine, I enjoyed the privilege of participating in UK’s first “Certificate in Medical Management” program. The business school faculty ran the course, with some additional input from other faculty. Although I might stumble on some specifics, the major themes of what we learned have stayed with me. I think that explains my fascination with the “drug cost” headlines that are appearing with alarming frequency.

This is a topic that can arouse even the most factually unarmed to foaming fury, so I’ll proceed very carefully. Peter Bernstein, in his wonderful book Against the Gods, documents that various forms of the insurance business have been around since at least 1800 BC. Without getting too technical, today’s insurance practices have benefitted from steady advances in both math, basically statistics, and data handling, so-called “big data.” However, there are some fundamental and intuitive facts that no one can dispute.

First, illness is not equally distributed in the general population. Some individuals have substantially greater health burdens than others. In fact, the National Institute for Health Care Management Foundation analysis of data from the 2012 Medical Expenditure Panel Survey shows that the less expensive 80% of the civilian non-institutionalized US population accounted for 18% of the cumulative total health care spending that year, while the more expensive 20% of the population accounted for the remaining 82% of spending. The “80/20 rule” has some validity!

Second, with the exception of a few dramatic diseases like Ebola, in developed societies the burden of illness is both chronic and costly.

Third, other things being equal, if the goal of insurance is to cover the health care costs (or automobile losses, or shipwreck costs) of a population, a larger the pool of insured individuals will result in a lower cost to each individual.

Given these three basics, the conclusion seems straightforward that the least expensive approach to health insurance is to require that everyone in a large pool, say the US population, have a basic policy.  Does this mean the end of the private health insurance business? It hasn’t in Europe, where private insurance often adds coverage beyond the basics. It’s the kind of approach that says, “At least, everyone should be able to ride a bus or a train. If you want a fancy car instead, that’s up to you.”

Now, just for fun, let’s move on to drugs. I would like to call your attention to a piece by Peter Sullivan posted on a site called “The Hill.” The Center for Medicare Services, or CMS, has collected some interesting data. The spreadsheet is available on line and worth a careful look. The take-home message is that just 40 drugs out of the 3,761 in the Medicare prescription drug program make up a full 33 percent of the total $121.5 billion in yearly costs. That’s even more lopsided than the 80/20 rule. What’s more interesting is that if we focus on the set of indications for those drugs, we will narrow the field even more to hepatitis-C, oncology, and severe forms of mental illness.

Well, cost cutters, one approach would be to deny progress. These expensive drugs are used to treat illness that has not been treated previously. Instead of having patients die from liver failure and metastatic cancers, we are adding to the population of individuals with expensive chronic diseases. Of course the total cost of drugs will go up! One alternative would be not to use these new agents, and let the diseases run their course. Aside from the moral issues, that’s NOT what insurance is about. It’s about spreading the cost across the largest possible pool.

In addition, as we have learned from the EU, national health systems have a lot of leverage in negotiating drug costs.

To summarize what the data really show about the US drug cost “crisis” is that:

  1. The real drivers of health care cost increases are hospital costs and personnel costs.
  2. A large majority of the population accounts for only a small portion of health care costs.
  3. Expansion of the subset of patients with complex chronic disease that can only be managed with expensive new drugs accounts for most of the increase in drug costs.

Are these problems that can be entirely attributed to the pharmaceutical industry? I think not. Rightly or wrongly, the industry has tried to figure out what price the fragmented market will bear. In the rest of our society, that’s a generally accepted practice. On the other hand, we can’t escape the fact that multiple competing interests have repeatedly defeated attempts to develop a more rational health care system.

Bodo has a toothache.

man with hoe


In my freshman year at Amherst, all of my class took a required course in the history of Western civilization. Early in the year, the professors used the life of a fictional medieval peasant named “Bodo” as a teaching tool as a sort of baseline. Bodo was illustrated by Millet’s painting, “Man with a hoe.”  If we had taken this a bit more quantitatively, “improvement” in daily life could have been graphed as a rise in Bodo-units of happiness vs. time.

For a long time, Bodo did not get much happier. In fact, the line of the graph probably ran asymptotic to unity for centuries. The inflection point heralding the sharp rise associated with our modern life probably came somewhere after the American Civil War. When large numbers of former officers from both the Union and Confederacy who had learned the basic logistics necessary to complete very large scale tasks rejoined civilian life, amazing things happened. For instance, those logistic skills lead to the transcontinental railway and dramatic improvements in communications.

Still, the Bodo-unit graph was only rising slowly. If Bodo had a toothache, there was no local anesthesia for his dental work. His kids didn’t get shots to prevent childhood illness. He had no refrigeration, no sanitation, and no education. Then came the post-WWII boom, and the graph shot up at an incredible rate. Bodo gave up his hoe, moved to the suburbs, got a factory job, and had two kids, a dog, and a Chevy.

Just before the holidays this year, Bodo made a surprise comeback, in the form of a vigorous discussion among my classmates about a recent epidemiology paper that received substantial attention in the press. Question #1 for approaching this sort of report is always, “are the data believable?” In this case, the authors are from Princeton, and the publication is in the Proceedings of the National Academy of Sciences. The citation is: Case A, Deaton A.  Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015 Dec 8;112(49):15078-83. doi: 10.1073/pnas.1518393112. Epub 2015 Nov 2.  Author information: Woodrow Wilson School of Public and International Affairs and Department of Economics, Princeton University, Princeton, NJ 08544.

The next important question is, “What did the researchers themselves have to say about their data?” The data showed, for the first time, increasing mortality rates in middle class whites. The entire paper is well worth reading (full free text is available on PubMed). Here’s a direct quote from the discussion. “A serious concern is that those currently in midlife will age into Medicare in worse health than the currently elderly. This is not automatic; if the epidemic is brought under control, its survivors may have a healthy old age. However, addictions are hard to treat and pain is hard to control, so those currently in midlife may be a “lost generation” (36) whose future is less bright than those who preceded them.”

This is a careful, scientific conclusion, and given the data, it does not sound overly pessimistic. I spent a couple of years on the faculty at the University of Kentucky medical school; hopeless, technologically unemployed coal miners and their families were part of daily life in Lexington. Their problems are so complex as to qualify as insoluble.

In other words, the Bodo-units vs time graph does not climb upward inevitably.

This is a startling new concept that should prompt all of us to do some serious thinking. More later; for now, best wishes for the New Year.