Tuesday: Hili dialogue

48 thoughts on “Tuesday: Hili dialogue”

1. A THOUGHT FOR TODAY:
   In a free country there is much clamor, with little suffering: in a despotic state there is little complaint but much suffering. -Lazare Nicolas Marguerite Carnot, statesman and engineer (13 May 1753-1823)

2. Please be on the mend, Masih (so many IV’s!)…and Matthew…

   1. Risking an over-comment to offer reassurance, Jim, about someone dear to us all. The harness of tubes curling around the base of Ms. Alinejad’s neck are the four insulated wires of a cardiac monitor for continuous recording of the ECG. The device at her left arm is an automated blood pressure cuff. While these are not exactly routine, they are still widely used in a patient who has had difficulty after surgery but is now steadily improving. (She may well have an i.v. in one or both arms not visible in the photo.) Also reassuringly, she is not requiring supplemental oxygen.

      So as much as we can tell from a single photo, I think she is on the mend. 🤞
      Sending her all my best wishes which I hope X users will pass on.

      1. Thanks leslie. I had looked at the blow-up image which shows what look like iv’s in both hands/wrists. I only know about these things from the patient side but did recognize the harness. Tap on the image to see if you can get down to her hands. I appreciate the expertise!

         1. Ah. Not being on X I didn’t realize these bits Jerry posts for us could be cropped. I see only two green i.v. cannulas. The blue objects are connector hubs for hooking different drips up to them. One (right) has tubing connected. The other appears to be locked off for later use. There is a third blue connector hub visible just below her right sleeve, possibly the proximal end of an unseen cannula sited on the inside of her forearm. Not incompatible with being on the mend, but yes she’s had an ordeal.

            Renewed nail polish is traditionally a really good sign. Seriously. I bet the nurses love her. How could they not?

3. Real wisdom from Dr. Coyne “I really dislike land acknowledgments because they’re purely performative. They are there to make the issuer look progressive and moral, but they accomplish exactly nothing.”

   This is so true. I spent two decades covering news in North Carolina and the Reverend William Barber. A good man who organized marches including “Moral Mondays” to protest legislation at the legislature. These efforts accomplished nothing other than getting television exposure.

4. You understand the problems with tariffs, but drug price controls are no better.

   Empirical evidence is very strong that restrictions on drug prices reduce innovation. From the recent Journal of Economic Perspectives:

   Numerous empirical studies show a relationship between a drug’s expected market size and the magnitude of research and development investments. Early studies focused on changes to market size resulting from the demographics of disease burden (Acemoglu and Linn 2004) and policy changes influencing market demand (Finkelstein 2004). These findings have largely been confirmed by more recent papers using changes in the generosity of insurance markets as shocks to market size ( Blume-Kohut and Sood 2013) or variation in demographics related to medical conditions (Dubois et al. 2015). For example, DuBois et al. (2015) find that each new drug requires an increase in market size of approximately $2.5 billion.

   Demonstrating the centrality of financial incentives to research and development investments, a series of studies have documented that firms respond to the potential economic size of a product’s market and not simply the number of potential patients. For example, Garthwaite, Sachs, and Stern (2022) examine the large Medicaid expansions that occurred as part of the Patient Protection and Affordable Care Act of 2010. Because Medicaid pays much lower prices than other US insurers, this large expansion had only a modest increase in revenue and did not result in increased investments. In another study, Agha, Kim, and Li (2022) exploit the increased use of stronger bargaining tactics in the form of excluding coverage for specific pharmaceutical products. Such tactics did not reduce the number of patients, but simply the expected financial return per potential patient. The authors found reduced R&D investments in products for therapeutic areas where there are already competing therapeutic substitutes, because new products could easily be pitted against existing drugs during price negotiations.

   1. Thanks for the pointer Barry. If you put in a link to the paper it will work (more than one link, and WordPress will probably disappear your comment.)

   2. ” . . . but drug price controls are no better.”

      Setting aside the core point about the relationship between revenue and R&D investment, you surely are not suggesting that we have free market pricing currently at work, are you?

      And let’s accept that current revenue is necessary for future investment. Should the US consumer be the one disproportionately paying for that? If not, how would you restructure the pricing mechanisms?

   3. Maybe they could transfer a little of the money they spend on television and radio ads to their R and D fund.

      1. Or pay back the government for the intellectual property that was funded by the taxpayer.

         Or pay a 20% excise tax on all lobbying expenses.

         Or give a damn.

         1. And all the fancy lunches their reps put on in mental health clinics (all the ones I worked in, at least) where they convince the docs how much superior their now off patent drug is to the generic equivalent they’re prescribing their patients.

   4. Here is the link
      https://pubs.aeaweb.org/doi/pdfplus/10.1257/jep.20251438

5. There is a more comprehensive video which includes the video above with good commentary from a geologist hopefully at url https://www.youtube.com/watch?v=CfKFK4-HNmk
   He provides some usgs-developed background information and the ground shift video starts at about 6:20 in. He shows it several times and points out some discrete events such as driveway cracking, gate swinging open, etc.

   1. Wow! That greatly enhanced how spectacular the video is. Most of that went unnoticed by me without this guy’s pointing the various things out. My eyes went straight to the most obvious thing – the opening gate – and missed the really exciting stuff. Like the professor, I feel a little guilty calling it “exciting” given the amount of human devastation the quake caused, but it is quite the trip watching the power of mother earth in action. Glad you posted this.

6. the Republican-led House released its new plan to trim $880 billion from Medicaid.

   Honored Republican-led House:

   $880 billion is not “trimming”. It is “slashing” or “going after with a chainsaw.”

   Sincerely,

   George Orwell

   1. Good point George. Maybe you should write a book.

7. It looks like the University of Washington is stretching things to claim that they sit on land formerly held by the Coast Salish people. Here is the map of the their historical territory:
   https://www.burkemuseum.org/collections-and-research/culture/contemporary-culture/coast-salish-art/coast-salish-people
   A quick search shows that the U of Washington is on land to the south of the map. Maybe there is a very small area of overlap, at best.

   1. Pure performative crap. People at universities should be ashamed to put such nonsense on their syllabi and, just as bad, to make land acknowledgements as pro forma introductions to lectures. I’ve seen it and it embarrassing. It’s good to know that some people are resisting, risking their positions to do so.

      Even if it’s true that your institution sits on “occupied” land, it’s completely disingenuous to believe that you’ve discharged your responsibility to the land’s predecessors simply by by acknowledging the theft. The acknowledgements I’ve heard and read aren’t even apologies; they are morally neutral statements that don’t even express contrition for the wrong. If the land is stolen, the settler-colonial institution should either try sincerely to give the land back or to pay meaningful restitution. Simply implying—but not even stating explicitly—that you kinda feel bad about it in a land acknowledgement means that you are in fact not taking any meaningful responsibility.

      This whole performative endeavor sets a very bad example for students. Is this kind of dishonesty what we want our young people to emulate?

      1. Oh land acks are utterly stupid, embarrassingly so. Full metal cringe.

         But wait…. Norm you ain’t seen nothing yet until you’ve sit in on a real DEI “training” module. I’ve suffered a few as I consult with a company and I’ve seen two more online. Both the quality of the “instructor” and the content of the “classes” are so terribly stupid they might just slow the rotation of the planet.
         For this and many other valid reasons I really hate woke and no longer can call myself a Democrat.

         D.A.
         NYC

         1. I worked at a giant technology company for 20 years and had to endure a few DEI training sessions. The ones I took called themselves “diversity trainings” but they were mostly about viewpoint diversity, how communication styles differ among cultures, and other such things. They were all run by external consultants—the same opportunists that taught TQM and Six Sigma when those fads were in vogue. The trainings I took were actually not too bad. I retired in 2019, so maybe I missed out on some of the more ideologically motivated content.

      2. I raised my boys in Seattle so I know the Salish people are valorized and it doesn’t surprise me a bit that the UW has it’s knickers in a twist about land acknowledgments. Not that the Salish aren’t worthy of honor and recognition, but the whitewashing was thorough. For example, it is routine for Seattle school children to go on field trips to see a “potlatch”, a native people’s celebration, including dancing, clothing and food. It really is quite delightful and worth seeing.

         However, they never mention one of the highlights of a traditional Salish potlatch; the ritual and brutal killing of slaves as spectacle. Slavery was common in the native American Northwest, mostly people captured during war, but also part of a slave trade throughout the Northwest*. Having slaves was seen as a sign of power and strength. Slaves were ritually (and horrifically) slaughtered at potlatches as a way to project that power. None of this is mentioned at the potlatches we see as shows today; the deprivations natives suffered at the arrival of white people is the focus.

         *I recommend “Slavery and Social Death” by Orlando Patterson for a complete, if academic and didactic, compendium of slavery from ancient times until the present.

         1. Our public library has the ebook version of a title written 35 years after the book you reference (we don’t have that title) entitled, “On Human Bondage After Slavery and Death” by various authors, 2016. Have you any thoughts of the second title? The description says it builds on what the original author (Orlando Patterson) wrote and it includes a chapter by him. So it doesn’t seem to be some hatchet take down of his work. I’m rather fascinated by this stuff.

8. So the University of Washington believes itself to be sitting on land formerly held by the Salish People? So are they proposing to give it back? Or pay rent? If not, isn’t a mere ‘land acknowledgement’ just adding insult to injury?

   1. Absolutely, Graham!

   2. Correct me if I’m wrong but wasn’t there a Free Palestine takeover at UW last week that caused a million bucks damage to a science lab? (I got this from twitter, so I wouldn’t put money on it but it checks out as consistent with that dynamic).

      D.A.
      NYC

      1. You are right. Some 20 of the protestors were arrested, a rarity.

      2. https://www.king5.com/article/news/local/seattle/protestors-occupy-uw-engineering-building/281-dea79745-8211-418b-b56f-40e7f55b9adb

9. The insulin used today is not the insulin our grandfathers read of with awe that Dr. Fred Banting used to save the lives of diabetic children in 1921. For one thing it’s human insulin made in bacteria, not extracted from animals, so people don’t develop inactivating antibodies to it. For another, through clever tweaking of the amino acids, it doesn’t have to be injected every few hours round the clock as the original “Toronto” insulin did, with near constant feeding to prevent lethal hypoglycaemia. Now, combinations of different types and formulations of insulin molecules are given to better mimic the normal physiologic response of insulin to food, in the constant quest to control blood sugar better without killing people. These developments cost money to develop and to demonstrate effectiveness in clinical trials. If free-riding Europe (and Canada) use state power to help themselves to the profits these drugs would otherwise make, then Americans will have to pay more if they want new drugs. (Maybe they don’t, and are happy stopping innovation now. “Progress was great at the beginning, but it has gone on entirely too long.”) Admittedly, in an insurance-based system where third parties pay, doctors will demand that every innovation get funded at the full asking price, even if the demonstrable benefit is modest, because patients demand they prescribe the innovation for them.

   I don’t see how you can make the bald categorical statement that high drug prices gouge Americans just to enrich drug companies unless you critically analyze the Pharma position beyond saying you don’t believe it.
   https://pmc.ncbi.nlm.nih.gov/articles/PMC7054843/ from 2020 showed that while big Pharmas are more profitable on average in terms of net income per share, — “the bottom line” — than other public companies listed on the S & P 500, an apples-to-apples comparison that takes R & D into account largely attenuated this difference. This accords with the judgment of portfolio managers and individual investors. We don’t just load up on Pharma stock and retire early on the obscene profits. Successful drugs have to pay not only for themselves but for the failures that had to be written off. (Of course, those who say all corporate profits are evil and should be collectivized will not be mollified.)

   As a large buyer, the Federal Government should certainly use its pricing power to negotiate lower prices, a power that the Bush expansion of the Medicare drug benefit denied it. There may well be room for Pharma to yield some on pricing if they want the Medicare contract. If this is all the EO ends up doing, fine. But drug companies sell elsewhere despite price controls because they know they can currently get full price in the huge American market to pay back innovation costs. If President Trump imposes price controls in the U.S., obese Europeans (and the 5% of diabetics with Type 1) are going to have to pay more for their insulin and all their other drugs, which might be a good thing. No free lunch.

   By all means let’s put the boots to Pharma and find out what happens.

   1. Why not let the craptastic medical insurance companies do it for us?

      Simply get rid of the nefarious Rube Goldberg-eques schemes of deductibles and co-pays, which are already too expensive for most American families. You pays your insurance quarterly, and you gets no more bills.

      Let’s get the insurance companies (and hospitals) to stop diverting more and more of their costs onto the public, and let them hammer out prices with each other and Pharma.

      1. Since you ask, I think the easy answer, arguing from first principles although a bit off topic from drug costs, is that insurance companies don’t want to stimulate demand (= their costs) by promising to pay for everything a doctor and a patient might want to avail themselves of. The purpose of cost-sharing is to get patients to say, “Hmm, this new treatment lists at $20,000 but it will cost me $1000 in co-pay out of pocket. The old treatment is not quite as good, at $5000, but the co-pay is only $50. Since I have $50, but not $1000, I’ll choose the old treatment and save the goddamm ins co $15,000. Why can’t I demand that the insurance company give me the $20,000 treatment, because it’s better, and not charge me any co-pays at all?

         You could get that if you socialize the whole system. Kick out the insurance companies who use cost-sharing to protect profits, not for Rube Goldberg reasons that seem not to make sense. (But of course they do.) Everything free for everyone, no co-pays or deductibles. Funds raised through progressive “fair share” taxation, not by flat premiums. But then the government wouldn’t buy the $20,000 treatment at all for anyone. Too expensive because of all the demand stimulated by the abolition of cost-sharing and regressive premiums. If you wanted it, you’d have to pay the whole shot out of pocket because the evil insurance companies have been driven out. Then the government would ration the $5000 treatment and force the providers to accept $4000 for it or impose heavy fines. Maybe everyone would be better off, and happier, with no expensive new treatments provided, rationing for medical need, and monopsony discounts on what is provided. Or maybe not. The government’s call.

         1. I don’t think the data supports sustained demand resulting from increased coverage. A temporary uptick as previously-untreated patients (because of cost) avail themselves of needed therapy? Yes, but then expenditures classically asymptote off (see NB).

            And there is certainly nothing to stop protocols which reserve expensive treatments only for patients who have failed standard treatments. These are decisions which doctors, not insurance companies, should make in my opinion.

            NB – I used to be a Pharma rep, retired 15 years ago. In my experience, docs are VERY attuned to cost containment. I don’t think that would stop in the absence of copays and deductibles. Doctors (and patients) also very much resent the insurance industry interfering in patient care. I would imagine that any increases in insurance companies payouts would be more than compensated by the reduction of bureaucracy they would enjoy.

            That said, my familiarity with the economics of health care pretty much ended 15 years ago. I could be way out of date.

      2. The “demand” for healthcare will always outstrip what is practically affordable. Inevitability there is always some mechanism to keep demand under control. This could be any of: explicit rationing, long queues for treatment, high cost to the patient, or insurance companies denying claims in order to keep premiums down. Any system is going to have some such mechanism. And that mechanism will get complained about.

         1. Right now in America that system which ostensibly (supposedly?) reduces demand is responsible for trillions of dollars of needless costs over a single decade. Insurance companies, hospitals, and individual medical offices have preposterously bloated administrative staffs at war with one another, chasing down authorizations, payments, and debts. I’ve seen medical practices with at least as many administrators as practitioners.

            The only argument against fixing this sorry mess is that if we ever did get a National Health Care system in place, it would put about one million administrators on the unemployment lines.

         2. I prefer the mechanism that allocates health care to those that benefit more (through more gained life expectancy and/or quality of life) instead of allocating it to those who can pay the most.

            1. Sounds good, but “To each according to their needs” has had mixed outcomes at best. And who decides whether something is a “need” and not just a “want”? One’s social credit score will also likely figure in the rubric.

               Yes, health care must of necessity be rationed in some manner, even though many people object to that word if not to the concept in general. We all eventually lose the battle, and a disproportionate amount of care is consumed in futile last-stands. IMO, structuring the rationing in a way that seems fair to most people will be hard, bordering on impossible. My life is considerably more precious to me than yours is, and vice versa.

   2. Having done my PhD in basic biomedical research, I can tell you that Europe isn’t “free-riding”. If anything, it’s the US pharma companies that profit from public research to base their development on – a lot of it is coming from European tax payer money creating US jobs and profits.
      Looking for jobs around 10 years ago in the sector, I can found that most companies have outsourced most if not all of their research and most of the time they only swoop in once a product is clearly on the horizon buying up start-ups and spin-offs based on publicly funded research.

      1. One thing that I feel should be commented on is public funding of research. It is an extremely important source of new methods, ideas, and discoveries. But finding a way to fiddle with the mechanism of action that will treat a disease is a very long way from making a drug or therapy. It is NOT a trivial matter to convert the findings of a public funded research program into a safe and effective drug or therapy. THAT process takes a great deal of expertise and money which the original inventors almost never have, and, owing to the properly rigorous and strict approval process, most (8 out of 10) that even make it to testing in humans will fail.

         Public funding of research that leads to new drugs is critically important, but the discovery is only the beginning of the work that needs to be done.

         1. I’m sure you know this but for those who don’t, the 8 out of 10 ratio does not even account for the effort and expense consumed by the projects that don’t make it off the bench into clinical trials.

      2. The numbers in this essay indicate that established pharma firms have not outsourced their R&D but complement those efforts with M&A. The essay also points out that smaller firms are often formed with the express intent of being bought by larger firms. Although this strategy is not unique to this industry, the pharma commercialization process is so onerous that few small firm have the resources to commercialize an innovations on their own.

         “In 2021, pharmaceutical firms around the globe invested a total of $276 billion, or 27 percent of global revenue, in R&D (Chandra et al. 2024). Unsurprisingly, the largest pharmaceutical industry investments were made by publicly-owned commercial firms, which tend to be larger firms actively selling products. These firms accounted for $244 billion of the total, with $44 billion at the pre-market research stage and $197 billion at the commercial development stage. Privately-held pharmaceutical firms—often hoping to sell or license their efforts to the larger companies for commercialization—accounted for almost $26 billion of “pre-revenue” research spending and only $6 billion of commercial-stage development (Chandra et al. 2024).”

         “Many successful products often start their path to market in academic labs and small biotechnology firms that hope to license or sell their innovation to larger firms. Even universities that are often thought of as pursuing “pure” or “basic” science have developed extensive transfer and licensing operations. Many of these scientists conducting this early-stage research ultimately form private firms aimed at future commercial development.”

         https://pubs.aeaweb.org/doi/pdfplus/10.1257/jep.20251438

         I’m familiar with a number of startups where the plan was always to be purchased by a larger firm. This was because the costs for the clinical trials was just too great.

10. There is a strange dynamic by which some US fads are mimicked in Europe. For comic relief, imagine how “land acknowledgements” might be phrased in east-central Europe, for example at the University of Kharkiv.

11. The economist/political commentator Noah Smith has an excellent piece debunking land acknowledgements:

    https://www.noahpinion.blog/p/no-you-are-not-on-indigenous-land

    1. That looks interesting. I’ve bookmarked it for later. Thanks for the link.

12. I looked up the labor theory of property and was rather amused. The theory comes from John Locke and concerns “by what right an individual can claim to own one part of the world.” Per Locke, the only way a person can gain a legitimate right to a piece of land is by laboring on the land to make it more productive via agricultural cultivation. Admittedly, I may have gotten the nuances of the theory wrong, but if I did, it doesn’t matter. What matters is the implications of Locke’s theory:

    … Wood … argues that Locke also provides a justification for the dispossession of indigenous land. The idea that making land productive [via agricultural cultivation] serves as the basis of property rights establishes the corollary that the failure to improve land could mean forfeiting property rights.

    Significantly, Locke doesn’t think that the mere fact hunter gatherers depend on a piece of land to survive gives them any right to it:

    Under Locke’s theory, “[e]ven if land is occupied by indigenous peoples, … their land is still open to legitimate colonial expropriation”[16]

    Locke’s theory is obviously morally deranged – at least by modern lights. But land acknowledgements are morally deranged too. So, the professor’s point may have been that he was no more wrong to deny that the indigenous inhabitants of the land had any right to the land that the settlers took from them than he would have been if he had had feigned believing that they do have a right to the land – while at the same time refusing to give it back!

    1. If on land unowned by anyone, you labor all day gathering acorns, are those acorns yours? If on land unowned by anyone, you labor all season tilling the soil and raising a crop, is that crop yours? The land? Seems to me there’s a bit of logic to Locke’s theory. I think Locke said that his theory held if there was enough land for everyone, which with the discovery of America seemed to be the case. Of course, Locke and his friends had their own reasons to justify property rights.

       1. Locke’s theory applies most cogently when land is scarce, rather, although this view may attribute to Hobbes, earlier: If two men both covet the same thing, whether for their sustenance or merely their delectation, and cannot share it, then they must become enemies. Nomadic hunter-gatherers can’t share land with settlers who want to farm it. The former need large tracts of land over which they can wander freely, in order to secure enough game. The farmer can make a life on a much smaller plot, because farming and livestocking are more productive than hunting. But he needs absolute private control of that fenced-off holding, protected with armed force. He can’t allow a nomad to wander onto his land “hunting” his livestock and “gathering” his tomatoes thrilled at his good fortune. He will shoot the interloper and expect the state to protect the settler community from organized retaliation by aggrieved nomads.

          So the two competing users of the land must drive one or the other off. Given time, the more productive and numerous farmers will drive the hunters off to land that isn’t fit for farming. (Farmers have been doing this since antiquity.) If that land isn’t fit for hunting either, sucks to be the hunter.

          This is what I think Locke is getting at when he says that even if the aboriginal hunter “needs” the hunting grounds for his survival, he can’t have them if the settler with his labour can support more people by farming that same land. (We see that surviving as eminent domain today.) The produce of farmed land is the farmer’s, not God’s. So he has superior rights to the land from his labour. If the nomad wants to assimilate and become a farmer (which was half-hearted Canadian assimilationist policy until we gave up on it around 1969), then he too can have rights to land, by buying it from the Crown.

          This is special pleading with motivated reasoning, of course. But if you need a moral justification for our living here in North America forever and not giving a single sliver of land “back”, it’s the best you’re going to get. Otherwise you’re left with Doctrine of Superior Force, aka, “All God’s chillun gotta eat.”

13. Re investors in Holmes’ partner’s new healthtech project¹, it strongly reminds me of the Nigerian Prince Effect: the best targets for a scam are those who are oblivious to well-known scams; anyone responding to a Nigerian Prince scam email these days is a very good prospect indeed; the vast majority of targets who reject it out of hand don’t matter, it’s the rare few soft targets that do.

    ¹ It took a while to find a non-defamatory descriptor.

14. Really enjoyed the strike slip fault video and the seiche ‘ringing’ the earth for 9 days.

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