Will You Still Study Me When I’m 64?

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When older patients seek out health care, they are unwittingly enrolling in an experiment: Will medical procedures that have been proved effective mainly on the young also help the elderly?

That’s the first sentence in the editorial that my colleague Dr. Donna Zulman and I have in the New York Times today. We discuss the exclusion of older patients from many medical research studies and how it both compromises quality of care and is socially unjust. It’s a specific example of the more general problem I have discussed before: The people who are enrolled in the research studies that guide the provision of health care are markedly different from real-world patients on many dimensions.

When I was a member of an National Institutes of Health (NIH) grant review section, I saw many proposals that restricted study enrollment to people under the age of 55 or 60 or 62 or 65. I would always ask “If a patient otherwise enrollable was one day over your upper age limit, how would you justify excluding them to their face?”. The dominant response by grant applicants was interesting: Continue Reading…

Weekend Film Recommendation: The Offence

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Howard ConneryThe James Bond films made Sean Connery an international superstar, but presented him few challenges as an actor. In the midst of Bondmania, desperate to avoid typecasting and to take on more substantial roles, Connery began collaborating with Director Sidney Lumet. This resulted in one financially successful and entertaining film (The Anderson Tapes), but more importantly led to Connery turning in two critically-praised, Oscar-worthy performances that hardly anyone saw. The first was in one of my prior film recommendations, The Hill. The second was in this week’s film recommendation: The Offence.

The back story of this far-too-rarely-seen 1972 movie reveals much of Connery’s psychology at the time, as well as his star power. He had walked away in disgust from the Bond enterprise, and his replacement (George Lazenby, not as bad an actor as reputed but also no Connery) had not had the same box office draw. United Artists was so desperate for their superstar’s return to Bondage that they offered him whatever he wanted. He could have insisted on the world’s biggest paycheck, but instead he demanded that United Artist support two low-budget art house films! One was to be a Connery-directed adaptation of Macbeth, which would have been a Scottish treat and was unfortunately never made. The other was The Offence, which everybody concerned made for art’s sake because they knew there was no way in the world this film would garner even 1% of the box office receipts of the Bond films. The modestly-paid cast and crew worked like dogs to complete the entire shoot in less than a month (Connery himself allegedly put in up to 20 hours a day). The resulting labor of love is a shattering cinematic experience.

The plot centers on disillusioned, angry and unstable Detective Sergeant Johnson (Connery). In the visually distorted, almost dissociative opening sequence that reflects the tortured workings of his mind, the audience sees that Johnson has just beaten a suspected child molester. He snaps out of his rage and realizes what he has done, but it’s too late. The suspect is being taken to hospital and may well die. We then learn the background: A child molester has been victimizing girls and getting away with it time and again despite the efforts of the police. Another girl is kidnapped and raped, but ultimately found by Sergeant Johnson. But rather than regard him as a rescuer, she reacts in terror to him, leading something inside him to snap. The smug, posh suspect who is eventually brought in gets under Johnson’s skin even more, causing him to lose control, although we do not learn the reasons why until the film’s devastating final act.

After this opening, the movie then turns into a three-act play, with each act being a two-hander (This staginess is the film’s only flaw; given more time and money I suspect Lumet could have escaped the story’s playhouse origins as he did in other films adapted from the stage). First is Connery and his long-suffering wife (Vivien Merchant), then Connery and the investigating senior officer (Trevor Howard), and finally Connery with the suspect (Ian Bannen).

The acting in these three scenes is a revelation. Continue Reading…

Hilary Clinton and the actuarial tables

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I don’t know any more than anyone else about Hilary Clinton’s health status or Presidential plans. I strongly hope she runs, because I’m confident that she would clobber any Republican and less confident that any other Democrat would do so. I’m glad to have my views validated by no less an expert on Presidential politics than Karl Rove. [Whatever the truth or falsity of the reports about Rove's sexual activity with underage goats, his expertise remains unmatched.]

One predictable and intended result of Rove’s low blow was to raise the age issue. Republicans, and reporters, who ignored the obvious signs of Ronald Reagan’s progressive dementia in the 1984 campaign.

(I remember vividly Reagan’s utterly confused closing in the first debate, and remember even more vividly the deafening silence from the political press corps and from Democrats that followed. Instead the buzz was about Reagan’s canned witticism on Mondale’s “youth and inexperience.” The Democrats suffer from a deficit of dirty players and subservient hacks, which on balance seems to me a good thing but can be costly at key moments.)

Charlie Cook of the National Journal – while making no reference to the the bestiality questions concerning Rove, which have as strong a factual basis as the brain-damage questions about Clinton – plays along with Rove’s nonsense by writing a beard-stroking column gravely pondering HRC’s age and her decision about whether to run. Topic sentence: “While Clinton’s age will be precisely the same as Ronald Reagan’s when he was first elected president, people in their late 60s do not make nine-year commitments lightly.”

Well, actually, no. Her calendar age will be the same as Reagan’s. But men – alas! – age faster than women. A quick glance at the mortality tables shows that a 69-year-old woman has the same annual mortality risk (1.49%) as a 64-year-old man. So in actuarial terms, Hilary Clinton in 2016 would be the age, not of Ronald Reagan in 1980, but of Mitt Romney in 2012. (Actually, adjusted for gender, she’d be a year younger than Romney was.) Did you hear anyone argue that Mitt was too old to be President? Me neither.

Of course age is a factor; other things equal, you’d rather have a younger president, because the job itself is so punishing. But let’s keep the relevant facts straight.

 

 

How Will David Axelrod Fare in the Blessed Plot?

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At New Statesman, Nick Faith argues that David Axelrod has “his work cut out for him” in his efforts to help Labour leader Ed Milliband become UK Prime Minister. I agree with much of what Faith says, but would raise some other considerations that will matter in what has the makings of a close election.

Contrasting the upcoming UK election with the 2012 US election in which Axelrod sparkled, Faith points out that David Cameron will not commit Mitt Romney-style gaffes and that Ed Milliband lacks Barack Obama’s charisma. Although true, these advantages of Cameron over Milliband count somewhat less in the UK than they would in the US. A certain proportion of UK voters are put off by overly polished candidates (Boris Johnson appreciates this better than anyone). In a country whose national emotion is embarrassment, awkwardness in a politician is viewed more sympathetically than it is in the U.S.

Faith emphasizes rightly that voters who are concerned about the poor will smile on the coalition government having raised the minimum wage, frozen the fuel duty and augmented the personal income tax exemption. But it has to be said that the government also hiked the value added tax from 17.5% to 20%. Consumption taxes fall disproportionately on lower-income groups and are experienced as particularly painful at a time when wages (until recently) have been stagnant. Unless the government are wise enough to reverse this move, they will be subjected to criticism for this inequality-maximizing policy.

In contrast, the improving employment situation could help incumbent politicians enormously in the next cycle. More people are working in the U.K. than at any time in history, which has pushed the unemployment rate down to 6.8%. If the blue line in the chart keeps going up faster than population growth in the next 12 months, Cameron’s support will rise in tandem.

jobs

But from Axelrod’s US-based viewpoint, all of the above may seem like small beer relative to another critical fact: Unlike when he was crafting Barack Obama’s campaigns, Axelrod doesn’t need to persuade 51% of the voters to pull the lever for his boss. Even though Labour is currently trailing the Conservatives in the polls, between constituency boundaries that make U.S. Congressional Districts look like models of rationality and the presence of third parties that draw double-digit support, Axelrod can probably get Ed Milliband the PM job even if two-thirds of the voters choose someone else in 2015.

Special Edition of A Measure of the Sin is Now Available

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measure_texture_new_02 The multi-award winning art house horror movie A Measure of the Sin will soon be distributed in North America by BrinkVision. The film is based on my wife’s poetic fiction, well adapted by Director Jeff Wedding. The first 200 copies come with a very nice set of special inclusions, which you can find here along with glowing critical reviews and the trailer. If you want to take advantage of the special edition, you’d be well advised to move quickly as they have been selling quickly. If you do miss out on the special edition, you will still be able to enjoy the movie on DVD or VOD beginning on June 17.

Two girl groups

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My wife’s mixed chorus gave its spring concert this weekend and performed Randall Thompson’s Choose Something Like a Star. This is an exquisite, choke-up beautiful, number that I had first heard performed as SSAA, but it seems that SATB arrangement is the original, and the piece has been rearranged so that women’s groups can enjoy it too.  Revising a paper last night, I teed up a Spotify station from a Patrick Saussois song and after a while,  along came a cut from Christine Tassan et les Imposteures that brought work to a stop.  This is a Montréal quartet in the middle of widespread revival of the “gypsy” jazz form that traces back to Django Reinhardt and has popped up all in the usual, and some unlikely, places with some really fine musicians.  A gang of Scots that call themselves Havana Swing, for example, and the Canadian group The Lost Fingers.  The jazz manouche  crowd likes to blur the boundaries, cover songs from all over, and bring in straight-ahead jazz musicians, and people like Peter Beets and David Langlois are happy to jam with Dorado Schmitt at Birdland every year or so.
But I digress, even from the threadlike theme of this post.  Tassan’s quartet combines drop-dead instrumental chops with a really good set of pipes, and they have the kind of radiant delight performing that illuminates the most watchable baseball players, like Willie Mays and Dustin Pedroia. Women jazz musicians have always been scarce except for “the ladies who sing with the band” that Fats dissed; someone like Deanna Bogart consequently has to be two of them (tenor sax too, indeed three, if you count vocals).  This group is mainly instrumental; the rhythm guitarist, bass player and fiddler mostly sing as backup for Tassan, like the golden-era rock and roll girl groups, though they have some fine four-part riffs.  They have three CDs out, two on Spotify; the latest one doesn’t seem to be available in the US.  Come on, Amazon!
Listening to them I was reminded of what may be the best ever, the Quarteto em Cy, four sisters who have recorded and performed, alone and with the top Brazilian talent, over four decades.  They’ll probably be back in the next samba post. Listening to them is a time machine that will remind you of voice qualities impossible to discern in the mechanized, processed popular music of today, stuff like, um, intonation and rhythm…and ensemble, hoo boy.  This is really difficult harmony, and only works if the singers are in complete control and together.  No melismatic shopping around for a note here, either; they’re very exposed, and punch every one.  One of my favorite cuts on the linked album is the charming Loura ou Morena, about a guy who can’t decide if he likes blondes or brunettes more, that Tassan’s Les Blondes reminded me of in tone.

The Incarceration Tipping Point

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The three-decade-plus growth of incarceration in the U.S. at one point seemed an unstoppable public policy juggernaut, insensitive to political and economic changes. Until it wasn’t: The number of people in prison finally began dropping under President Obama and appears likely to continue doing so.

One key determinant of the size of the prison population is the number of admissions each year. I have presented a longer series of data on the prison admission rate before; here I will just focus on the past decade of data to better highlight something unusual about recent history. In interpreting the data, note that the government defines admissions as sentences exceeding one year, so every admission represents a unique individual.

Incarceration Tipping Point

The shape of the curve is singular. Initially the rate continues its decades-long ascent. But in 2006 it hits an invisible ceiling and begins plummeting with increasing speed. This is an unusual finding in public policy analysis. Particularly at the national level, it usually takes awhile for major policy changes to be consolidated. But in this case, we have experienced an unambiguous U-turn. Further, while the 2007 and 2008 drops in the rate of prison admission are roughly equal in size, from that point forward the drop each year exceeds that of the prior year. The drop in 2012 was about double that of 2010, four times that of 2009 and six times that of 2008.

I could tell a story about the causes of this policy turnabout and I am sure many other people could also (get the lead out, Kevin…). But all I want to do here is highlight the striking nature of the change: Outside of tulip bulb investing and the like, you rarely see national policy go so vigorously in one direction and then abruptly travel with accelerating speed in the opposite direction.

p.s. Some people have cited my prior posts on the prison admission rate change as “Humphreys’ research”, so let me clarify that I do not deserve credit for doing anything groundbreaking here. I am simply taking two numbers produced annually by your federal government (the number of prison admissions and the size of the general population) and dividing one by the other. In the chart above I multiplied the result by 100,000 as this is the standard incarceration rate used by criminologists.

Is the cannabis market headed for “Bud-lightification”?

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Annie Lowrey has a smart piece in the NYT Magazine about how the cannabis business is likely to look after legalization. She gets one key point – much lower prices – though she doesn’t develop its implications for the size of the cannabis market and the prevalence cannabis abuse disorder; that’s not what her story is about.

The focus of the article is on consistency, and how the industry is stumbling toward being able to deliver a reproducible product, to the point where two joints with the same brand name will be alike as two beers with the same brand name. If that happens – and I think Lowrey is right that it will – that might make cannabis a much safer product. But there’s a subtlety here.

Bud Light is reliable, but it’s also pretty bad (or so my beer-drinking friends tell me). So’s a McDonald’s burger. On the other hand, there are also products that are both reliable and of high quality.
Other than quality, there’s the question of diversity.  The beer market is overwhelmingly dominated by four more-or-less-identical brands. It’s not just that every can of  Bud is the same as every other can of Bud; they’re pretty much the same as cans of Miller or Coors. So other than the choice between regular lager and light, there’s not much actual consumer choice among mass-market beers, which account for upwards of 70% of the beer sold in the U.S.
It’s possible that the pot market will wind up like the beer market. But it could instead end up like the wine market, with greater variety and higher quality along with reliability. That would matter both to the consumer experience and also to the distribution of political power.
So standardization is good. Bud-Lightification, not so much. And they’re different phenomena.

 

 

 

 

 

 

 

 

 

 

 

 

One cure for one cancer

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The Mayo Clinic:

In a proof of principle clinical trial, Mayo Clinic researchers have demonstrated that virotherapy – destroying cancer with a virus that infects and kills cancer cells but spares normal tissues – can be effective against the deadly cancer multiple myeloma. ….. Two patients in the study received a single intravenous dose of an engineered measles virus (MV-NIS) that is selectively toxic to myeloma plasma cells. Both patients responded, showing reduction of both bone marrow cancer and myeloma protein. One patient, a 49-year-old woman, experienced complete remission of myeloma and has been clear of the disease for over six months.

Research report here in Mayo Clinic Proceedings (no paywall, thanks!); WAPO.

“Patient 1” has a name: Stacy Erholtz, and we owe her not only our admiration but thanks for allowing us to put a human face to the antiseptic research prose.

The researchers and the Mayo media people studiously avoid the word cure. Continue Reading…