Posted by: Prajwal | March 31, 2010

Is healthcare reform constitutional? Part 2

Part 2: Arguments that are worse than mine–Bad points hurt good conclusions

In this series, I attempt to resolve through my complete absence of legal powers, whether healthcare reform is constitutional. More reasonably, I try to lay out some arguments, inconsistencies, and reasoning. In Part 2 of a series that is probably mostly wrong (but very interesting!), I take a look at a historical approach that has been used to resolve this issue.

If you recall from Part 1, we started with three basic concerns with the healthcare reform bill:

1) Forcing individuals to have health insurance is unconstitutional

2) Forcing individuals to purchase a private product is unconstitutional

3) The regulation of insurance is more or less a matter for states to decide, not the federal government

I decided that the third one is really obviously not a problem and not worth exploring further. But I did not address how to resolve #1 or #2, except to say that resolving #2 should take care of #1 (more or less).

There is another approach proposed to address #1, brought to my attention by Greg, a fellow US/UK Fulbright Scholar studying in the United States, in a DailyKos link by LaurenMonica that he shared. LaurenMonica discusses an article by Paul J. O’Rourke in Open Salon called Our Founding Father’s Socialized Healthcare System. The topic of both pieces is legislation signed by John Adams entitled “For the Relief of Sick and Disabled Seamen.” (I should note that Greg says that he is not a supporter of mandates, but I will leave it to him to make his position on these articles, my arguments, and healthcare reform in the United States as a whole.)

It is a pretty straightforward act, being about a page long. So I can proudly say that I read it, unlike the current healthcare bill. The way it worked was that owners of ships were required to deduct 20 cents a month from the salaries of their sailors (a payroll tax) for payment to the federal government. The government then disbursed the money for the payment of healthcare services at the ports for sailors. This could be in government hospitals, where those existed, or in a manner decided by the President (so perhaps in a private hospital).

LaurenMonica and O’Rourke (in a later article) assert that this is proof that a federal health insurance mandate is constitutional. I share their sentiment that such a mandate is constitutional (my concern with mandates is largely operational–perhaps more on that in another post) and my sense is that most people agree. But I think this argument is a bit shaky.

These are two major fallacies on which their argument depends:

1) Having not been challenged in hundreds of years, the aforementioned act must be constitutional (a corollary is that President John Adams, a framer of the Constitution, must certainly have acted within the parameters of the Constitution he helped to design!)

2) The provision of government insurance is equivalent to a requirement of private insurance

I will begin by addressing the first fallacy. I have actually done the authors a bit of a favor in phrasing this the way I did. In fact, their argument is a little less nuanced, using the federal statute as a stand-in for constitutionality, instead of making the direct argument that its lack of challenge confirms its constitutionality. Of course, we know that the passage of a federal statute does not equate with constitutionality; otherwise, there would be no debate over the federal healthcare reform bill’s constitutionality. So with that in mind, we’ll give the authors the benefit of the doubt.

Unconstitutional acts can stay on the books and be enforced for outrageous amounts of time while remaining unconstitutional, both at the state and the federal level. This is in part because of the way that tests of constitutionality operate and in part because of the changing meaning of constitutionality as the Supreme Court itself changes.

To test an act’s constitutionality, someone must file a lawsuit. For a court to strike down a law, someone must challenge that law. As a complete layman, I don’t know the case law on this, so it might be that a challenge upheld this law, but LaurenMonica and O’Rourke do not provide this evidence. That would be the test of constitutionality.

Of course, we must recognize that interpretations of constitutionality do change over time. Separate but equal laws were held constitutional in Plessy vs. Ferguson, but subsequently struck down in Brown vs. Board of Education. It is true that our Supreme Court places high value in precedent, but it is not unheard of for the court to overturn precedent where necessary. Even if the precedent of this case’s constitutionality existed, it is conceivable that an argument could be made either from other precedent (of which I am not aware) or from first principles of the Constitution that this is a violation.

Both LaurenMonica and O’Rourke place a lot of value in the provenance of this document. As LaurenMonica writes:

I guess now President John Adams was a tyran[t] who took away Amer[i]cans’ freedom or even worse, he was a “SOCIALIST”. I wonder if the teabaggers will now scream that President John Adams didn’t know the US Constitution. After all, he “just” help[ed] writing the US Constitution, Glenn Beck or other T-Baggers are more experts of the US Constitution than John Adams was.

This is clearly a flawed argument. First of all, while I don’t think many people would claim that President Adams was a socialist, a number of contemporaries certainly did think he was a tyrant.The Alien and Sedition Acts were seen by many, including Adams’ rival and Vice President, Thomas Jefferson (who himself knew a thing or two about the Constitution), as a gross overstepping of the boundaries of federal power. Those acts, because of the politics of the sitting Supreme Court, were never challenged directly, and they expired towards the end of Adams’ presidency. But the Court has noted in subsequent opinions, and I think the historical sentiment on this is pretty resounding, that the Alien and Sedition Acts were unconstitutional.

The Alien and Sedition Acts smell of witch hunts and clearly seem like an abuse of power; this welfare of sailors business seems much more benign. Nevertheless, they arise from the same Federalist philosophy. It is a philosophy, I should say, that I agree with in broad strokes. The Alien and Sedition Acts were overstepping, but I do like central banks, civil rights, and the other gifts that the Federalist perspective has given us.

At the beginning of our union, there was a great debate over the nature of the United States. The Federalists, like Adams, wanted a strong central government, while their opponents thought that the individual states had a significant amount of sovereignty. Over the years, we have moved towards more and more central power, the watershed moment of course being the Civil War, which asserted the preeminence of the union over the states.

My suspicion is that if the courts had been stacked with anti-Federalists instead of Federalists during the Adams administration, a challenge to the sailors’ relief act could have been successful. But that is hand-waving hypotheticals. At the very least, we know that the national sentiment for states’ rights was much stronger then than it is now; striking down such an act would have had a lot better luck in the early 19th Century than the early 21st.

All this presupposes that the sort of government insurance provided by the sailors’ relief act is the same as a mandate for the purchase of private insurance. In fact, they are wildly different, and their differences underscore one of the big problems that even the left has with this bill: The subsidy of the inefficient private insurance market.

What the sailors’ relief act provides is something a lot more akin to traditional Medicare. The government charges a tax on its citizens and uses the revenue to provide for the care of the ill, by funding treatment at public and private clinics. The government here serves as the middle man between policy holders and care providers. If we accept that the government has a role in the provision of social services and a power to collect taxes, this is entirely reasonable.

The irksome thing about the healthcare bill for some is that the government becomes the intermediary between policy seekers and policy providers (insurance companies). This would be fine if the government did not then use its legislative powers to force that relationship by mandating purchase. It is this step beyond subsidy to coercion that gives some pause. It is a step that has no relevance to the sailors’ relief act or Medicare because we all agree that the federal government has the power of coercion through taxes. As you can see, these are two entirely different questions.

Now that we see that this is the wrong way to answer this question, let’s find a less wrong way to solve it. We begin that journey in Part 3 of the series, Armchair philosopher bloviates on the role of government in society, in which I show that the mandate of health insurance is reasonably within the purview of government in general. I leave it to a later part of this series to determine whether federal government has a role (not to ruin anything, but I think it does).

Posted by: Prajwal | March 30, 2010

Gene patents: A failure of incentives

In the New York Times:

United States District Court Judge Robert W. Sweet issued the 152-page decision, which invalidated seven patents related to the genes BRCA1 and BRCA2, whose mutations have been associated with cancer.

This is potentially huge. According to the Times, there are patents on about 20% of human genes. The scope of patents has liberalized over time, sometimes rightly–as with patents for computer algorithms–and sometimes wrongly–as, I would argue, with patents on genes.

As with all patents, the argument in support of gene patents is both technical and practical.

The technical argument is that cloning a gene is a considerable effort that makes it fundamentally different from the gene in vivo and also fundamentally more useful. The latter is a particularly powerful argument, since it is the same justification that was used to small biological molecules like adrenaline and Vitamin B12 and proteins like insulin.

The practical argument is, of course, that patent protection of genes creates an incentive for researchers to develop gene-based therapies and diagnostics. In the case of BRCA1 and BRCA2 this is of particularly importance, because these are markers for breast cancer.

The questions are 1) where the innovation is, 2) where the product/utility is, and 3) where the incentive is.

Where the innovation is

No one would argue that scientists or companies that clone genes are innovating at the sequence level. Genetic sequence innovation belongs to evolution. All that cloning does is to identify and extract a small bit of that information from the vast ocean of nucleic acids in a genome.

Particularly at the beginning, cloning was arduous and required lots of hard work, creativity, know-how, and luck. Cloning is not easy now (and still requires a lot of luck), but since we have sequenced the human genome, it is much, much simpler. Imagine you are Christopher Columbus sailing the ocean blue. Now imagine that someone hands you GPS. That’s the difference we’re talking about. GPS doesn’t make the seasickness any better, but it does mean you’re much more likely to get to India like you wanted.

Isolating DNA, purifying it, and cloning genes might sound fancy. But I am suspect about whether it is a strong enough basis for patents in the genomic era. I will cut it a little slack in my resolution, so read on.

Now one might argue that the real innovation is at the recognition that BRCA1 is a marker for cancer. I am not sure if this claim is made, but I am just trying to test out the possibilities. The problem with such an argument is that it means that our epidemiological data is for sale. Observations are not innovations, and patents ought to be for innovations.

Therefore, if the process of cloning a gene has any innovation, it is not at the level of the sequence and it is not at the level of the population. At best, it is at the level of the cloning method, and even this is shaky because a lot of these methods are standard protocols.

Where the product/utility is

The standard for biological patents seems to be that you make the substance more useful than it would be sitting in a chunk of flesh. I would argue that as the transition between flesh and pure substance becomes cheaper, easier, and more standardized, the potential utility of the flesh approaches that of the pure substance. This is particularly true for DNA, whose extraction and purification is facile.

More generally, the goal of a patent ought to be to spur and protect marketable discoveries. The gene itself is not a product and has no utility. It is rather a biological attribute of an individual, like an arm or a leg. Would you patent an arm or a leg?

Instead, the value derived from knowing something about the gene is what you do with that information. If someone develops a diagnostic, that is a real product with utility, a marketable discovery. It makes sense to patent the diagnostic; it makes less sense to patent the physical state it identifies or diagnoses.

Where the incentive is

This, of course, all brings us to incentive. As a society, we have little need to incentivize the collection of genes through patents. The incentives of basic research–grants, prestige, publications, degrees, positions, and tenure–are largely sufficient. What’s more, there is an indirect incentive on cloning genes when one allows patents that require that the genes have been cloned.

An example in the non-monetary scientific world is this: It is unlikely that Nature will publish my paper if I just clone a gene, but in order to get Nature-worthy results, I might have to clone the gene. Hence, the allure of Nature was sufficient to make the secondary, and necessary, contribution of the existence of the clone.

What we really want in society is to incentivize those marketable discoveries. These are the culmination of a lot of hard work and have clear financial potential following a set of fairly obvious steps. There is a complexity around giving patents for things in between the beginning and the end. Yes, it could be useful to provide a milestone patent so that the risk of undertaking a big project is not too large. Yet such a patent reduces the number of people who can take part in innovating on the second stage of that project. There is a barrier to participation for everyone besides the holder of the first patent, meaning that the chance of getting through that second part is smaller. Since the first part is not marketable by itself, society is left subsidizing risk with a dubious gain on reward.

The solution

A resolution to this contradiction is to distinguish between product and process patents. I learned about product and process patents when I was reading about patent policy in India. In order to enable generic companies to make cheap drugs, India used to recognize process patents, but not product patents. (Here is a nice article from Kannan Sivaprakasam on the transition from process to product patents in India in 2005.) Therefore, if you made a small molecule, you did not own the molecule, but rather the method to synthesize it. If someone else developed a different method to synthesize it, he could get a patent for that; while he did not contribute the molecule, he may have contributed a cheaper way to make it–another marketable discovery.

I see the problems with this, because having the molecule itself is of value and we want to incentivize those who are first to market with new ideas. Therefore, I think a hybrid system would be best, where we sharply reduce the length of product patents but increase the length of process patents. This way, we shield the innovation of the first to market, but provide incentives for process innovation sooner.

This could have an impact on the gene therapy and diagnostic market, but not by considering genes patentable. Genes are not products and they are not discoveries. Perhaps the specific methods used to clone them, like the specific arrangement of 1’s and 0’s in an algorithm, are patent-worthy. After all, it is this difficult cloning process that supposedly justifies patents on the stuff that makes us who we are.

I think we would be better off if we kept the method to ourselves and left the substance to Nature.

Posted by: Prajwal | March 30, 2010

Is healthcare reform constitutional? Part 1

Part 1: An unqualified rube attempts to outline the problem

In this series, I attempt to resolve, through my complete absence of legal powers, whether healthcare reform is constitutional. More reasonably, I try to lay out some arguments, inconsistencies, and reasoning. In Part 1 of a series that is probably mostly wrong (but very interesting!), I provide my very basic outline of what the problem is.

I am not a lawyer. I will never be a lawyer. In fact, barring any catastrophes, I will be the natural prey of lawyers: A doctor. But armed with only a high school background in American history, a healthy interest in current affairs, and a not insignificant possession of reasoning ability, I will attempt to weigh in on the question of healthcare unconstitutionality.

My understanding is that people consider this as an abuse of the interstate commerce clause, which allows the federal government to regulate trade between states and has been responsible for the progressive expansion of federal power. Opponents consider it an encroachment of state and individual rights.

My very sketchy understanding of the argument is that they are formulated in the following ways:

1) Forcing individuals to have health insurance is unconstitutional

2) Forcing individuals to purchase a private product is unconstitutional

3) The regulation of insurance is more or less a matter for states to decide, not the federal government

I feel most comfortable waving away #3. I think it can be demonstrated that because insurance companies operate in multiple states, there should be some federal authority to regulate how they behave. Moreover, the impacts–particularly the negative–of poorly regulated insurance companies largely accrue to the federal government in the form of increased burden on Medicaid and other federally-funded public assistance programs.

I think if #2 were disproved, #1 would become difficult to defend. In my opinion, the constitutional questions that hold some weight, subtlety, and interest, are over mandates. In the next part of this series, Arguments that are worse than mine–Bad points hurt good conclusions, I will take a look at a historical approach that has been made to resolve this issue.

Posted by: Prajwal | March 28, 2010

Whistling Dixie in Cambridge

I thought I’d take a break from the politics to justify the the genre of this blog, which is ostensibly a “travel diary.”

So Cambridge is a lovely old town with gorgeous architecture and august traditions. It is at once regal rustic, grand and quaint. Now that Spring has sprung, the sun deigns to greet us in the day and it is occasionally warm. Especially when the weather is nice, I find myself making excuses to take longer strolls. And whenever I walk, I whistle.

Often it’s old favorites like the Battle Hymn of the Republic. In high school band, we played a version that had a few extra flourishes, and I like to throw those in and my own as I make my rounds.

I’m also very fond of what has been called the Black national anthem, Lift Every Voice and Sing. It’s really one of the most beautiful songs I know. It was written at the turn of the 20th century and it is filled with so much heartache and hope. There is an exhilaration at the end of slavery, but a recognition of the challenges of freedom; it is a strong song, full of resolve in the face of arduous trials. You can hear it in the melody, too, the way it rises up and back down, major to minor, tinged with both sadness and joy. I like Amazing Grace, too, many of whose most moving renditions have been performances by African Americans and which became an important song spiritual liberalism in the 19th Century. (It is ironic, of course, that it was written by an Englishman inspired during his work in the Transatlantic Slave Trade.)

So when I’m not singing civil rights standards, I might dabble in a little classical music–Canon in D or the Four Seasons or Water Music. Otherwise, just snippets of things I’ve played. Most everything I whistle, I’ve played on the flute; I couldn’t even manage to whistle until after I learned to play.

Now a song I avoid whistling is Dixie. Its tune is sweet, nostalgic, and old-timey, and when I was growing up, an immigrant without full cultural context, I didn’t quite know its history. Living in the South, I learned it, though. I learned that for millions of people, it represents the very worst kind of sweet nostalgia for a time that is shameful, but integral, to Southern history. Actually, until I just looked it up on Wikipedia, I didn’t know that Dixie’s original lyrics were written by a white man in the voice of a black slave praising his own enslavement. Awful stuff.

Dixie is a pariah, but in American culture, it is a beloved pariah. It’s everywhere! Most vividly for me: It sets the stage for Foghorn Leghorn’s entry on Looney Toons. It’s a song that is almost on the lips of a lot of people, but without the words and without the terrible import. It’s just that quintessentially American tune they remember. Still, most of those people have the good sense to keep it to themselves. It’s a catchy song, but it’s probably better not to go around whistling it.

So I don’t really stroll around Cambridge whistling Dixie. But it doesn’t mean that ol’ Dixie doesn’t reach the aging cobblestone of the Cantabrigian streets. Someone near the Department of Chemistry has a car horn that plays Dixie. If you’re American, you can hear it in your head. You know exactly the sound. It’s from the Dukes of Hazzard, the timeless horn of General Lee.

I understand that Dixie is an heirloom in a wicked tradition. I understand that I shouldn’t be whistling it. But the idea that someone is driving General Lee by the University of Cambridge Department of Chemistry, honking it loudly for us all to hear Dixie in the streets, is amazing to me.

Posted by: Prajwal | March 27, 2010

America’s Most Fascinating Man

I just had the distinct pleasure to watch the first episode of Season 9 of the Apprentice, and let me tell you, it was a doozy. Now some people might be watching for Daryl Strawberry or Sharon Osborne, but I tuned in for Rod Blagojevich, the indicted former Governor of Illinois (OK, I know, indicted former Governor of Illinois is not very specific–the most recently indicted former Governor of Illinois).

I believe that Rod Blagojevich is the most fascinating man in America. And it’s not just because I made the worst mistake of my life and voted for him–naïvely–in my very first election in 2006. To be fair, so did the majority of Illinoisans. There were rumblings about his corruption, but to be fair, the rumblings about his opponent’s corruption were only somewhat milder. And he was a Democrat and she was a Republican. And his hair was…Well, it was his hair.

I can’t say that I’ve ever loved Rod Blagojevich. He’s never inspired me. And I was engaged along with fellow activists in a battle against his healthcare plan, which subverted a single payer approach with a hodge podge of programs that didn’t address systematic reform (OK, so I’m 0 for 2 on that). He struck me like all the other moderate Democrats whose language outstrips their courage, albeit with the faint unpleasant odor of Illinois state politics. And that hair. Oh, that hair.

After 2006, the sheer rottenness, and more importantly, the sheer stupidity, of our embattled Governor became increasingly clear. Those of us in Illinois asked not only how he could have done all of those terrible things–threatening Children’s Memorial Hospital’s funding unless its executives made campaign contributions; attempting to “sell” Barack Obama’s Senate seat for a political appointment or a cushy job; and hinging plans for the state to buy Wrigley Field on the Tribune Company firing editors critical of the Governor, among other things. I mean, this was crummy stuff, but nothing new in a state where three governors have gone to prison in the last 35 years (including the one Blago replaced).

What shocked us in Illinois was Blagojevich’s temerity, his audacity, his complete and unadulterated foolishness. Who says all that stuff he said on tape when he knows he’s being recorded by the DA? After getting arrested on corruption charges, who goes around comparing his struggle with that of Mandela or Gandhi? Who goes to Northwestern to give a talk about “ethics” after all of this?

Who goes on the celebrity Apprentice to compete, claiming that this is his way of fighting back against the people tearing him down with lies?

Rod Blagojevich, that’s who.

This man, this one of a kind man, this special man, with that special hair, will go anywhere, do anything, as long as he gets to say something.

Rod Blagojevich is shameless with a sort of aggressive earnestness that almost makes you believe him. When he says to “play the tapes” to prove his innocence while being a waiter in an Apprentice faux diner–you say, maybe I should play the tapes. Of course, then you remember reading Patrick Fitzgerald’s indictment and the Governor’s story seems unlikely.

In many ways, Blagojevich is emblematic of American media and public discourse. We are voyeuristic, curious about the next national soap opera. There was a time when we had to wait for reality to provide it, but with the advent of reality television, we can extend our pleasure by inducing our favorite anti-heroes to reproduce their worst traits in preposterous circumstances.

The Celebrity Apprentice is schadenfreude, to be sure. We get the joy of watching Rod Blagojevich be Rod Blagojevich. It is addictive because we know that he knows that we’re watching. We’re obsessed with a man whose greatest desire is to have people obsessed with him. Throughout the episode, Blagojevich greeted customers with a proclamation of his innocence. He even got in trouble from Donald Trump for of a complaint that he was derelict in his serving duty because he kept stopping to have conversations. This produced his best line of the show: “Um, uh, ah, I don’t recall exactly.”

What distinguishes Blagojevich from Tiger Woods or Britney Spears is that it is tough to know what his angle is. It is clear that he believes that a victory with the public is his only chance at a victory in the courtroom. But sometimes, I think that he’s just so desperate to be known and recognized that he will risk it all. Other times, I think the calculus is more sophisticated. He definitely knows something about appealing to people–he did win a series of elections.

Maybe he understands something we don’t. Perhaps the path to redemption lies in the satisfaction of the mob’s worst instincts. By playing the fool, living out his outsized caricature, maybe Rod Blagojevich is making himself known, familiar, and sympathetic. While we watch along, laughing at the jester, what we might not realize is that the joke is on us.

All the reports suggest that Rod Blagojevich’s ego is blinding, deluding, confounding. And maybe that’s his genius.

Children, what doesn’t make sense in this excerpt from the New York Times?

Representative Eric Cantor of Virginia, the Republican whip, told reporters that he had also been the subject of threats and that a shot was fired through a window of his campaign office in Richmond this week.

But he said he chose not to publicize the incident for fear of inciting more, and he said that Democrats were wrongly amplifying reports of vandalism and death threats made against lawmakers.

Now I wasn’t born in America, so maybe my English is a little rusty. But let’s break this down for a second. To publicize is to make public. One might make that public by informing others. In fact, over the course of history, the dissemination of information to the public has fallen on the shoulders of a profession of report-makers, reporters as we call them. When one wishes to make a piece of information public, to publicize it, that is, he often does so by telling reporters.

Therefore, when Eric Cantor told reporters that he was choosing not to publicize an incident that he then described, he may have actually created a small tear in the space-time continuum, not dissimilar to the one that the Large Hadron Collider could generate as it recreates the very beginnings of our universe.

As if it were not enough that Congress Cantor’s cognitive dissonance–that is a fancy way of saying “bald-faced hypocrisy”–is destabilizing the galaxy, let’s take a look at what else he had to say.

“It is reckless to use these incidents as media vehicles for political gain,” said Mr. Cantor, who delivered a stern-faced statement on the issue but did not take questions from reporters. “To use such threats as political weapons is reprehensible. By ratcheting up the rhetoric, some will only inflame these situations to dangerous levels. Enough is enough. It has to stop.”

Why would it be that a politician would attack his opponent? Perchance, to gain…politically? Might it be that the shot fired in Mr. Cantor’s office was, in fact, an incident. Could it be that citing it when attacking Democrats in the media was a vehicle for…wait for it now folks…political gain?! J’accuse!

Let me tell you what is reprehensible. Hurling racial epithets at civil rights heroes John Lewis and James Clyburn is reprehensible. “Ratcheting up the rhetoric” by calling Democratic attempts at healthcare reform socialist, Nazi, and totalitarian–that is reprehensible. Lying about this bill and everything else Democrats do in a desperate attempt to keep the government from doing anything is reprehensible. Doing all this as part of a strategy that courts people’s worst instincts and deepest fears on false premises–that, my friends, is reprehensible.

As for Eric Cantor’s unflappable unfamiliarity with irony. Well, that’s just laughable.

Oh, and the gunshot? It turns out it was from a random firing of the gun, not intended for the Congressman’s office at all. It’s still a big deal, people firing guns without knowing what they’re doing. I wonder if there is a way we could prevent that. You know, keep guns out of the hands of people who are not responsible enough to use them properly. Some sort of “control” of the use of guns to prevent unfortunate damages to health and property. Huh. I guess nothing really comes to mind.

Posted by: Prajwal | March 26, 2010

Sarah Palin’s Alaska–Episode Guide

An episode guide to the eight part TLC series, “Sarah Palin’s Alaska.”

Week 1. “Snow mobiles through Denali.”

Week 2. “Room with a view” or “To Russia with love.”

Week 3. “Sarah Palin’s Alaska Tours America.”

Week 4. Unfortunately, this show will be going on hiatus.

Week 5. “Princess Cruises: Alaska Infomercial Part 1.”

Week 6. “Princess Cruises: Alaska Infomercial Part 2.”

Week 7. Rerun of Week 3.

Week 8. “The Exciting Conclusion.”

Posted by: Prajwal | March 25, 2010

Humans vs. Lasers

The New York Times reported today on a study of a laser-based procedure for cataract surgeries in PLoS One. The original study is here. In the battle between humans and lasers, I always bet on humans.

Cataracts are the world’s leading cause of blindness. They involve an opacification of the eye’s lens that makes it difficult to see. Cataracts are usually treated by removal of the lens and implantation of a plastic Intraocular Lens (IOL). Outcomes are fantastic and the surgery can be very, very cheap. That is because a skilled surgeon can perform the operation quickly and effectively (often in 5 minutes or less) and the material required for each surgery can be obtained cheaply. A number of Indian companies have specialized in manufacturing low-cost ophthalmic equipment that has driven down developing world prices.

Kessel and colleagues apparently disagree. The premise of their approach’s utility is that cataract surgeries are currently inaccessible because they are too expensive. The New York Times puts it like this:

Cataracts can be treated by lens-replacement surgery, but the procedure is invasive and costly, requiring special treatment and skilled eye surgeons. To make cataract treatment available to more people around the world, a less-invasive, less-expensive technique is needed.

It is true that cataract surgery requires special treatment and skilled eye surgeons. It is invasive.

But I vigorously dispute the claim that it is costly. At the Aravind Eye Hospital, the pioneer of the low-cost and high-volume approach, a recent study indicates that provider cost for the recommended manual small incision cataract surgery is $17.03. (Muralikrishnan et al, Ophthalmic Epidemiology, 2004)

What about the authors’ approach? Their idea is to provide a low-frequency, low-intensity laser pulse to deopacify the lens. In cataracts, proteins in the lens misfold and become able to absorb light in the visible spectrum–keeping light from passing through to the retina. The authors’ hypothesis was that this laser pulse would change the absorptive properties of lens proteins, clearing up the lens.

The study is a proof of concept, at best. To put it simply, donor lenses from patients were subjected to laser treatment. Because the lens gets more yellow with age, the authors wanted to show whether treating it with a laser would reduce the yellow and let light get through. It seems that this yellowing occurs as a precursor to the formation of cataracts. The authors demonstrated that treating the lens with a laser did in fact allow more light to get through afterwards. However, it does not appear that they considered whether scattering effects might still occur. Moreover, the study does not really address safety, though it seems that this level of treatment should be OK. The authors mention that it is comparable to LASIK.

LASIK? Let’s pause for a second. If you think a scalpel, a microscope, and a lens are too high-tech, what would you make of the equipment necessary for LASIK? I think that a laser is actually quite a sophisticated piece of equipment. The claim that one could create a mobile clinic to do these surgeries using this kind of technology seems highly suspect, especially if we’re going for a price point that beats $15.

As for the level of training required: Who is going to wield this new laser? My guess is you’ll still need an ophthalmologist. It’s not like we’ve appointed an army of LASIK technicians without medical degrees to go around shaving people’s corneas at will. Similarly, I think we’ll need ophthalmologists to zap people’s cataracts. It also strikes me that this fairly sophisticated approach will require training, as different types of cataracts will need different laser power, etc.

To make matters worse, the authors suggest that they estimate such a procedure would take no more than 30 minutes. A feasible cataract surgical intervention in the developing world better not take 30 minutes. That is a huge use of the biggest expense, surgical time, and it’s not fast enough to scale up efficiently. This is true even in the hospital, where one has a little bit more control over pacing. In the setting of an eye camp, there is no way people will wait around for this kind of procedure. To do just 10 or 15 patients, what should be no more than a couple of hours’ work with surgery, would become an all day task. Done in a mobile clinic, it would mean that the surgeon would be tied up with surgery all day, not to mention diagnostics and travel. If he has clinical responsibilities at a more central hospital, those would be abandoned entirely on camp days.

I think it is often the case that we look for technical solutions to problems that have management solutions. Is there a problem with the delivery of cataract surgeries in the developing world? Absolutely, but not because the treatment we have is not good enough. Cataract surgery, in fact, is an example of an intervention perfect for the developing world. With its low cost, speed, and great outcomes, it benefits from economies of scale that make it possible to reverse blindness for many people in a sustainable way.

The right solution for cataracts is to build human resources, not lasers.

Posted by: Prajwal | March 25, 2010

The essential moral victory

This is for my fellow activists, for my brothers and sisters in the fight for equitable healthcare. It’s for everyone who is disappointed with compromise and frustrated with the slow creak of progress. It’s for Nick Skala, who isn’t here to advise us on what to do and where to go, and it’s for Quentin Young, who is.

The bill that passed is not the one we wanted. It’s not the one we hoped for and worked for and fought for. It is piecemeal, not systematic; it is incomplete. It might seem we’ve settled, but I believe that we have won.

What we won this week was not legislative, but moral. Indeed, the one hundred year struggle, from Teddy Roosevelt to Teddy Kennedy, has not been legislative. It has been moral. We had had no consensus in this country on the idea of providing healthcare to all Americans. We had made no decision on healthcare as a human right. Not the immortal words of Martin Luther King, nor the haunting stories of America’s families, had been enough to end that debate.

Roosevelt, Truman, Johnson, and Clinton all fought an opponent that did not believe that every American had a right to seek treatment for his illnesses. They fought an opponent that did not agree that when we’re sick, we ought to have a chance to see a doctor, no matter whether we’re rich or not, lucky or not, strong or not.

But in the last two years, I have seen the words change. Republicans have been saying–and I’ll take them at their word–that we need to help Americans get care. And the insurance companies have been saying–and I’ll take them at their word, too–that Americans should be able to see the doctor. And the AMA is saying it, too. Everyone’s saying it. Maybe nobody’s doing the right thing about it, not even the Democrats, but everybody’s saying it.

And yet there is an undercurrent, a murmur below the surface, that is saying something quite different. That is saying that maybe it isn’t worth it to make sure the needy can go see the doctor. Maybe their health is too expensive and too troublesome, not important enough to the health of this country. We know that that undercurrent, that murmur, we know that it’s wrong. And we know that it’s dangerous.

For now, it is quiet. The winds of public opinion are in our favor: All people deserve treatment when they’re sick.

So in thinking about legislation, all that was left to debate was how to do it. Many of us believed it was single payer. I still think we’re right. But when my friends get angry over the passage of a bill that they think might weaken our economy, that they think might help insurance companies, that they think might squeeze the middle class, I want them to imagine the alternative.

Imagine that this bill had not passed. Maybe it would have just been a chance to do what the Republicans said–“start over”–and find another way to get to this thing that we all agree on in spirit. One thing’s for sure, we wouldn’t have been starting at single payer. But what I think is more likely is that we would have emboldened that bubbling undercurrent, given power to that disquieting murmur. After all this, that fundamental consensus that we all deserve healthcare–we could have lost it.

By passing this bill, by having the President of the United States sign it into law, we solidify a principle. We set a precedent that every one of us should have a doctor to see. That every one of us should have a place to go when we’re sick. That every one of us deserves compassion and care and the triumphs of medicine. That every one of us is a person, with a life and with struggles and with dignity.

Now I know this bill doesn’t get us there. But it vindicates the belief.

This is a new day of justice, not for what we have earned, but for what we have promised. We have promised ourselves and our children and our children’s children that healthcare is for them, for all of them. We have begun with the premise of righteousness and shown that it can win.

If we had not won this modest victory, if we had not passed this modest bill, we would still be in the quagmire of moral relativism. But we’re done with that. The moral victory is ours. We finally agree on common decency. Now it’s our job to get us to common sense.

Posted by: Prajwal | March 23, 2010

Please, sir, I want some jobs

Please, no more controversy until November. We passed healthcare, great, fantastic. We can’t afford a fight on education now. I know that President Obama’s insatiable appetite for radically moderate social reform means he wants to move on to education now. I know that Arne Duncan is itching for his chance at the big dance.

But we have to stop and wait. Social reform is done for the year.

Democrats need to do two things:

1) Pass a series of modest bills targeting unemployment, including small stimulus bills. If they can get a few Republicans on board, that is ideal. In a spirit of wishing to see the government work, I’d like to see broad bipartisan support for fixing the economy.

2) Pray, pray, pray that that jobless rate goes down. That is, if the Democrats don’t want to be the next people collecting unemployment checks come January.

As an addendum: I was at Barclay’s headquarters in London for a meeting today. The elevators have a little screen with Bloomberg playing–what was on? Geithner talking about reforms to Fannie and Freddie. I am sure coverage in the US is dominated by the healthcare signing, but internationally, it seems that some folks have moved onto the next thing. The White House is clearly ready to push the next bit and avoid the Republican noise.

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