Coyote Blog

After the scandalous management practices in the Phoenix VA which were proved to sacrifice patient well-being, and even patient lives, in favor of artificially pumping up managers' metrics and bonuses, someone with experience in the private sector might have expected the agency to clean house.  Hah!

First, Congress rewarded the failing VA with more budget and headcount, the very things that motivate most government managers.

Now, the VA has assigned what appears to be their worst manager from a tiny, overseas branch of the agency to run the sensitive Phoenix office.

The Department of Veterans Affairs has named a new director to its beleaguered Phoenix VA Medical Center, and the decision instantly came under fire because the appointee left a previous hospital leadership post after it got the lowest satisfaction rating of any facility in the VA system.

RimaAnn Nelson, who most recently headed a tiny VA clinic in the Philippines, is expected to take charge of a Phoenix VA Health Care System that was the epicenter of a national crisis over its treatment of veterans. She is the seventh director during the past three years to enter a revolving leadership door at Carl T. Hayden VA Medical Center....

Nelson, who began her career as a nurse, was sent to the Philippines in 2013 after a series of incidents under her leadership at the VA St. Louis Health Care System. The Daily Caller, a non-profit, investigative news organization, said the incidents included two closures of the hospital due to medical safety issues, and potential exposure of HIV to hundreds of veterans.

How is this person even still employed, much less being rewarded with a larger, more responsible post?

Apparently there is a daily pill called Truvada that can help reduce (but apparently not prevent) the transmission of HIV through unprotected sex.   Many public health agencies are promoting its use.

Apparently there is also at least one skeptic, a man named Michael Weinstein, who fears the pill may not be as effective as advertised, but more importantly is concerned that the pill's existence will reduce the use of condoms among at-risk men.

As I read the article (and I know zero about it on my own)  the ranking in terms of effectiveness is:  condoms+Truvada > condoms > Truvada > nothing.

The amazing thing to me is how broken the dialog about these issues appears to be.  Truvada supporters claim that there is a consensus on Truvada and that Weinstein is alone in his criticism, and that he is as bad as a "climate-change denialist" (eek!)

Weinstein claims that many others believe as he does but have been silenced by intimidation by the Truvada supporters.  Further, he argues that public officials who support Truvada are all paid off by the drug makers in one way or another.

Jeez, this all sounds so familiar to this veteran of the climate wars that it is just amazing.  And the real tragedy of this broken discourse is that both sides have a totally valid argument.  I have no doubt that Truvada provides incremental protection (even Weinstein's clinic proscribes it).  On the other hand, it is fairly "settled science" in the safety world that an easier-to-use protection method can actually reduce total safety by undercutting a parallel protection mechanism -- the drop in seat belt use after air bags were added to cars is a classic example.    Weinstein argues that Truvada use will reduce use of condoms, and thus undermine safety.  Truvada supporters argue that condom use is so low already, even after 30 years of education efforts, that the drug is better.  Essentially, Weinstein sees the baseline as men who use condoms and worry about them getting worse.  The other side sees the baseline as men who don't use condoms and argues the drug makes things better.

It is a shame to see two groups of people who likely are motivated by good intentions devolve into name-calling and ad hominem attacks.   Just read the quotes in the article - no one in the debate seems to acknowledge that the other side includes people of good will who simply disagree.

From CNN via Carpe Diem

A 24-year scandal was quietly acknowledged last week. On July 3 the U.S. Food and Drug Administration approved the first "rapid home" test for HIV—a test that people can take in the privacy of their own homes to determine whether they have the virus that causes AIDS.

The approval is an unambiguously good thing—or so you would think. The saliva test in question, made by OraSure Technologies and known as OraQuick, costs less than $60 and takes just 20 minutes to self-administer. According to statistics an FDA advisory committee presented at a hearing in May, it holds the potential to prevent the transmission of more than 4,000 new HIV infections in its first year of use alone. That would be about 8 percent of the roughly 50,000 new infections we currently see annually in the United States. (About 1.2 million people in the U.S. are now living with HIV, according to the Centers for Disease Control and Prevention, of whom about 20 percent don't realize they have it. Since the epidemic began in the early 1980s, about 1.1 million people have been diagnosed with AIDS, and more than 619,000 have died from it.)

The scandal is that the approval of a rapid home test for HIV did not occur until last week—about 24 years after the FDA received its first application seeking permission to market one.

Apparently, for years, even decades, only tests of clinical options were allowed to proceed, basically because the government considers Americans to be infants:

There was great concern that the patient receive proper counseling, both before and after the test. The patient needed to appreciate the possibility of false positives, so he wouldn't panic unnecessarily if he got one. He needed to appreciate the danger of false negatives, so he wouldn't become reckless, endangering sexual partners. And he needed to understand the options and support groups available in the event he received a true positive. (On top of all these concerns, many AIDS activists at the time were opposed to almost any form of HIV testing out of fear that results could be used to ostracize and persecute HIV-positive people—though one hopes that public health concerns were paramount to the FDA, rather than political pressure and hysteria.)

From California State contract language I am reviewing:

During the performance of this Contract, Concessionaire and its employees shall not unlawfully discriminate, harass, or allow harassment against any employee, applicant for employment, or any member of the public because of sex, sexual orientation, race, color, religious creed, marital status, need for family and medical care leave, ancestry, national origin, medical condition (cancer/genetic characteristics), age (40 and above), disability (mental and physical) including HIV and AIDS, need for pregnancy disability leave, or need for reasonable accommodation.

People live every day with excruciating pain that is untreatable with current medications, either because the medication has nasty side effects or they have built a tolerance or both.  So I would have thought the prospect of a new medication to help these folks would be an occasion for good news.

But not according to Chris Hawley of the Associated Press.  I first saw this story in our local paper, and was just staggered at its tone.  The article begins this way:

Drug companies are working to develop a pure, more powerful version of the nation's second most-abused medicine, which has addiction experts worried that it could spur a new wave of abuse.

And it goes on and on in that vein, for paragraph after paragraph.  Through it all there is all kinds of over-wrought speculation, with nary a statistic or fact in sight.   This is not atypical of the tone:

"It's like the wild west," said Peter Jackson, co-founder of Advocates for the Reform of Prescription Opioids. "The whole supply-side system is set up to perpetuate this massive unloading of opioid narcotics on the American public."

or this gem:

Critics say they are troubled because of the dark side that has accompanied the boom in sales of narcotic painkillers: Murders, pharmacy robberies and millions of dollars lost by hospitals that must treat overdose victims.

Recognize that murders and robberies associated with narcotics are almost always due to their illegality, not their basic nature.  These are a function of prohibition, not the drug itself, which in fact is more likely to make users docile than amped up to commit crime.

It is not until paragraph 11 that the article actually acknowledges there might be some folks who benefit from this new medication.  And even this is a dry discussion of side effects by some doctors -- how about heart-rending quotes from pain sufferers?  Newspapers love to include these, except in articles on pain medications where I have yet to see one such quote.

But then the author quickly goes back to arguing that pharmaceutical companies are purposefully addicting patients as part of the business model

"You've got a person on your product for life, and a doctor's got a patient who's never going to miss an appointment, because if they did and they didn't get their prescription, they would feel very sick," said Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing. "It's a terrific business model, and that's what these companies want to get in on."

That's a pretty ugly way to portray this.  Couldn't you argue the same thing about, say, medications that suppress HIV?  What these opponents never discuss is that they are basically proposing to consign people who have chronic pain to life-long torture.   They are saying "better in pain than addicted."  Really?  I will take the addiction.  Hell, by the same logic I am addicted to water and air too.

The notion that we should force a person to live in lifelong pain because some other person makes choices we don't like regarding their own narcotic use is just awful.  Seriously, these are the same folks who say that libertarians have no empathy.

Postscript.  Only after her death have I really learned about the contributions of Siobhan Reynolds, who died the other day after years of fighting to bring the interests of pain sufferers into this debate.  Radley Balko has a memorial, but this AP article is about all you need to understand what she was fighting, and how easily the plight of pain sufferers is ignored in these discussions.

I just couldn't bear to post this at my climate site, which I really try to keep science-based.  Since this doesn't have even a sniff of science to it, I will post it here for your entertainment:  According to the UN, Global Warming Causes Prostitution

The effects of climate change have driven women in communities in coastal areas in poor countries like the Philippines into dangerous work, and sometimes even the flesh trade, a United Nations official said.

Suneeta Mukherjee, country representative of the United Nations Food Population Fund (UNFPA), said women in the Philippines are the most vulnerable to the effects of climate change in the country.

"Climate change could reduce income from farming and fishing, possibly driving some women into sex work and thereby increase HIV infection," Mukherjee said during the Wednesday launch of the UNFPA annual State of World Population Report in Pasay City.

Perhaps the scariest potential effect of the proposed health care bills is the negative effect they likely will have on innovation.  And if we adopt the bill, we will never know what we have lost.  Unlike budgets, which with near certainty will become overdrawn quickly, we will never be able to point to the health care innovation we didn't have.

I want to quote liberally from a Ronald Bailey post, but I encourage you to read the whole thing:

Yet, the elements of market competition that still manage to survive have had the salubrious effect of driving medical innovation and improving patient health outcomes. A new study by the free market Cato Institute, "Bending the Productivity Curve: Why America Leads the World in Medical Innovation" reports:

...In three of the four general categories of innovation examined in this paper "” basic science, diagnostics, and therapeutics "” the United States has contributed more than any other country, and in some cases, more than all other countries combined. In the last category, business models, we lack the data to say whether the United States has been more or less innovative than other nations; innovation in this area appears weak across nations....

...Harvard University economist Kenneth Rogoff observed:

"[I]f all countries squeezed profits in the health sector the way Europe and Canada do, there would be much less global innovation in medical technology. Today, the whole world benefits freely from advances in health technology that are driven largely by the allure of the profitable U.S. market. If the United States joins other nations in having more socialized medicine, the current pace of technology improvements might well grind to a halt."

In my column, "2005 Medical Care Forever," I suggested this thought experiment:

...what if the United States had nationalized its health care system in 1960? That would be the moral equivalent of freezing (or at least drastically slowing) medical innovation at 1960 levels. The private sector and governments would not now be spending so much more money on health care. There might well have been no organ transplants, no MRIs, no laparoscopic surgery, no cholesterol lowering drugs, hepatitis C vaccine, no in vitro fertilization, no HIV treatments and so forth. Even Canadians and Britons would not be satisfied with receiving the same quality of medical care that they got 45 years ago....

As Rogoff suggests, the nationalized health care systems extolled by progressives have been living off the innovations developed by the "only country without a universal health care system." I wonder how Americans would vote if they were asked if they would be happy freezing medical care at 2005 levels forever?

Volokh points out this bit of stupidity:

Family Research Council Opposing Vaccination:

New Scientist reports:

Deaths from cervical cancer could jump fourfold to a million a year
by 2050, mainly in developing countries. This could be prevented by
soon-to-be-approved vaccines against the [sexually transmitted HPV]
virus that causes most cases of cervical cancer . . . . [T]o prevent
infection, girls will have to be vaccinated before they become sexually
active, which could be a problem in many countries.

In the US, [however,] religious groups are gearing up to oppose
vaccination . . . . "Abstinence is the best way to prevent HPV," says
Bridget Maher of the Family Research Council, . . . [which] has made
much of the fact that, because it can spread by skin contact, condoms
are not as effective against HPV as they are against other viruses such
as HIV.

"Giving the HPV vaccine to young women could be potentially harmful,
because they may see it as a licence to engage in premarital sex,"
Maher claims . . . .

This is just wrong on any number of levels.  The lamest part of this, beyond the sheer wrongheadedness of it, is it strikes me as a sign that these religious groups are unsure of their own teachings and moral standing.  I will never be confused with a religious expert, but I would think that religious groups would be fighting for abstinence as a positive moral principal.  Trying to deny vaccinations in order to make sexual intercourse incrementally more dangerous and threatening strikes me as a sign that the religious groups have given up on moral teaching and are now relying on bald scare tactics. 

When my kids were about 2, we had trouble with them getting out of bed and coming into our room.  Increasing the likelihood of STD's in order to discourage sex strikes me as similar to if I had spread tacks on the ground around my kids bed to keep them from wandering around at night.  When we come up with an HIV vaccine, are these groups going to oppose that as well?