CATEGORY / epidemiology

Economic Evaluations

Greetings from inside a workshop on economic evaluation in the Courtyard Marriott hotel in Toronto. Here’s a bit of trivia: toilet seats in the Marriott are heated!

Something one of my economics instructors said this week has resonated with me: if you hire a housekeeper, the economy improves (GDP goes up). But if you marry your housekeeper, the economy deflates. This is because the way that governments keep accounts is from a market perspective, whereby only businesses can produce, and whereby the only role for households is to consume.

But the reality, as I hope is obvious, is that there is a great deal of economic activity that occurs within the household, but which is invisible to formal accounting. When you raise your kids, you are improving the economy by creating more consumers and producers and by preventing the creation –one hopes– of criminals and other resource drains. When one spouse does the chores, it frees the other spouse to do more measurable economic activities. By tending your garden you improve property values. And so on.

Yet societies who have excelled at such subtle and long term economic activities have been artificially devalued by the expanding global market perspective. The result is that the Western-style accounting stance is being exported to all societies, with mixed results.

The positive results are there: seeming increased wealth. But the negative results are often hidden because our methods of accounting do not permit us to measure or even acknowledge them: reduced social cohesion, less time spent between parent and child, etc.

More and more, I’m starting to suspect that much of the woe in the world is not caused so much by capitalism per se, or by evil imperialists (though both play a role). Rather, it’s all due to our mistaken reliance on flawed and non-inclusive economic models, the outputs of which feed the overvaluation of such things as the free market and currency valuation.

Okay, back to the heated toilets…

Good, Bad and Ugly (News, That Is)

Dig this, my droogies. After an anti-war sermon was delivered in an LA church, the church was warned by the IRS that its tax-exempt status was now in jeopardy. Technically, the IRS is in the right, since tax-exemption is dependent upon the church remaining apolitical. Yet how many evangelical churches get away every day with Bush-worshipping sermons? Some churches were known to have printed and distributed Bush/Cheney stickers during the 2004 campaign. Why were they not visited by the IRS? Could it be –God forbid!– that the US federal government is using its power to selectively quash dissent?


Avian Flu, Etc.

I forgot to mention that last Thursday I attended the official diwali celebrations on Parliament Hill. In attendance were the Prime Minister, opposition leader Stephen Harper, celebrity minister Belinda Stronach, the omnipresent Indian High Commissioner and a host of lesser known political types. Strangely, the best speech by a Canadian politician was given by Stephen Harper, who showed a thorough knowledge of the history and tenets of diwali. The Prime Minister was not to be outdone, even sitting for puja and seemingly speaking off the cuff. Belinda rushed off before I could say hello. I doubt if she’d remember me anyway. I was looking for some visible signs of animosity between Belinda and Harper; can’t say I saw any.


More On Vaccinations

(This is a follow-up to a previous post, “Vaccines and Dumb Asses”)

vaccine 1

I feel I have to post a follow-up to yesterday’s screed about people who don’t get vaccinations. I have a few friends who fall into this camp, and at least one has taken exception to what I wrote. So let me be clear about a few things….

First, vaccines, like all medical interventions, have a risk associated with them: a risk of illness, discomfort, disease and even death. Not getting the vacine also has a risk associated with it: a risk of disease, morbidity and possible death. Those who appreciate fully the extent of these two risks and yet still choose not to get vaccinated are not dumbasses. In my opinion, they have made unwise choices, but that is their right.

On the other hand, those who deny that vaccines confer an effective benefit are exhibiting extreme dumbassery. To look around during flu season and not see anyone with the flu, then conclude that you don’t need the flu vaccine is idiocy. On the other hand, to choose not to have the flu vaccine because you think the risk of getting the flu is less frightening than the adverse reactions of the vaccine itself may be an inadvisable decision, but it’s not idiocy per se.

Are we clear now?

Now let’s consider some of the science. This all started in 1998 when the respected medical journal The Lancet (for which I am a peer reviewer) published an article suggesting a connection between the MMR vaccine (for mumps, measles and rubella) and bowel disorders and between bowel disorders and autism. The Lancet editors have since regretted its publication, since the selection procedure for the subjects was severely tainted (the subjects were sent to the investigator by lawyers eager to prove a linkage between MMR and autism) and the sample size of 12 was miniscule. In 2004, 10 of the paper’s original 13 authors issued a statement saying that the paper was not evidence of a connection between MMR vaccine and autism, and indeed reams of large epidemiological studies have since been put forward to discredit the initial finding.

Somewhere along the way, the compound thimerosal was brought up as a potential cause of autism. Thimerosal contains mercury, which is a known neurotoxin, and is often used as a preservative in vaccines. To this day, many in the anti-vaccination lobby derides the MMR vaccine for its thimerosal-mediated cause of autism. But here’s the kicker: the MMR vaccine has never contained thimerosal. Ever.

It has been suggested to me that there are other ways to bolster one’s immune system to prevent against the big name disease. Okay, I’m open to that idea. But let’s see some evidence. The accusation is oft lain at the foot of Science that the risks associated with such things as vaccination have not been widely measured. Maybe that is true, but the benefits of mass vaccination are impossible to deny. I would ask, have the risks associated with alternative immune treatments been widely measured? And how about the benefits? Where are the numbers? Show me some data and I will be open to the idea of discarding vaccination in favour of alternative means. Until then, the verdict of science is clear: vaccination remains the most effcicient, effective and concomittantly riskless means of reducing certain diseases in large populations.

“Traditional” medical methods have been in play for thousands of years, yet epidemics of forgotten diseases ravaged nations regularly. So why were they not successful in curtailing epidemics? As for allopathic medicine, when was the last time you knew of someone with measles, mumps, rubella, polio, diphtheria or small pox? Decades, I’d warrant, because vaccination programmes have been so successful.

Now, I am the first to say that vaccination is not perfect. Sometimes the formulation is poor; the yearly flu vaccine, for example, is a bit of hit-and-miss. Sometimes the vaccine can make you sick and, I’m told, lead to death. There is some evidence to suggest that even in immunized people, there exists unnoticed sub-clinical infection that may or may not make the person into a longterm carrier. And even herd immunity has its flaws as a theory, since outbreaks have been known to occur in highly immunized populations. But given all that, the overwhelming evidence is that innoculation prevents killer diseases among the vast majority of immunized people, without causing them any serious adverse effects.

Is it possible that there are longterm effects yet to be discovered? Yes, it’s possible. But there is no appreciable evidence for this and no reason to suspect it is so. With a century of vaccination data, it’s a matter of number crunching to see if such effects have arisen. Until someone shows me evidence of such, Occam’s Razor dictates that such speculation has no place in this discussion. It is, for example, possible that toothpaste causes migraines; but without evidence, should we abandon toothpaste despite its many benefits?

I am not anti-alternative medicine. I swear by my chiropractor and I have sought treatment from naturopaths, accupuncturists, reiki healers, witch doctors and even that Indian dude on TV who says he can heal you with his eyes. But I also believe in science. So if your therapy is so gosh-darned effective, it should be able to withstand the full brunt of objective scientific scrutiny. Studies of homeopathy, for example, have been largely disquieting. Yet, the Society of Homeopaths responds with:

“It has been established beyond doubt and accepted by many researchers, that the placebo-controlled randomised controlled trial is not a fitting research tool with which to test homeopathy.”

What does this mean? Why is the gold standard medical test for effectiveness not appropriate for homeopathy? The means of taking the treatment (usually a pill of fluid) is usually the same as any other intervention. Why then must homeopathy be given a pass by science? Please, someone tell me!

For years, many chiropractors claimed that spinal ajustments can be useful in treating allergies. Then a series of objective studies showed that there was no association between chiropractic care and allergy relief. To its great credit, the chiropractic profession accepted this evidence and backed away from making this claim any longer. All medical practitioners –allopathic, homeopathic and naturopathic– should show the same degree of honour and reason.

My point is this: either you accept science or you do not. What is science? The procedural test and re-test of theory in an objective fashion to elucidate truth. In absence of science, from where does medical knowledge arise? Superstition and religion, of course. We are thus back to the culture of the middle ages, where we seem to be heading anyway, with large scale denial of science at every turn: intelligent design, climate change denial, and now vaccine efficacy denial. So if we are to accept science as a methodology for extracting truth, where does that leave us with respect to medicine? Simply that if a treatment can be shown to be efficacious, using the gold standard evluative tools at our disposal (i.e., the randomised clinical trial), then its risks should be measured and it should be presented to the public as an option for use. And if it cannot be shown to be efficacious, it should be abandoned. This goes for modern medicine and homeopathy/naturopathy alike.

But let us not forget: in areas of the world with no MMR vaccination, measles kill hundreds of thousands of children yearly; 12oo die of it every day in Africa. It is one of –if not the– leading cause of blindness in kids around the world. There is a real cost in the spread of poor science. If the risks associated with vaccination continue to be inflated to the point where their uptake in large populations is curtailed, real people will suffer. Say it with me: real people will die.

PLEASE READ the follow-up to this post, “That Vaccination Question Again

Update: here’s a personal and historical take on the anti-vaccination movement.

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