December 5, 2020

Long term care shame

 Spending on long-term care

The share of LTC spending in total health spending or as a share of GDP has gradually increased over the last 15 years in many OECD countries as demand for care grows with population ageing and the extension of publicly financed services. 

In some countries, spending on LTC has not grown much faster than the economy as a whole. In Slovenia and Spain, for example, the shares of LTC relative to GDP in 2018 were only 0.1-0.2 percentage points above those in 2005, at 1.2% and 0.9% of GDP, respectively.

In Spain, the share of LTC spending has been stagnating since 2009, with LTC spending tracking GDP growth.

Nothing to add.

PS. You'll not find such data in the spanish press. Somebody cares about it.

December 4, 2020

Risks and benefits of self-testing (2)

 Direct to Consumer Testing: The Role of Laboratory Medicine

A specific issue on the topic has been released in Clinics in Laboratory Medicine. Inside the issue, you'll find this article: Direct-to-Consumer Tests on the Market Today: Identifying Valuable Tests from Those with Limited Utility 13. This is a key topic. It says:

Debate exists between the consumer and the health care provider when it comes to the value of direct-to-consumer (DTC) testing. At the heart of the issue is the observation that consumers are identifying value in DTC testing as evidenced by an expanding market, and health care providers are skeptical of their value from an analytical and clinical utility perspective. The aim of this article is to briefly review the subject of DTC testing with a specific focus on value from the perspective of the consumer and the health care provider.

 Paul Strand at KBr Barcelona


December 3, 2020

Trust in professions

 In the UK, nurses and doctors are the most trusted professions, with 93 per cent and 91 per cent of the public saying that they trust them to tell the truth. Advertising executives, politicians and journalists receive the lowest scores

In Spain, doctors as well.

December 2, 2020

Investing in pandemic preparedness

 The Cost Effectiveness of Stockpiling Drugs, Vaccines and Other Health Resources for Pandemic Preparedness

A short review on the topic, many questions, few answers. 

Health economics methods can be used to decide the optimal pandemic preparedness strategy based on cost effectiveness because different stockpiling of available measures can be implemented. The economic evaluation of pandemic preparedness strategies and pandemic preparedness measures is based on methods developed for health technology assessment. Nevertheless, this assessment differs from the traditional economic evaluations. The cost-effectiveness evaluation of a new drug compares healthcare costs and health effects for patients treated and not treated with the drug. The cost effectiveness of the drug will depend on the effectiveness of the drug in reducing clinical outcomes and healthcare costs. The drug will be used by the health system in patients with certainty. In contrast to this, the cost-effectiveness evaluation of pandemic preparedness measures and interventions is affected by several facts. First, pandemic preparedness measures are costly because they must be used to prevent and treat pandemic infections in a great number of persons. Second, investments in pandemic preparedness measures could be made many years before the emergence of the pandemic pathogen. Third, the health and economic benefits generated by pandemic preparedness measures will depend on the virulence and infectiousness of the pandemic pathogen. Fourth, pandemic preparedness measures can be associated with large costs and benefits outside the health system and great macroeconomics effects. There is a risk that an unknown pandemic agent will emerge and cause high morbidity and mortality, but we do not know when this will happen or how virulent and infectious a new pandemic agent will be. Although a new pandemic can be similar to previous pandemics, it can be also very different.

Ventilator support and intensive care for acute respiratory failure due to acute respiratory distress syndrome is a cost-effective intervention [8], but the cost effectiveness of stockpiling ventilators depends on the number of stockpiled ventilators and the severity of a future pandemic. The cost effectiveness of ventilator support and intensive care ranges from US$29,000 per QALY in low-risk patients (≥ 70% probability of surviving at least 2 months from the time of ventilator support) to US$110,000 per QALY in high-risk patients (prognostic estimate ≤ 50%) [7]. The question about the optimal number of stockpiling ventilators for pandemic preparedness depends on intervention costs and uncertainty about when the pandemic will happen and how virulent and infectious the pandemic pathogen will be.

Paul Strand at KBr


December 1, 2020

Risks and benefits of self-testing

 Benefits and Risks of Direct-to-Consumer Testing

These are the pros and cons of two options for the same production process and its impact (a US view only applicable to certain conditions). (Professionalism vs. commercialism).



And its impact:

Potential and Perceived Benefits of Direct-to-Consumer Testing

Potential Risks of Direct-to-Consumer (DTC) Testing

With DTC testing, consumers may not know the risks or what significance a result has in terms of current and future health. It is challenging for consumers to distinguish tests for health and wellness from entertainment and commercial marketing. This can leave consumers open to misdiagnosis and susceptible to unproven treatments and questionable claims for cancer and disease cures. DTC tests are both an opportunity for an individual to better participate in their health and in the management of chronic diseases, as long as consumers are aware of the risks for inappropriate utilization and inadvertent interpretation that can lead to avoidable follow-up, unnecessary procedures, and additional costs of care. DTC testing is an emerging field and an opportunity for laboratory experts to participate through providing professional advice, consultation on test limitations, interpretive services, and recommendation on optimal test utilization.

My view, now it's time to stop recreational testing and commercialism of lab testing. Later it will be too late. 

November 30, 2020

How monopolies make our lives harder every day & destroy our future

Monopolies Suck7 Ways Big Corporations Rule Your Life and How to Take Back Control

7 Key messages from the book








So what? You'll find the details on how to take back control in Chapter 8, a set of clear tools to fight the monopolistic pandemic.

November 29, 2020

On ecosystems

 ECOSYSTEM EDGE.Sustaining Competitiveness in the Face of Disruption

Selected statements from the book:

Each of the four ways in which the development of an ecosystem can unlock new value—through new product bundles, new customer solutions, new platform economies, and spawning new industries—shares a common characteristic: they require a process by which new customer value is discovered. The new value is not just assembled or delivered from existing elements by following a predetermined blueprint; it has to be identified. Business ecosystems come into their own by facilitating the process of discovery.

Discovering new sources of value requires the three key capabilities that ecosystems excel at: a huge potential for rapid, joint learning and innovation; the ability to harness the capabilities of diverse players and channel them toward a common goal through the leadership of an enlightened company; and the flexibility for continuous reconfiguration in the face of an uncertain, fast-changing environment.

Given these demands, what can you do as an ecosystem leader to catalyze and promote the discovery of new value through your ecosystem strategy?

The rise of ecosystems will also rewrite the rules of competition and strategy as we have come to know them, encapsulated in the seminal work of Michael Porter. The classic cost-leadership strategy based on growing the volume of products and services a company produces to reap economies of scale that drive down costs below competitors, will be replaced. In a world of competing ecosystems, cost advantage will come from aggregating the scale of your entire partner network to spread the fixed costs of investments in everything from design and innovation through to production and distribution. Your ability to reap network economies will become decisive.

As competition between ecosystems grows, rewriting the rules of competition in the process, the demands on ecosystem leaders are only set to increase. The pressure to discover new sources of value for customers and to craft unique and attractive offerings will intensify. Partners will evaluate whether joining an ecosystem can deliver benefits, as well as how one ecosystem’s value proposition compares with that of another network. A potential ecosystem leader’s value proposition to partners will need to be top-notch. In the competition between ecosystems, the speed with which a leader kick-starts a virtuous spiral of cooperation and the rate at which it can scale its ecosystem are both critical. Those that get ahead because of network economies will surge forward in what could easily become a winner-take-all game. However, to sustain the ecosystem leader’s competitive position, the amount of learning and innovation generated by the ecosystem, and its ability to capture that learning, will be critical. Ecosystems that are less productive and efficient will be unable to compete. Mastering the strategies and capabilities we described earlier will become even more essential tomorrow than they are today.

This is the only book that finally provides some clear conceptualisation on ecosystems., as far as I know. 

November 27, 2020

The impact of COVID-19 on life expectancy

 Monitoring life expectancy levels during the COVID-19 pandemic: Example of the unequal impact of the first wave on Spanish regions 

Our estimates of a 0.9 year decline in annual life expectancy in Spain suggest that the COVID-19 pandemic has the potential to cause life expectancy stalls not seen for decades. 

 In the first half of 2020, Spain has been one of the most affected countries both in terms of directly related COVID-19 deaths [1], as well as in terms of total excess mortality [4]. We estimated the annual life expectancy drop between 2019 and the one year window that closes out on 5 July, 2020 to be 0.9 years (~11 months) in Spain. In contrast, the average annual increase in life expectancy in Spain increased on average two months per year from 2009 to 2019. Altogether, this suggests that life expectancy drop between observed and expected annual life expectancy in the recent one year window would be around or below one year.

Annual life expectancy at birth in 2019, 2020*a and differences between periods for Spain

November 26, 2020

Health for all (once again)

Achieving Health for All: Primary Health Care in Action

From chapter 2 of the book, on life expectancy and GDP (Preston curve)

The list of best-performing countries is still limited because it is often the case that a country looks like it is deriving a high health output from minimal economic growth simply because it has had a prolonged spell of economic stagnation, and health improvements are simply occurring as a result of secular trends set up by past introductions of public health technology. Thus, what often appear to be “top-performing” countries in climbing the Preston Curve frequently appear successful because of stagnant and barely positive economic growth. The project of empirically identifying exemplary countries achieving good health at low cost or “punching above their weight” needs to reexamine foundational assumptions about (1) whether countries are actually engaged in transforming economic growth into better health and (2) what counts as a valid comparison group for a given country at a given time depending on its starting LEB.


November 25, 2020

Cheap crime

Financial Penalties Imposed on Large Pharmaceutical Firms for Illegal Activities

From JAMA: 

Among 26 firms in our sample, 22 (85%) had financial penalties for illegal activities. The combined dollar value of financial penalties totaled $33 billion for 2003 to 2016. Eleven firms with financial penalties exceeding $1 billion in inflation-adjusted dollars accounted for $28.8 billion (88%) of the total penalties (Table 1). The firms with the highest penalties as a percentage of revenues (ie, >1%) were Schering-Plough, GlaxoSmithKline, Allergan, and Wyeth; the number of penalties for these firms varied between 1 (Allergan) and 27 (GlaxoSmithKline). Four firms had financial penalties that totaled less than $80 million and no more than 2 penalty settlements (Actavis [Watson], Roche Group, Genzyme, and Perrigo). All but 1 firm (Perrigo) engaged in illegal activities associated with penalties for 4 or more years. An additional 4 firms received no financial penalties for illegal activities during this period. The most common types of illegal activity involving penalties (Table 2) were pricing violations, off-label marketing, and kickbacks. The firms with the greatest variety in the types of illegal activities involving penalties were GlaxoSmithKline, Bristol Myers Squibb, and Merck. Three firms (Actavis, Allergan, and Perrigo) had penalties limited to a single violation type.


That's it.

November 24, 2020

Prophets and self-fulfilling prophecies

 The Corona Crash. How the Pandemic Will Change Capitalism

Always you may find a prophet around the corner. Fukuyama predicted the end of history, the triumph of liberal democracy and the arrival of post-ideological world. Recently Y. N. Harari predicted the end of liberalism and the arrival of a post-humanism and nothing happened. The history goes on and some of them only may expect that their predictions transform into self-fulfilling prophecies. This is the case of today's book. It distorts reality to adjust to the ideology and desires of the author. I must say that some parts may be true, but on the whole, reading it is a waste of time in my opinion. Just some pieces, and you may judge:

In this context, the suggestion that governments must refrain from ‘interfering’ in the forces of free market competition to create jobs, reduce inequality and increase environmental sustainability is laughable. We do not live in a competitive economy – we live in a planned economy. But the planning is not democratic – it is being undertaken by central bankers, senior politicians and their advisors in big business and finance.

For the rich world, the lesson of the coronavirus crisis is that states can spend to meet the needs of their populations without limit. For the vast majority of the world’s population, this crisis will simply reinforce what they already knew: that the poorer, less powerful members of the international ‘community’ most certainly can’t. Socialists in the Global North must learn the right lesson: that the limits of fiscal policy are determined by political power. International solidarity requires us to return to the issue of debt forgiveness and push for relief for Global South states when this crisis is over.

The free market ideology which serves to legitimise forms of government intervention that support the interests of capital and prohibit state interventions that might increase the power of workers has been placed under significant strain in the period since the financial crisis. As we have seen, the foundation of this ideology is the separation between politics and economics.

You may remember that with the great recession there were voices saying that capitalism was in crisis and there was a need to rebuild it. And?. Any system lives in continous unstability. This is not the end, it needs an urgent fine tuning right now but absolutely different from the book proposal.


November 23, 2020

Digitization and health professionals

 Empowering the health workforce Strategies to make the most of the digital revolution

From the latest OECD report

In order to enable a successful digital transformation of health systems and overcome barriers governments need to provide the necessary political leadership and implement a range of policy actions to support three main objectives:

  • build trust in the benefits of digital transformation among health workers and patients whileminimising any risks, which requires guaranteeing proper assessment of technology;
  • advance the expertise and skills needed for the safe and effective use of digital health technologies;
  • adapt the institutional environment – i.e. the legal, financial, and organisational frameworks –to enable the full potential of the technologies

 These messages sound familiar and general, details inside the report. However, there is a long way to go in order to achieve a real digital transformation.

Bill Brandt 

November 22, 2020

The time to stop recreational testing has come

 Direct-to-Consumer Genetic Testing: Value and Risk

Piecing together information from a variety of sources, one reporter concluded that by early 2019, more than 26 million people worldwide had been tested by the four leading companies, 23andMe, Ancestry, Gene By Gene, and MyHeritage (1). That volume was fueled by aggressive marketing, including discounts in the lead-up to major holidays to promote gifting of test kits. As of May 2020, the  undiscounted price of the basic test offered by the leading companies was $59–$99.

This is an example of what should not had happened. Recreative genomics doesn't add value and increases uncertainty and anxiety. 

Although many consumers of DTCgenetic testing express an intention to modify their lifestyle to address risk factors, studies typically show no changes at follow-up (15, 30). In the PGen Study, 59% of participants said that test results would influence their management of their health (31). However, an analysis of the 762 participants who had complete cancer-related data found that those who received elevated risk estimates were not significantly more likely to change lifestyle or engage in cancer screening than those who received average or below-average risk estimates (44). It may be relevant that no participants tested positive for pathogenic variants in highly penetrant cancer susceptibility genes. As for population health, the Centers for Disease Control and Prevention identify three conditions—hereditary breast and ovarian cancer syndrome,Lynch syndrome, and familial hypercholesterolemia—that are poorly ascertained despite the potential for early detection and intervention to significantly reduce morbidity and mortality (45). The hope is that DTC genetic testing could improve the situation (15). However,DTC genetic testing as currently carried out is likely to fill gaps in haphazard fashion, given the characteristics of purchasers, the scope of available products, and integration issues.

One message. Right now and until we don't know the implications of recreational genetic testing, direct to consumers testing should stop.



November 21, 2020

Q&A COVID-19, economics and health

 Diálogos en la interfaz de la economía y la salud a propósito de la covid-19

A new book of interest has been released on economics and health perspectives on COVID-19. One message from the introduction: 

En definitiva, resulta controvertido el juzgar la bondad de nuestros sistemas de salud, puestos hoy a prueba con el stress test de la COVID-19. Algunos apuntan a que los recortes presupuestarios son los responsables de que España gaste poco en sanidad. Esto es erróneo; los recortes son coyunturales y responden a procesos normales de consolidación fiscal. El problema es estructural de baja financiación del sistema sanitario, desde la interpretación política de qué parte de la recaudación tributaria se ha de dedicar a cada  una de las parcelas del gasto social o, en su falta, el compromiso a articular medidas complementarias de financiación. Como consecuencia de todo ello, se ha instalado en el sector cierta resistencia contra la contención del gasto sanitario público. El modo en el que los profesionales sanitarios han respondido a la pandemia avalaría dicha posición. Otros piensan que más allá de los recursos disponibles, la razón fundamental de nuestros déficits es la gobernanza con la que las instituciones sanitarias desarrollan su actividad: es la rigidez y no la falta de musculatura lo que dificulta adaptaciones flexibles a las diferentes coyunturas. Dicha percepción pone el foco en la diferente genética de los sistemas públicos, ya organizados como servicios nacionales de salud o como sistemas de aseguramiento social sanitario. Por otra parte, las cifras de gasto como indicadores de buen o mal funcionamiento ofrecen a menudo falsas pistas que no permiten resolver por esta vía las bondades relativas a través de simples indicadores cuantitativos.

There are many more messages in a Q&A format. Inspiring.


November 20, 2020

Health reform zombies (2)


Three years ago in a OECD Health Ministerial meeting, everyone accepted the statement on the criteria for next health reforms. Now, 3 years later, we can confirm that nothing happened about it.

Inside the document there was also a recommendation on health data governance. And the same, nothing happened.

That's it, an extraordinary built narrative that leads to nowhere. Death and taxes remain as only truths.


November 19, 2020

Health expenditure at a glance, or how Bulgaria spends the same as Catalonia

 Health at a Glance: Europe 2020. STATE OF HEALTH IN THE EU CYCLE

Health expenditure as a share of GDP, 2019 (or nearest year)

Health expenditure as a share of GDP, EU27 and selected countries, 2005-19

Health expenditure by type of financing, 2018 (or nearest year)
Health expenditure from public sources as share of total health spending, 2018 (or nearest year)

November 18, 2020

Mazzucato as a supplier of a flattering narrative for politicians

 The Myth of the Entrepreneurial State

Some delicious words by Deirdre McCloskey on Mazzucato recent contributions:

Mazzucato, a loyal daughter of the left, is suspicious of private gain, of the sort you pursue when you go shopping, say, and is therefore suspicious of people doing things for a private reward. She wants the State, advised by herself, to decide for you. Yet the private entrepreneur, she would concede, gets a reward if she pleases her customers. And it is in fact what Mazzucato in her own trade has done. She has parachuted herself into the center of the debate about the role of state planning as against private profit-making for innovation and allocation. It is not because she is innovative herself (though that is what her brave rhetoric suggests), but because she is, market-style, giving people what most of them want: magical thinking, mythical certitude, free lunches all around, wise and loving parents guiding the people in a coerced routine from on high. Modern “statism.” Her theory is the illiberal one that has dominated economics since John Maynard Keynes eight decades ago spoke out loud and bold.

 The statists imagine that it is always COVID-19 time, for anything: the legitimate actions by a State to suppress a plague or a forest fire or a military invasion are to be applied to all manner of private matters, always, with no such persuasive claim to legitimacy as fighting plagues, forest fires, or invasions, being technically speaking public goods. Braiding hair for a living is to be regulated by the State. Innovation and allocation, says Mazzucato in particular, are to be socialized.

And we could say that Deirdre is a loyal daughter of the right. And no problem. However, you may imagine what her book. I have read Mazzucato and part of her arguments are convincing. However, there is a need for a balanced perspective according to the current trends. Deirdre provides such perspective. A book that deserves to be read.

November 17, 2020

The claims of reason and the imperative of power

The Professor and the Politician. For Max Weber, only the most heroic figures could generate meaning in the world. Does his theory hold up today?

Charisma and Disenchantment: The Vocation Lectures

For Max Weber:

The professor and the politician are not figures to be joined. Each remains a lonely hero of heavy burden, sent to ride against his particular foe: the overly structured institution of the modern mind, the overly structured institution of the modern state.

 The politician needs to convert effort into effect, to “make an impression” on the world. But there’s a fine line between molding the world into a shape and needing to see one’s signature at the base of it. The politician is always at risk of swapping out “actual power”—power tethered to purpose—for “the brilliant appearance of power”—power untethered from purpose. The first is the aim of the true politician; the second, the temptation of vanity, which is “the deadly enemy of any commitment to one’s goals.” When a politician gives in to vanity, amending or adapting his aims in order to perform effectiveness, his power is drained of its design.

 The spectre haunting Weber is neither bureaucracy nor capitalism (although capitalism does play an under-remarked role in these lectures). Instead, it’s an ancient tension between hero and fate, transposed to modern life. Where classical tragedy sees the hero felled by a destiny that he resists, the nemesis of the Weberian actor is absorption in the institutions that he’s meant to oppose. Society is a siren, forever tempting us to forsake our tasks and seek the smaller goods of reputation and status. The scholar becomes a scribe; the politician, a hack. The danger is not defeat of the opposing self from without but corruption of the self from within, where the self’s diminishing desire to oppose comports all too well with society’s needs.

Great op-ed by Corey Robin at The New Yorker.

Joana Biarnés


November 16, 2020

Prioritising the vaccine

 Framework for Equitable Allocation of COVID-19 Vaccine

Health equity is intertwined with the impact of COVID-19 and there are certain populations that are at increased risk of severe illness or death from COVID-19. In the United States and worldwide, the pandemic is having a disproportionate impact on people who are already disadvantaged by virtue of their race and ethnicity, age, health status, residence, occupation, socioeconomic condition, or other contributing factors.

Framework for Equitable Allocation of COVID-19 Vaccine offers an overarching framework for vaccine allocation to assist policy makers in the domestic and global health communities. Built on widely accepted foundational principles and recognizing the distinctive characteristics of COVID-19, this report's recommendations address the commitments needed to implement equitable allocation policies for COVID-19 vaccine.

If vaccines are coming in the next months and we all agree that supply will not fulfill demand, then we need to prioritise. This publication of the National Academy of Medicine provides some usegul insights. However, the most important is to have a concrete application in specific contexts.

Joana Biarnés

November 15, 2020

Health Reform Zombies


Morris Barer and Bob Evans first coined the term “health care zombies” in 1998. A health care zombie is a terrible idea about health care that refuses to die. No matter how many times you drive an evidence-based stake through its heart, it rises from the (un)dead to confront you in the newspapers of the nation, ruining a perfectly good morning cup of coffee.

These ideas have often been proposed as solutions to the pressures on our health care system. But they’ve all been shown, time and time again, to weaken health care quality and sustainability. They also undermine our shared values.

These words sound familiar in our context. However it comes from a canadian book.

A canadian physician reflects her views in a well written book about the health reform. It says:

When care is necessary to improve health, every Canadian deserves reasonable access to it. That means solutions to wait times that help everyone, not just people who can afford to pay for their care. And it means finally bringing medicines under medicare. Across the country, people like Ahmed the taxi driver are forced to sacrifice their long-term health because of the short-term crunch of prescription drug costs. Alongside that profound inequity lives the uncomfortable truth that we pay some of the highest prices in the world for our prescription medicines. Only our governments can take the necessary steps to establish a national pharmacare program that would ensure access, safety, and appropriate use of medicines at a cost that is affordable not just for governments, but also for citizens and for employers.

It is quite incredible that canadians don't have drugs in the benefits package. And this is the outline of the book:


Dr. Martin Goes to Washington

Getting Our Facts Straight

Taking the Pulse of the System

Health Care Zombies

BIG IDEA 1 Abida: The Return to Relationships

Primary Care: When It Works, It Works

Three Relationships for Health

Rewarding What Matters

BIG IDEA 2 Ahmed: A Nation with a Drug Problem

Medicare’s Unfinished Business

The Price Is Wrong

Prescribing Smarter

BIG IDEA 3 Sam: Don’t Just Do Something, Stand There

The Compulsion to Cure

Slow Medicine

BIG IDEA 4 Susan: Doing More with Less

The Revolving Door of Health Care

What Better Looks Like

The F-Word

BIG IDEA 5 Leslie: Basic Income for Basic Health

Sick with Poverty

Curing Income Deficiency

BIG IDEA 6 Jonah: The Anatomy of Change

From Pilot Project to System Solution

Data: The Brain of the System

The Heart of the Matter

Feet to Do the Walking

CONCLUSION Worthy Action


November 14, 2020

Paying for (Artificial) Intelligence

 The US Government Will Pay Doctors to Use These AI Algorithms

The US Centers for Medicare & Medicaid Services (CMS) recently said it would pay for use of two AI systems: one that can diagnose a complication of diabetes that causes blindness, and another that alerts a specialist when a brain scan suggests a patient has suffered a stroke. The decisions are notable for more than just Medicare and Medicaid patients—they could help drive much wider use of AI in health care.

The incentives for technology adoption are related to professionalism, organizational, and economic. In this case are the latter one.Though, FDA must have cleared both algorithms, and this is the case

We could also think on using AI for reducing radiation exposure in CT scans for example..

EU is lagging behind developed countries in this (and many other issues)...

November 13, 2020

Prioritising population health or the economy (2)

  The Pandemic Information Gap. The Brutal Economics of COVID-19

Joshua Gans has updated his former book on covid economics. And says:

Pandemics are an information problem. Solve the information problem and you can defeat the virus. There is a big difference between knowing someone you interact with is infectious and having to make a guess as to whether that person is infectious. In the former case, you can act and limit the interactions. In the latter case, you have to take a risk. And, in evaluating that risk, what we care about is not just whether you become infected but also whether you might pass that infection on to others.

 The difference between perfect knowledge and no knowledge is what causes an infectious disease to have an impact on social and economic interactions. With perfect knowledge, some people get sick, they are isolated, and life is (for most of us) essentially unchanged. With no knowledge at all and no interventions to prevent infections, then for COVID-19, at its peak, about 21 million people in the United States alone would likely be infectious at one time. With no restrictions on activity, the probability that you interact with one of the infectious people on a given day is 21 million divided by 327 million (the US population), or 6.4 percent.4 However, suppose you interact with only 10 people per week. In that situation, the probability that you are able to avoid any of those infected people is about 50-50. When going to public spaces, you may interact with over a hundred people per week. In that case, your probability of avoiding an infected person becomes close to zero. In other words, perfect knowledge allows you to avoid all infected people. No knowledge makes it near certain that you will encounter at least one infected person.

 Without knowledge of how many people are infected and whether particular people are carriers of thecoronavirus, we are forced to take drastic actions.

True. Pandemics are an information problem but information will never be perfect and complete. Uncertainty sorrounds us. And pandemics are more than an information problem. Because you may know who is infected, and not "act and limit interactions". Therefore, emotions, incentives and expectations count. We do have also a behavioral problem. And if it is behavioral, it has ethical implications. And finally, that's life, decisions with or without information and behavioral and ethical implications of such decisions.

Anyway, a useful introductory text.

November 12, 2020

Measuring covid-19 related deaths

 Excess mortality. Measuring the direct and indirect impact of COVID-19

Estimations of excess mortality can give an overall understanding of the impact of  COVID-19, by not only comparing deaths that are directly attributable to the virus, but also by 
taking into account indirect mortality. There may be, for example, deaths due to health systems not being able to cope with other conditions or to the longer-term impact of the pandemic on population health. There has been preliminary evidence of disruptions to continuity of care, hindering people suffering from heart attacks, strokes and other conditions from seeking necessary treatment in emergency rooms, or of delays in accessing regular preventive or ongoing care in primary care practitioner (GP), surgeries or outpatient departments for chronic conditions.

And a clear message on this OECD report:

 Comparing the number of reported deaths from all causes against the average over the previous five years, Spain recorded a 61% increase in overall mortality over this 10-week period. At the beginning of April (Week 14), Spain also recorded the highest excess mortality for a single week, with a 154% increase in mortality, equating to more than 12 500 additional deaths compared to the 5-year average for the same week.

November 11, 2020

The politics of care in US

The Politics of Care. From COVID-19 to Black Lives Matter. Edited by Boston Review

After the US elections, now it's time to rebuild. A new book provides some insights.

WHERE DO WE GO from here? Our answer must connect to a broader politics that addresses the deep structural roots of the problems we face in the United States. We must build for a better future, not just climb out of the rubble of this pandemic, brush ourselves off, and return to business as usual. We need a new politics of care, one organized around a commitment to universal provision for human needs; countervailing power for workers, people of color, and the vulnerable; and a rejection of carceral approaches to social problems. The question now is how to connect that vision to programmatic responses that address the needs of the moment and beyond. We need to aim at “non-reformist reforms”—reforms that embody a vision of the different world we want, and that work from a theory of power-building that recognizes that real change requires changing who has a say in our political process.

The proposals from the progressive wing of the Democratic Party, and even those from democratic socialists, are missing what we might call a New Deal for Public Health. Here, social movements are indispensable. In particular, the AIDS movement of the past forty years offers a template for the kinds of mobilization we’ll need to achieve our goals: not only bringing the virus under control, but also building a future where something like this never happens again.

What might that include? The Medicare for All component has been mapped out, but less obvious and just as crucial is a new, robust, long-lasting infrastructure of care. For example, people need to be able to stay home when they are sick. Yet employment in this country systematically undermines our ability to care for ourselves and others. Women have it the worst, especially immigrant women and women of color, for they are the ones with the highest burdens of paid and unpaid care. The truth is stark: more than 32 million workers lack access to paid sick days. While 93 percent of the highest-wage workers have access to paid sick days, only 30 percent of the lowest-wage workers do. The risk of job loss and precarious scheduling all add to employees’ difficulties. Without anything like universal sick pay or income insurance, self-employed and gig economy workers are cast adrift at a time like this.

November 10, 2020

Diagnostic Testing for the COVID-19 Pandemic (again)

 Rapid Expert Consultation on Critical Issues in Diagnostic Testing for the COVID-19 Pandemic

Yesterday I was thinking about the implications of having spare structural capacity in hospitals for pandemics and disasters. With a larger capacity, the need for lockdown to preserve health system operations would be less important. However, how much capacity is needed is uncertain. Therefore, the cost and benefit of spare capacity of the health system is very difficult to estimate. And I would add, it is really much more difficult to manage such investment, because spare capacity in physical terms is not enough, you would need also spare capacity in human resources!. Maybe there is a technological innovation that I can foresee. Forget it. 

Right now the hotest issue are the tests and the vaccine. And NASEM has released a rapid consultation of interest about tests.

This rapid expert consultation draws attention to four critical areas in developing diagnostic testing and strategies to reduce the number of COVID-19 infections and deaths: (1) advantages and limitations of reverse transcription polymerase chain reaction (RT-PCR) testing for viral RNA; (2) the status of POC testing; (3) testing strategies, namely, considerations in the deployment of types and sequences of tests; and (4) next-generation testing that offers the prospect of highthroughput, rapid, and less expensive testing.

If you want to know the state of the art, this is the document to read. I can't see anywhere any cost-benefit approach of different options...We are still dealing with precision and accuracy, i.e. effectiveness.

PS. Quite surprising that today everybody is talking about a vaccine and its 90% effectiveness without any scientific paper being published. Can you accept that?. Information merchants looking for attention.


November 8, 2020

Drug approval and geographic differences

 Approval of Cancer Drugs With Uncertain Therapeutic Value: A Comparison of Regulatory Decisions in Europe and the United States

We know that the regulation of medical devices is quite different between US and Europe, and with COVID tests we have experienced such divide. In drugs, one could expect a closer approach to approval. However, this is not the case. 

Regulatory agencies may have limited evidence on the clinical benefits and harms of new drugs when deciding whether new therapeutic agents are allowed to enter the market and under which conditions, including whether approval is granted under special regulatory pathways and obligations to address knowledge gaps through postmarketing studies are imposed.

In a matched comparison of marketing applications for cancer drugs of uncertain therapeutic value reviewed by both the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA), we found frequent discordance between the two agencies on regulatory outcomes and the use of special regulatory pathways. Both agencies often granted regular approval, even when the other agency judged there to be substantial uncertainty about drug benefits and risks that needed to be resolved through additional studies in the postmarketing period.

Postmarketing studies imposed by regulators under special approval pathways to address remaining questions of efficacy and safety may not be suited to deliver timely, confirmatory evidence due to shortcomings in study design and delays, raising questions over the suitability of the FDA’s Accelerated Approval and the EMA’s Conditional Marketing Authorization as tools for allowing early market access for cancer drugs while maintaining rigorous regulatory standards.


November 7, 2020

The long and bumpy road to CRISPR (2)

 Editing Humanity. The CRISPR Revolution and the New Era of Genome Editing

In 2017 I wrote a post about the book by Jennifer Doudna, A Crack in Creation, now Kevin Davies, the editor of the CRISPR journal has published a new book on CRISPR. It is an effort to put all the information and details about CRISPR in one book. Therefore, if you want to now the whole story (or close to) this is the book to read. If you are interested in a general approach, then the Doudna book is better.

It is quite relevant the chapter that explains the role of Francis Mojica in CRISPR (chapter 3), and the chapter 18, on crossing the germline and what happened about the scandal of genome editing by JK.

“When science moves faster than moral understanding,” Harvard philosopher Michael Sandel wrote in 2004, “men and women struggle to articulate their own unease.” The genomic revolution has induced “a kind of moral vertigo.”49 That unease has been triggered numerous times before and after the genetic engineering revolution—the structure of the double helix, the solution of the genetic code, the recombinant DNA revolution, prenatal genetic diagnosis, embryonic stem cells, and the cloning of Dolly. “Test tube baby” was an epithet in many circles but five million IVF babies are an effective riposte to critics of assisted reproductive technology.

With CRISPR, history is repeating itself,

That's it, great book.


November 6, 2020

NGS: from research to clinical use

 Expanding Use of Clinical Genome Sequencing and the Need for More Data on Implementation

During the past 5 years, next-generation sequencing (NGS) has transitioned from research to clinical use.At least 14 countries have created initiatives to sequence large populations (eg, All of Us, Genomics England), and it is projected that more than 60 million people worldwide will have their genome  sequenced by 2025.

If this is so,

 Understanding how NGS is being used and paid for is critical for determining its clinical and economic benefits and addressing current and future challenges to appropriate implementation.

 Without consistent information on clinical utility and how NGS tests are implemented in clinical care, it is not possible to develop an understanding of benefits and harms associated with NGS. It is not always the case that evidence of clinical utility leads to improved outcomes, and evidence about implementation is required to complete the assessment of the effects on population health. Implementation science is intended to support the integration of findings from scientific evidence to uptake in routine clinical care in the ongoing cycle of a learning health care system.

This is clearly a call for action. However, in my country the call is for both developing NGS  (nothing has started) and asessing implementation. Is there anybody in the room?


November 5, 2020

A nation that failed too many of its citizens

THE HEALTH OF A NATION. A President Looks Back on His Toughest Fight. The story behind the Obama Administration’s most enduring—and most contested—legacy: reforming American health care.

This is the case of US and health reform. In the last issue of New Yorker, Barack Obama explains why health reform was so difficult when he proposed Obamacare, in few words:

"one person’s waste and inefficiency was another person’s profit or convenience"

A lot of details inside the article. Useful hints to understand the intricated world of Washington politics. 

"both the politics and the substance of health care were mind numbingly complicated. I was going to have to explain to the American people, including those with high-quality health insurance, why and how reform could work"

 One thing felt certain: a pretty big chunk of the American people, including some of the very folks I was trying to help, didn’t trust a word I said. One night, I watched a news report on a charitable  organization called Remote Area Medical, which provided medical services in temporary pop-up clinics around the country, operating out of trailers parked at fairgrounds and arenas. Almost all the patients in the report were white Southerners from places like Tennessee and Georgia—men and women who had jobs but no employer based insurance or had insurance with deductibles they couldn’t afford. Many had driven hundreds of miles to join crowds of people lined up before dawn to see one of the volunteer doctors, who might pull an infected tooth, diagnose debilitating abdominal pain, or examine a breast lump. The demand was so great that patients who arrived after sunup sometimes got turned away. I found the story both  heartbreaking and maddening, an indictment of a wealthy nation that failed too many of its citizens.

Now that somebody wants to block its application, there is a need to emphasize the great job that was done.

President Obama in the Oval Office as a vote on the Affordable Care Act approached. Proposals for some sort of universal health care in the U.S. stretched back a century but had always been defeated.Photograph by Pete Souza

November 4, 2020

Uneven human germline genome editing regulation

Human Germline and Heritable Genome Editing: The Global Policy Landscape

Françoise Baylis et al. have made an excellent review of current genome editing regulations around the world. And the conclusion is that there is no agreement on this extremely delicate issue. Somebody (UN) should do something to fix such a mess.

The summary in one figure:

 Some details:

Regarding human germline genome editing (not for reproduction), potentially relevant documents yielded no relevant information for 56 of 96 countries. Among these 56 countries are 22 of the 29 countries that have ratified the Oviedo Convention, which prohibits heritable human genome editing but leaves the status of germline genome editing to be determined by each country. Among the remaining 40 countries with relevant information, 23 (58%) prohibit this research—19 prohibit it outright and four prohibit it with potential exceptions. Eleven countries explicitly permit human germline genome editing; and six countries are indeterminate



November 3, 2020

On healthcare and its contribution to decline in mortality

 The (Still) Limited Contribution of Medical Measures to Declines in Mortality

The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century

 “Medical measures appear to have contributed little to the overall decline in mortality in the United States since about 1900.” Readers might assume that this statement is from a recent research article or policy report featuring the social determinants of health. But no, it is from the 1977 seminal Milbank Quarterly article by John and Sonja McKinlay titled “The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century.”

 In the section of Milbank Quarterly Classics, David Kindig explains his favourite topic while reviewing the McKinlays 1977 article:

 “if they [medical measures] were not primarily responsible for it [the decline in mortality], then how is it to be explained?” They did not answer this question themselves, but referred back to McKeown, who had concluded that “the main influences were: (a) rising standards of living, of which the most significant feature was a better diet; (b) improvements in hygiene; and (c) a favorable trend in the relationship between some micro‐organisms and the human host.”2 However, in their conclusion they magnified this point, stating that “profound policy implications follow from either a confirmation or a rejection of the thesis. 

 For many years, I taught a session of my population health course featuring the two contemporary papers that frame what we know today—the first by McGinnis and colleagues, based on CDC surveys, argues that medical care is responsible for about 10% of preventable mortality, and the second an econometric analysis by David Cutler argues that medical care was responsible for 50% improvement in certain causes of mortality over the period of 1960 to 2000. When students are shocked by this range, I remind them that, in a world that still predominantly assumes the pre‐McKinlay reality of medical care being close to fully responsible for preventing or curing disease and death, it is still a profound statement to many that much more than medical care goes into the production of health.

A must read. There are still many unanswered questions.


November 2, 2020

Health reform, a lost chance (once again) (2)

 Consenso por un sistema sanitario del siglo XXI

A new report and new proposals for health reform. The authors start saying that Informe Abril (released 29 years ago. Yes! I was there) was not finally considered as a source for any reform, as we all know. After that, there are 40 reports available, and nothing happened. After three decades, the probability of a health reform, in the wake of current pandemic and political weakness, is still lower in my opinion. Authors highlight the current difficulties of the health system and generic approaches to be considered.

However, health reform requires a consensus on values, and such consensus will not arise from experts, it is a social and political consensus. Expert consensus is a way to reflect concerns about a topic and ways to tackle it, but on policy terms its relevance and impact is minor.

Anyway, it's up to you your final assessment. 

La Sieste. Matisse at Pompidou is right now fermée

November 1, 2020

Covid and the Value of Statistical Life

 COVID-19 and Uncertainties in the Value Per Statistical Life

Do the Benefits of COVID‐19 Policies Exceed the Costs? Exploring Uncertainties in the Age–VSL Relationship

For an individual, VSL can be derived by dividing WTP by the risk reduction. A population-average VSL of $10 million indicates that the typical individual is willing to pay $1,000 to decrease the chance of dying in a given year by 1 in 10,000. Individual WTP also can be summed across individuals expected to accrue the risk reduction. If 10,000 people will experience a 1 in 10,000 risk reduction and are each willing to pay $1,000 for the risk change, the total value is $10 million (10,000 times $1,000), and one less person would be expected to die that year as calculated by 10,000 times 1/10,000.


Individual WTP, then, is the fundamental measure—the $1,000 in this case. The conversion to a $10 million VSL is simply for convenience. 

 In a recent study with Ryan Sullivan and Jason F. Shogren, I compare the effects of three approaches often used to adjust for age: an invariant population-average VSL; a constant value per statistical life-year (VSLY); and a VSL that follows an inverse-U pattern, peaking in middle age. We find that when applied to the U.S. age distribution of COVID-19 deaths, these approaches result in average VSL estimates of $10.6 million, $4.5 million, and $8.5 million. The differences in these values is substantial enough to alter the conclusions of frequently cited analyses of social distancing.

 Table II. VSL by Age Group (in 2019 millions of dollars)

Age GroupInvariant VSLConstant VSLYInverse‐U Relationship
Under 1 year$10.63$13.88$5.38
1–4 years$10.63$13.74$5.38
5–14 years$10.63$13.37$5.38
15–24 years$10.63$12.64$5.38
25–34 years$10.63$11.76$8.50
35–44 years$10.63$10.63$10.63
45–54 years$10.63$9.19$10.72
55–64 years$10.63$7.54$8.15
65–74 years$10.63$5.68$8.15
75–84 years$10.63$3.72$8.15
85 years and over$10.63$2.03$8.15

 Table III. COVID‐19 Age‐Weighted Value (in 2019 millions of dollars)

Invariant VSLConstant VSLYInverse‐U Relationship
Total value, all COVID‐19 deaths$937.6 billion$394.8 billion$773.4 billion
Average VSL, weighted by COVID‐19 deaths by age$10.63 million$4.47 million$8.31 million
Table IV. Effect of Alternative Approaches on Analytic Results
Thunström et al. (2020)$7.2 trillion1.24 million$12.4 trillion$13.16 trillion$5.54 trillion$10.30 trillion
Greenstone and Nigam (2020)N/A1.76 million$7.94 trillion$18.72 trillion$7.88 trillion$14.64 trillion
Acemoglu et al. (2020)$2.15 trillion8.7 millionN/A$92.44 trillion$38.93 trillion$72.31 trillion

Does this make sense? It seems quite high. If we value identified life more than a statistical life, can you imagine the final figure?

Whether the social distancing policy considered by Thunström et al. (2020) yields net benefits varies depending on the valuation approach. The authors use an invariant VSL but apply a somewhat lower value than we use in our analysis ($10 million rather than $10.63 million). However, both our invariant VSL and inverse‐U approaches lead to positive net benefits. Under our invariant approach, the benefits increase by almost $800 billion due to differences between the VSL estimates. Benefits decrease when using the inverse‐U approach, but not by a large enough amount to drop below estimated costs. Under the constant VSLY approach, benefits decrease by a substantial amount and the policy no longer appears cost‐beneficial.

While Greenstone and Nigam (2020) do not include a cost estimate in their calculations, the effects of our three approaches on their featured benefit estimates are significant. The benefit estimates more than double when applying the invariant VSL approach rather than their age‐adjusted approach. Interestingly, their estimates are very similar ($7.94 vs. $7.88 trillion) to the results using our constant VSLY method, while applying our inverse‐U estimates almost doubles the value in comparison to their inverse‐U approach. This result reflects the relative steepness of their curve at older ages as well as our assumption that values level off at older ages under the inverse‐U approach. As noted earlier, the additional sensitivity analyses reported by the authors also show siginificant variation in the results.

Acemoglu et al. (2020) have by far the largest estimates of lives saved across the three social distancing studies, which naturally increases the benefit values. Under all three approaches, we find that benefits exceed costs by an order of magnitude. However, Acemoglu et al. (2020) find that approaches other than the scenario reflected in Table IV are more cost‐effective, particularly if they target higher risk, older age groups.

Anyway, let's search a little bit more on that. Let's take the press. I don't think that this helps to take policy decisions in the current pandemic. It's just recreational research.

PS. The price of freedom is 103€ per day in my country (cost of non being free by mistake). Explained here.