[extropy-chat] Are vaccinations useless?

Thu May 4 07:55:14 UTC 2006

Here I am back to my old tricks, not following on good threads for way
too long...

Sorry for the long delay. In the meantime, I reached lvl 55 as Undead
warlock on the Khaz Modan server and amassed a fortune of 1700 gold,
now ready to take on end-game instances. A note to all of you who
still have a life - never, never, set foot on Azeroth, or would will
be lost to this world.

I will answer Robin's last post at the end of this contribution, which
promises to be a long one. Let me first comment on a few other posts
that accrued since my last presence here:

Somebody mentioned that unidentified parties on this list have gone
mau-mau on Robin's ass. Such activities are probably illegal in many
jurisdictions and I strongly disapprove of them (except if on a
strictly consensual basis). I expect that the list authorities will
take a swift and uncompromising action to end the outrage.

Now back to Robin's medical views:

Jeff Medina wrote:

 as Robin's position is the consensus position
of experts on this matter (or so he has claimed, and no evidence
against this has been provided by anyone else, including you -- in
fact, unsolicited corroboration was provided, by Finney armed with a
mainstream health economics textbook).

### Robin makes two claims which according to the best of my knowledge
are well beyond the mainstream of experts on medicine (much less being
the consensus):

1) Smallpox vaccinations are responsible for between 1 and 10 % of the
reduction in smallpox lifetime prevalence observed in developed
countries since their introduction.

2) The utility of modern medicine in developed countries, as measured
by life extension and improvement in the quality of life is negligibly
different from zero.

while I take issue with both of them, I agree with Robin's statement:

3) The utility of pre-modern medicine (before  ~ 1850) is close to zero.

We need to very clearly differentiate between claims #2 and #3. There
are very good reasons to doubt the efficacy of almost all medical
interventions before 1850, with the exception of vaccinations but
after that time, with the work of Lister and Pasteur, the modern era
of medicine started and eventually led to "exceptional returns". Let
me quote a document from the Lasker foundation that Robin listed on
his webpage of health-care resources:

http://www.laskerfoundation.org/reports/pdf/exceptional.pdf

"economists came to a virtual consensus that medical research has
produced exceptionally high returns in the past and is likely to
deliver exceptional returns in the future."

The other documents listed on Robin's page are also in general
supportive of the notion that medicine produces significant utility. A
PubMed search for "(health-care OR healthcare) cost-effectiveness"
yields today 17856 citations, and a random sampling of them shows that
most describe net *gains* from specific medical treatments, rather
than net losses. If there is anything that economists agree on, it is
that overall medicine is useful.

-------------------------------
No, but Robin didn't make that claim.  In fact, he explicitly stated
that he's perfectly willing to grant that *some* treatments are
worthwhile.  You don't mean to suggest that all, or nearly all, of the
treatments suggested by doctors are backed up by RCTs, do you?  Or
that the gains from the minority of worthwhile treatments make up for
the majority of low, zero, and negative value ones?  It seems you'd
have to back one or the other of these for your question to apply
here.

### If you grant that some treatments work but still say that all
treatments on average don't, then you must postulate that the
beneficial effects of some treatments are precisely (within
measurement error) offset by negative effects of others.

I once posted here a long list of beneficial treatments, and I
challenged Robin to come up with a list of deleterious treatments
necessary to offset the beneficial effects. In another discussion on
wta Robin actually conceded that clearly deleterious treatments are
unlikely to survive the scrutiny of providers, patients, and their
lawyers for long, so not surprisingly he didn't compile the anti-list
I asked him about. But, this leaves the claim of zero average utility
prominently unbalanced.

----------------------------
Robin:
Let me confirm that the majority of medical practice is *not* now
backed up by well-done RCT.   An easy test:  the next time your doc
advices some treatment, ask him for the RCT that backs it up.
If he gives you a RCT, look to see how well done it is and how
relevant it is to your situation.v

### I will concede that under some legitimate interpretations of
"majority of interventions" indeed the majority of medical practice
would not be backed up by well-done RCT. However, under other
interpretations, the opposite is the case.

Specifically, if you look at the majority of medical treatment
interventions (as opposed to diagnostic algorithms), most of them are
pharmacological or surgical. All drugs in the US have to prove safety
and efficacy in FDA-monitored trials (which should be abolished but
this is another story) before being approved, and therefore their use
tends to be supported by RCTs. Even the off-label use usually begins
with a few case presentations, followed by RCTs if the use is
significant. I can support virtually every prescribing decision I make
daily by an RCT, or an AAN practice guideline.

Furthermore, many if not most of the of the most common surgical
procedures are backed by RCTs as well - from CABG to lithotripsy to
epidural steroid injections, there is actually a lot of data.
Sometimes it turns out that a traditional intervention is actually
useless - for example, recently we have found out that surgery for
intracranial hemorrhage is useless, or endoscopic knee surgery is
useless - but the number of commonly used procedures without an RCT to
their credit is probably dwindling.

So, yes, I would contend that if you count my medical treatment
decisions throughout a representative week, the majority of them will
be RCT-supported. If you come to me for a consultation and ask
questions, I will be able to dig out the data (but would charge you
extra). I hardly think that I am exceptional in this respect.

This is not to say that most doctors will be able to show that what
they order is the optimal treatment - far from it, neither I nor most
other practitioners have the comprehensive knowledge needed to select
the best possible drug (in part because few entities have the economic
incentive and means to conduct the research needed to find it) but
most physicians will give medications that work somewhat, perhaps
better than an alternative drug, perhaps a bit worse than a direct
competitor. I vacillate between triptans (migraine medication) each
time after eating a drug rep dinner but this because all triptans seem
to work in a similar fashion, not because there are doubts whether
they work at all.

-----------------------
Robin:
To be clear, I do not at all think the RAND study is anything close to "junk".
Its quality is substantially better than the typical study you will find via
MedLine, for example.  Its main "flaws" are that it is now 30 years old and it
only looked at 5000 people over five years, and that it had a needlessly
complicated set of varying treatments (mainly because they didn't anticipate
that the main result of the experiment would be no effect).    It would cost
about a billion dollars to now do a study of 10,000 people over ten years.

### Well, you might also mention that the study does not control for
access to medicine in the control (uninsured) group - therefore it
measures the effect of *free* medical care, not medicine in general.
This is an important distinction - most people will actually pay for
medical treatment that they feel is needed (e.g. extraction of an
abscessed tooth), but many will undergo optional treatments only if
they are free. The Rand control group still went to the dentist when
they had a bad tooth-ache, didn't they? The Rand study didn't show a
big difference in the number of abscessed teeth that were removed in
the both groups, did it? It didn't count how many people would be dead
from sepsis stemming from a tooth abscess if they were actually
forbidden to use medical care, as opposed to merely having to pay out
of pocket, isn't this right?

Yes, this study was useful to prove that universal free medical
insurance is a stupid commie idea gone berserk but it has nothing
useful to say about the utility of medicine. If you wanted to actually
tell how much medicine us worth using the general methodology used in
the Rand study, you would need a control group of people who would not
use any medicine, period.

In fact, if you manage to convince enough people to follow your notion
of medicine's futility, you could do the study. Have half of them use
all medical services at their disposal (since medicine is only futile,
not actively harmful, this would be ethical, if profligate), while the
others will abstain from all medicine (again, since medicine is
futile, this would be ethical, as no harm can be done from abstaining
from useless stuff). And I mean no medicine - no heartburn drugs, no
dentistry, no nursing home placement, no cast for a broken ankle, no
blood transfusion after a car accident, no suturing of wounds,
nothing.

Ten years later we will poll the groups on the amount of suffering
they have undergone, and count the disabled and the corpses. Are you
ready to be the first subject of this study?

Perhaps a patient I saw many years ago would be the inspiration for
you: He had diabetes and never saw a doctor for it. As it frequently
happens, he developed circulatory abnormalities in his foot, the
"diabetic foot". After a while the foot died. It didn't really upset
him, until one day it actually broke off above the ankle. This is when
he finally came to the attention of my profession, and in line with
your contention of medicine's futility, they didn't actually do much
for him.

This is an actual true and accurate first-hand story, not some Wes
Craven fantasy. I am sure the proposed study would provide many more
darkly entertaining yarns of this kind.

-----------------------------------------------

On 4/18/06, Robin Hanson <rhanson at gmu.edu> wrote:

> >The RAND study is the single most informative study we have about the
> >overall (marginal) health value of medicine in rich nations today.  I know
> >Rafal has complaints about it, but one can find imperfections in any
> >study.  I challenge Rafal to point to another study he thinks is more
> >informative.   We could then compare flaws.

and then also:

> Well it has been a month now, and Rafal hasn't offered a study he prefers,
> using the method he says he prefers, i.e., aggregating studies of specific
> treatments.   Let me suggest that this is because there are no such studies.
> Rafal prefers the conclusion he guesses would be the result of such a
> study to the conclusion of the actual studies I have pointed him to.   The
> actual studies have flaws, while of course his hypothetical study need have
> none.

### As Jeff Allbright (I think) has noted, even if I was unable to
point to a study aggregating outcomes of treatments, this would not
prove your point, merely indicate the absence of knowledge on which a
point of view could be based.

But, there are studies aggregating outcomes. You quoted one of them
yourself, the Bunker et al. in Milbank Quarterly, Volume 72 Number 2,
1994. Such studies consistently show a benefit of anything from 2 to 5
years.

Let me admit, my mind is totally boggled by all what you say on this subject.

Rafal