• Help me learn new things! – Art History

    This post is part of a series in which I’m dedicating a month to learning about twelve new things this year. The full schedule can be found here. This is month five. (tl;dr at the bottom of this post)

    This month was super busy, so much so that I contemplated abandoning my reading for the month. I’m glad I didn’t. Along with month one (water management), this month was one I’ll carry with me for a long time.

    I read five books. I’m only going to discuss one, because in the end, it’s the only one that matters. For those who want to know the others, they are (in no particular order):

    • Air Guitar, by Dave Hickey (which was ok, but not totally on topic)
    • The Shock of the New, by Robert Hughes (which I found really difficult to read)
    • The Lives of the Artists, by Giorgio Vasari (Author), Julia Conway Bondanella (Translator), Peter Bondanella (which was good, but not what I wanted)
    • Look! Art History Fundamentals, by Anne D’Alleva (which is clearly only written for college students trying to pass Art History)

    The fifth, The Story of Art, by E.H. Gombrich, is a book you should go out and get right now. I’m serious. Go. I’ll wait.909524

    It was so well written, I was never bored. Plus, Gombrich knows his stuff and is a master teacher. I know nothing about him, but I have to assume he was a phenomenal professor. If not, he missed his calling.

    There was so much about art I never considered. I was one of those people who looked at paintings and wondered how they got in museums when it looks like a kid could do it. I was wrong. Gombrich has forever changed me. Of course, Van Gogh cold paint a realistic looking animal. He chose not to. Duh.

    But beyond that, I learned why art history is so important. Like many of you (or maybe I’m the only one), I assumed that art has always been stuff that people could buy to decorate their homes and hang in museums. But that’s such a recent development. I mean, really recent. Here are some of the things I learned that I never bothered to think about before:

    • For a long, long time artists had to be responsible for making their own materials. You couldn’t go out and buy paint in a store. Canvas wasn’t cheap and ubiquitous. When Gombrich described how the invention of oil paints (one artist did it) changed art, I was simply stupefied. I had to put down the book and walk away for a bit. Every piece of art required real thought and investment. You couldn’t just make it up as you went.
    • In that vein, so many things I take for granted had to be learned. The math of perspective was an unbelievable achievement. People looked at it like we do “3-D” today. We just assume anyone can do it.
    • Almost all art, until really recently, had to have a purpose. You didn’t buy it for your bathroom. Almost all of it, for a long time, was religiously focused and put in temples or churches. Straying from that was a revolution (almost literally).
    • Museums are a recent development. Before that, you had to go to temples or churches to see it.
    • For that matter, owning a piece of mass produced art didn’t happen until really recently as well. You couldn’t mass produce sculptures.
    • Getting the human body right took so, so, so much time and learning. Again – we take that for granted.
    • Some artists were literal geniuses. I’ve been to the Vatican and I was overwhelmed by Michaelangelo’s work, but it wasn’t until now that I realized what a ridiculous achievement the roof of the Sistine Chapel was.
    • The Mona Lisa? Missed all of its genius until I read this book.
    • Making things look sharp and defined is a choice. Making them blurred is a choice. Making them realistic is a choice. Making them abstract is a choice.
    • All those things you hear about mastering light in a painting and how it’s important. Don’t roll your eyes. I did. I was wrong. These things can’t be taken for granted. Paintings aren’t photographs.
    • All sculptors are amazing. Full stop.
    • Architecture is art as well. This book touched on it, but I think it needs a full month. If I do this again in 2017, it’s going on the list.

    The book pretty much has an illustration on each page as an example to discuss what Gombrich is discussing. You can almost feel like this could be a running slide show with his lecture. It’s perfect. You see enough that you start to feel like you could recognize the masters in a museum, yet you’re also exposed to artists you might never have heard from before. I also learned that there are plenty of “masters” who I didn’t know about, but should.

    More importantly, I learned enough to appreciate that I likely need to see more of the actual paintings instead of looking at pictures in a book. The medium is important.

    When I was in medical school, I spent a couple weeks in Italy one summer. I saw lots of art, but it was almost all in churches and such, because I loved the history more than the art. I grew up a couple blocks from the Barnes museum, and went there a lot, but that was more for the oddness of the museum than for the art. Other than that, I haven’t spent much time actively considering art.

    But a couple years ago, my wife and I were in Spain – adding on a vacation to a meeting at which I was speaking. We went to a modern art museum in Madrid. This was one of those things I felt like I was doing for her, because I didn’t care much for art museums, especially for “modern” art. I wanted to spend more time seeing the castles and such.

    I enjoyed it much more than I thought I would. The exhibits on the Spanish Civil War, and how the art of Goya and Picasso fit into it, fascinated me. I should have paid more attention to how I felt then. I should have spent a bit more time considering that art, and its history, might be worth my attention.

    I’m glad I finally did.

    tl;dr: Go buy and read The Story of Art. Now.

    @aaronecarroll

    P.S. I also want to use this post to plug my friend Sarah Urist Green’s YouTube show The Art Assignment, produced by the same awesome people who make Healthcare Triage. It’s great! You should all be watching it.

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  • Violence sans frontières: Acts of war against health care workers

    151004200204-kunduz-afghanistan-hospital-airstrike-doctors-without-borders-robertson-lklv-ct-00013723-exlarge-169
    The international humanitarian law of war requires that

    Medical personnel exclusively assigned to medical duties must be respected and protected in all circumstances.

    Article 19 of the 1949 Geneva Convention states that

    Fixed establishments and mobile medical units of the Medical Service may in no circumstances be attacked, but shall at all times be respected and protected by the Parties to the conflict.

    These norms could not be clearer. Yet the World Health Organization (WHO) reports that health care workers and health care facilities are being targeted in war:

    Over the two-year period from January 2014 to December 2015, there were 594 reported attacks on health care that resulted in 959 deaths and 1561 injuries in 19 countries with emergencies. More than half of the attacks were against health care facilities and another quarter of the attacks were against health care workers. Sixty-two percent of the attacks were reported to have intentionally targeted health care. [Emphasis added.]

    Medicins Sans Frontières reports that:

    Last year, 75 hospitals managed or supported by international medical organization Doctors Without Borders/Médecins Sans Frontières (MSF) were bombed. This was in violation of the most fundamental rules of war which gives protected status to medical facilities and its patients, regardless if the patients are civilians or wounded combatants.

    I naively expected that most of the attackers would have been terrorists, where ‘terrorist’ means an irregular, non-state militant. Not so, according to WHO:

    Of the 594 attacks reported over the two-year period, 53% were reportedly perpetrated by State actors, 30% by non-State actors, and 17% of the perpetrators remained unknown, unreported or undetermined.

    Syria is the worst offender. But are only ‘pariah’ states to blame?

    Speaking in a special session of the U.N. Security Council on the protection of health care workers,… Joanne Liu [the Canadian pediatrician who is President of MSF] said four of the council’s five permanent members — Britain, France, Russia, and the United States — “have, to varying degrees, been associated with coalitions responsible for attacks on health structures over the last year.”

    Liu may have been referring to Russian support of Syria. She may also have been referring to the repeated attacks by Saudi Arabia, a close US ally, on MSF hospitals in Yemen.

    I’m persuaded by Steven Pinker that on a long view of history, humanity has adopted norms that have reduced violence. These norms, however, are fragile.

    Declines in violence are caused by political, economic, and ideological conditions that take hold in particular cultures at particular times. If the conditions reverse, violence could go right back up.

    Writing in the NEJM, Michele Heisler, Elise Baker, and Donna McKay warn that

    If the international community does not mobilize to stop the attacks on Syria’s medical professionals and infrastructure, civilians will continue to suffer and die… The effects of these violations and absence of accountability will go far beyond Syria. The longer the international community fails to enforce humanitarian law, the greater the chance that these violations will become the “new normal” in armed conflicts around the world, eroding the long-standing norm of medical neutrality. Left unchecked, attacks on medical care will become a standard weapon of war.

    Are US forces attacking medical personnel? On October 15, 2015, a US Special Operations AC-130 gunship attacked an MSF hospital in Afghanistan, killing 42 people.

    Bombed MSF Hospital in Afghanistan.

    Bombed MSF Hospital in Afghanistan.

    US Army General John Campbell stated that the targeting was accidental and that

    We would never intentionally target a protected medical facility.

    The State Department has also reaffirmed the US commitment to the international laws governing medical neutrality.

    It’s inconceivable to me that the US military would intentionally target medical personnel. Nevertheless, the US has been at war for 15 years with no end in sight. We may be losing the norms restraining violence in war. The US has tortured prisoners and the leadership of the American Psychological Association helped blur the bright line norm prohibiting psychologists’ participation in torture. As Megan McArdle pointed out, a candidate for the US Presidency advocated war crimes as part of his campaign.

    I wish it was a nightmare too.

    @Bill_Gardner

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  • Normal A1C

    Via Jeanne Lenzer:

    normal A1C

    @afrakt

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  • 6 Things That Happened in Health Policy This Week

    6 Things That Happened in Health Policy This Week was created by Zoe Lyon and Garret Johnson. Find them on twitter @zoemarklyon and @garretjohnson22.

    This newsletter is produced each week by a mix of research assistants from the Healthcare Quality & Outcomes (HQO) Initiative at the Harvard T.H. Chan School of Public Health. In each edition we feature a variety of news articles, reports, and studies focused on U.S. health policy and health services research.

    CQ Roll Call: Medicaid Plans Succeed in Obamacare Exchanges as Others Struggle

    • In contrast to some of the nation’s biggest insurers (e.g. United, which saw double-digit losses), several small plans with experience in Medicaid managed care (e.g. Centene, Molina) are making headway in cutting their losses in the turbulent ACA exchange market.
      • A McKinsey report recently found that these Medicaid insurers had an average profit margin of -2.7%, significantly better than other insurers.
    • Many of the big insurers had prepared for exchange enrollees behaving similarly to those enrolled in employer-based coverage. In fact, their patterns are similar to those of Medicaid enrollees.
    • One of the keys to success on the exchange has been keeping premiums low, often through narrow networks, which consumers have tolerated if they are paired with low premiums and good care coordination.
    • Heritage Foundation senior fellow Ed Haislmaier on the ACA exchange market: “This is a population that when they need care, they go to the emergency room. You’re going to have to change that behavior [to limit costs]. And [Medicaid plans] understand that population.”

    WSJ: Implantable Buprenorphine Device Approved by FDA to treat Opioid Addiction

    • The FDA has approved Probuphine, an implantable device releases buprenorphine and lasts 6 months, to treat opioid addiction in patients already taking buprenorphine orally.
    • The device, which consists of 4 implants inserted into the upper arm, eases opioid cravings for 6 months and guarantees that patients will adhere to their medication (in contrast to oral buprenorphine).
    • A recent study of 175 opioid-addicted patients – funded by the manufacturer of Probuphine – found that the rates of illicit opioid abuse were no higher in those that received the arm implant than in those that continued taking oral buprenorphine.
    • Still, all medications to treat addiction face some resistance from those that see pharmacologic therapy as switching one addiction for another.
      • Nora Volkow, director of NIDA: “Scientific evidence suggests that maintenance treatment with these medications in the context of behavioral treatment and recovery support are more effective in the treatment of opioid use disorder than short-term detoxification programs aimed at abstinence.”

    Kaiser Health News: Missouri Hospital Association Makes Strong Push for SES Adjustment in Readmission Penalties

    • As bipartisan legislation works its way through the U.S. House and Senate to adjust the federal Hospital Readmissions Reduction Program (part of the ACA) for patients’ socioeconomic status (which has been repeatedly shown to be an independent predictor of readmissions), the Missouri Hospital Association is taking the lead in attempting to eliminate what it sees as an unfair policy.
    • Specifically, the group re-made its consumer-facing website to include a readmission rate adjusted for patients’ Medicaid status and neighborhood poverty rates.
      • It also commissioned a study which found that poverty-related factors explain 43% to 88% of the variation in readmission rates in Missouri
    • Herb Kuhn, president of the Missouri Hospital Association and MedPAC commissioner: “hospitals in difficult neighborhoods are getting worse scores, and those in affluent [ones] are getting better. It’s time to adjust [rates] for the disease of poverty.”
    • But Leah Binder, the CEO of Leapfrog Group, disagrees: “Hospitals are paid a lot of money. I think they can find a way to handle their readmissions, the way they should have been handling them all along.”

    WSJ: Insurers Seek Big Premium Boosts for 2017 Exchanges

    • Reeling from losses in the first few years of the Affordable Care Act, many insurance giants are seeking hefty premium hikes for individual plans sold through insurance exchanges for 2017.
    • Beneficiaries on the exchanges in more than a dozen states would be affected by the proposed rate increases, which could exceed 50% in some cases.
      • Large plans in New York, Pennsylvania, and Georgia are seeking to raise rates by 20% or more.
      • In Georgia, the average premium increase proposed by Humana is 65.2%.
    • Proposals still have to be approved by state regulators and a full picture of final approved rates won’t be known until HealthCare.gov (and state equivalents) reopens on Nov. 1.
    • Obama administration officials are hoping that state insurance regulators will review the rate proposals and force insurers to lower those that can’t be justified.
    • Insurers staying in the exchanges feel the need to increase premiums for the same reason that some insurers have decided to leave the exchanges all together: big losses due to heavier-than-expected costs from patients who were sicker than insurers expected.

    Modern Healthcare: CMS lambasted for failing to curb Medicaid, Medicare fraud and abuse

    • The government reported that nearly $80 billion was misspent on Medicare and Medicaid in 2014.
    • The Office of the Inspector General (OIG) found that:
      • 37 states had not implemented fingerprint-based criminal background checks, and
      • 11 were not performing site visits when enrolling providers in their Medicaid programs.
    • Recent review found nearly all provider names from Provider Enrollment, Chain and Ownership System (PECOS) did not match the names filed with state Medicaid agencies.
    • 12% of providers terminated for cause by a Medicaid agency in 2011 were still participating in another state’s Medicaid program in January 2012 because of CMS’s inability to identify providers that have been terminated.
    • An investigation found that weaknesses in the CMS software used to ID provider addresses lead to more than 26,000 providers with addresses not matching any on file.

    Health Affairs: Uninsurance Rates and the Affordable Care Act: What does recent research show about changes in uninsurance rates since 2010?

    • A new HealthAffairs policy brief considers how uninsurance rates are changing under the ACA.
    • Both the American Community Survey (ACS) and the National Health Interview Survey (NHIS) show a decline in uninsurance rates (2013-2014) of nearly 3 percentage points, representing the largest one-year decline in uninsurance rates since 1997.
      • 2013-2014 is an important year because of the subsidized Marketplace plans becoming available and Medicaid being expanded.
    • The decline in unisnurance rates from 2013 to 2014 (when coverage provisions went into effect) is one measure of the ACA’s effect of providing “quality affordable healthcare for all”.
      • Still to be seen is how uninsurance rates continue to decline as time goes on.
      • Improving outreach to the uninsured who are eligible for Medicaid or the subsidized Marketplace is important, but just as important is creating federal and state policy changes that expand the number of people who are eligible for assistance and ensure that assistance is sufficient to make coverage affordable.
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  • AcademyHealth: How should we pay for gene therapy?

    For many, many years we’ve been hearing about gene therapy – the chance that we can get into people’s DNA and fix it to resolve problems and fix disease. In a recent piece in Science, Stuart Orkin and Philip Reilly discuss what finally achieving success might mean:

    Go read about that, and what I think about it, over at the AcademyHealth blog! Go!

    @aaronecarroll

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  • None of you can troll me like Austin can. Also, cell phones and cancer. Again.

    Seriously, he’s got more game than all of you combined:

    This is from the STAT News email** he sent me.

    Stat

    Now, to the study (which may not be even be published yet). It was a rat study. They exposed pregnant rats to whole body CDMA- and GSM-modulated radiofrequency radiation, for 9 hours a day, seven days a week. Then they exposed 90 pups of each sex to each to three levels of each type of radiation for up to 2 years (12 groups of 90). They had controls (2 groups of 90).

    The pregnant rats who were exposed to this had no differences in the percent of dams littering, the size of the litters, or the sex of the pups. It appears that pups born to the exposed rats were smaller, but no statistics are presented, so I can’t tell if the differences are significant. Early in lactation, though, these differences disappeared. No further weight differences were seen for the rest of the study.

    At the end of the study, survival was lower in the control group of males than in all the exposed males. Survival was lower in the control group of females for two of the three exposed groups. Yet no headlines blared that cell phones extend life. Nor will mine. No statistics are presented on whether this is significant.

    Now let’s get to brain cancer. There were no significant differences in the incidences of lesions in exposed male rats compared to controls. There was a “statistically significant positive trend in the incidence of malignant glioma (p < 0.05) 16 for CDMA-modulated RFR exposures.” Not GSM, though.

    No differences were seen in the female rats at all.

    The cardiac schwannomas were more compelling, but again, only for males. No differences for females.

    Where to begin? I didn’t see any sample size calculation, nor any discussion of what they expected to see. One of the reviewers did a power calculation for them (page 37) and found that based on 90 rats per group, the power was about 14%. This means that false positives are very likely. The cancer difference was only seen in females, not males. The incidence of brain cancer in the exposed groups was well within the historical range. There’s no clear dose response. Why schwannomas? Schwannomas in other locations than the heart were not significantly different. These are rats. I don’t know how this compares to real world exposure. And one more thing – the survival of male rats in the control group was relatively low, and if these tumors developed later in life, this could be the whole reason for the difference.

    Also, this:

    BC

    Cell phones are UBIQUITOUS in the United States. If they were causing cancer, we would expect to see rates of cancer going up, right? That’s not what we’re seeing. They’ve been decreasing since the late 1980’s. At least when we talk about vaccines and autism, the rates of the latter went up as we increased the former. With cell phones, there’s an inverse relationship. What’s going on?

    And why does the media keep doing this?

    **The actual article from STAT News by Megan Thielking and Dylan Scott is much more balanced and nuanced than the headline would signal. I wish whoever wrote the headline had toned it down.

    @aaronecarroll

    P.S. Read this. Watch this:

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  • What is Governor LePage talking about? I’m seriously asking.

    Healthcare Triage has just completed a month on opioids (History, Science, Abuse, and Treatment). I admit I’m a little more on edge about them than usual. We were in the midst of production when Governor LePage of Maine made news by vetoing a bi-partisan bill that would allow pharmacists to dispense naloxone without a prescription. When asked to explain his veto, he released a statement:

    In a statement explaining his rationale, the Republican governor argued, “Naloxone does not truly save lives; it merely extends them until the next overdose.”

    This was not an “out-of-context” remark. It wasn’t a “gotcha” moment. It was a prepared statement, which basically said that naloxone shouldn’t be available because it keeps addicts alive longer until they inevitably overdose.

    Naloxone isn’t addictive. It doesn’t give you a high. It can help prevent overdoses and it stops the opioids from doing what they usually do. The Maine state legislature overrode the governor’s veto.

    At a town hall recently, LePage doubled down on his beliefs, relating a story:

    “A junior at Deering High School had three Narcan shots in one week. And after the third one, he got up and went to class. He didn’t go to the hospital. He didn’t get checked out. He was so used to it. He just came out of it and went to class,” LePage said.

    He told the audience that he could support the use of Narcan if someone given the shot would be taken directly to rehab afterward. Instead, he thinks the current approach is ineffective.

    “It will kill our society. And we’re gonna lose a whole generation,” he said.

    I’m all for addicts getting help. But depriving them of naloxone doesn’t “save a generation”. I don’t understand the anecdote. It gets worse, though. It appears LePage might have made up the story. The school says it isn’t true. They say that the medication isn’t even available in the school nurse’s office.

    Further confronted, LePage stood by his story. He told reporters to talk to Portland Police Chief Michael Sauschuck for verification of the story.

    Saruschuck said that the anecdote isn’t true.

    There’s a massive opioid epidemic in the US. Addiction isn’t a moral failure, and those who are addicted aren’t lost causes. I’m baffled by all of this, but it’s made worse when it appears that efforts to improve the situation are being thwarted by people who can’t even be bothered to say things that are true.

    @aaronecarroll

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  • Sorry, There’s Nothing Magical About Breakfast

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company).

    I don’t eat breakfast. It’s not that I dislike what’s offered. Given the choice of breakfast food or lunch food, I’d almost always choose eggs or waffles. It’s just that I’m not hungry at 7:30 a.m., when I leave for work.

    In fact, I’m rarely hungry until about lunch time. So, other than a morning cup of coffee, I don’t eat much before noon. This habit has forced me to be subjected to more lectures on how I’m hurting myself, my diet, my work and my health than almost any other. Only a fool would skip the most important meal of the day, right?

    As with many other nutritional pieces of advice, our belief in the power of breakfast is based on misinterpreted research and biased studies.

    It does not take much of an effort to find research that shows an association between skipping breakfast and poor health. A 2013 study published in the journal Circulation found that men who skipped breakfast had a significantly higher risk of coronary heart disease than men who ate breakfast. But, like almost all studies of breakfast, this is an association, not causation.

    More than most other domains, this topic is one that suffers from publication bias. In a paper published in The American Journal of Clinical Nutrition in 2013, researchers reviewed the literature on the effect of breakfast on obesity to look specifically at this issue. They first noted that nutrition researchers love to publish results showing a correlation between skipping breakfast and obesity. They love to do so again and again. At some point, there’s no reason to keep publishing on this.

    However, they also found major flaws in the reporting of findings. People were consistently biased in interpreting their results in favor of a relationship between skipping breakfast and obesity. They improperly used causal language to describe their results. They misleadingly cited others’ results. And they also improperly used causal language in citing others’ results. People believe, and want you to believe, that skipping breakfast is bad.

    Good reviews of all the observational research note the methodological flaws in this domain, as well as the problems of combining the results of publication-bias-influenced studies into a meta-analysis. The associations should be viewed with skepticism and confirmed with prospective trials.

    Few randomized controlled trials exist. Those that do, although methodologically weak like most nutrition studies, don’t support the necessity of breakfast.

    Further confusing the field is a 2014 study (with more financial conflicts of interest than I thought possible) that found that getting breakfast skippers to eat breakfast, and getting breakfast eaters to skip breakfast, made no difference with respect to weight loss. But a 1992 trial that did the same thing found that both groups lost weight. A balanced perspective would acknowledge that we have no idea what’s going on.

    Many of the studies are funded by the food industry, which has a clear bias. Kellogg funded a highly cited article that found that cereal for breakfast is associated with being thinner. The Quaker Oats Center of Excellence (part of PepsiCo) financed a trial that showed that eating oatmeal or frosted cornflakes reduces weight and cholesterol (if you eat it in a highly controlled setting each weekday for four weeks).

    Many studies focus on children and argue that kids who eat breakfast are also thinner, but this research suffers from the same flaws that the research in adults does.

    What about the argument that children who eat breakfast behave and perform better in school? Systematic reviews find that this is often the case. But you have to consider that much of the research is looking at the impact of school breakfast programs.

    One of the reasons that breakfast seems to improve children’s learning and progress is that, unfortunately, too many don’t get enough to eat. Hunger affects almost one in seven households in America, or about 15 million children. Many more children get school lunches than school breakfasts.

    It’s not hard to imagine that children who are hungry will do better if they are nourished. This isn’t the same, though, as testing whether children who are already well nourished and don’t want breakfast should be forced to eat it.

    It has been found that children who skip breakfast are more likely to be overweight than children who eat two breakfasts. But that seems to be because children who want more breakfasts are going hungry at home. No child who is hungry should be deprived of breakfast. That’s different than saying that eating breakfast helps you to lose weight.

    The bottom line is that the evidence for the importance of breakfast is something of a mess. If you’re hungry, eat it. But don’t feel bad if you’d rather skip it, and don’t listen to those who lecture you. Breakfast has no mystical powers.

    @aaronecarroll

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  • Stuff for Healthcare Systems (PHMD2350)

    What is this post about? Look here.

    @afrakt

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  • Living in the antibiotic-resistant future: Answers for @MattYglesias

    Matt Yglesias asked:

    Thanks for asking, Matt! I’m 63 and I will happily oldsplain tell you what you need to know about your future.

    First, some advice about how to think about the problem. One of the difficulties in predicting your future health is that the data come from earlier generations (like me). Unfortunately, your experience will differ from mine, in part because the health care system you will face will be different from the one that I’ve experienced. For several generations, we’ve largely unconsciously assumed that future health care will be better than current health care.

    But that’s no longer clear. Our current antibiotics are failing and they are not being replaced with new ones. I’m sure you know this, but Aaron has great explainers here and here, Kevin has one here, and I have a rant here. In my piece, I quote Arjun Srinivasan, an associate director at the CDC:

    For a long time, there have been newspaper stories and covers of magazines that talked about “The end of antibiotics, question mark?” Well, now I would say you can change the title to “The end of antibiotics, period.” We’re here. We’re in the post-antibiotic era… we are literally in a position of having a patient in a bed who has an infection, something that five years ago even we could have treated, but now we can’t.

    We are already at a point where antibiotic-resistant bugs kill more Americans than AIDS does. Because there is uncertainty about whether this problem will be solved, the risks implied by future widespread antibiotic resistance should condition your current health care decision making.

    Given that you report having random knee pain, this is relevant to you. I started experiencing pain in my hip in my early 30s. My family is disposed to osteoarthritis. But I also made a questionable set of athletic choices. I got hooked on endurance sports (cycling, distance running, triathlon) and martial arts (an acrobatic style of kung fu). I loved these sports, but I could have made smarter choices. I’m 6’2″ with the frame more like an offensive lineman than a marathoner (or Jet Li).

    I logged many running miles, chronically stressing the tissue separating my femurs from my pelvis. I also injured my left hip landing an aerial kick involving 270 degrees of rotation. As a result of these traumas, by my late 50s that hip was trashed by osteoarthritis. I could not walk for long distances or without a cane.

    Then I got a hip replacement. OMG was that wonderful. But here is what joint replacement surgery looks like.

    Joint replacement surgery.

    Joint replacement surgery.

    These operations are spectacularly invasive and they are impossible without effective antibiotics.

    Of course, if we can’t do surgeries, the disappearance of joint replacements will be just one horrible detail. Peter Lee, Scott Regenbogen, and Atul Gawande estimate that the typical American will have 9 surgeries during their life. This will change, and not for the better, without antibiotics. Everyday events will once again become occasions of terror. I was once bitten by my cat while trying to protect her from a dog. Cat bites are amazingly dangerous. Within 24 hours there was a swelling on my hand about the size of half a softball. No big deal, though. It was quickly fixed through surgical debridement and intravenous antibiotics. Otherwise, I would have lost my hand.

    But you mentioned knee pain, so let’s talk about joint health. The upshot is that you have to make health decisions now with the knowledge that you may not be able to replace your joints. You can live without a joint replacement, at the cost of constant pain, with the attendant risks of mental health and substance abuse problems. Moreover, even with a cane or walker your mobility is significantly restricted, and you will discover how many buildings still do not meet the requirements of the Americans with Disabilities Act.

    In light of these risks, you should think through how to minimize the chance that you will need a joint replacement. About 1.2 million of these procedures are performed a year and about 10% of men develop osteoarthritis, so your prior probability even without early knee pain was already significant. See your physician, find out what your risk of developing joint disease might be, and learn what you can do to prevent it. Keep your weight down and engage in regular exercise. But don’t take up a sport that stresses the joints of big men.

    Finally, keep covering the problem of antibiotic resistance at Vox. Antibiotic resistance is in the class of problems that includes global warming and nuclear holocaust. They are all rooted in the foundations of how things work rather than in the easily fixable details. Any solution faces difficult coordination problems. Keep writing because people don’t get it yet; but they need to if we are going to get through this.

    @Bill_Gardner

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