• Milk and Juice Are Not as Needed as You Might Think

    The following originally appeared on The Upshot (copyright 2020, The New York Times Company)


    Is there such a thing as a healthful beverage?

    In truth, there’s not much of a health case to drink any beverage other than water after the age of 2 — despite the marketing and advertising you might have seen on the benefits of things like dairy milk, plant-based milks, juices and more.

    All other mammals consume only two liquids over the course of their lives: breast milk and water. The evidence for telling humans that some beverages are necessary and that others should be avoided isn’t nearly as clear as many believe.


    Recommendations from experts

    Last year, a group of leading health organizations released recommendations on what children should drink. They convened a panel and a scientific advisory committee. They pored over documents, studies and reports from all over the world.

    The undertaking was about as thorough as it could be. Yet the recommendations they released are still somewhat disputed.

    For children above the age of 1, dairy milk is “recommended,” although the fat content and amount changes with age. Juice should be limited, the panel says. Pretty much everything else except water should be “avoided.” This includes all plant-based milks, unless necessary because of allergies. This also includes “toddler milk,” which has increased rapidly in popularity (it contains mostly powdered milk, corn syrup and vegetable oil).

    Before going any further, let’s acknowledge where there is consensus. Human infants, like all mammals, depend on milk for sustenance at the beginning of life. Breastfeeding (human milk) is almost always recommended, as well as baby formula until 1 year of age if breastfeeding is not feasible. Most experts also think that children should continue to be breastfed or transition to whole cow’s milk until they’re 2. The fat is believed to aid in brain development.

    It’s at that point that things get tricky.

    There’s very little high-quality evidence, and no comparable mammalian example, to argue for the specialness of cow’s milk after this period. Arguments that it’s good for you because it has protein and other vitamins and minerals could be made about many, many other foods (but those foods don’t receive such official recommendations of support).

    The recommendation that we limit juice, and not just avoid it, is also somewhat questionable. The argument for juice is that while we’d prefer that children eat fruits and vegetables, some just won’t. In that case, the experts argue that 100 percent fruit juice “may be an important way to meet these recommendations.”

    But juice is not healthful. It’s full of sugar. A 12-ounce glass of apple juice has the same amount as a can of soda (grape juice has even more). It’s also a processed food. It contains no fiber and does nothing to sate you. It’s empty calories. Studies show that adults who eat an apple before a meal consume fewer calories during that meal; drinking a glass of juice instead has much less of an effect on calorie consumption.


    Questionable stance on plant-based milks

    Oddly, the recommendations take a much stronger stance against plant-based milks, like almond milk or soy milk. Those should be “avoided” for children, not limited. Why? Because, as the authors of the recommendation note, in studies of their nutritional content they come up short compared with dairy milk.

    It’s true that, with the exception of soy milk, plant-based milks have significantly less protein than cow’s milk. It’s also true that while some plant-based milks are fortified with calcium or vitamin D, it’s not clear that these are absorbed as well from other milks as they are from cow’s milk. But does that matter?

    The authors cite two studies that show the “negative” impact of plant milk in children. The first was a cross-sectional study of children in Canada, and it found that children who exclusively drank noncow’s milk were more likely to have low vitamin D levels than those who only drank cow’s milk (11 percent versus 4.7 percent).

    But only 5 percent of children drank exclusively noncow’s milk, and it’s very possible that there are confounding factors in their diet that might lead to this result. It’s also unclear if this low vitamin D level had any health implications.

    The second study reviewed the literature and found 30 cases of clinical conditions associated with exclusive consumption of plant-based milks. First, this is essentially a collection of anecdotes. Second, almost all cases occurred in the first year of life, when children shouldn’t be consuming any milk except human breast milk. Even cow’s milk isn’t recommended there.

    Of course, none of this should be taken as an argument that plant-based milks are superior to cow’s milk. Regardless of the hype (there’s usually plenty of that), they’re no more healthy or special than any other beverage.

    I can’t imagine eating cereal without milk. But both are optional, and once you get to optional, it doesn’t really matter which milk you pick. Might children get a bit more protein from cow’s milk? Sure. But most children aren’t deficient in protein. Might children get a bit more vitamins and minerals from cow’s milk than fortified plant-based milk? Sure. But most children aren’t truly deficient in those in a way that would make a difference.

    Moreover, too many children get more calories than they need, and cow’s milk has a lot more calories — and a lot more sugar — than plant-based milks.

    When it comes to juice, it’s hard to argue that the empty calories are good for you at all. We’d never tolerate soda as being “healthy,” even if it came fortified with vitamins and minerals. It’s not that juice and soda are dangerous. They’re most likely fine in moderation, but we can allow them as a treat for children while still recognizing they’re not “recommended.”

    The bottom line, as I’ve written before, is that every beverage other than water and breast milk might be treated the way alcohol is for adults — you can have it if you want it, but don’t be under the illusion that you need it.


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  • There’s Money in Starting School Later in the Day

    Last week we talked about why pushing school start times back to later in the morning is good for students. There’s also an economic argument for it. Today, Aaron talks about how starting school later in the day benefits the economy in the long run.

    This video was adapted from a column Aaron wrote for the Upshot. Sources can be found there.


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  • Measuring Geographic Accessibility for Community Health Centers

    Cecille Joan Avila is a Policy Analyst at Boston University School of Public Health. She tweets at @cecilleavila.

    Community Health Centers (CHC) are located in medically underserved areas and have provided necessary care to millions since the 1960s. CHCs serve everyone, regardless of ability to pay. Increased access leads to better health outcomes, including lower mortality rates.

    Federal funding to open new CHCs is allocated based medical underservice, a measure of unmet need and access barriers. The measure is primarily attributed at the county-level and accounts for the provider-to-population ratio (per 1,000 persons), percentage of the population over age 65, percentage of population below the Federal Poverty Level, and infant mortality rate. An issue with this approach is that it overlooks variation in need within counties and leaves some individuals with the greatest need for care without access.

    New Research

    A new study assessed geographic access to CHCs and examined changes in CHC accessibility from 2008 to 2016, time points that correspond with two Obama-era policies that allocated significant funding to support both established and new centers. Researchers focused on Arkansas, Louisiana, and Mississippi, states with similar overall demographics, poor health outcomes, and noteworthy health disparities.

    The authors of this study are Leigh Evans, PhD, Martin P. Charns, DBA, Howard J. Cabral, PhD, and M. Patricia Fabian, ScD. They are affiliated with Abt Associates, the Departments of Health Law, Policy, and Management, Biostatistics, and Environmental Health at Boston University School of Public Health, and the Center for Healthcare Organization and Implementation Research (CHOIR) at Veterans Affairs Boston Healthcare System.

    Researchers applied a method that could be used to identify pockets of limited CHC accessibility within counties. Additionally, they hypothesized that greater changes in CHC accessibility would be associated with indicators of need (e.g. socioeconomic factors, race, and educational attainment). They did not find evidence of a relationship, suggesting that CHCs established between 2008 and 2016 may not have targeted the areas with most need.


    Researchers compared accessibility to CHCs within counties (census tract) using three different methods, from crudest to most refined: CHCs to population (per 10,000 people), CHC to population within 30-minute driving time from a population-weighted center, and the two-step floating catchment area (2SFCA) method.

    The 2SFCA method has previously been used in other areas of health services research but not yet for determining CHC accessibility. This method takes a user-specified catchment area and estimates the supply-to-demand ratio (CHC-to-population). Researchers defined catchment areas by using commute time data, theorizing this mirrors an individual’s willingness to travel to a health center. This also allows for measuring CHC accessibility without regard to county lines, an arbitrary political boundary that does not influence individual behavior. Only brick-and-mortar health centers open year-round that provided primary care services to the entire population were included, as to avoid overestimating access for the general population (e.g. women-only clinics).


    There were no observable relationships between improved access and aforementioned indicators of need, suggesting that CHCs had not been placed specifically to improve accessibility for people who could benefit most from these services. The study also found that the 2SFCA revealed better baseline accessibility than previously estimated, illustrated with Mississippi, below.

    Changes in accessibility using different methods of measurement

    By 2016, overall CHC accessibility increased 192 percent across all three states, and there were fewer tracts with no access at all. State by state, Arkansas saw the largest overall increase in CHC accessibility, followed by Louisiana, and then Mississippi. Despite this improvement, Arkansas still had the highest number of census tracts with no accessibility in 2016. Mississippi, which had better baseline accessibility, had the lowest number of census tracts with zero accessibility by 2016.


    Using the 2SFCA method to measure CHC accessibility reveals more concentrated pockets of underservice than when simply looking at county-level distribution. By specifically targeting these areas for new health centers, overall primary care accessibility would increase while also prioritizing those currently afforded the fewest health care resources. If federal funding is allocated based on medical underservice, determining a measure that draws out particularly at-risk areas could be a way to distribute funds more efficiently and equitably.

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  • Drug decriminalization and harm reduction in Portugal: a review of the evidence

    Liam Bendicksen is an undergraduate at Brown University studying Public Health and Public Policy. He tweets at @liambendicksen and you can reach him at liam_bendicksen@brown.edu.

    In 2001, the Portuguese government functionally decriminalized drug use and instituted a set of policies aimed at encouraging people with substance use disorders to seek treatment. This unprecedented move and its implications sparked responses from the international press. Most mass-media articles cite this set of policies not just as a success, but as a model for the rest of the world to follow. But what does the evidence say? This post outlines what we know and what is unclear about the effects of Portugal’s drug reforms.

    So what did the reforms tangibly change? According to the legal statute, the drug reforms decriminalized possession up to “the quantity required for an average individual consumption during a period of 10 days” of all psychoactive drugs as well as public and private drug use. Quantities exceeding that threshold are considered evidence of drug trafficking.

    The decriminalization of drug use and possession is distinct from drug legalization, which would sanction the legal sale and distribution of previously-llicit drugs under government supervision. This is not the case in Portugal, where drug trafficking remains a crime. Decriminalization is also distinct from depenalization, in which people who use drugs do not face legally-imposed penalties like fines or community service. This is also not the case in post-reform Portugal. The gist is that Portugal does not incarcerate individuals for using drugs, but people who use drugs still purchase those drugs from illicit markets.

    While popular articles tend to focus on decriminalization, Portugal’s adoption of a harm-reduction approach arguably deserves more attention. This public health-driven strategy primarily entailed the implementation of eighteen regional panels made up of social workers, medical professionals, and drug experts. Instead of arresting people who use drugs, the police refer them to these panels. At that point, panel members refer people who are dependent on drugs to treatment programs. In the case of people who casually use drugs, the panel has the option to assign community service time, fines, or other penalties. In the case of people who use drugs like marijuana that are generally perceived as benign, panels usually follow the recommendations of the statute and choose not to issue any penalty whatsoever.

    The government’s rollout of the panels did not go smoothly and the system still has kinks to iron out. Roughly three-quarters of the cases that the panels processed in 2009 involved cannabis, raising questions about the efficiency of a structure meant to help people who use cocaine or opioids find and access treatment. The lack of an alternative legal framework for people who casually use marijuana means that panels spend an excessive amount of time and resources processing those cases. Aside from that inefficiency, however, the reforms and accompanying social destigmatization of drug use have tangibly increased the availability and provision of drug use treatment. The number of outpatient treatment centers jumped from 53 in 1998 to 79 in 2010, and the number of people receiving treatment for drug addiction increased by about 15,000 in the ten-year span from 1998 to 2008. These programs and facilities seem to have been put to good use, seeing as three-quarters of the population treated in 2008 received medication-assisted treatment for an opioid use disorder, an evidence-based practice and the current standard of care.

    Although decriminalization might seem like a drastic measure from an American perspective, the 2001 reforms in Portugal were not a sea change. Starting in 1998 with the National Strategy for the Fight Against Drugs, the Portuguese government began to accept the growing medical consensus that substance use disorders are psychological conditions, not personal moral failings. The seminal Decriminalization of Drug Use Act essentially codified the prevailing consensus at the time that drug policy should treat people who use drugs, not punish them. Well before the 2001 law, people convicted of drug use were primarily punished with administrative fines. From 1993 to 2000, the total number of people incarcerated for drug consumption alone ranged from 4 to 42. (For scale, the population of Portugal over this period ranged from about 9.9 million to 10.3 million people.)

    Before examining the effects of these reforms, it is important to note that self-reported data on drug use is notoriously unreliable. The Portuguese government did not start surveying national drug use until the reforms took place in 2001. In addition, since the harm reduction policies and decriminalization took effect concurrently, it is impossible to isolate the causal effects of each individual aspect of the reform.

    That said, there are a few reliable results from the reform. For example, there was a substantial and temporary increase in experimental illicit drug use after the law took effect. For the most part, this experimentation did not translate into more regular use in the years following the reforms. The number of people ages 15-24 who reported regular (past 30 days) and recent (past 12 months) drug use declined significantly, while that number rose for people above the age of 24.

    In addition, the burden of drug use-associated diseases and complications declined almost universally, such as notable reductions in opioid-related overdose deaths and the number of new cases of infectious diseases like hepatitis C and HIV that were a growing issue pre-reform. This latter improvement is remarkable because those numbers were recorded by drug treatment facilities, meaning that even as the number of treatment facilities and people receiving treatment increased, the burden of disease decreased. It’s impossible to attribute this reduced burden to any one cause, but the increased availability of treatment and harm reduction programs like needle exchange programs likely helped facilitate this change.

    The policies also reduced prison overcrowding and eased the strain on Portugal’s resource-strapped criminal justice apparatus. However, the number of murders in Portugal increased by 41% in the first five years post-reform, and cocaine seizures increased by 700% over the same period, raising concerns about the policies’ effects on drug trafficking patterns. As Stanford Professor Keith Humphreys put it, “transnational criminal organizations may have taken the new policy as a sign that Portugal would be a safer, lower-enforcement venue in which to operate.”

    It is worth emphasizing that none of these changes can be unambiguously attributed fully to the reforms, as we don’t know what would have happened in their absence.

    In addition, other factors such as broader drug use trends and perceptions of social stigma likely affected self-reported survey responses and other data on drug use-related health outcomes. The claim that decriminalization alone caused these shifts, as many popular accounts imply or state explicitly, is not backed by the empirical evidence. The reality is much murkier and obscured by the lack of reliable, nationally-representative, and longitudinal data on drug use and drug-related health outcomes.

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  • Bariatric Surgery for Kids?

    Childhood obesity is a rapidly growing problem in the United States, and one of our best tools for treating obesity in adults is bariatric surgery. So should this procedure become common in kids as well?



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  • The drug price-innovation tradeoff: ideas and points of contention

    Liam Bendicksen is an undergraduate at Brown University studying Public Health and Public Policy. He tweets at @liambendicksen and you can reach him at liam_bendicksen@brown.edu

    As debates over high drug prices continue to grab headlines, it’s worth taking a deeper dive into the substance of the policy issues at stake. Recent Kaiser Family Foundation polling found that while almost 90% of Americans supported Medicare negotiating drug prices if it could help people save money, around two-thirds opposed that same measure when told it could limit innovation.

    Studies indicate that limiting drug industry profits would negatively impacts innovation. So how can we balance this apparent tradeoff between making drugs affordable and preserving future innovation?

    Our current regulatory scheme, as Professor Craig Garthwaite points out, heavily favors maximizing innovation. In Professor Garthwaite’s words, “[t]he existing U.S. system refuses to truly say no to any pharmaceutical product regardless of its price.” The popularity of scapegoating ‘big pharma’ in the media and the popular support for lowering drug prices suggests that this arrangement may not be politically sustainable much longer. While the substance of current bills will be covered in a future post, it’s worth looking at what scholars and policymakers are proposing from a bird’s-eye view.

    In a report released this month, the White House Council of Economic Advisers argued for a globally-focused free-market solution to the price-innovation tradeoff. The council contends that “reducing foreign price controls would increase profits and innovation, thereby leading to greater competition and lower prices for U.S. patients.” The Trump administration has also promoted price transparency here in the U.S., passing two laws in 2018 that aimed at outlawing pharmacy gag clauses that prevent pharmacists from helping consumers pay less out of pocket.

    Some scholars like Dr. Peter Bach have advanced more regulation-based approaches. In an article published in the New England Journal of Medicine in November, Dr. Bach proposed that government insurance programs like Medicare could negotiate the prices of drugs that haven’t been proven to improve clinical outcomes and drugs that have been on the market for a long time. Dr. Bach reasons that this approach would preserve incentives for innovation while lowering prices for patients, adding that the government could lower drug prices even further if it were willing to forfeit some future innovation. The Council of Economic Advisers and Dr. Bach’s divergent proposals illustrate how prominent policymakers and experts still differ on how to best navigate the drug profit-innovation tradeoff.

    One important distinction to make here is that the tradeoff is not between drug prices and innovation so much as between drug profits and innovation. Blume-Kohouta and Sood (2013) showed, for example, that the passage of Medicare Part D in 2003 increased drug profits while simultaneously lowering prices. By increasing the number of seniors with prescription drug insurance and thus the volume of drug purchases nationwide, policymakers could lower prices without negatively impacting drugmakers’ bottom line. In fact, profits actually increased on average across the industry.

    If generalizable and reproducible, this analysis has substantial ramifications for the possibility of future legislation that could simultaneously extend insurance coverage and lower drug prices. It also clarifies the point that profits, not prices, are the primary driver of drug industry innovation.

    Drug profits do not come from just anywhere, though. Generous patent exclusivity laws, the lack of a central health technology assessment agency, and passive reimbursement schemes in the United States mean that American patients bankroll global drug innovation. This setup arguably isn’t fair. But the reality is that if American policymakers constrain prices, and therefore constrain drugmakers’ profits, there will be far-reaching consequences for patients worldwide.

    As the work of Frank and Ginsburg (2017) demonstrates, however, the relationship between drug manufacturers’ profits and innovation is not linear. Rather, investments in research and development are governed by the law of diminishing returns. This means that each additional investment in research and development yields less of a return in innovation, which is reflected in recent increases in me-too drugs. It’s worth considering whether some of what American patients and the government spend on prescription drugs could be used more efficiently elsewhere, like on education, infrastructure, or other priorities.

    As Frank and Ginsburg argue, studying how to align the profit-making incentives of drugmakers with the needs of American patients should be a priority for researchers and policymakers. One option is to look at how other countries navigate the profit-innovation tradeoff, which I will explore in my next post.

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  • The Health System We’d Have if Economists Ran Things

    The following originally appeared on The Upshot (copyright 2020, The New York Times Company). It also appeared on page B5 of the print edition on February 19, 2020.

    Imagine if American health policy were established by the consensus of health economists. What would the system look like? A survey of nearly 200 Ph.D. health economists working in the United States provides some clues.

    The survey, presented at the American Society of Health Economists conference in Washington last summer, was conducted by the health economists John Cawley of Cornell University, Michael Morrisey of Texas A&M and Kosali Simon of Indiana University.

    Whether the Affordable Care Act should be repealed has been one of the highest-profile health policy issues ever since its passage in 2010. Health economists are clear on this: They strongly reject repeal, with 89 percent opposing the idea.

    Health economists also overwhelmingly (81 percent agreement) said the A.C.A.’s individual mandate — in which people paid a fine if they chose not to be insured — was essential for its success. Without it, they said, the people who sign up would disproportionately be sicker, causing insurance to become ever more expensive. This phenomenon, also known as adverse selection, could collapse the market.

    The need for an individual mandate is consistent with both economic theory and research and seemed sensible at the time of the survey in 2018. But its necessity is less clear today. The tax cuts signed into law at the end of 2017 reduced the penalty for not having coverage to zero last year, yet marketplaces have by and large remained stable.

    popular feature of the A.C.A. is that insurers cannot raise premiums for pre-existing conditions. Health economists appear to agree with this, with 80 percent saying premiums should not be higher for those with “genetic defects” (the poll’s wording).

    But nearly 70 percent of health economists are comfortable charging people more if they engage in unhealthy behaviors that lead to higher health costs. The A.C.A. allows marketplace plans to do just that based on smoking. The idea that people should pay for the consequences of their personal choices — sin taxes, basically — has some intuitive appeal. (Another sin tax would be to increase taxes on soft drinks, an idea favored by 62 percent of health economists.)

    But disciplines other than economics view health behaviors differently. Addictions, in particular, are often viewed as diseases, not informed choices. “Adult addiction to nicotine usually stems from decisions made as a teen, which are shaped as much or more by circumstances than rational thought,” said Michael Stein, chair of the Health Law, Policy & Management Department at Boston University School of Public Health. “Charging a higher premium for a smoker is punishing someone with a disease, so why this disease?”

    Various ideas to cut costs in Medicare and Medicaid have been proposed in recent years. Health economists generally oppose those changes.

    The poll asked them if they favored converting Medicare into a program based in part on income. That would mean that full Medicare coverage would not be available to everyone upon reaching 65, but only to those whose incomes are below some cutoff. This idea is opposed by 71 percent of health economists.

    A related idea for Medicare is to convert it to a voucher-based program. This would establish a set amount the government would pay for your coverage so that you could shop for a health plan. Most health economists (61 percent) also oppose this idea. This is in step with the broader public, according to most polls over the years.

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  • Let the Kids Sleep: The Argument for Starting School Later

    A lot of people worry about whether or not they get enough sleep. While there’s no single answer to how much sleep a given individual needs, one thing we’re pretty sure about is that younger people need more of it, including teenagers. Later school start times would help make that a reality, with many associated benefits.


    This video was adapted from a column Aaron wrote for the Upshot. Links to sources can be found there.


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  • My next performance with the Mystic Brass Ensemble (March 8, 3pm)

    The theme is Viennese Post-Romanticism (Strauss, Bruckner, and Mahler). The concert will be on Sunday, March 8, 2020, 3pm at the First Baptist Church of Arlington (819 Mass. Ave., Arlington, MA). Admission is free with a $10 suggested donation.

    As always, if you come, please find me at intermission or afterwards and say hello.


    Richard Strauss

    Vienna Philharmonic Fanfare

    Feierlicher Einzug der Ritter des Johanniterordens (Solemn Procession)

    Festmusik der Stadt Wien

    Anton Bruckner​

    Cristus Factus Est

    Scherzo from Symphony No. 4

    Gustav Mahler

    Trauermarsch (Funeral March) from Symphony No. 5

    Resurrection Suite from Symphony No. 2

    The Great Call

    Primeval Light (vocal soloist: Andrea Wozniak, soprano)


    Now the Sun Wants to Rise as Brightly from Kindertotenlieder

    Finale “What Love Tells Me” from Symphony No. 3


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  • Different Ways the New Coronavirus Might Play Out

    We’re still firmly on the “Don’t Panic” message with the new Coronavirus outbreak. This week we’re going to look at a couple of scenarios for how this thing could play out.



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