Physiology and Politics

Olivia Judson blogged yesterday (10/21/2008) on her NYT blog about a potential link between obesity and political attitudes. While most students and observers of politics would immediately think of a story involving health care policy (e.g. "Obese people need more expensive medical care for related chronic diseases and therefore would support candidates who lower the cost of care and increase access"), or underlying determinants of both obesity and attitudes (e.g. "If obesity is related to low income, education or being a minority, then it is desire for higher taxes, more education spending and expansion of minority rights that drives political attitudes, not obesity."). But Dr. Judson has something else in mind. Her question is: "Could the obesity epidemic have a political impact? In particular, could obesity in a pregnant woman influence the eventual political outlook of her child?" Namely, can physiology (and especially endocrinology of early development) explain political preferences? Her article is available here.

The controversy stirred up by Dr. Judson is based on evidence published last month by a team of political scientists led by Oxley at U Nebraska-Lincoln and Kevin Smith at Rice. In a small-sample experimental study of voters with "strong" political attitudes, they found out that right-wing political orientations (e.g. support for defense spending, war in Iraq, capital punishment, wire-tapping) were associated with heightened physiological responses to sudden noises and threatening visual images. The team's article, published in the journal Science, is tittled "Political Attitudes Vary with Physiological Traits," and was published by Science. Here is the abstract provided free by the journal:

Although political views have been thought to arise largely from individuals' experiences, recent research suggests that they may have a biological basis. We present evidence that variations in political attitudes correlate with physiological traits. In a group of 46 adult participants with strong political beliefs, individuals with measurably lower physical sensitivities to sudden noises and threatening visual images were more likely to support foreign aid, liberal immigration policies, pacifism, and gun control, whereas individuals displaying measurably higher physiological reactions to those same stimuli were more likely to favor defense spending, capital punishment, patriotism, and the Iraq War. Thus, the degree to which individuals are physiologically responsive to threat appears to indicate the degree to which they advocate policies that protect the existing social structure from both external (outgroup) and internal (norm-violator) threats.

Politics kills! A new study on traffic fatalities on the election day

A brilliant research report published in the Oct 2 issue of JAMA found that driving fatalities increase significantly on the election day in the US. Redelmeier from U of Toronto and Robert Tibshirani from Stanford found that the hazard of being hurt or dying in a traffic accident rises on the day of the Presidential election. While the effect seems to be bipartisan (or non-partisan?), the risk is higher for men, for those in the Northeast, and for those who vote early in the day. To my knowledge, this is the best systematic evidence that shows the dark side of political participation in the US; despite all the benefits and necessities of active participation to keep democracy alive, there also seem to be significant costs. Remember to vote, but be careful when driving or crossing the street this election season! The article was covered by Reuters and the New York Times here. The original research report is available from JAMA here and is titled "Driving Fatalities on US Presidential Election Days." Here is the free excerpt from JAMA:

The results of US presidential elections have large effects on public health by their influence on health policy, the economy, and diverse political decisions. We are unaware of studies testing whether the US presidential electoral process itself has a direct effect on public health. We hypothesized that mobilizing approximately 50% to 55% of the population, along with US reliance on motor vehicle travel, might result in an increased number of fatal motor vehicle crashes during US presidential elections.

Decline in Inequality? In the US?

There is finally some evidence that inequality in the US is declining! No, it's not income inequality, but instead inequality in the distribution of happiness. Betsey Stevenson and Justin Wolfers from the Wharton School discovered that while Americans on average have not gotten happier since the 1970s, the dispersion in happiness has declined steadily. Their NBER working paper is available here.

Here is the abstract:
This paper examines how the level and dispersion of self-reported happiness has evolved over the period 1972-2006. While there has been no increase in aggregate happiness, inequality in happiness has fallen substantially since the 1970s. There have been large changes in the level of happiness across groups: Two-thirds of the black-white happiness gap has been eroded, and the gender happiness gap has disappeared entirely. Paralleling changes in the income distribution, differences in happiness by education have widened substantially. We develop an integrated approach to measuring inequality and decomposing changes in the distribution of happiness, finding a pervasive decline in within-group inequality during the 1970s and 1980s that was experienced by even narrowly-defined demographic groups. Around one-third of this decline has subsequently been unwound. Juxtaposing these changes with large rises in income inequality suggests an important role for non-pecuniary factors in shaping the well-being distribution.

The Politics Behind Treating Combat Veterans for Brain Injuries

Traumatic Brain Injury (TBI) has emerged to the top of the list of medical conditions that have long-term consequences on US veterans.
In another in-depth look on US veterans' health, The New York Times reported a story titled "War Veterans' Concussions Are Often Overlooked." The story documents the types of long-term health costs of the war in Iraq for American soldiers once they return home. The Pentagon estimates that as many as 300,000 combat veterans have suffered at least one concussion. Of those, tens of thousands are left with long term problems such as persistent memory loss, headaches, mood swings, dizziness, hearing problems and light sensitivity. Medically, the Army classifies these as Traumatic Brain Injury (TBI). Because of high rates of under-diagnosis, the Congress ordered the Army to follow only the Veterans' Affairs new set of diagnostic tools that tend to give veterans more disability pay. The Department of Defense invested $300 million into TBI research through the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. The very diagnosis and treatment of TBI has become an economic and public policy issue, with significant distributive effects for veterans.

Very little is known scientifically about mild traumatic brain injuries and their long-term effects, and research on the effects of combat have emerged only recently. The same New York Times article reported on Charles W. Hodge's research at the Walter Reed Army Institute. Published in the New England Journal of Medicine, and available here, the research quantified the prevalence of TBI symptoms in soldiers returning from Iraq and Afghanistan. Importantly, only 23-40 percent of those with symptoms sought any kind of mental health care. The study was also the first to find that TBI, especially when patients lose consciousness as a result of a bomb blast for example, are associated with prevalence of the post-traumatic stress disorder (PTSD), suggesting a specific neurophysiologal mechanism behind PTSD in combat veterans. Here is their abstract:

Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.

Would you trust your doctors' prognosis?

Our study of doctors' prognoses showed that most doctors over-estimate their patients' chances of survival. This opens up the question of how we could improve the accuracy of prognosis and limit some of the costs patients' families and health care systems suffer when doctors make wrong prognoses. See: Alexander, M. and Christakis, N.A. "Bias and Asymmetric Loss in Expert Forecasts: A Study of Physician Prognostic Behavior with Respect to Patient Survival," Journal of Health Economics 27 (2008): 4: 1095-1108. Here is the abstract:

We study the behavioral processes undergirding physician forecasts, evaluating accuracy and systematic biases in estimates of patient survival and characterizing physicians’ loss functions when it comes to prediction. Similar to other forecasting experts, physicians face different costs depending on whether their best forecasts prove to be an overestimate or an underestimate of the true probabilities of an event. We provide the first empirical characterization of physicians’ loss functions. We find that even the physicians’ subjective belief distributions over outcomes are not well calibrated, with the loss characterized by asymmetry in favor of over-predicting patients’ survival. We show that the physicians’ bias is further increased by (1) reduction of the belief distributions to point forecasts, (2) communication of the forecast to the patient, and (3) physicians’ own past experience and reputation.

New Hampshire paper on Obama's health plan

One of the most interesting comparisons of Democrats' health plans was an editorial published by the Concord Monitor titled "Don't get sidetracked by the mandate debate." It sharply critisized the use of mandates as a substitute for offering universal health care coverage. The editorial was published a month before the New Hampshire primary, and reflects well the fact that the candidates' health care proposals may be very different in practice once implemented. Here is an excerpt:

The great health care mandate debate is a sideshow. Democratic presidential candidates Hillary Clinton and John Edwards insist that forcing individuals to buy a policy is crucial to providing universal health care or something close to it. Rival Barack Obama disagrees. A mandate may be necessary to force those who refuse to sign up once affordable options are available, he says, but that step should come at the end of the march to universal care, not at the beginning.

Doctors' empathy and cancer

A study of doctors' communication with their cancer patients found that physicians come short, on average, of listening well, and understanding, their patients' emotions. The research by Duke Medical School Professor James A. Tulsky is described in a recent feature New York Times article, "For Cancer Patients, Empathy Goes a Long Way." The study has several interesting findings, suggesting a possibility of a vicious cycle in the doctor-patient relationship. That is, physicians rarely engage their patients when they try to talk about their emotions, and the patients in turn tend to bring up their emotions surprisingly rarely. The article argues that this is relevant not only for quality of life but also for improving the odds that patients would remain compliant to their, often-long and difficult, course of therapy, with potential improvements in final treatment outcomes.

Hilary makes an emotional connection...

In addition to her performance in the NH democratic primary debate, Hilary's tearful moment on ABC displayed an emotional side. When it comes to health care policy, Hilary's main position seems to be that she is the most experienced candidate to set agenda for reform and to implement it starting from day one.

"Culture Can Change our Genes" --- What about Politics?

In an answer to what empirical evidence changed his mind, Nicholas Christakis at Harvard Medical School, wrote a penetrating essay arguing that human genes may be much more influenced by culture that most social scientists would admit. However, there is almost no systematic attempt in the social sciences to think about the question of how the human body (its physical makeup, health status and ultimately genetic expression) is shaped by the everyday political processes. If most culture and social interaction involves politics of power, to what extent could politics also govern human physical well-being, the makeup of our bodies, the physical survival of entire communities, and consequently human evolution in the long-run? You can read Christakis's essay here; its entitled, controversially, Culture Can Change our Genes. More than anything else, it poses some fascinating questions that could guide research in decades to come:

There may be genetic variants that favor survival in cities, that favor saving for retirement, that favor consumption of alcohol, or that favor a preference for complicated social networks. There may be genetic variants (based on altruistic genes that are a part of our hominid heritage) that favor living in a democratic society, others that favor living among computers, still others that favor certain kinds of visual perception (maybe we are all more myopic as a result of Medieval lens grinders). Modern cultural forms may favor some traits over others. Maybe even the more complex world we live in nowadays really is making us smarter.

Why John Edwards May Win on Health Issues

If you listen to speeches of top finishers in Iowa, both Democrat and GOP, there is little doubt that John Edwards was the only candidate to make universal health care coverage the central message of his presidential campaign. While most point to Obama and Huckabee as inspiring speech-givers, John Edwards' speech was clearly equally, if not more, inspired and passionate one on the night of the Caucuses.

Bush White House against expansion of Medicaid

In a yet another turn that continues its strategy of opposing the expansion of the State Children's Health Insurance Program, the White House took measures to prevents states from expanding their Medicaid coverage to higher-income brackets. While most of the Democratic presidential candidates agree that universal health coverage in the US is attainable and necessary, the GOP and (more importantly for currently uninsured and those who cannot afford medical bills), the White House still thinks the federal government must stall and prevent any moves towards such as system. The New York Time's Robert Pear reports on the story in U.S. Curtailing Bids to Expand Medicaid Rolls:
The Bush administration is imposing restrictions on the ability of states to expand eligibility for Medicaid, in an effort to prevent them from offering coverage to families of modest incomes who, the administration argues, may have access to private health insurance.

An amazing story behind this year's Nobel Prize

Behind this year's Nobel Prize in Medicine is a remarkable story of Mario R. Capecchi, who was born in Italy, survived the fascist regime to immigrate to the US, studied political science before moving to MIT and Harvard, and worked with the man who discovered the double helical structure of the DNA, James Watson. For academics, perhaps the most interesting part of Capecchi's story is that he left his faculty position at Harvard for the University of Utah, reportedly because of disagreements and infighting at Harvard and the atmosphere in Utah that allowed for more long-term projects instead of demanding immediate results. The article about Capecchi and the other two Nobel Prize winners in Medicine for 2007 is available from The New York Times. Here is an excerpt:

When young Mario was not yet 4, the Gestapo came to their home in Tyrol, in the Italian Alps, to take his mother to the Dachau concentration camp — an event he said he remembered vividly.

Because she knew her time of freedom was limited, she had sold all her possessions and given the proceeds to an Italian farming family, with whom Mario lived for about a year. When the money ran out, the family sent him on his way. He said he wandered south, moving from town to town as his cover was exposed. He wandered, usually alone, but sometimes in small gangs, begging and stealing, sleeping in the streets, occasionally in an orphanage.

Aging Gay in the USA

While it is not surprizing that older gay and lesbian Americans face prejudice and discrimination, it is only recently that the issue has been brought nation-wide attention as a number of social justice organizations have tried to educate the public and fight discrimination. An article in The New York Times by Jane Gross reports on the issue:

Elderly gay people like Ms. Donadello, living in nursing homes or assisted-living centers or receiving home care, increasingly report that they have been disrespected, shunned or mistreated in ways that range from hurtful to deadly, even leading some to commit suicide.

Some have seen their partners and friends insulted or isolated. Others live in fear of the day when they are dependent on strangers for the most personal care. That dread alone can be damaging, physically and emotionally, say geriatric doctors, psychiatrists and social workers.

The Health and Happiness of Nations

David Blanchflower and Andrew Oswald, two researchers at NBER, found that happiness of nations, regardless of the number of physicians or a particular choice of survey used, is associated with lower levels of hypertension. The study adds yet another interesting, yet surely to be controversial, argument for continuing to expand the field of behavioral economics to better understand economic and consequently political individual behavior. Their article is available on the NBER site, and here is the abstract:

A modern statistical literature argues that countries such as Denmark are particularly happy while nations like East Germany are not. Are such claims credible? The paper explores this by building on two ideas. The first is that psychological well-being and high blood-pressure are thought by clinicians to be inversely correlated. The second is that blood-pressure problems can be reported more objectively than mental well-being. Using data on 16 countries, the paper finds that happier nations report lower levels of hypertension. The paper's results are consistent with, and seem to offer a step towards the validation of, cross-national estimates of well-being.

Clinton unveiled the highly-anticipated health care plan: $110 billion/year

Clinton unveiled her new health-care plan in Iowa. The New York Times reported the story here. As expected, the plan builds on the successful experience of Medicare, and in addition tries to help accommodate fears of those currently receiving high-quality private insurance. The plan will offer a wide degree of choice and offer a combination of subsidies for employer-provided insurance, private insurance, and government health insurance.

Two other Democratic candidates have different health care programs as a part of their campaign platform. Barack Obama's plan focuses on requiring employees to provide insurance and on expanding insurance for those worse off. John Edwards' program is similar to Clinton's in that it focuses on giving people the choice, but in addition promises to fund the new plan by increasing taxes on those at the top of the income distribution.

Epidemiology, trials and medical knowledge

While there is an increasing attention on monitoring drugs for safety after being approved by the FDA -- including large registries to study drug use and its effects in the 'real world setting' -- it is still remarkable how much confidence we put in the present-day state of medical knowledge. An analysis piece in the New York times points to the interesting dynamic of establishing then refuting, or revising scientific knowledge that affects the medical treatment of millions of Americans. Here is an excerpt from the article by Gary Taubes:
Many explanations have been offered to make sense of the here-today-gone-tomorrow nature of medical wisdom — what we are advised with confidence one year is reversed the next — but the simplest one is that it is the natural rhythm of science. An observation leads to a hypothesis. The hypothesis (last year’s advice) is tested, and it fails this year’s test, which is always the most likely outcome in any scientific endeavor. There are, after all, an infinite number of wrong hypotheses for every right one, and so the odds are always against any particular hypothesis being true, no matter how obvious or vitally important it might seem.
You can access the New York Times article here.

How expansion of state insurance can harm some children

Gruber and his colleagues at NBER found that for every 100 children who start receiving public health insurance about 60 lose their private insurance. They write about this new form of "crowding out" in their newest paper, published as an NBER working paper. The question then arises on how advocates of expanding state insurance can ensure that families affected are compensated for this welfare loss. Here is the abstract of their new paper:
he continued interest in public insurance expansions as a means of covering the uninsured highlights the importance of estimates of "crowd-out", or the extent to which such expansions reduce private insurance coverage. Ten years ago, Cutler and Gruber (1996) suggested that such crowd-out might be quite large, but much subsequent research has questioned this conclusion. We revisit this issue by using improved data and incorporating the research approaches that have led to varying estimates. We focus in particular on the public insurance expansions of the 1996-2002 period. Our results clearly show that crowd-out is significant; the central tendency in our results is a crowd-out rate of about 60%. This finding emerges most strongly when we consider family-level measures of public insurance eligibility. We also find that recent anti-crowd-out provisions in public expansions may have had the opposite effect, lowering take-up by the uninsured faster than they lower crowd-out of private insurance.

The paper can be accessed on the NBER website here.

Bush White House vs. Children Insurance

It seems that President Bush is determined to make it more difficult for uninsured children in California and New York to get their state's help in obtaining health insurance. The New York Times reports on the story:
The Bush administration, continuing its fight to stop states from expanding the popular Children’s Health Insurance Program, has adopted new standards that would make it much more difficult for New York, California and others to extend coverage to children in middle-income families.

The politics of Medicaid funding allocation

The new expansion of health insurance for children in the US provides an excellent example of how Congressional politics influences the distribution of government funding across the US, and down to the regional and even city-wide level. Through political negotiation and bargaining, the legislators are able to funnel directed funding to specific hospitals, under the auspices of a universal legislation such as the Children's Health Insurance Program. Here is an excerpt a recent article by the New York Times describing the process in more detail:

One hospital, Bay Area Medical Center, sits on Green Bay, straddling the border between Wisconsin and the Upper Peninsula of Michigan, more than 200 miles north of Chicago. The bill would increase Medicare payments to the hospital by instructing federal officials to assume that it was in Chicago, where Medicare rates are set to cover substantially higher wages for hospital workers.
Lawmakers did not identify the hospital by name. For the purpose of Medicare, the bill said, “any hospital that is co-located in Marinette, Wis., and Menominee, Mich., is deemed to be located in Chicago.” Bay Area Medical Center is the only hospital fitting that description.

Guiliani's health plan

Yesterday, the NYT had a good feature about Guiliani's helath care plan. While it is difficult to compare the GOP and Democratic plans at this stage of the campaign, it is refreshing to see health care discussed in detail on the GOP side as well.