Johns Hopkins, William Osler, and the Founding of Modern American Medicine

Johns Hopkins (1795–1873) was a Maryland-born Quaker from a business family. He got early into the wholesaling business, moving manufactured goods to farm country in western Maryland and Virginia and buying the products of those regions in return. He built up enough capital to be an early investor in the Baltimore & Ohio Railroad, serving for a while as its Treasurer, and ran a bank that invested in manufacturing companies. By 1847 he had retired.

Then he did something quite remarkable. He bought thirteen acres of land east of Baltimore and set aside his whole fortune of about $7 million to found three new institutions: "Johns Hopkins University", "The Johns Hopkins Hospital", and "Johns Hopkins Colored Orphan Asylum." At the time this was the largest charitable bequest in US history. Never one to leave things to chance, Hopkins recruited twelve prominent Maryland men to serve as trustees of the new institutions and wrote detailed instructions for them to follow.

For our purposes the most important instructions governed the hospital. It should "in construction and arrangement, compare favorably with any other institution of like character in this country or in Europe." The trustees should "secure for the service of the Hospital, physicians and surgeons of the highest character and greatest skill." And they should "bear constantly in mind that it is my wish and purpose that the hospital shall ultimately form a part of the Medical School of that university for which I have made ample provision in my will."

And thus was born the modern teaching hospital. I can't find out much about the trustees, but they must have been capable fellows, because they brought Hopkins' vision to life. They recruited those top surgeons by the simple expedient of offering the highest salaries ever paid to doctors, anywhere. One of those who accepted was Canadian physician William Osler (1849-1919).

Osler was another remarkable man, one of the generation of doctors who turned medicine from a mishmash of quackery, Galenism, folk wisdom, and surgical speed into a scientific discipline. He was also, apparently, a great teacher, a man who could take something everyone sort of knew and express it in an unforgettable phrase. Like, "Listen to your patient, he is telling you the diagnosis."

Before this time, medical school consisted almost entirely of lectures and demonstrations. But Osler thought a more practical approach was needed, and he created one:

Osler, the first chief of the Department of Medicine, is credited with originating the idea of a residency, in which recently graduated physicians receive advanced training in their specialty while treating patients under supervision; then, as now, residents comprise most of the medical staff of the hospital. He also introduced the idea of bringing medical students into actual patient care early in their training; at the time medical school consisted almost entirely of lectures. Osler's contribution to practical education extends to the creation of "grand rounds", the practice of leading physicians discussing the most difficult cases in front of assembled medical students, for the benefit of patients and students. The term "rounds" derives from the circular ward where bedside teaching occurred. He once said he hoped his tombstone would say only, "He brought medical students into the wards for bedside teaching."

That last seems to have been one of his favorite lines, since it exists in several slightly different versions of different dates. And since I just witnessed my own doctors bringing students or "fellows" with them on their own rounds, I can confirm that it remains central to the teaching experience of Hopkins. (Sadly I never got to be the subject of discussion; I think I was too boring and simple a case. But the unfortunate person in the shadowed ICU room two doors down got at least two long discussions that I witnessed.)

Johns Hopkins went on to be one of the great institutions of modern medicine, launching whole branches of surgery and being the first place in the Americas to train female doctors, This, you know, is the thing that distinguishes the modern world from all that came before. In our day a man can get filthy rich in business and decide to invest his profits in creating an entirely new class of institution to solve a problem that past ages regarded as just an inevitable part of life.

I believe in a dynamic world where we try to make things better, not a bitter one in which everyone idiotically moans on about how much better things were in the old days. So I celebrate men like Johns Hopkins and William Osler who glimpsed the future and worked in concrete ways to make it real.

Heart Surgery, or, We Live in a Future Utopia

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Well, that was something.

On Friday I arrived at Johns Hopkins hospital in Baltimore at 5 AM and made my way in. By 7:30 I was on the operating table, and by 1:30 I was the proud owner of a new aortic valve and a repaired aorta.

The first 36 hours after surgery were basically torture, the next 36 utter misery. I remember thinking at some point that if I were presented with this choice again I might just buy a gun and end it. I hurt all over, I felt nauseated, I had to contemplate the 11 separate lines, tubes, and wires sprouting from my body, all of which had to be removed over the next few days, each one an experience. Sleep came at me like waves on a beach, dragging me under and then leaving me stranded on wakeful shores at 2 AM or 4 AM. It sucked.

After that improvement was remarkably fast, and by Tuesday I was bored and longing to go home.

I did have some medical hiccoughs. My blood pressure spiked a couple of times, and one night my heart kept going into atrial fibrillation. But it nothing the team at Hopkins couldn't handle using the vast armada of powerful drugs that have at their fingertips.

By dinner time Thursday I was home. I am still profoundly weak and looking at a months-long healing process, but I am home, and safe, and ready to write.

And I think, what an incredible miracle. What an age of wonders I live in, what a thousand-times blessed life I lead, and what is wrong with humanity that even this cornucopia cannot satisfy us?

I am no kind of special person, just a middle class, middle manager with a regular suburban house and ordinary American health insurance. But when my heart was failing I was whisked away to a temple of science where I received a level of care that did not exist 20 years ago.

Think what a miracle a place like Johns Hopkins is, thousands of people of every ethnicity coming together from across the globe to care for other humans. My doctors had names like Aziz, Shibaz, Ta Jung, and Richardson. My nurses were born on three continents. Not long ago a hospital was a monument to gender roles, but now no one bats an eye at a male nurse and doctors will soon be majority female. Everyone I saw was polite, friendly, efficient and, I think, devoted to helping me. 

All of this is only possible because of things about our world that millions of us hate. I see complaints every day from people who hate capitalism because it forces us to work, but if nobody worked, who would have cared for me? (All of you miserable young folks out there, think about becoming a nurse; it's just a two-year degree and if you are smart and unsqueamish you can earn $100,000 a year actually helping other people.) People complain about competition, but it is competition between scientists, surgeons, and medical companies that has produced all these wonders. People complain about inequality, but I don't begrudge my surgical team what they earn; I know the level of effort and ambition it takes to become a heart surgeon at a place like Hopkins, and if paying them a lot gets the top people to pursue those jobs, why not? Yes, our world is unequal, but as I just wrote, that means an ordinary man like me can get surgical care past kings and emperors could not dream of. Is that not a powerful kind of democracy?

All the things we are really good at, from heart surgery to video games to pop music, are that way because those fields are savagely competitive. Because people work at them from a combination of personal ambition, a desire to get rich, and a desire to be where the action is. That means many people fail. So? Is there some system in which we all get to do what we want that doesn't end up a wallow of mediocrity?

The model of a better world is right in front of us, in hospitals like Johns Hopkins. The key is to focus, not on who people are, but on what they can do.

And now to get on with the rest of my life.

My Terrible, Horrible, No Good, Very Bad Year

In February, my wife Lisa died after 34 years of marriage.

And now in September I am facing open heart surgery for aortic valve replacement. I go in tomorrow, September 4.

These things compound, because my wife was a nurse who was always wonderful at taking care of her family when we were sick, and to be facing this without her at my side feels cruel and wrong. I have been missing her lately with the same brutally painful intensity I felt in the weeks after her death.

The causes are also mixed up together. My wife slipped into renewed drug addiction before my eyes, but I did not notice because I was depressed myself and, I think, ignored plain evidence because I did not have the strength to deal with the consequences of calling her out. My doctor first detected my heart murmur two years ago and suggested I see a cardiologist, but I did nothing. Partly this was because I felt fine – still feel mostly, fine, actually – and partly because I did not want to deal with it. If I had gone to a cardiologist two years ago I would have gone into surgery with Lisa at my side, and maybe that would have given her a reason to go on living at least a little longer.

But I did nothing, and now I face surgery and recovery without Lisa, wondering if the kind of life I can have without her is worth the effort and suffering of going through this.

There is one possible bright side, which is that I have had this problem all my life. I was born with a bicuspid (two flaps instead of the usual three) aortic valve, and this may have limited me physically. As the valve grew more stenotic (=calcified), a process that takes years, it may have limited blood flow in ways that messed with my brain. Some people who have had this surgery report feeling healthier afterwards than they have in decades.

Maybe I will be one of them. But I fear the regrets that haunt me will keep the remainder of my life from ever having the depth and breadth of joy that I knew in my good years with Lisa.

Still, there is this, from Wendell Berry:

It may be that when we no longer know what to do,
we have come to our real work,
and when we no longer know which way to go,
we have come to our real journey.

Odds are that I will be back in about two weeks. Thanks to all of you who have supported me and enjoyed my work, and to my many friends. I hope to hear from you again soon.

mRNA is the Future of Medicine

Moderna's cancer vaccine reminds us of the vast potential of mRNA medicine:

An experimental mRNA vaccine allowed people with high-risk melanoma to live longer, cancer-free, the pharmaceutical companies Moderna and Merck announced Wednesday.

For decades, cancer vaccines have been one of the most tantalizing ideas in cancer treatment — offering the hope of harnessing a person’s own immune system to attack tumors. . . .

The mRNA technology that was instrumental in the rapid vaccine development in the Covid-19 pandemic added a new element of speed and flexibility to the quest for therapeutic cancer vaccines. Scientists can use the mRNA platform to create bespoke, individualized vaccines matched to the genetics of patients’ tumors.

Which makes the flaky, MAHA opposition to mRNA technology the absolute worst part of our contemporary politics. I have talked to people who are freaked out that this technology "changes your genetic code," which is completely wrong. It avoids messing with your genetic code by injecting pre-made mRNA molecules; your cellular DNA doesn't have to be involved. Summary here.

When a movement opposes the most exciting medical breakthrough in decades, you know that it is based mainly on ignorance and fear.

Why Young People Report So Much Mental Illness

Via Marginal Revolution:

Christoph Henking and Ben Baumberg Geiger found that while there has been a steep rise in the share of young Britons reporting a mental illness, the share of people who say a mental health problem limits their day-to-day functioning has barely budged.

…when asked if they would consider someone experiencing typical fluctuations in mood (described as broad happiness but occasional moments of worry, frustration or loss of confidence) as having a mental illness, more than half of young Americans say yes, up from just a fifth 15 years ago. Older people’s views show no such change. 

Things Look Different When the Responsibility is Yours

NY Times:

Trump administration officials, confronted by overlapping outbreaks of Ebola and the hantavirus, have taken a more aggressive approach to locking down potentially exposed people than in past outbreaks, surprising many public health experts.

The instructions from President Trump’s top health appointees, some of whom were vocal opponents of Covid-era public health restrictions, go well beyond tactics that were used to successfully contain previous outbreaks of the diseases.

They include instructing more than a dozen people to remain in home confinement with twice-daily checks; quarantining 18 passengers from a hantavirus-infected cruise ship at a federal facility in Nebraska for 21 days; and keeping American doctors exposed to Ebola at foreign hospitals, rather than repatriating them to specially designed U.S. treatment centers.

Notice that these outbreaks began in very different populations. You could chalk up the fear of Ebola to racism and disgust at the Third World, but not hantavirus on a cruise ship.

The State of Life Extension

Via Cremieux on Twitter/X:

The only rigorously proven things you can do for life extension right now are:

• Don't be fat
• Be fit
• Control your blood sugar
• Control your blood pressure
• Have low cholesterol
• Don't poison yourself

Almost everything else is speculative and dubious.

Most Penicillin Allergies are Fake

Just learned about this 2020 paper at PubMed:

Many patients report allergies to penicillin, although in over 90% of these the label of penicillin allergy is shown to be incorrect following comprehensive testing. Inappropriate and inaccurate penicillin allergy labelling is a barrier to antimicrobial stewardship and can lead to patient harm. This review assesses an emergent evidence base and trend favouring delabelling using direct oral penicillin challenges following a stratified risk assessment of the likelihood and existence of true penicillin allergy, to identify and make recommendations for key components for implementation in standard practice.  

Do Doctors Get Rich Off Vaccines?

Jess Steier, Elana Pearl Ben-Joseph, Jen Covich Bordenick, and David Higgins: 

Recently, the Texas attorney general launched a formal investigation into what he called “unlawful financial incentives” for childhood vaccines, saying that he would “ensure that Big Pharma and Big Insurance don’t bribe medical providers to pressure parents to jab their kids.”

The timing was uncanny. The four of us had just completed a six-month investigation into this exact question: Do pediatricians get rich from vaccines? 

Our answer, after analyzing available commercial reimbursement data from four major insurers across all 50 states, reviewing state Medicaid fee schedules, and interviewing pediatricians about the financial realities of vaccine delivery: no. . . .

The economics vary dramatically depending on where you practice and who you serve. In Colorado, commercial insurers pay a median of $42 for vaccine administration; Medicaid pays $21. In Mississippi, commercial rates hover around $22, while Medicaid pays just $11.68, well below what it actually costs to store and administer a vaccine.

That's why many doctors have stopped giving vaccines to adults; because it costs so much to store and administer vaccines that they lose money. Like most Americans I get all my vaccines at the pharmacy, because the volume of shots they give greatly reduces their storage costs, and they have lower overhead than physicians' offices.

The big numbers being thrown around about payments for giving vaccines relate to insurance company "quality programs," some of which do indeed pay doctors for giving vaccines. That's because they reward doctors for doing things that limit future costs to insurers, and giving people vaccines has enormous payoff in terms of reducing future hospitalizations etc. But those are broad programs that pay related to all sorts of metrics, of which giving vaccines is only one. And, remember, insurance companies do this because these programs reduce their costs in the long run.

Another point about the bogus numbers is that the people spreading them seem to think that the whole amount paid to the practice is income to the doctor, which is of course not true; again, many doctors actually lose money giving childhood vaccines, especially with Medicaid patients. They do it anyway because they know how important it is.

Does Politics Matter, Vaccine Edition

Sometimes it seems that politics has no impact, and people just go on believing what they believe and doing what they want regardless of what their "leaders" say. For example, study after study has found that pro-natal government campaigns have very little impact on fertility. Which makes this case particularly dramatic.

I have to think that millions of people have always hated and feared injections –with what does Darth Vader threaten Princess Leia? – and RFK pseudoscience has given them an excuse to indulge those fears.

Data is from Gallup.

Molon Labe

Via Matt Yglesias

More Researcher Trouble at Harvard

Sad to say, the evidence the Trump administration is using to blame autism on Tylenol comes from a Harvard dean. The Crimson:

Harvard School of Public Health Dean Andrea A. Baccarelli received at least $150,000 to testify against Tylenol’s manufacturer in 2023 — two years before he published research used by the Trump administration to link the drug to autism, a connection experts say is tenuous at best.

Baccarelli served as an expert witness on behalf of parents and guardians of children suing Johnson & Johnson, the manufacturer of Tylenol at the time. U.S. District Court Judge Denise L. Cote dismissed the case last year due to a lack of scientific evidence, throwing out Baccarelli’s testimony in the process.

“He cherry-picked and misrepresented study results and refused to acknowledge the role of genetics in the etiology” of autism spectrum disorder or ADHD, Cote wrote in her decision, which the plaintiffs have since appealed.

Something about autism seems to make a lot of people crazy. 

Autism is really weird, and I get why a strange condition that destroys young minds in a largely random way freaks people out. But we absolutely do not know what causes it or even what it is, so at present all claims about causes are just sound and fury.

On Medical Research Gone Wrong

At the NY Times, Ari Schulman on Jay Bhattacharya, the new head of the NIH. Bhattacharya got the job because he was a strident critic of Covid lockdowns, but he is a real scientist with an agenda:

Take Alzheimer’s research. Nearly every scientific research reformer will cite the fact that the N.I.H. funded vast amounts of research based on a single theory of the disease that largely turned out to be wrong.

Dr. Bhattacharya argues that this happened because science is structured around authority. “You have, in field after field after field, a kind of set of dogmatic ideas held by the people who are at the top of the field. And if you don’t share those ideas, you have no chance of advancing within those fields,” he told me.

He told Congress that he believes there are promising ways to prevent Alzheimer’s that haven’t received support because they don’t align with the “dominant narrative,” as he called it. “This is why I’m so interested in replication,” he told me, referring to the need for researchers to repeat each other’s findings, because it “turns over the determination of what’s true to nature rather than authority.”

Which is interesting, and perhaps explains why MAGA types like Bhattacharya. But it is, I think, far from sufficient to understand the problems with our scientific establishment. Schulman agrees:

It’s a plausible diagnosis and a good prescription. Science can’t answer questions if it’s conformist. But there’s another way to think about the problem.

Dr. Susan M. Fitzpatrick, a former biochemist, has pointed not to ideology but the mechanics of research. Large-scale medical studies rely on standardized methods, one of which is testing theories on mice. But mice don’t get Alzheimer’s, only humans do. So studying them might be useless. Yet, she wrote, this approach “dominates federal funding and academic science” on Alzheimer’s research because it easily produces the publications and citations that careers depend on.

From this angle, the N.I.H. looks like a big factory that churns out research papers. Dr. Bhattacharya is like a new manager trying to figure out why sales are down and proposing more diversity in the product line.

For the sharpest reformers, like Dr. Cook-Deegan and Dr. Fitzpatrick, the issue isn’t which group of scientists’ ideas win out. It’s that when countless jobs and storied institutions depend on the mills to keep churning, it stops mattering what comes out on the other end. The question is not whether the factory’s settings are wrong but whether it should be a paper factory in the first place.

Here is the fundamental point that science reformers keep screaming about: the system can't be reformed until we have some other way, besides publication counts, of  judging researchers and research. Since nobody has any idea what that might be, real reform seems unlikely.

There seem to be whole fields of research that exist mainly because scientists can publish about them and thus keep their jobs. But what else are scientists supposed to do? They, like everybody else, want to keep their jobs. Many of them would probably rather do weird, cutting-edge stuff that will most likely fail; others would rather switch to a completely different area of science, but our system makes that extremely difficult.

In his conclusion, Schulman comes back to the weirdness of Bhattacharya talking scientific reform in a department headed by RFK, in an adminstration headed by Trump. True, those are big hurdles, but until we have a workable model for reforming science it almost doesn't matter who the president is.

The Cato Institute Trashes the MAHA Report

Loving this:

Again? Make America Healthy Again? It’s an odd slogan in a country that has long ranked last in health outcomes among its peers. If the United States were merged with Canada, Greenland, and Panama, our average health statistics would improve overnight. Consider, for example, the pellagra epidemic that began at the start of the 20th century and lasted into the 1940s.

Between 1900 and 1940, some three million US citizens developed pellagra, of whom 100,000 died—this when pellagra was rare outside the home of the brave and the land of the free. Pellagra is a debilitating disease known for the four Ds (diarrhea, dermatitis, dementia, and death). Pellagra’s prevalence was disproportionately high in the Jim Crow South, where systemic racial injustice shaped both diet and disease.

Its cause was discovered by an immigrant, Dr. Joseph Goldberger, a graduate of New York University. While working for the precursor body of the National Institutes of Health (NIH), he demonstrated that pellagra was a disease of malnutrition. Pellagra is a vitamin deficiency that occurs in people who eat little but industrially milled corn. Indeed, it’s hard to acquire pellagra because the key vitamin [Niacin] is found in practically all foods except industrially milled corn.

Dr Goldberger made his key observations at the Georgia State Sanatorium, a mental asylum where pellagra was rampant. For his experiment, Goldberger fed a group of patients a balanced diet of, you know, meat and vegetables and stuff. Whereupon their pellagra was cured. Once the experiment was complete, the fiscally responsible burghers of the peach state promptly returned the subjects to their former diet of industrially milled corn and industrially milled corn alone. And their pellagra promptly returned. . . .

Happily, the Commission already knows why US children are uniquely unhealthy. By a strange coincidence, these reasons happen to be the ones the Commission’s chairman, one Robert F. Kennedy Jr., has been trumpeting for years. They include US children’s consumption of ultra-processed food, their use of smartphones, the chemicals in their environment, their lack of exercise, their stress levels, their lack of sleep, and their overmedicalization, especially with those pesky vaccines.

Oddly, however, the data in the report bears little relationship to its conclusions. For example, the first sentence of the introduction reads: “Despite outspending peer nations by more than double per capita on healthcare, the United States ranks last in life expectancy among high-income countries—and suffers higher rates of obesity, heart disease, and diabetes.” But the graph the Commission supplies shows that, dating back to 1970, the US has always ranked last in life expectancy among comparator nations. Were Americans back in 1970 dying sooner than Canadians, Europeans, or the Japanese because of ultra-processed food, smartphones, chemicals, a lack of exercise, stress levels, a lack of sleep, and overmedicalization? Probably not.

The reason for the US’s poor medical performance lies in the culture that gave us pellagra, which includes the nation’s unusually high level of social inequality for a rich country, regulatory barriers to access to health care, its extraordinarily high levels of road traffic deaths (which are today seven times higher in the US than in Sweden), its unusually high levels of gun deaths (which are today 340 times higher in the US than the UK for example), its extraordinarily high incarceration rate (prisoners may die from natural causes 20 years earlier than the general population), and other obvious social factors—which is why Mississippi has a life expectancy 8 years lower than states like Hawaii or Washington.

It's Hard to Treat Back Pain

NY Times:

Low back pain affects an estimated one in four American adults and is the leading contributor to disability globally. In most diagnosed cases, the pain is considered “nonspecific,” meaning it doesn’t have a clear cause. That’s also partly what makes it so hard to treat.

In the study, published on Tuesday in the journal BMJ Evidence-Based Medicine, researchers reviewed 301 randomized trials that compared 56 noninvasive treatments for low back pain, like medications and exercise, with placebos. They used a statistical method to combine the results of those studies and draw conclusions, a process known as a meta-analysis.

The researchers found that only one treatment — the use of nonsteroidal anti-inflammatory drugs, or NSAIDs, like ibuprofen and aspirin — was effective at reducing short-term, or acute, low back pain. Five other treatments had good enough evidence to be considered effective at reducing chronic low back pain. These were exercise; spinal manipulation, like you might receive from a chiropractor; taping the lower back; antidepressants; and the application of a cream that creates a warming sensation. Even so, the benefit was small.

But remember that this is a meta-study that lumps dozens of studies together to come to a global conclusion. Some of those individual studies have found that particularly interventions, like heat or exercise, work very well for some patients, but effects like that would be washed out in a big meta-study. The best advice is probably to try all the different options and try to find one that works for you; a doctor cited by the Times says you might as well try things like heat, which is cheap and causes no harm, or exercise, which is good for you even if it doesn't help your back pain. After all, they seem to help some people quite a bit.

It doesn't look like this study even considered the evidence that back pain is related to psychological issues and life stresses. Yet one of the things we are most certain about is that people who have recently gotten divorced or lost a job suffer more back pain than those with less stressful lives. That might not seem like a very useful piece of information – like, gee, sorry we can't help you, it's just that your whole life is messed up – but I find that awareness of how stress or other life factors are impacting my body helps me move to a better plane.

Chemicals in Food

As you have probably heard, RFK Jr. wants to ban a range of chemical food additives, starting with petroleum-based dyes. Ok, whatever, we can live without bright orange Cheetohs. But I was very disturbed by this Julia Belluz piece in the NY Times. Here is the red flag:

Research on chemicals that have been vetted by the F.D.A. tends to be extremely narrow in focus, looking mostly for cancer, genetic mutations or organ damage in animal or laboratory studies. This means the ingredients in our coffee creamer, cereal, ketchup and frozen pizza aren’t tested for more subtle effects on long-term health, or whether they may increase the risk of the other common chronic diseases, such as obesity, cardiovascular disease and Type 2 diabetes. What’s more, most safety studies examine single chemicals in isolation, not how the hundreds or thousands of chemicals we consume might interact with one another or affect our long-term health.

How, even in principle, would you study how hundreds or thousands of chemicals consumed in various combinations might impact our health? I submit that this is completely impossible. But don't take my word for it, go read John Ioannidis's magnificent article (summary here) on dietary research:

Individuals consume thousands of chemicals in millions of possible daily combinations. For instance, there are more than 250 000 different foods and even more potentially edible items, with 300 000 edible plants alone. Seemingly similar foods vary in exact chemical signatures (eg, more than 500 different polyphenols). Much of the literature silently assumes disease risk is modulated by the most abundant substances; for example, carbohydrates or fats. However, relatively uncommon chemicals within food, circumstantial contaminants, serendipitous toxicants, or components that appear only under specific conditions or food preparation methods (eg, red meat cooking) may be influential. Risk-conferring nutritional combinations may vary by an individual’s genetic background, metabolic profile, age, or environmental exposures. Disentangling the potential influence on health outcomes of a single dietary component from these other variables is challenging, if not impossible.

The mistake that both Belluz and Kennedy make is assuming that if our food is making us sick, the problem must be some nefarious modern chemical. But why assume that? We live much longer than our ancestors, which means that 1) we are exposed to potential natural hazards for decades longer, so whatever dangers those compounds present will show up much more often in our world, and 2) whatever dangers modern food presents, it doesn't keep us from leading long, healthy lives.

So far as I can see, the biggest dangers in the modern diet are fat and sugar, which are both perfectly natural. The reasons we eat too much are complicated, and the advertising and product optimization of big food companies probably play a role. But mainly we do it because we like it. Giving up things that make you feed good is just hard, especially if you feel that your life doesn't offer enough other pleasures. The notion that this can be fixed by tinkering with chemical food additives strikes me as absurd.

Meanwhile in MAGAland

News from St. Paul:

A group of eight Republicans in the Minnesota House have introduced legislation (HF3219) that would designate certain vaccines and medical treatments as “weapons of mass destruction” and make possessing or administering them a crime punishable by up to 20 years in prison.

The legislation specifically targets messenger RNA (mRNA) treatments, which include several COVID-19 vaccines. Those vaccines have saved millions of lives and are considered one of the most important medical and public health achievements of the 21st century so far.

The bill’s language appears to have been drafted by Joseph Sansone, a Florida hypnotist and conspiracy theorist who believes that mRNA treatments are “nanoparticle injections” that amount to “biological and technological weapons of mass destruction.”

Sansone has falsely claimed that “more Americans have died from mRNA injections than in WWI, WWII, and the Vietnam War combined,” and has said he has stood “alongside an Army of the Dead” to file unsuccessful legal complaints against vaccines in Florida.

The bill has no chance of passage given the narrow margins in the House and Senate, as well as the DFL’s control of the governorship. But its support among multiple Republican representatives, including several members of GOP House leadership, give a sense of how the party would govern if it controlled the state legislature.

Bad as it is, it could get worse.

The RFK Regime is Censoring Researchers Who Agree with Their Agenda

Kevin Hall:

After 21 years at my dream job, I’m very sad to announce my early retirement from the National Institutes of Health. My life’s work has been to scientifically study how our food environment affects what we eat, and how what we eat affects our physiology. Lately, I’ve focused on unravelling the reasons why diets high in ultra-processed food are linked to epidemic proportions of chronic diseases such as diabetes and obesity. Our research leads the world on this topic.

Given recent bipartisan goals to prevent diet-related chronic diseases, and new agency leadership professing to prioritize scientific investigation of ultra-processed foods, I had hoped to expand our research program with ambitious plans to more rapidly and efficiently determine how our food is likely making Americans chronically sick.

Unfortunately, recent events have made me question whether NIH continues to be a place where I can freely conduct unbiased science. Specifically, I experienced censorship in the reporting of our research because of agency concerns that it did not appear to fully support preconceived narratives of my agency’s leadership about ultra-processed food addiction.

I was hoping this was an aberration. So, weeks ago I wrote to my agency’s leadership expressing my concerns and requested time to discuss these issues, but I never received a response. Without any reassurance there wouldn’t be continued censorship or meddling in our research, I felt compelled to accept early retirement to preserve health insurance for my family. (Resigning later in protest of any future meddling or censorship would result in losing that benefit.) Due to very tight deadlines to make this decision, I don’t yet have plans for my future career.

The Ongoing Mystery of ADHD and its Treatment

Good NY Times piece today by Paul Tough on the controversy surrouding ADHD and its treatment with stimulants. It begins with James Swanson, one of the early experts on the problem and one of the first to experiment with giving stimulants to patients. In the mid 1990s, he was part of a major, NIH-funded study:

Swanson was in charge of the site in Orange County, Calif. He recruited and selected about 100 children with A.D.H.D. symptoms, all from 7 to 9 years old. They were divided into treatment groups — some were given regular doses of Ritalin, some were given high-quality behavioral training, some were given a combination and the remainder, a comparison group, were left alone to figure out their own treatment. The same thing happened at five other sites across the continent. Known as the Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study, or M.T.A., it was one of the largest studies ever undertaken of the long-term effects of any psychiatric medication.

The initial results of the M.T.A. study, published in 1999, underscored the case for stimulant medication. After 14 months of treatment, the children who took Ritalin every day had significantly fewer symptoms than the ones who received only behavioral training. Word went out to clinics and pediatricians’ offices around the country: Ritalin worked. . . .

Though Swanson had welcomed that initial increase in the diagnosis rate, he expected it to plateau at 3 percent. Instead, it kept rising, hitting 5.5 percent of American children in 1997, then 6.6 percent in 2000. As time passed, Swanson began to grow uneasy. He and his colleagues were continuing to follow the almost 600 children in the M.T.A. study, and by the mid-2000s, they realized that the new data they were collecting was telling a different — and less hopeful — story than the one they initially reported. It was still true that after 14 months of treatment, the children taking Ritalin behaved better than those in the other groups. But by 36 months, that advantage had faded completely, and children in every group, including the comparison group, displayed exactly the same level of symptoms. Swanson is now 80 and close to the end of his career, and when he talks about his life’s work, he sounds troubled — not just about the M.T.A. results but about the state of the A.D.H.D. field in general. “There are things about the way we do this work,” he told me, “that just are definitely wrong.”

This exactly matches our experience in this house. Our eldest son is a classic ADHD case – and since we have two other sons, we know the difference between that and normal boyishness. We put him on Ritalin for a while, and he showed immediate changes: he did better in school, started reading books, bothered his siblings less. At first he was excited about this, but after some time – a couple of months, maybe? – he started to complain that he didn't like the way the meds made him feel, so we took him off them. After that we left the decision about taking them entirely up to him, and he used them on and off over the next few years, we think taking them when he got anxious about his grades. 

As I have written here many times, I think the human quest for drugs that change how we feel is ancient and unending, and that this says something important about how evolution has shaped us. It presumably also says something important about our society, in which the ability to sit still and concentrate on demanding work is very highly valued. So in principle I see nothing wrong with drugs that help some people sit still and concentrate. But I do not think we really understand what we are doing, or what the long-term consequences might be. So I very much appreciated this, from British neuroscientist Edmund Sonuga-Barke, who says that so far as he can tell "people with ADHD" is not a real category with definable boundaries:

I’ve invested 35 years of my life trying to identify the causes of A.D.H.D., and somehow we seem to be farther away from our goal than we were when we started. We have a clinical definition of A.D.H.D. that is increasingly unanchored from what we’re finding in our science.

Tough's piece covers many of the current controversies including whether ADHD patients should be sorted into different groups that are treated differently, whether the medications have unpleasant side effects, and whether the real answer is to let kids study what interests them. I recommend it. For me it strongly reinforced my basic assumption about all psychological issues, that you should never trust anyone who claims to have the answers.

AI Medical Diagnosis

Google has just published a paper on a major trial of their new medical diagnosis AI, which they call AIME. As the graph above shows, AIME scored significantly better than primary care physicians on pretty much every metric. (This google blog post is the best summary)

This is not especially surprising; one of AI's most famous early achievements was getting very good at predicting the 5-year survival chances for heart disease patients. One analysis I read of that study said that maybe AI did better because it was focused only on quantifiable data, whereas the human physicians were distracted by other factors. Anyway, results like this have been around for twenty years.

In the current study, the investigators took a standard LLM and trained it using transcripts of recorded doctor-patient conversations. But just as chess programs learn by playing against themselves, AIME honed its skills via "a novel self-play based simulated diagnostic dialogue environment with automated feedback mechanisms to enrich and accelerate its learning process." That is, the AI simulated both the doctor and the patient, holding thousands of conversations with itself.

The investigators then had a bunch of physicians hold conversations with patients via texting, with no face-to-face interactions, while AIME had similar conversations with other patients. The physicians and AIME both then issued diagnoses. Both the conversations and the diagnoses were then evaluated by "specialist physicians" who scored them for quality and accuracy without knowing which were human doctors and which were AIs.

Two things to note about this are that 1) the physicians did not have face-to-face interactions with the patients, which at least some doctors think makes a big difference (which is why telemedicine is controversial), and 2) the scoring was still done by humans. Since we have other data (from the cardiology studies) showing that in some cases AI can be better than any human, that is a limitation on the accuracy of the whole study.

In another note, some people think the future will be doctors using AI assistants, but Google has data showing the AIME is more accurate than a doctors/AI combo.

Google tries to soften the blow by saying this is all about supplying medical expertise in parts of the world where doctors are in short supply, but I think this points to a vast array of professions in which AI already is or soon will be better than people.

I, for one, would be happy to see investment bankers be entirely replaced by machines.