A crappy post

I was about to queue this up for quick hits, but then I thought, damn, as long as I’ve been fascinated by fecal transplants, this excellent NYT story deserves its own post.  Lots of good stuff here:

There’s a new war raging in health care, with hundreds of millions of dollars at stake and thousands of lives in the balance. The battle, pitting drug companies against doctors and patient advocates, is being fought over the unlikeliest of substances: human excrement.

The clash is over the future of fecal microbiota transplants, or F.M.T., a revolutionary treatment that has proved remarkably effective in treating Clostridioides difficile, a debilitating bacterial infection that strikes 500,000 Americans a year and kills 30,000.

The therapy transfers fecal matter from healthy donors into the bowels of ailing patients, restoring the beneficial works of the community of gut microbes that have been decimated by antibiotics. Scientists see potential for using these organisms to treat diseasesfrom diabetes to cancer.

At the heart of the controversy is a question of classification: Are the fecal microbiota that cure C. diff a drug, or are they more akin to organs, tissues and blood products that are transferred from the healthy to treat the sick? The answer will determine how the Food and Drug Administration regulates the procedure, how much it costs and who gets to profit. [emphases mine]

“People have good reason to worry because for many patients, fecal transplants are a matter of life and death,” said Catherine Duff, founder of the Fecal Transplant Foundation, a patients group. “The concern is that corporate greed will get in the way of patient access.”

As the F.D.A. nears a final decision, both sides are ramping up the pressure. More than 40 prominent gastroenterologists and infectious disease doctors recently wrote to the agency, urging it to rethink its approach.

Dr. Alexander Khoruts, a gastroenterologist at the University of Minnesota, said he feared the F.D.A. was favoring the interests of what he calls the “poop drug cartel,” a group of companies seeking approval for new ways to deliver the active ingredients in transplanted feces. Three of the companies, RebiotixSeres Therapeutics and Vedanta Biosciences, have raised tens of millions of dollars from investors and they recently formed an association to advance their interests with the F.D.A.

“An obscene amount of money is being thrown around by companies trying to profit off of what nature made,” said Dr. Khoruts. “I don’t think there are clear villains here, but I worry that the regulators are not caught up on the latest science and that the interests of investors may be exceeding those of patients.”

I don’t know enough to pretend I know the right way to proceed.  For example, if for-profit companies can come up with a system where you isolate the key bacteria and people can really just take it in a pill instead of an enema a slurry of another person’s feces, that’s amazing and more power (and reasonable profit) to them.  But the power for huge amounts of money at stake to corrupt the process is absolutely something to be very much concerned about.

Quick hits (part II)

1) Alex Sheppard on the meaninglessness of “socialism” in contemporary political discourse.  It’s government ownership of the means of production, damnit!

2) This visualization of global brand popularity over time is amazing.  Watch it (though, it’s too slow, worked at 2-3x for me).

3) I love that even though we now know so much about our universe, it is still utterly baffling.

4) I did feel somewhat obligated to try and understand what’s going on with India and Pakistan.  And I do know enough to know that if I’m not going to read much, Dexter Filkins is a good way to go:

Where does it end? To me, the main impediment to a final peace has always been the Pakistani military. Not only have Pakistan’s generals fuelled the insurgency, and sheltered and abetted terrorist groups such as Jaish-e-Mohammed and Lashkar-e-Taiba, but, by smothering Pakistani democracy, they have also made reconciliation between the two countries all but impossible. The Pakistani military needs an enemy in order to justify its vast budgets and regular interventions in domestic politics. In a televised address this week, Imran Khan, Pakistan’s Prime Minister (who came to power with the military’s support), appealed to India’s leaders in a way that seemed designed to break the impasse. “With the weapons you have and the weapons we have, can we afford miscalculation?” Khan asked.

5) Interview with Quinta Jurecic on takeaways from Cohen:

What takeaways did you have from the afternoon session?

What I was struck by is how careful Cohen has been in what he says Trump has and hasn’t done. The Republicans and Trump himself and his family members have really tried to push this idea of Cohen as someone who has been spurned, who’s out to get Trump, but there are plenty of questions where Democrats will ask whether Trump did such-and-such egregious thing and Cohen will actually say no. The main examples were congresswoman Jackie Speier’s questions about the National Enquirer story [which was never published] about a possible illegitimate child of Trump’s, and the rumor about Trump assaulting Melania in an elevator. And Cohen went out of his way, in both cases, to basically say he didn’t believe that they were true. I think that actually does a lot for him in terms of his credibility.

The testimony today could very well be damning politically and legally for Trump. But does the testimony make you think that more extreme versions of a Russia conspiracy are not true?

It depends how you define what constitutes an extreme theory. It’s interesting that you say that, because my reaction to reading Cohen’s prepared statement was actually the opposite. I felt, like, Oh, right, this is a reminder of how bigand how serious this is. In recent weeks, maybe because the investigation has been relatively quiet and there have been reports of it wrapping up, I felt like the mood has shifted toward wondering whether the report will be kind of a dud—that there wasn’t really collusion and there was just a disorganized effort that didn’t really come together.

The Cohen statement, on the other hand, seemed to me to be a splash of cold water. If he is telling the truth, it sounds like Trump really did know about Roger Stone’s alleged efforts to contact WikiLeaks and approved of them, and that strikes me as a lot more than a dud. It doesn’t corroborate the most explosive details of the Steele dossier—it is not the most extreme version—but it is pretty bad politically.

6) And I really liked Catherine Rampell’s very big-picture take:

There were lots of takeaways from Michael Cohen’s explosive ­congressional testimony this week: about Russia, racism, redemption.

To me, the biggest lesson was that we desperately need to increase the Internal Revenue Service’s budget.

Cohen, formerly President Trump’s personal lawyer, repeatedly offered accounts of not only how comfortable Trump became with cheating Uncle Sam but also how ill-equipped our tax cops were to catch him.

We heard, for instance, Cohen’s story about how the president used the Trump Foundation, supposedly a charitable organization, as his personal piggy bank.

According to Cohen, Trump directed him to hire a straw bidder to purchase a nine-foot painting of Trump at auction. The bidder was then reimbursed with tax-advantaged funds from the Trump Foundation. Cohen said Trump had similarly used foundation funds to buy other portraits of himself that now hang in his golf clubs, a pattern previously documented by my colleague David Fahrenthold…

Further questioning from Rep. Alexandria Ocasio-Cortez (D-N.Y.) addressed a New York Times report about the Trump family’s use of dubious or outright ­fraudulent schemes to duck taxes on Fred Trump’s estate. And, of course, Republicans hammered Cohen about ­Cohen’s owntax misdeeds; as part of his plea agreement, Cohen pleaded guilty to tax fraud. Trump has said he has “brilliantly” used the tax laws to his advantage, but has repeatedly denied any ­lawbreaking…

If true, that statement (that Trump feared an audit) would undercut Trump’s sorry excuse for not releasing his returns (that he was already under audit). But it would also reflect a grim reality: IRS enforcement activity has indeed loosened over the years, especially when it comes to the ultra-wealthy.

Since fiscal 2011, the audit rate for large corporations (with at least $10 million in assets) has halved. For households with income of more than $1 million, it has declined by two-thirds, according to IRS data.

Likewise, federal prosecutions referred by the IRS have plunged to their lowest level on record, according to data from Syracuse University’s Transactional Records Access Clearinghouse. In fact, adjusted for population size, IRS-referred prosecutions are just a quarter of their early-’90s peak…

So why has enforcement fallen? Why have people such as Trump — and Cohen, Paul Manafort and others with major red flags — been so confident their taxes won’t be scrutinized? It’s not because the “deep state” wants to go easy on well-heeled tax cheats.

It’s that our policymakers have systematically hobbled the IRS. Congress has given the agency more responsibilities while simultaneously slashing its resources. IRS staffing for key enforcement occupations has shrunk by about a third over the past six years.

That’s bad news if you care about fiscal responsibility, since the IRS brings in several dollars for every dollar it spends. It’s also bad news if you care about catching bad actors. [emphasis mine]

7) I’ve long since stopped watching baseball– too slow and boring.  Though, I was really intrigued by Nate Silver’s diagnosis of the problem (the way relief pitching is used) and proposed fix.

8) Adam Rogers argues that we know how to fix homelessness— we’re just not doing it.  Interesting take, but I think it needs to deal more thoroughly with the mental illness aspect.

9) When I covered health care in class last week, at least two students worried that if we did not stop insanely over-spending on health care in this country, we might lose our innovation edge.  Personally, I’d take that trade.  Also, it’s not all it’s cracked up to be.  Aaron Carroll (of course) and Austin Frakt are on the case:

Rather, the nation’s innovation advantage arises from a first-class research university system, along with robust intellectual property laws and significant public and private investment in research and development.

Perhaps most important, this country offers a large market in which patients, organizations and government spend a lot on health and companies are able to profit greatly from health care innovation.

The United States health care market, through which over one-sixth of the economy flows, offers investors substantial opportunities. Rational investors will invest in an area if it is more profitable than the next best opportunity.

“The relationship between profits and innovation is clearest in the biopharmaceutical and medical device sectors,” said Craig Garthwaite, a health economist with Northwestern University’s Kellogg School of Management, and one of the judges in our tournament. “In these sectors, firms are able to patent innovations, and we have a good sense of how additional research funds lead to new products.”…

In fact, some question whether the innovation incentive offered by the health care market is too strong. Spending less and skipping the marginal innovation is a rational choice. Spending differently to encourage different forms of innovation is another approach.

“We have a health care system with all sorts of perverse incentives, many of which do little good for patients,” said Dr. Ashish Jha, director of the Harvard Global Health Institute and the other expert panelist who favored the U.S. over France, along with Mr. Garthwaite. “If we could orient the system toward measuring and incentivizing meaningfully better health outcomes, we would have more innovations that are worth paying for.”


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