Thursday, 30 August 2007

Replacing animal experiments

Nick Anthis at the Scientific Activist finds another article about the evils of animal research published in Bioessays. Gill Langley from the "Dr Hadwen Trust for Humane Research" gets some real scientists in on the act:
"Universities are failing to take up the challenge of replacing their animal experiments with non-animal techniques, whilst industry has made significant strides forward, says an article to be published in the September issue of the international peer-reviewed journal BioEssays. Animal experiments conducted by industry in Britain have fallen significantly over several years, but those carried out by universities and medical schools have risen by 52% in the last decade.

The article is authored by eminent professors engaged in academic research in immunology, infection and pain, as well as the Dr Hadwen Trust’s Dr Gill Langley, one of the world’s leading authorities on non-animal replacement techniques...Replacing animal experiments is a well-established concept in industry, especially in the pharmaceutical, chemical and cosmetics sectors. By contrast, in academia, animal use continues to rise and efforts to replace animal experiments are all too often poorly prioritised or focused. In areas where researchers have pioneered replacement efforts, some animal experiments have been successfully replaced, such as in neurological, reproductive and dentistry research. But elsewhere in the university sector progress has been unnecessarily slow.
“In recent years industry has started to respond actively to the replacement challenge in a way that we have yet to see within academia. In safety testing, particularly within the cosmetics, chemical and pharmaceutical sectors, non-animal techniques are recognised as advanced methods that are more ethical and also more relevant to humans, as well as being quicker and cheaper solutions. There is a growing acknowledgement of the need to develop non-animal methods, with legislative reform and consumer pressure for cruelty-free choices both playing a key role in speeding up the pace of change. However, universities tend to be less accountable and more isolated from these external factors and as a consequence their animal use has continued to increase unabated.”"
So says the Dr Hadwen Trust about its own article. Not sure why they think that industry large scale toxicity testing has any repercussions for basic scientific research, but what do I know?

The article starts by making the perfectly valid observation that industry has reduced the number of animals used, whilst academia has increased the numbers (likely due in part to increased use of transgenics as Nick points out) and then highlights a couple of examples of where replacement has taken place (toxicity testing, computer models of placental physiology and orthodontics, and transcranial magnetic stimulation in brain research) and then goes on to suggests how replacement may help in other fields, for example in sepsis:
"Animal models have provided a large body of evidence to establish the major pathophysiological mechanisms that operate during sepsis, and as a springboard in the development of new therapies. However, they are imperfect models...The in vitro tools of molecular and cellular biology will still provide much important information in the future...Newer methods of cell culture using three-dimensional supports hold promise as better models of tissue function...and advances in stem cell biology may well allow quite complex tissues to be constructed entirely in vitro. Similarly, progress being made in computer modelling of sepsis may also allow modelling of septic processes without the use of animals...A greater use of human subjects and material in sepsis research could contribute to the reduction of animal experimentation, while providing mechanistic insights into this serious medical problem."
or respiratory disease:
In the case of COPD, epithelial cells at baseline and following exposure to tobacco smoke extract also exhibit markers of injury and repair that occur in vitro in the airway cells of patients, but not in those from normal volunteers...Building upon the in vitro monolayer system, it has been possible to produce a fully differentiated airway epithelium...they can be used to look for novel molecular targets using genomic and proteomic platforms. They can also be used as test systems for novel therapeutics...Computer simulations have also been used to explore mechanisms of asthma pathology and predict the efficacy of potential treatments"
and pain:
"Animal models have provided us with key information about the detailed anatomical connections of nociceptive pathways...and potential physiological mechanisms of pain perception...To achieve a more physiological approach to pain classification, it will be necessary to identify the normal physiological...and pathophysiological mechanisms of pain perception...For example, PET studies have shown a selective reduction in receptors for natural opiates in the brains of patients with severe pain due to stroke...Following identification of mechanisms in humans, targeted drug development should be narrowly based on modulation of those mechanisms. Having identified and measured the pathophysiological mechanisms, proof-of-concept trials will be much more cost-effective. Preferably no drug should be developed without establishing that it reaches the target organ in humans, prior to clinical trials. In many cases, this can be achieved using molecular imaging e.g. PET. In summary, techniques exist to begin to reclassify human pain physiologically and to identify candidate pathophysiological mechanisms in volunteers. By working back from these mechanisms to drug development, some animal experiments maybe replaced."

They go on to conclude that:
"In academia, with an emphasis more on fundamental medical research, change has been slower. There are several reasons: (1) open-ended research questions are perceived as being more difficult to pursue without animal experiments, (2) there are few avenues for consumer pressure to be exerted, and (3) academic research is less shaped by legislative and regulatory initiatives. However, recent systematic reviews of the translation of animal research into clinical benefit may well signal a change."

I'm sure this article will be jumped on by the anti-vivisection crowd but when you analyse it this is all so much smoke and mirrors. To a naive reader this looks like what the anti-vivs have to say is true, that there are all these alternatives to animal research out there and the evil scientists are ignoring them.

It is worth noting that they explicitly don't say that animals are so different to humans that all research on them is meaningless, and that is a rather popular trope among the anti-viv crowd, so it is interesting that they couldn't get the scientists to say that here. If you read the sections written by the scientists they explicitly say that animal research has contributed much knowledge (and notice the caveats about what non-animal methods may add), but what they don't say, and this goes to the heart of it, is that all scientists are well aware of these other techniques and they are already very widely used because they are complementary to other research (they are also relatively, last 20 years say, new, and could never have contributed to biological knowledge in the past because they simply didn't exist).

I mean, seriously, for fuck's sake, what working medical scientist isn't either aware of, or actively involved in in vitro molecular and cellular work? And how do we think these computer models and other assays were developed, how do we know they are accurate reflections of the biology? Oh yes, the animals. And that is not even to think about where half the reagents and tissue comes from (I'll give you a clue, they're fluffy).

When a working scientist reads this they are bemused, 'what is this article trying to tell us?', it simply mentions a few techniques which are already widely known and widely employed, they represent the state of play in a field of research, they are not replacements because they are doing different things. Sure, new techniques might give us new knowledge, quelle fucking surprise! This paper has absolutely nothing to add to the vivisection debate.

For instance, much of the rise in animal research has been in transgenics, animals with genetic manipulations. Let us take an example of a disease Huntington's disease, a neurodegenerative condition where mutations in the Huntingtin gene have been implicated. Now where do we go from here? We might wonder whether we can reverse the effects of this mutation with treatment or is the damage done too early for us to do anything about it? Luckily enough we can engineer an animal model with mutant Huntingtin, and interestingly it turns out that we can't reverse the neuronal damage and behavioural deterioration when it manifests, but we can arrest it by turning off the gene - making gene silencing therapies a promising avenue of research. But this was animal research precipitated by non-animal 'alternatives', oh no - it is like the alternatives aren't alternatives after all, but different modalities for research, complementary but not necessarily replacing animal experiments.

These genetic animal models, in, for example, Alzheimer's are loads better than the models we had before the genetic knowledge was there (for example, anticholinesterase treatment was inspired by previous models based on the degeneration of cholinergic cells in Alzheimer's, but this is merely a downstream consequence of the pathology, so the treatments cannot be curative only relieve symptoms).

This kind of stuff just seriously pisses me off - it isn't that offensive in and of itself, but it is just meaningless platitudinous drivel in pursuit of a wider agenda. It looks all reasonable until you see that it is attempting to provide intellectual cover for the anti-vivs through confusing non-scientists into thinking that there are somehow these magic replacements for animal research.

What they try and imply is that there are all these new techniques that don't (necessarily) require animal vivisection (true), and that animal research in academia has been rising in recent years (also true), but the link is not that scientists are therefore ignoring non-animal techniques because they are stupid, or not subject to 'consumer pressure', but quite possibly because new knowledge spurs on further research, some of which has to be done with animals.

Rant over!

Bizarrely one of the authors has this to say in spiked:

"I should teach the world that higher animals, and specifically humans, function
as complex systems, where the individual inputs produce effects greater than
their sum parts. While reductionist science can help in identifying the parts,
the real difficulty for medical science is how the parts interact in the intact
organism, and how the intact organism is ordered. This must be the challenge of
medical science for the current millennium."

Saturday, 25 August 2007

The effect of shifting socioeconomic stucture on GCSE results

There's some discussion on badscience about GCSE grade inflation. I was wondering whether shifts in the socioeconomic stucture of the UK could be driving some of the increase in GCSE results, and I was just about to get into some serious analysis of data from the Youth Cohort Study when I plotted this to get an idea of how likely the hypothesis was. Turns out not so likely after all - the increase in grades runs across all socioeconomic groups (SEG until 2000, then I included NS-SEC: Higher professional, Lower professional, Intermediate, Lower supervisory, Routine, and Other - which likely explains the inflexion points at 2000). This suggests that an incresing proportion of middle class kids, or improved attainment amongst working class kids is unlikely to explain the rise in GCSEs. Obviously, if you believe that IQ is a good unbiased measure of intelligence you might explain grade increases as the esult of the Flynn effect - the secular increase in IQ scores with each cohort. As I think that modern increases are largely a result of increased familiarity with IQ tests that option isn't open to me. But the large differences between different groups, presuming you don't think they are a result of the intellectual inferiority of the poor, suggests a very large role for social and cultural factors - and if these change over time this could have a large effect on overall grades. Now I'm not sure what these factors might be - motivation and parental assistance are obvious ones, but I think it is pretty likely that at least some of the current grade inflation could be explained by this - rather than exams getting easier, although I doubt anyone will choose to focus on that when the cheap headlines practically write themselves each year.

Monday, 20 August 2007

Eight facts

Been tagged by Jean Kazez - you're supposed to list eight random things about yourself and then tag eight more people. I'll play along with the eight things about me - but I think I'll avoid tagging anyone else, the sort of people I'd choose are even grumpier than me and unlikely to take blogging chain letters well I reckon (you know who you are Matt):
  1. I was brought up a Christian and stayed more-or-less theist until I was 18

  2. I like real ale

  3. My favourite musician is David Bowie

  4. My eyesight is atrocious (myopia of the order of -10, not even counting the astigmatism)

  5. I can't sing for toffee

  6. I suck at bar sports (pool, snooker, darts etc.)

  7. I prefer non-fiction books to fiction, but the last fiction I read was Koestler's Darkness at Noon (very good)

  8. In hot weather I burn in about 5mins in the shade!

Saturday, 18 August 2007

Too much depression?

There's been a fair bit of media coverage of Gordon Parker's contention that depression is overdiagnosed (e.g. Nick Johnstone in the Guardian). Parker argues that drug company influences are promoting this over diagnosis of mild and subthreshold depression, which seems strange given that NICE recommends antidepressants not be used for mild depression:
"Antidepressants are not recommended for the initial treatment of mild depression, because the risk–benefit ratio is poor."
Which isn't to say that the government hasn't willfully and unaccountably failed to provide resources for cognitive behavioural therapy (6 month waiting lists are almost useless) which has proven cost-effectiveness when compared to antidepressants.

He basis his claims on a prospective study of teachers where he found that:
"By 1993, 79% of teachers in our cohort (in their late 30s) had already met symptom and duration criteria for lifetime major, minor, or subsyndromal depression (unpublished data)."
Subthreshold depressions (including subclinical/minor, recurrent brief, and subsyndromal depressions) are defined in similar ways to major depressive episodes but with generally less symptoms or <2 weeks duration - these are often more usefully considered research, rather than clinical definitions, and were created to capture the experience of people with significant impairment in their lives yet who didn't meet the criteria for major depression. The requirement for impairment in social functioning in these definitions - you aren't depressed if it doesn't have a detrimental effect on how you carry out normal functions is fundamental.

I'll repeat again what Parker said about those teachers, they "met symptom and duration criteria for lifetime major, minor, or subsyndromal depression" - since he doesn't specify that they met criteria for impaired function, or that they didn't meet exclusion criteria for reactive depression, I must assume that what he's saying is that they experienced two or more symptoms for two weeks, without necessarily any adverse effects on their lives - that is somewhat different to claiming that they all met criteria for major depression! It is a bit like the claim that some 10% of people have, at some point in their lives, heard voices - and therefore people with schizophrenia aren't ill despite the massive deleterious effects on their lives.

Johnstone makes some odd points about real depression being due to lack of serotonin and thus treating people without it with SSRIs is bad - presumably he is unaware of how little evidence there is that depression has anything to do with serotonin other than that we know antidepressants increase serotonin levels (as does ecstasy). JP's rather uncharitable reading is that he's trying to draw a distinction between his real depression and those saps that just think they're depressed. He also talks about antidepressant medication prescriptions as if they accurately reflect the number of people with depression - unlikely given the widespread use of SSRIs for anxiety and tricyclics for neuropathic pain:
"Last year, in Britain alone, 31m prescriptions were handed out for antidepressants, a 6% rise on 2004, suggesting that we're either collectively bending under the strain of modern life or doctors are far too freely handing out prescriptions.
the danger with overdiagnosing a bad patch in life as clinical depression is that doctors are using medication to treat brains that fundamentally work the way they are supposed to."

Criteria for major depression in DSM-IV-TR are:
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either
(1) depressed mood or
(2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
(4) Insomnia or Hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms do not meet criteria for a Mixed Episode (see p. 335).

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
note that the DSM distinguishes between Major Depressive Disorder that has been characterised by only a single episode, versus recurrent major depressive episodes. Dysthymia is defined as
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) of the following:

(1) poor appetite or overeating
(2) Insomnia or Hypersomnia
(3) low energy or fatigue
(4) low self-esteem
(5) poor concentration or difficulty making decisions
(6) feelings of hopelessness

C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.

D. No Major Depressive Episode has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
Note: There may have been a previous Major Depressive Episode provided there was a full remission (no significant signs or symptoms for 2 months) before development of the Dysthymic Disorder. In addition, after the initial 2 years (1 year in children or adolescents) of Dysthymic Disorder, there may be superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be given when the criteria are met for a Major Depressive Episode.

E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.

F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.

G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Whitehall II

Listened to an old More or Less recently about the socioeconomic gradient in health outcomes (specifically mortality) in the UK. The presenter Andrew Dilnot, and his interviewee, referred to the Whitehall II study as showing how people's job status and sense of control in work are related to this. This is a common conclusion to draw from the Whitehall II study and, while this may be a somewhat controversial view, one that I think is utterly unfounded.

As in many other studies, Whitehall II found that coronary heart disease mortality was associated with job grade, which is obviously seriously confounded with socioeconomic status:

This gradient is somewhat due to known coronary risk factors as we would expect, but is not entirely so. Other factors that have been associated with coronary risk are height (considered a marker of early life and genetic differences) and job control - it is job control that is supposedly associated independent of socioeconomic status, and what leads people to assume that it is job status, rather than socioeconomic status per se, that is associated with heart disease.

This evidence has lead many researchers to accept that psychosocial factors have a profound influence on coronary heart disease and that it is not material deprivation but status that is important in socioeconomic health inequalities (the argument here is about direct aetiological effects of psychosocial factors on health, rather than, for example, indirect effects mediated via know risk factors such as smoking). Others have worried that this view could lead to a regressive lack of emphasis on material factors in addressing health inequality.

So we should consider the evidence base for this contention because health inequalities are a rather pressing public health concern, and policy making should be based on the best evidence. The latest update of the Whitehall II study on job control is Kuper & Marmot (following on from the Bosma et al study).

They looked at two outcomes, all coronary heart disease (all CHD; including self-reported angina) and myocardial infarction (MI; fatal or non-fatal). They find no effect for women, but for men there is a highly significant effect of job control on all CHD even adjusted for coronary risk factors (smoking, cholesterol, hypertension, exercise, alcohol, BMI). But there is no effect of job control on the harder endpoint of MI - even unadjusted for coronary risk factors. i.e. low job control is associated with angina (self-reported chest pain - it is unclear whether this is solely derived from the Rose questionnaire or whether clinically diagnosed angina is also associated, but in the original Bosma study the effect was driven largely by Rose questionnaire scores) but not more objective measures of coronary heart disease. Studies of other 'psychosocial' risk factors in Whitehall II have similar problems.

The fundamental problem with this conclusion is that most studies have tended to only find associations between subjective reports of psychosocial factors (such as sense of workplace control) and subjective measures of cardiovascular disease, rather than objective measures. Obviously it is possible, and in this case pretty likely, that people report more symptoms of angina when they feel less in control of their work (causality here may be direct, or via third factors like personality). Without an effect on objective coronary endpoints we can only assume that an explanation of this form is most likely. I can only think that the popularity of the 'psychosocial' explanation is due to its trendy image, rather than the strength of the evidence.

George Davey Smith has a good chapter on the less than successful history of psychosocial explanations of physical disease (e.g. peptic ulcers) in Biopsychosocial Medicine. In particular he points out the similarities of the findings from the Whitehall II study on CHD and job control and a study of his own where they found that perceived stress correlated with Rose angina but not more objective measures of cardiovascular disease:
"The broad categories "cardiovascular disease" and "coronary heart disease" are made up of different constituent diagnoses. Admissions for coronary heart disease did not increase with increasing stress, whereas admissions for cardiovascular disease did. We have broken down these categories to explore this discrepancy. Admissions for "coronary heart disease" are dominated by those for acute myocardial infarction, a condition where admission would normally be considered mandatory and where diagnostic classification depends primarily on objective criteria (such as the measurement of cardiac enzymes). Reporting bias will not influence these, hence admissions for myocardial infarction are not related to stress. For most classes of hospital admission the decision to admit and the classification of cause of admission depends on a combination of symptoms and signs. Where symptoms have the dominant influence, reporting bias may exert an important influence. This probably explains the weakly positive associations between angina admissions and stress and the more strongly positive association between stress and the group of admissions for cardiovascular conditions where admission was likely to be, to a substantial degree, discretionary or when diagnostic classification reflected non-specific symptoms or signs. Because of this, admissions for "cardiovascular disease" overall were positively associated with stress. Some studies have used disease diagnosed by a doctor as an "objective" outcome.19 These results suggest that it may also be influenced by reporting bias.

We are not questioning the reality of symptoms to the person experiencing them. Nor, given the strong association between angina and mortality, are we suggesting that self reported angina is, in general, a poor predictor of coronary heart disease. However, reporting tendency as well as physical disease can lead to angina being experienced and reported. This has important implications for treatment and prevention.

The weak inverse association between higher stress, ischaemia detected by electrocardiography, acute myocardial infarction, and mortality is also likely to be non-causal. In this population, socially advantaged men perceived themselves to be most stressed, leading to a confounded association between higher stress and better health. Adjustment for current occupational class attenuated but did not abolish this relation. Adjustment for other markers of social position had little additional effect (data not shown). All measures of social position are relatively crude, and statistical adjustment for them is likely to leave a residually confounded association between any socially patterned exposure and health.

In the systematic review concluding that evidence supported a causal relation between stress and cardiovascular health, these associations were most consistently observed between stress and substantially subjective end points such as self reported symptoms. 2 20-23 It seems likely that at least some of these relations are artefactual in the same way as the ones we report here. Only one study in this review reported an association between perceived stress and mortality, in a population where stress was associated with social disadvantage and therefore likely to show a confounded association with health.

Associations between "psychosocial" factors and objectively poorer health have been shown in other studies. In all of these, where the social distribution of the psychosocial factor was described, "adverse" exposure was associated with social disadvantage. It is possible that these relations were also residually confounded."

Friday, 17 August 2007

Iraqi Quislings

This shameful article by Neil Clark on the Guardian's Comment is Free site has rightly received the contempt it deserves - I was particularly struck by his claim that:
"An illegal, immoral war doesn't become a legal and moral one as soon as it breaks out. I am pleased that Britain and the US have had a major setback in Iraq, in the same way I'm pleased that the German invasion of the Soviet Union was defeated."
"it's an intellectual cop out to say that we oppose the war, but that we hope Britain and America are successful."
Surely many of us on the anti-war left recognised that Saddam was a tyrant the Iraqis would be better off without, but worried that the US would screw up both the war and the reconstruction (and it looks like we were right about that) - but that's consequentialist thinking, something I'm not sure Clark understands with his talk of it being immoral and illegal - morality and legality are not quite so black and white, particularly not morality, it may be morally wrong (and illegal) for a policeman to recklessly and indiscriminately fire at terrorists, causing death to civilians, but that doesn't mean we should cheer on the terrorist, or that we shouldn't prefer the policeman to avoid killing civilians, or be happy that he kills the terrorists. To make the analogy even closer, that doesn't change even if the policeman's motivation is due to his psychopathic love of firearms rather than altruistic motives.

I don't even think he's making some larger consequentialist point about giving the US and UK a bloody nose for their imperialist adventure (the sort of point that people like the SWP might make in backing the insurgency) - no - he sees it as some kind of conflict of good versus evil - where have we heard that before?

Thursday, 16 August 2007

US Exceptionalism V

Ok, so maybe the US system is afflicted by supplier driven demand, and the population are generally unhealthy, and the doctors are over paid - but is the US healthcare system actually delivering the extra operations, investigations and drugs all that funding is supposed to be paying for?

Now obviously this sort of information is a bit harder to find, but I could locate the in-patient operation rate from the OECD and surprisingly enough - no, the US does not seem to be getting more surgery for its money compared to, say, Germany, nor more consultations, nor a whole load of other things you might think there'd be. So where's the money going?

US Exceptionalism IV

An interesting way to look at the data, given the flaws of PPP is pecentage of GDP. Obviously it is complicated by differing GDP between countries, but it might remove some of the problems of, for example, booming economies paying doctors more. Note that there is now less of a relationship with life expectancy, this is likely due to confounding with the size of the economy, but the US is still way ahead in terms of the size of its GDP being spent on healthcare, even given its larger economy.

US Exceptionalism III

Here's the figure that should really be worrying the small state rightwingers - when you plot public spending on health against life expectancy the US fits right in with the general trend. But unlike the rest of the OECD countries, the US spends as much again from the private sector - so why is it getting such poor value for money?

US Exceptionalism II

In case anyone was thinking that life expectancy is a statistical quirk - here's data for infant low birth weight.

The trend is a bit less obvious here (although it does look like more spend = lower rates as we'd expect) but the US is again not doing that well given the huge expenditure - obviously that US pharmaceutical subsidy of the rest of the world I've been hearing about.

As with life expectancy the US is doing about as well as the UK (which is somewhat similar as a country) despite the UK's evil socialist NHS.

US Exceptionalism

Prompted by Michael Moore's 'Sicko' there's been some debate recently about the high costs of US healthcare compared to the rest of the world, most notably the more socialised healthcare of Europe, and what this means. Many people (most obviously rightwing Americans) think this reflects the magnificent standard of US healthcare compared to European health rationing, others are not so sure, and I'm one of them. I just dug this graph out which shows a comparison of healthcare expenditure (public and private) per capita, against the ultimate hard endpoint - life expectancy at birth - in OECD countries (OECD 2007 Health Data). The data is from 2002 which is the most recent complete year (other years unsurprisingly look pretty similar). Now I know that purchasing power parity is a rubbish measure, and that there will be historical health effects unrelated to present healthcare funding rates, that US data is skewed by poor health outcomes in the uninsured or poorly insured, and that there are (small) genetic and (large) cultural/lifestyle differences making cross national comparisons somewhat dubious. So don't over interpret the graph, but just look at that trend, and see what you think about US exceptionalism.