Global pacemaker retransplantation

 There are innovative approaches to global health care.  Here is one, that involves reusing pacemakers recovered from deceased donors and refurbished for use in countries where pacemakers are too expensive for wide use.  Unlike some of what we encounter in kidney transplants across borders, the legal bans that have to be overcome may not come from the war against the poor.  A careful clinical trial is underway. There is also an unregulated black market...

Here's the encouraging story from Helio.com:

After death, a new life for refurbished pacemakers in low-, middle-income countries, February 23, 2024

"Lack of access to pacemakers is a major challenge to the provision of CV health care in low- and middle-income countries; however, postmortem pacemaker utilization could offer an opportunity to deliver this needed care, according to Thomas Crawford, MD, an electrophysiologist and associate professor of internal medicine at University of Michigan Health and the medical director of My Heart Your Heart, a cardiac pacemaker reuse initiative at the University of Michigan Cardiovascular Center

...

"Crawford: The need is great. Each year, somewhere between 1 million and 2 million people worldwide die due to a lack of access to pacemakers and defibrillators. There is literature reflecting this. When you query pacemaker implantation data for the United States, it is roughly 800 pacemakers per 1 million population. When you query countries like, for example, Nigeria, it says four pacemakers per million. Quite a difference.

"Per capita gross domestic product is such that, in many countries, a pacemaker costs more than a person’s annual income.

...

"Healio: What are the regulations around using a refurbished pacemaker?

"Crawford: Pacemaker reuse is illegal in all jurisdictions. The FDA states that pacemaker reuse is an “objectionable practice.” We know we can do it, but we need to develop partnerships with other entities to give us credibility. One of those methods to do this is by engaging the government. FDA issues export permits for this type of activity. We created a protocol where we reprocess the device, working with Northeast Scientific, which provides the pacemaker cleaning and sterilization. We have received permission from the FDA to export them. We have to put a sticker on them saying “not for use in the United States.” We are doing this in countries in which governments will allow it. One of the limitations is needing a government letter from each of the recipient countries. We have about 12 countries now, and the collection of countries we are working with is purely accidental. It is not a normal methodological process. A lot of it is through contact with individuals and opportunities that arise.

...

"Healio: You are leading a randomized controlled trial called Project My Heart Your Heart: Pacemaker Reuse. What is the study design, and what do you and your colleagues hope to learn?

"Crawford: The objective of the clinical trial is to determine if pacemaker reutilization can be shown to be a safe means of delivering pacemakers to patients in low- and middle-income countries without resources. The target enrollment is 270 patients, all from outside the United States, who each have a class I indication for pacing and who attest that they do not have the ability to purchase a device on their own. They must consent to be randomly assigned to receive either a brand-new pacemaker, which we purchase, or a reprocessed pacemaker, for which we provide the leads and accessories. Donated devices are inspected according to specific protocols that evaluate physical and electrical suitability, including battery longevity, for future use. Devices deemed to be acceptable are shipped to a third-party vendor, Northeast Scientific, for disassembly, cleaning and re-sterilization. There will be about 130 participants in each arm. We will follow those patients and report any adverse events. The countries that have contributed patients include Kenya, Nigeria, Paraguay, Sierra Leone and Venezuela. We hope to soon begin enrolling patients in Mexico and Mozambique.

"I have had clinicians outside the U.S. who tell me they removed a pacemaker device, cleaned it, reprocessed it and then implanted it in someone else — but the government does not know about it. This practice does happen and it is not regulated in any way; patients and physicians know about it and keep it quiet. The difference with what we are doing and these other efforts is we bring it to a much higher level, because that is what the FDA requires. "

Tim Besley reviews "What Money Can't Buy" by Michael Sandel

Besley likes Sandel's book (while recognizing its flaws): Here's the opening sentence of his review in the Journal of Economic Literature(2013, 51(2), 478–495):

"Michael Sandel’s What Money Can’t Buy (WMCB hereafter) is a great book and I recommend every economist to read it even though we are not really his target audience."

I've written a bunch of blog posts about Sandel's views on markets, and others on repugnant transactions and markets, so I won't go into the details again here.

Let me instead give Besley the last word. Here are two paragraphs from his Final Remarks:

"The timing of WMCB may seem ironic in a year in which the Nobel Prize was awarded to Alvin Roth and Lloyd Shapley for their important work on market design that underpins a large expansion of exchange and matching into domains such as school choice, labor markets, and kidney exchange.
As Roth (2008) explains, the approach that he has taken is sensitive to issues of social constraints on market allocations. For example, he acknowledges that having a role for prices in kidney exchanges offends societal values. So the market design that has been proposed in this setting looks for exchanges that are feasible without prices. Thus, the concerns in WMCB are already taken on board by those who are actively promoting more socially sensitive forms of exchange.
...
"At the outset, WMCB identifies two obstacles to rethinking the role and reach of markets. One is the power and prestige of market thinking. The other is the rancor and emptiness of public discourse. Most economists will regard the first as well earned and many would gladly take a bow. But it seems hard to dispute that the need to participate in and engage with debates about markets (and governments) is a central obligation of the economics profession. WMCB is to be applauded for supplying both provocation and insight on a wide range of important topics. And it suggests
a range of challenges to which the discipline of economics can respond."


HT: Parag Pathak

The Harvard Crimson on Michael Sandel on economists

One of the clearest reviews of Michael Sandel's thoughts on economics and economists appears in the Harvard Crimson (the student newspaper), written by Jonathan Zhou, and undergraduate, and titled Luddite of the Mind. (As is often the case, the url is more entertaining than the headline: http://www.thecrimson.com/column/homo-economicus/article/2013/2/13/Sandel-vs-Mankiw/ )

Zhou writes, in part:

"Professor Sandel criticizes economists for applying efficiency arguments to buying and selling kidneys without thinking about its moral consequence. If Sandel cares to talk to any economist at the Harvard Faculty Club, he will find that his colleagues not only think about such moral complexities, but have also devised solutions. Instead of cash incentives, the “kidney exchange” will use an algorithm to swap donated kidneys, so that people who cannot receive donated kidneys from a loved one can still get a donated kidney from a stranger. This can improve efficiency of kidney donation based on the economic principle of coincidence of wants, but not in a morally contentious way. The study of markets without financial incentives became such an important subfield of economics that its intellectual godfather, Harvard economist Alvin E. Roth, received the Nobel Prize in Economics last year for this contribution. It is intriguing that in Sandel’s book about economists’ fixation with monetary markets, he forgets to include such alternative markets offered by mainstream economists.

More broadly speaking, economists are no strangers to difficult discussions about civic life. The great economists Kenneth J. Arrow and Amartya Sen founded the field of social choice theory, a mathematical formalism for making collective decisions with consideration of fairness, rights, liberties, and human folly. Of course, such ideas would not be included in Professor Sandel’s hypothetical textbook, because he dismisses the “rigor of natural sciences” in economics as deviant from the discipline’s origin as moral philosophy."

Is market life sucking the meaning out of real life?

Are too many things available to buy? That seems to be a theme of much recent literature that, at its worst, regrets how the economy has sucked the meaning out of life ever since the invention of trade and agriculture. The idea is that economic life weakens the close bonds with kin and community we used to build while we helped each other ward off starvation.

Markets are not the only focus of that concern: the expansion of cities and the encroachment of technology are others. For technology, think of the internet and social media, but don't forget the earlier effects of the automobile and the phonograph. As for  what you can buy these days with money, and the growth of markets, don't forget bottle feeding and washing machines, and women in the labor force.

But even if we have no nostalgia for the bad old days, it doesn't hurt to be aware of how the increasing scope of markets, like the growth of cities and technology, changes how we relate to one another.

In a recent NY Times Op Ed, the sociologist Arlie Russell Hochschild, who teaches at Berkeley, writes of her concerns about the increased reach of markets, The Outsourced Life. The article is accompanied by pictures of ads for all sorts of services that can now be bought and sold, from birthday party planners to cooking coaches, to upgraded accommodations in a private prison, to someone offering a service called "rent a dad."

The article announces her new book on the subject, The Outsourced Self: Intimate Life in Market Times

I recently received a review copy (one of the few signs that the world notices a blog).

It is a thoughtful book, on a topic in which I have a professional interest, but I wasn't encouraged when it began by regretting the loss of small town community that the author experienced as a child visiting her grandmother's farm. She visited from the city, a life her parents had chosen, and which she later chose herself. But the book is saved from nostalgia for the lost world by the acknowledgement of how much easier it would have been to take care of her elderly grandmother, years later when she was frail, if only she had lived near a city and the services that money could buy, and which a granddaughter could not easily deliver from far away.

So, and here is the interesting part of this kind of discussion, the loss of community isn't just something that happens because people choose to move to cities for the better opportunities and bigger markets they offer (even though they may regret, at least in memory, leaving the town behind). Loss of community is also something that happens to those left behind, as the towns are thinned out by those who moved on, so less community remains. Professor Hochschild and her parents chose to move away from the farm, and didn't ever really want to go back, but there's no going back even if they did want to: that old community isn't there anymore.

Of course, some of it was never really there. The book compares her grandfather's courtship of two sisters, one of whom became her grandmother and the other who apparently made a poor marriage (to "a n'er-do-well farmer"), with today's internet dating. Internet dating also doesn't always work out, it seems. Her grandmother did better with the old fashioned process, but it wasn't so great for her great-aunt.
**********


Closely related is Michael Sandel's book What Money Can't Buy: The Moral Limits of Markets (about which and whom I have blogged before). While Hoschschild's lost world is that of her grandparents' youth, Sandel regrets the changes he sees since he was young himself: here's a recent review (whose title is a summary of it's contents):.
What Money Can't Buy: The Moral Limits of Markets, By Michael Sandel: Should you pay to jump the queue – or for a new kidney? It's hard to define where cash has no place.

Sandel turns out to be a childhood friend of NY Times columnist Thomas Friedman, who writes about Sandel's book in a May 12 column called This Column Is Not Sponsored by Anyone
" Seen in isolation, these commercial encroachments seem innocuous enough. But Sandel sees them as signs of a bad trend: “Over the last three decades,” he states, “we have drifted from having a market economy to becoming a market society. A market economy is a tool — a valuable and effective tool — for organizing productive activity. But a ‘market society’ is a place where everything is up for sale. It is a way of life where market values govern every sphere of life.”

"Why worry about this trend? Because, Sandel argues, market values are crowding out civic practices. When public schools are plastered with commercial advertising, they teach students to be consumers rather than citizens. When we outsource war to private military contractors, and when we have separate, shorter lines for airport security for those who can afford them, the result is that the affluent and those of modest means live increasingly separate lives, and the class-mixing institutions and public spaces that forge a sense of common experience and shared citizenship get eroded."
***********

Tim Harford shared his thoughts on Sandel on markets on Google+:  He asks, "Why oh why is Michael Sandel so famous?"
***********

The role of markets in life, how these have changed over time, and peoples' perceptions of these things, are well worth the attention of economists. I initially organized my thoughts on the subject in my 2007 article Repugnance as a constraint on markets, and it's a subject I return to often in blog posts on repugnance and repugnant transactions.
**********

The Market and Marketization

I'm following at a distance a series of workshops in Helsinki on the philosophy and sociology of economics: The Market and Marketization
"Is there something wrong with the market for human kidneys, child labour, chemical weapons, or greenhouse gas emissions? Is it possible to have markets for electoral votes, scientific ideas, love, moral praise, or salvation? Do we have markets in our heads? How do models of the Market relate to real world markets? How do the diverse models and theories of the Market in various scientific disciplines relate to one another? In what sense is the Market mechanism a mechanism? Does the same mechanism function outside of the ordinary economy? Does marketization always lead to more efficiency? Does it increase human happiness and wellbeing? What are its preconditions and consequences regarding our moral character? Does the marketization of society have any limits at all? "

Participants (and hangers on) were each asked to introduce ourselves to an interdisciplinary audience. My contribution:

"Two papers of mine that might be helpful for an interdisciplinary readership are
Roth, Alvin E. "What have we learned from market design?" Hahn Lecture, Economic Journal, 118 (March), 2008, 285-310.
Roth, Alvin E. "Repugnance as a Constraint on Markets", Journal of Economic Perspectives, 21:3, Summer, 2007, pp. 37-58."

Made in the USA, but also sold in Canada

We're advised to "think locally and act globally," and the product labels on my new shoes illustrate some of the tension between those mandates.

This label strikes a balance between the wish to be local (and sell to those Americans who prefer to "buy American"), and the wish to be global (and to sell in Canada, where the labelling laws require two languages). And the issue isn't that Canadians are (North) Americans too:

So, I'm happy to show my Solidaire des Travailleurs Americains, whose products, Fabrique aux Etats-Unis, compete in the fairly free global marketplace.