Tuesday, May 31, 2022

Food fight in California: Foie gras is legal for private consumption from out of state providers

 The Ninth Circuit has confirmed a nuanced lower court verdict about foie gras, in the latest episode of a long running California food fight about gavage, the force feeding of ducks:

California court okays import of foie gras from out of state, barred in 2012. The law, passed in 2004, went into effect in 2012 and banned the sale of the delicacy if produced by force feeding geese or ducks.

"A California law that effectively bans foie gras sales in the state was limited in part on Friday. Californians can continue purchasing the controversial pate from out-of-state retailers, the ninth circuit court of appeals said in a ruling.

"The law, which passed in 2004 and went into effect in 2012, bars the sale of foie gras if produced by force feeding geese or ducks, according to Courthouse News Service. As the mousse is traditionally produced from the engorged livers of force-fed geese and ducks, the legislation is a near-prohibition.

"The ninth circuit’s decision upheld a lower court’s 2020 ruling, which also permitted the shipping of out-of-state foie gras through third-party delivery companies, according to the Associated Press."

"This ruling is only applicable to people who purchase foie gras for their individual use; California law still bars retailers and restaurants from selling or giving away foie gras. The law has been challenged repeatedly since its enactment."

Monday, May 30, 2022

Eliminating cruelty (and methane) from the food chain: lab-grown ("no-kill") meat

 The Guardian has the story:

World’s largest vats for growing ‘no-kill’ meat to be built in US by Damian Carrington

"The building of the world’s largest bioreactors to produce cultivated meat has been announced, with the potential to supply tens of thousands of shops and restaurants. Experts said the move could be a “gamechanger” for the nascent industry.

"The US company Good Meat said the bioreactors would grow more than 13,000 tonnes of chicken and beef a year. It will use cells taken from cell banks or eggs, so the meat will not require the slaughter of any livestock.

"There are about 170 companies around the world working on cultured meat, but Good Meat is the only company to have gained regulatory approval to sell its product to the public. It began serving cultivated chicken in Singapore in December 2020.


"“I think our grandchildren are going to ask us about why we ate meat from slaughtered animals back in 2022,” said Josh Tetrick, the chief executive of Good Meat’s parent company, Eat Just.

“Cultivated meat matters because it will enable us to eat meat without all the harm, without bulldozing forests, without the need to slaughter an animal, without the need to use antibiotics, without accelerating zoonotic diseases.


"Cultivated meat has not yet been approved for sale by the US Food and Drug Administration. 


"Another cultivated meat company, Upside Foods, raised $400m in April, in part to fund a commercial-scale facility to produce thousands of tonnes of meat a year.


"Other companies with facilities for cultivated meat include SuperMeatMosa MeatFuture Meat Technologies and the seafood producers Wildtype and Shiok Meats. There are also many companies making plant-based meat replacements."

Sunday, May 29, 2022

Tipping in taxis

 The WSJ writes about a working paper about tipping in taxis by my Stanford GSB colleague (and taxi driver emeritus) Kwabena Donkor.

Here's the WSJ article:

When Given a Menu of Tipping Options, People Tip More  By Lisa Ward

"People tend to use tip menus as a reference point or anchor, interpreting the options as indicators of what they should actually tip, says Kwabena Donkor, an assistant professor at Stanford University’s School of Business, the paper’s author and a former New York City taxi driver.

"The study found that 58% of riders chose to use the taxi cabs’ tip menus, though riders tended to opt out of using the menu when the calculations were easiest."


And here's the working paper:

The Economic Value of Norm Conformity andMenu-Opt-Out Costs

Kwabena Donkor, Stanford GSB December, 2021

"Abstract: This paper theoretically and empirically analyzes trade-offs between consumption versus norm-adherence and choosing from a menu of default options versus computing a non-default choice. In the theoretical model, peoples’ choices depend on consumption, norm conformity, and menu-opt-out costs. Using passengers’ tips sampled from a billion NYC taxi rides, I empirically estimate the model parameters.I find that the cost of deviating from the norm tip and opting out of the default tip menu are both high relative to the taxi fare. I then examine the welfare implications of norm conformityand the positive and normative effects of default menu design."

Saturday, May 28, 2022

EU purchases of Russian natural gas: some market design thoughts

 Coordinated action might help the EU curb how much it spends on Russian natural gas. Here are some thoughts by Cramton, Lévêque, Ockenfels and Stoft, in Vox.eu (followed by a Financial Times editorial):

An EU gas-purchasing cartel framework  by Peter Cramton, François Lévêque, Axel Ockenfels, and Steven Stoft  26 May 2022

“Instead of outbidding each other and driving prices up,” on 25 March, the 27 EU nations decided to “pool [their] purchasing power” for the “voluntary common purchase of gas”. In short, they decided to form a buyers’ cartel. So far, difficulties have been identified, but what is needed is a systematic design effort addressing those difficulties. This column proposes a simple, but fairly comprehensive framework for an EU gas-purchasing cartel."


"While a tariff on Russian gas is justified and can avoid the severe consequences of an outright ban, it would be best implemented as part of a gas-purchasing cartel that could also organise a quick and vigorous response in the form of a price ultimatum.


"Although only one piece of a responsible plan, a gas-purchasing cartel could play an essential role in protecting EU economies from Russian blackmail and also in helping to keep the EU unified as Putin tries to fracture it, as he is attempting to do (WSJ Editors 2022). Its twin goals would be reducing the EU’s financial support for Russia’s Ukraine invasion and reducing Putin’s ability to hold EU economies hostage to Russian gas supplies. It could do this in two steps.

"1. A quick-start Russian price ultimatum with some part (up to 100%) of the price reduction placed in an escrow account. 

"2. Collective purchasing of additional gas from all sources but with targeted tariffs (leaving non-Russian long-term contracts undisturbed).

"Behind the cost-benefit justification for an EU cartel lies a strategic vision recognising the benefits of credible, step-by-step reductions in Russia’s energy revenues until the conflict is resolved (Eichstädt 2022). This is only possible with the coordination that comes with some form of buyer’s cartel."


And here's the FT editorial:

A tariff on Russian oil could pave the way to an embargo. The best way to squeeze Moscow’s war machine is to deprive it of energy profits

"The EU’s economy commissioner Valdis Dombrovskis this week summed up the dilemma as the bloc struggles to agree on an embargo on Russian oil. “We are discussing massive financial support to Ukraine on one hand, and continue to provide financing for Russia’s war on the other hand,” he said. “It needs to be stopped.” A ban on Russian imports should remain the priority. But an interim measure designed to stem Moscow’s profits from energy sales more quickly — a punitive EU tariff on Russian oil, proposed by the US and others — is worth looking at too.

"An embargo choking off the 3.4mn barrels a day of oil and oil products that Russia exports to the EU would be a stunning blow to its revenues. But an EU embargo is vigorously opposed by landlocked Hungary, which says it is less able than coastal states to source alternative oil, and its refineries are set up to process Russian crude so require costly conversion. Bringing Budapest round is likely to need financial support and a phase-in period for an embargo.


"After a meeting with US President Joe Biden this month, Mario Draghi, Italy’s premier, mooted a global “buyers’ cartel” that would attempt to reduce global oil prices."

Friday, May 27, 2022

Personal data as a national (not international) resource

 The NY Times has the story:

The Era of Borderless Data Is Ending. Nations are accelerating efforts to control data produced within their perimeters, disrupting the flow of what has become a kind of digital currency.  By David McCabe and Adam Satariano

"France, Austria, South Africa and more than 50 other countries are accelerating efforts to control the digital information produced by their citizens, government agencies and corporations. Driven by security and privacy concerns, as well as economic interests and authoritarian and nationalistic urges, governments are increasingly setting rules and standards about how data can and cannot move around the globe. The goal is to gain “digital sovereignty.”


"In Washington, the Biden administration is circulating an early draft of an executive order meant to stop rivals like China from gaining access to American data.

"In the European Union, judges and policymakers are pushing efforts to guard information generated within the 27-nation bloc, including tougher online privacy requirements and rules for artificial intelligence.

"In India, lawmakers are moving to pass a law that would limit what data could leave the nation of almost 1.4 billion people.

"The number of laws, regulations and government policies that require digital information to be stored in a specific country more than doubled to 144 from 2017 to 2021, according to the Information Technology and Innovation Foundation.

"While countries like China have long cordoned off their digital ecosystems, the imposition of more national rules on information flows is a fundamental shift in the democratic world and alters how the internet has operated since it became widely commercialized in the 1990s.

Thursday, May 26, 2022

Displaced people passes 100,000,000

 The Guardian has the story, focusing on the causes of displacement. But efficiently matching diverse refugees to places of temporary or permanent asylum is still one of the biggest unsolved matching problems.

Number of displaced people passes 100m for the first time, says UN. ‘Staggering milestone’ calls for urgent international action to address underlying causes of conflict, persecution and the climate crisis, says high commissioner for refugees.  by Diane Taylor

"The UN refugee agency (UNHCR) has said the global number of forcibly displaced people has passed 100 million for the first time, describing it as a “staggering milestone”.

"The UN high commissioner for refugees, Filippo Grandi, said the grim new statistic should act as a wake-up call for the international community and that more action is needed internationally to address the root causes of forced displacement around the world.


"The figure hit 90 million at the end of 2021, propelled by a range of conflicts including in Afghanistan, Burkina Faso, the Democratic Republic of the Congo, Ethiopia, Myanmar and Nigeria.

"Eight million Ukrainian people have been displaced within their home country as a result of the war, along with more than six million refugee movements registered from Ukraine.

“The international response to people fleeing war in Ukraine has been overwhelmingly positive,” said Grandi. “Compassion is alive and we need similar mobilisation for all crises around the world. But ultimately humanitarian aid is a palliative, not a cure. To reverse this trend the only answer is peace and stability so that innocent people are not forced to gamble between acute danger at home or precarious flight or exile.”

"The term “displaced person” was first used during the second world war, in which more than 40 million people were forcibly displaced."

Wednesday, May 25, 2022

Matching prisoners to jails: peer effects are of first order importance

 Akhil Vohra points me to this very interesting matching problem, which is apparently quite far from a good solution:

RIKERS ISLAND: City Jails Scrap Last Remnants of Pricey Consultant Plan as Deaths Mount BY  REUVEN BLAU, May 18, The City

"In 2018, the city Department of Correction began using a new detainee classification process created at great expense by consulting group McKinsey & Company. 

"The de Blasio administration had paid the white-shoe firm $27.5 million to create the system that used an algorithm based on a host of factors — including age, possible gang affiliation, and any prior history in jail — to determine where to house people behind bars with the least risk for confrontation

"On Tuesday, jail Commissioner Louis Molina announced that the pricey system — widely criticized for failing to reduce violence — will be formally scrapped after just four years as part of the department’s court-mandated overhaul plan. 


"jail officials have long struggled where to place new detainees to reduce the likelihood of fights. Top jail supervisors have traditionally tried to avoid creating housing units based on gang affiliation, according to current and former jail insiders. 

"Units made up of just one gang tend to get along with each other but also have the ability to gang up on the officers in the area and are more likely to join forces to ignore basic orders, jail experts say. 

"Housing units mixed with people from at least two different gangs as well as some people who are totally unaffiliated are considered the golden standard, according to criminologists. 

"But other factors are also important such as a person’s prior criminal history, age, and possible previous record in jail. 


"“It’s a revolving door of stupidity and poor decisions,” one high-ranking jail official, who spoke on condition of anonymity, told THE CITY. 

“We changed from that system because it wasn’t working, now we are reverting back to it,” the jail insider said. 


"Jail officials said the result was part of the chaos that has led to a massive spike in the number of stabbings and slashings among detainees and assaults on staff."

Tuesday, May 24, 2022

Erling Skancke defends his dissertation

 Erling Skancke defended his dissertation last week:

Here's his job market paper:

Welfare and Strategic Externalities in Matching Markets with Interviews (Job Market Paper)
Recent debate in the medical literature has raised concerns about the pre-match interview process for residency and fellowship positions at hospitals. However, little is known about the economics of this decentralized process. In this paper, I build a game-theoretic model in which hospitals conduct costly interviews in order to learn their preferences over doctors. I show that increased interview activity by any hospital imposes an unambiguous negative welfare externality on all other hospitals. In equilibrium, both hospitals and doctors may be better off by a coordinated reduction in interview activity. The strategic externality is more subtle, and conditions are derived under which the game exhibits either strategic complementarities or substitutes. Moreover, an increase in market size may exacerbate the inefficiencies of the interview process, preventing agents from reaping the thick market benefits that would arise in the absence of the costly interviews. This effect increases participants' incentives to match outside of the centralized clearinghouse as markets become thicker, jeopardizing the long-term viability of the clearinghouse. The model also provides new insights into several market design interventions that have recently been proposed.

Congratulations, Erling! 
Welcome to the club.

Monday, May 23, 2022

Gabe Carroll and Jamie Morgenstern win the Social Choice and Welfare Prize

Congratulations to Jamie Morgenstern and Gabe Carroll. Their joint prize is a sign of how economics and computer science are advancing both separately and together.


"A jury composed of Pietro Ortovela (Princeton University), Ariel Procaccia (Harvard University), Szilvia Papai (Concordia Universtiy),  Arunava Sen (President of the Society for Social Choice and Welfare) and Marc Fleurbaey (Chair, President-elect of the Society for Social Choice and Welfare)  has chosen to award the eleventh Social Choice and Welfare Prize jointly to Gabriel Carroll (University of Toronto) and  Jamie Morgenstern (University of Washington).

"The purpose of the Social Choice and Welfare Prize is to honour young scholars of excellent accomplishment in the area of social choice theory and welfare economics. The laureate should be 40 years or less as of January of the year when the International Meeting of the Society for Social Choice and Welfare is scheduled to take place. During this meeting, the prize winner(s) will give a plenary lecture. For more information about the prize, please click here.

"The SCW prize medal "La Pensée" ("The Thought") is due to Raymond Delamarre (1890-1986), a rather well-known French sculptor associated with what has been called "Art Deco" (Chrysler Building and Empire State Building in New York, the architects Mallet-Stevens or Le Corbusier in France). He is in particular famous for his work at the entrance of the Suez Canal. A web site: www.atelier-raymond-delamarre.fr.












Gabriel Caroll

University of Toronto

Sunday, May 22, 2022

Seventh Marketplace Innovation Workshop (MIW), May 23-26, 2022 (10:45am EST - 2:45pm EST)

 Seventh Marketplace Innovation Workshop (MIW),  May 23-26, 2022 (10:45am EST - 2:45pm EST)   The conference will be virtual

Here is the program.


Itai Ashlagi, Management Science and Engineering, Stanford University

Omar Besbes, Columbia Business School, Columbia University

Nicole Immorlica, Microsoft Research

Vahideh Manshadi, School of Management, Yale University

Nicolas Stier-Moses, Core Data Science, Meta Platforms

Fanyin Zheng, Columbia Business School, Columbia University

Plenary speakers

Alessandro Bonatti, MIT

Bar Ifrach, Uber Freight

Myrto Kalouptsidi, Harvard University

Azarakhsh Malekian, University of Toronto

Michael Schwarz, Microsoft

Peng Shi, University of Southern California

Tim Roughgarden, Columbia University

Gabriel Weintraub, Stanford University

Saturday, May 21, 2022

Iowa State University celebrates Bertan Turhan

 The Iowa State University News Service has an article about the market design work of Bertan Turhan.

New model could improve matches between students and schools

"For the majority of students in the U.S., residential addresses determine which public elementary, middle, or high school they attend. But with an influx of charter schools and state-funded voucher programs for private schools, as well as a growing number of cities that let students apply to public schools across the district (regardless of zip code), the admissions process can turn into a messy game of matchmaking.

"Simultaneous applications for competitive spots and a lack of coordination among school authorities often result in some students being matched with multiple schools while others are unassigned. It can lead to unfilled seats at the start of the semester and extra stress for students and parents, as well as teachers and administrators.

"Assistant Professor of Economics Bertan Turhan at Iowa State University and his co-authors outline a way to make better, more efficient matches between students and schools in their new study published in Games and Economic Behavior. Turhan says their goal was to create a fairer process that works within realistic parameters.

“There are a lot of success stories in major U.S. cities where economists and policymakers worked together to improve school choice,” said Turhan. “The algorithm we introduced builds on that and could give school groups some degree of coordination and significantly increase overall student welfare in situations where there’s a lot of competition to get into certain schools.” 


"Over the next year, Turhan and his team will be studying the implementation of their model in India where two types of colleges have revamped their admissions process."


Here's the paper that was the occasion of the story:

Parallel markets in school choice by Mustafa Oğuz Afacan, Piotr Evdokimov, Rustamdjan Hakimov, and Bertan Turhan

Games and Economic Behavior, Volume 133, May 2022, Pages 181-201, https://doi.org/10.1016/j.geb.2022.03.003Get rights and content

Abstract: When applying to schools, students often submit applications to distinct school systems that operate independently, which leads to waste and distortions of stability due to miscoordination. To alleviate this issue, Manjunath and Turhan (2016) introduce the Iterative Deferred Acceptance mechanism (IDA). We design an experiment to compare the performance of this mechanism under parallel markets (DecDA2) to the classic Deferred Acceptance mechanism with both divided (DecDA) and unified markets (DA). Consistent with the theory, we find that both stability and efficiency are highest under DA, intermediate under DecDA2, and lowest under DecDA. While IDA is not strategy-proof, we show theoretically that strategic reporting can only lead to improved efficiency for all market participants. The experimental results are consistent with this prediction. Our findings cast doubt on whether strategy-proofness should be perceived as a universal constraint to market mechanisms.

Friday, May 20, 2022

Research on pedophilia presents career hazards

 It's not always easy to investigate repugnant things, let alone crimes.  Old Dominion University has parted ways with an assistant professor, Allyn Walker, who uses the pronoun "they."  They studied people who are sexually attracted to children, but don't act on their attraction, i.e. who aren't child molesters.  Walker's book on the subject drew unwanted attention and accusations that it promoted child molesting.

The Chronicle of Higher Ed has the story:

An Unacceptable Idea. A university says it supports free inquiry. So why does this pedophilia researcher no longer work there? By Emma Pettit

"Walker’s book, A Long, Dark Shadow: Minor-Attracted People and Their Pursuit of Dignity, examines adults who are sexually attracted to children but say they refrain from acting on that attraction. The scholar avoids the term “pedophiles,” even though its literal meaning describes only desire, not behavior, in part because it has come to be synonymous in the public mind with “child molester.” 


“Allow me to be clear: This book does not promote sexual contact between adults and minors,” Walker writes in the introduction. Knowing some readers might see it that way, though, Walker prepared. Before the book’s publication in June 2021, the scholar, then an assistant professor of sociology and criminal justice at Old Dominion University, wrote a memo for university leaders with talking points to respond to that misconception, should objections to the research arise.


"When Tucker Carlson covered the story, he referred to Walker as “a self-described ‘nonbinary assistant professor,’” adding, “we have no idea what that means, by the way, but that’s what this person calls him or herself.” Beside Carlson was a graphic that announced: “The Left’s Depraved New Low.”

"Students at Old Dominion also objected. They mounted a protest and urged the university to fire Walker. 


"Walker was placed on indefinite administrative leave.


"Walker’s leave notice, obtained by The Chronicle, said that the action was being taken “due to concerns over your safety and that of the campus, and to address the immediate effects of the reaction to your research and book which has impacted the University’s mission of teaching and learning.”


“Research into sensitive topics and the expression of new or controversial views lie at the heart of academic research. … At the same time,” Hemphill wrote, “this freedom carries with it the obligation to speak and write with care and precision, particularly on a subject that has caused pain in so many lives.”


"on November 24, Walker and the university jointly announced that the assistant professor had “decided to step down.”


"Though the wave of reactions was mighty, leaders at Old Dominion could have done more “to resist the power of the misreading of Dr. Walker’s work” and to protect the scholar’s reputation in the institution’s messaging, the university’s chapter of the American Association of University Professors wrote in an open letter. Old Dominion’s response “essentially indicated that if a conflict emerges between academic freedom and hateful political groups that threaten violence, then the politics of hate will win,” Kent Sandstrom, a professor in Walker’s department and a former dean of the college, said in an email. “I can’t think of a more troubling precedent.”


"Walker’s Old Dominion contract ends this month. For the time being, at least, they have found an academic home. They’ll be a postdoctoral fellow at Johns Hopkins’s Moore Center for the Prevention of Child Sexual Abuse."

Thursday, May 19, 2022

Frontiers of Economic Design (FED): Ellen Muir and I speak tomorrow (Friday) on Zoom

 We hope to start off this new seminar with a bang (9am Pacific time, noon on the East Coast, 18:00 in middle Europe...)

To hear us you have to register to get a link

Here's the seminar site:

Frontiers of Economic Design (FED)

"The goal of this seminar series is to bring young researchers in economic design and related areas together, to promote their work, and also to disseminate cutting-edge research. Each meeting will feature two presentations: one from an established researcher and one from a graduate student or post-doc. "


Black market tattoos in S. Korea: “No one’s trying to go to medical school to become a tattoo artist,”

 Tattooing is illegal (but tattoos are not) in S. Korea.  The NY Times has the story:

Tattoos, Still Illegal in South Korea, Thrive Underground. Tattoo artists, long treated as criminals for their work, say that it is time to end the stigma against their business.  By Christine Chung

"Under a ruling that has been in place since 1992, tattooing without a medical license can result in fines of up to $40,000 or even imprisonment. Opponents of decorative tattoos have invoked concerns about longstanding associations with organized crime, as well as fears about inadequate hygiene and potential harm inflicted by tattoo artists, who they say lack adequate skills.

"Attempts to overturn this ban have repeatedly failed. In March, the Constitutional Court in Seoul reaffirmed the tattoo industry’s illegality in a 5-to-4 ruling. South Korean tattoo artists and customers believe that the ruling is at odds with reality, citing drastically changed social norms that have fostered a thriving underground industry, greater openness and acceptance of tattoos, and rising international demand for what are known as “k-tattoos.”

"While tattoos have grown in acceptance in most parts of the world — exceptions include several Islamic countries — South Korea remains one of the few where the artists are treated as criminals. Tens of thousands of them work in secret here, under constant threat of exposure to law enforcement.


“No one’s trying to go to medical school to become a tattoo artist,” she said.


"Mr. Kim is the founder of a 650-member tattoo labor union that advocates rights of artists. Legalization would create safer, more sanitary environments for both customers and artists, he said.

"Tattoo artists often meet clients alone and trust strangers to keep their secret. Female artists are particularly vulnerable to sexual violence. In the past, the police have conducted sweeps rounding up artists, Sanlee said. Rival shops have been known to flag artists to the police.

“Since what we’re doing is illegal, we’re in the blind spot,” she said. “Because of that, there are many people that are exploiting the situation.”

Wednesday, May 18, 2022

Medical resident sleep time reduces harmful errors

 Here's a new study of the effect on patient safety of the limitation on resident work hours to no more than 16 hour shifts, which was in effect in the US from 2011 to 2017.

National improvements in resident physician-reported patient safety after limiting first-year resident physicians’ extended duration work shifts: a pooled analysis of prospective cohort studies  BMJ Quality & Safety Published Online First: 10 May 2022. doi: 10.1136/bmjqs-2021-014375by Matthew D   Weaver1,2, Christopher P Landrigan1,3,4, Jason P Sullivan1, Conor S O'Brien1, Salim Qadri1, Natalie Viyaran1, Charles A Czeisler1,2, Laura K Barger1,2

Abstract: Background The Accreditation Council for Graduate Medical Education (ACGME) enacted a policy in 2011 that restricted first-year resident physicians in the USA to work no more than 16 consecutive hours. This was rescinded in 2017.

Methods "We conducted a nationwide prospective cohort study of resident physicians for 5 academic years (2002–2007) before and for 3 academic years (2014–2017) after implementation of the 16 hours 2011 ACGME work-hour limit. Our analyses compare trends in resident physician-reported medical errors between the two cohorts to evaluate the impact of this policy change.

"Results 14 796 residents provided data describing 78 101 months of direct patient care. After adjustment for potential confounders, the work-hour policy was associated with a 32% reduced risk of resident physician-reported significant medical errors (rate ratio (RR) 0.68; 95% CI 0.64 to 0.72), a 34% reduced risk of reported preventable adverse events (RR 0.66; 95% CI 0.59 to 0.74) and a 63% reduced risk of reported medical errors resulting in patient death (RR 0.37; 95% CI 0.28 to 0.49).

"Conclusions These findings have broad relevance for those who work in and receive care from academic hospitals in the USA. The decision to lift this work hour policy in 2017 may expose patients to preventable harm."


"From 2003 to 2011, the Accreditation Council for Graduate Medical Education (ACGME) limited residents in their first postgraduate year to a maximum of 30 consecutive work hours, including 6 hours for continuity of care and educational activities (30 hours 2003 ACGME work-hour limit).2 Subsequent evaluations found that shifts of 24 or more hours were associated with increased odds of fatigue-related medical errors and preventable adverse events (PAEs),3 percutaneous injuries4 and motor vehicle crashes.5 A randomised controlled trial found that limiting first-year resident physicians to 16 consecutive work hours significantly improved resident alertness and patient safety.6 7 Altogether, a body of evidence accumulated suggesting that reducing or eliminating shifts longer than 16 hours did not negatively impact resident education and likely improved patient safety and resident quality of life.8 Subsequently, the Institute of Medicine of the National Academies (IOM) reviewed the available evidence and concluded that it was unsafe for any resident physician to provide clinical care for >16 consecutive hours without sleep.9 10 In response, the ACGME issued new work-hour regulations on 1 July 2011, limiting first-year resident physicians to a maximum of 16 consecutive work hours and emphasising a commitment to patient safety and mitigation of fatigue-related risks (16 hours 2011 ACGME work-hour limit).11

"The response within the medical community to the 16 hours 2011 ACGME work-hour limit was mixed.12 Many stakeholders expected the changes to diminish the educational experience.13 The increased frequency of patient handoffs raised concerns, as physician-to-physician handoffs have historically been non-standardised and prone to error.14 In addition, the work-hour limitations were not accompanied by an increased number of residency slots, leading to work compression and a shift in some responsibilities to other clinical providers,15 as well as concerns about resident physician understaffing. Several studies of the 16 hours 2011 ACGME work-hour limit found that it had no impact on hospital-level mortality or mortality following surgical procedures.16–18 In light of these studies and opposition to the work-hour limit from within the medical community, the ACGME lifted the 16-hour limit as of 1 July 2017, again allowing first-year resident physicians to be scheduled for 24 hours of continuous work, plus up to 4 hours for care transitions (28 hours 2017 ACGME work-hour limit)."

Tuesday, May 17, 2022

Fentanyl test strips save lives. Why do Kansas and Missouri ban them?

 You can imagine a world, with virtually no drug abuse, in which we would want to inhibit the recreational use of fentanyl and so might outlaw tools that might promote it.  But that isn't the world we live in, and instead simple tests for the presence of fentanyl can save lives by preventing fatal accidental overdoses.

Here's an editorial bemoaning the fact that these tests are sometimes banned.

Simple, cheap fentanyl test strips save lives. Why do Kansas and Missouri ban them? BY THE KANSAS CITY STAR EDITORIAL BOARD

 "As the Kansas and Missouri legislative sessions come to a close, there’s at least one more matter lawmakers in both states should attend to. They could save lives with tiny strips of paper that can detect the presence of fentanyl in recreational drugs. 

"Fentanyl test strips are designed to prevent people from overdosing on illegal recreational drugs that have been spiked with potentially fatal amounts of the synthetic opioid fentanyl. 

"Overdose deaths have risen to well over 100,000 a year in the United States. Synthetic opioids — primarily fentanyl — are the primary reason for the overall increase in total drug overdose deaths, according to the U.S. Drug Enforcement Administration. 


"But in some states, including Kansas and Missouri, the strips are considered drug paraphernalia and are not legal. Now there are proposals before both state legislatures to decriminalize them. This is not a partisan issue, and no one should oppose this move."

Monday, May 16, 2022

Happy birthday to Bob Wilson

  Happy birthday Bob!

Sunday, May 15, 2022

U.S .annual overdose deaths surpass 100,000, a new high

The CDC has released some new (still preliminary) data on drug overdose deaths in the U.S.

Here's the NYT:

Overdose Deaths Continue Rising, With Fentanyl and Meth Key Culprits. New data shows a surge in overdose deaths involving fentanyl and methamphetamine. Overall, the nation saw a 15 percent increase in deaths from overdoses in 2021.  By Noah Weiland and Margot Sanger-Katz

"After a catastrophic increase in 2020, deaths from drug overdoses rose again to record-breaking levels in 2021, nearing 108,000, the result of an ever-worsening fentanyl crisis, according to preliminary new data published on Wednesday by the Centers for Disease Control and Prevention.

"The increase of nearly 15 percent followed a much steeper rise of almost 30 percent in 2020, an unrelenting crisis that has consumed federal and state drug policy officials. Since the 1970s, the number of drug overdose deaths has increased every year except 2018.


"Drug overdoses, which long ago surged above the country’s peak deaths from AIDS, car crashes and guns, killed about a quarter as many Americans last year as Covid-19.


The Guardian  also has the story:

‘Completely devastating’: US passes 1m overdose deaths since records began. 2021 was a record year for overdose deaths with an estimated 107,622, CDC says, an increase of 15% from the previous year  by Melody Schreiber

"US overdose deaths in 2021 [were] a record year for such fatalities with an estimated 107,622, the US Centers for Disease Control and Prevention (CDC) said on Wednesday.

"It was an increase of 15% from the previous year, which was also a record.

"The US has now passed 1m overdose deaths since the CDC began collecting data about two decades ago.

"The surge in deaths in 2021 was fueled primarily by fentanyl, a highly dangerous synthetic opioid that accounted for about 70% of fatalities.

"Black American men and boys have the highest fatality rates from drug overdoses, followed closely by American Indian and Alaska Native men and boys – a significant increase among these demographics in recent years.


"The almost fiftyfold increase in illicit pills containing fentanyl happened between 2018 and 2021, she said – a “huge proliferation”.


Here's a CDC chart:

12 Month-ending Provisional Number and Percent Change of Drug Overdose Deaths

Saturday, May 14, 2022

Xenotransplantation and pork chops

 There's been recent news about xenotransplantation, with attempts made to transplant kidneys or hearts from genetically modified pigs into humans.  Those haven't been successful yet, but the organs weren't immediately rejected, because the special pigs involved don't have the alpha-gal sugar molecule on their cells that non-human mammals have and that immediately alerts human immune systems to reject the organ.

But while pig organs aren't ready for transplant yet, it turns out that there are some people who are allergic to the alpha-gal sugar, and hence to meat. But they can eat the meat of these almost-transplant-ready pigs.

The Atlantic has the story:

A Tick Bite Made Them Allergic to Meat. And an organ-transplant company has an unexpected solution. By Sarah Zhang

"It just so happens that the same molecule—a sugar called alpha-gal—that causes the human immune system to reject pig organs also causes the tick-associated red-meat allergy, known as alpha-gal syndrome. To make a pig whose organs could be harvested for transplant, Revivicor first had to make an alpha-gal-free pig. And when it did, the company realized that transplant surgeons weren’t the only ones interested.

"Since last fall, Revivicor has been quietly sending refrigerated packages of alpha-gal-free bacon, ham, ground pork, chops, and pork shoulders to people in the alpha-gal-syndrome community. These packages were free, but Revivicor has told the FDA it is exploring a mail-order business. And so a biomedical company has found itself an accidental purveyor of specialty pork products."


In the background of this story is Revivicor part of the public benefit corporation United Therapeutics, founded by the remarkable Martine Rothblatt.


Friday, May 13, 2022

The No Club, by Babcock, Peyser, Vesterlund and Weingart

 I had the pleasure of hearing Lisa Vesterlund talk about her new book, The No Club: Putting a Stop to Women’s Dead-End Work, by Linda Babcock, Brenda Peyser, Lise Vesterlund, and Laurie Weingart.

One nice market design suggestion comes from the (well documented) observation that it's disproportionately women who volunteer for 'non-promotable' tasks, such as note-taking at meetings, and writing up the minutes afterwards. These are tasks that anyone can do pretty well, so the suggestion is that they should be assigned by lottery, rather than by seeing who volunteers...

Thursday, May 12, 2022

Medical residents organize to bargain collectively

Medpage has the story:

Stanford Health Care

"In December 2020, Stanford Health Care rolled out a COVID-19 vaccination plan that excluded nearly all 1,400-plus resident and fellow physicians from eligibility. For the residents and fellows who had been working tirelessly at the frontlines of the pandemic, this was the last straw. In our view, this didn't appear to be a one-time mistake of some algorithm, but a continued pattern of employer neglect and exploitation of our labor. That's when we knew we had to start organizing for real power.

"A little over a year later, on February 22, 2022, we had gathered supermajority support from our co-workers to unionize with the Committee of Interns and Residents (CIR). However, our request for voluntary recognition from Stanford was denied. In the face of potential anti-union tactics from Stanford, we communicated through our own website and tweetorials, re-centering our mission for a meaningful voice and focusing on widespread support, not only from our own residents, but also from our local elected officials and other labor unions.

"The Stanford nurses were some of our biggest supporters -- we shared a need for better working conditions to deliver better patient care. They have been unionized for over 50 years, and their collective strength protected them from being stretched even thinner during the pandemic. ... Despite a tough employer campaign to defeat our union, we won our election 835 to 214 this week.

Greater Lawrence Family Health Center

"On March 15, 2022, we officially won our union. While the hospital's efforts did manage to turn a few who had initially supported the union, 72% of our unit voted in favor of CIR in an election where every single resident participated. A 100% turnout rate is unprecedented even in a small program. It speaks volumes to how connected we've become throughout this process. We are in solidarity with house staff everywhere going public, filing for unionization, and taking the next step toward social progress and justice for academic medicine.

"While we don't know where this new movement in resident unionization will ultimately lead, we know we're headed in the right direction. Doctors are people too and we must rehumanize medicine for everyone -- both our patients and the people who make hospitals run.

"Jessie Ge, MD, is a fourth-year urology resident at Stanford Health Care. Rayyan Kamal, MD, is a second-year family medicine resident at Greater Lawrence Family Health Center.


Wednesday, May 11, 2022

Surrogacy in wartime Ukraine

 The NY Times follows the war-disrupted surrogacy market in Ukraine, where in addition to the normal surrogacy issues, surrogates have to decide whether to deliver in Ukraine or in Poland (where surrogacy isn't recognized), and parents have to decide whether to attend the birth in Lviv or wait for the baby in Poland.  It's tough stuff, for both surrogates and parents.  I'll just excerpt some of the background information on surrogacy.

The Nightmare of Being a Surrogate Mother in Wartime. Ukraine’s booming surrogacy business has become a logistical and ethical mess — and hell for the women at the center.   By Susan Dominus

"After a friend of hers worked as a surrogate, Maryna started considering the possibility. Ukrainian law required that women who would be hired as surrogates had already successfully given birth, and she had two healthy daughters. By helping another family, she hoped to buy a home, a goal that would otherwise have been a significant stretch for her and her husband, who worked on cars. On Aug. 21, she was impregnated with two embryos for a couple in North America. Surrogates for Delivering Dreams typically earn around $18,000 a year, but because she was pregnant with twins, she would be paid a bonus of several thousand more. In Ukraine, a typical schoolteacher would make less than a quarter of that over the course of a year.


"Delivering Dreams, Kersch-Kibler’s agency, celebrates, in its name, the meaningful benefit of surrogacy to both parties in the arrangement — for the parents, the gift of a biological child; for the surrogate mother, a potentially life-altering sum of money. That arrangement is also, however, a business contract, which entails, for the expectant women, a job — one with managers, rules, oversight and risks to their physical health.

"Even as reproductive technology has advanced, the number of countries that explicitly permit international paid surrogacy has dropped. Opponents of the practice argue that the transactional arrangement commodifies one of the most profound human experiences, the birth of a child. Feminists tend to divide on the ethical issue of surrogacy, with some seeing in the practice a means of financial autonomy, and others perceiving it, especially in less-developed countries, as a kind of reproductive coercion: Could a woman really be said to have choice in deciding to become a surrogate, if doing so was the only way to lift her family out of poverty?

"Concerns about trafficking and exploitation led India to pass a law in 2019 that officially shut down what was once, according to a 2012 estimate, a $2.3 billion surrogacy industry. Cambodia, Thailand and Nepal also once served as frequent destinations for foreigners seeking paid surrogates until those countries, too, legally restricted the practice.

"In those countries, as in many others, the only form of surrogacy allowed is among nationals, provided that no compensation is received. Altruistic surrogacy — in which only pregnancy-related expenses are covered — is legal in countries like England and the Netherlands; in heavily Catholic countries like France, Belgium and Spain, the intended parents of children born to surrogates often face challenges claiming their legal rights as parents, despite a European Court of Human Rights decision, finalized in 2019, that recognized children’s inherent right to belong to their biological families. In other countries, like Argentina and Albania, the law does not address the issue one way or another, diminishing the market for commercial surrogacy, as the ambiguity leaves all parties vulnerable in the event of a dispute. In the United States, legal protections vary state by state: Some states, like Illinois and California, allow surrogacy contracts; others do not recognize surrogacy contracts but do provide for judicial recognition of intended parents’ claims to children born with the help of a surrogate. In Michigan, paying a woman to be a surrogate is a felony.


"Since various countries have restricted international surrogacy, agencies have rushed in to take advantage of Ukraine’s relatively well regulated market. One Ukrainian embryologist has estimated that before the war, roughly 3,200 implantations were performed in the country each year — creating, through the fees and also the associated tourism, a new, thriving economic sector. Typically, parents who opt for surrogacy fly into the country and work with a local clinic, conceiving embryos that are subsequently implanted in the wombs of Ukrainian women whom they have interviewed (usually by video call) or chosen from descriptions the agency provides. In some, but not all, cases, the parents choose to build a relationship with the woman carrying their child, texting regularly, even flying in to visit her; almost always, the parents fly back into the country nine months later, either to be there for the birth, if all parties agree, or to receive their newborn and take the child back home.

"Even under the best of circumstances, the arrangement can be fraught. Now, Ukraine’s surrogates are working under the worst of circumstances, forcing everyone involved — agencies, intended parents and surrogates — to make decisions based on imperfect information regarding matters of life and death. The starkness of war has laid bare the many ethical tensions that exist in surrogacy arrangements, casting into bold relief the power dynamics that underlie a contract in which a woman signs over the whole of her physical self.