March 2002 (vol. 18, #3)
1601 N Tucson Blvd #9, Tucson AZ 85716
c 2001 Physicians for Civil Defense
If cure is impossible, resources should not be wasted on ``futile care'' of seriously sick patients-or people not killed im-mediately in a nuclear war. This mentality is accompanied by extreme risk aversion, at least for certain types of hazard.
Though supposed savings are trumpeted, attempts at prevention often cost megabucks-or gigabucks-while savings are trivial or purely hypothetical. For vac-cines, the most cost-effective preventive, the cost-utility ratio ($/quality-adjusted life year saved) ranges from net savings to $140-,000, with a median of $1,100. For heart disease risk counsel-ing, the ratio is as high as $8.9 million (Am J Prev Med 2000;19:15-23). Treatment can be much cheaper: defibrillators in emergency vehicles cost only $39 per life-year saved; mitral valve surgery, only $6,700.
Regulatory costs are much higher. For toxin control, the median cost is $2.8 million, or up to $99 billion/life-year for the chloroform private well emission standard at 48 pulp mills (Tengs et al. Risk Analysis 1995;15:369-390)-also see p. 2.
If challenged, the regulatory forces will shift ground: the cost, however high, is worth it ``if it saves just one child.''
But what if prevention fails-in medicine, or defense? As anti-defense advocates such as PSR love to point out, the disastrous Maginot Line did not protect against all possible points of attack, and then the guns could not be turned around to fire on Germans behind the Line. Likewise, the Mutual Assured Destruction (MAD) doctrine did nothing to protect against the attack on the World Trade Center, or anthrax letters.
In America's Real War, Orthodox Rabbi Daniel Lapin gives the example of two American girls marooned at sea because of a storm and engine failure. The Indonesian boat crew lay back and awaited death. The girls, ``the unmistakeable products of a Judeo-Christian culture,'' attempted to rig sails, capture rain water, and navigate. Which view will win in the culture war?
The worst consequence of overreliance on prevention is the weakening of resistance or defense. The change in mindset has serious consequences, including economic ones. The majority of regulations actually cost lives, simply by diverting funds from more beneficial uses (Hahn RW, Lutter RW, Viscusi WK, ``Do Federal Regulations Reduce Mortality?'' AEI-Brookings Joint Center for Regulatory Studies, 2000). For this reason, John Stossel has suggested that the motto of OSHA should be ``to save four, kill ten'' (Imprimis 5/01).
In national defense, biological weapons are both an example and a metaphor for the importance of host resistance: for resilience, flexibility, dispersal of assets, in-genuity, redundancy, economic strength-and a will to survive.
It is impossible to guarantee that invaders will never penetrate the border, the skin, or medical shields. The very effort to eradicate the last vestige of smallpox (see Jan 2002 issue) also wiped out all natural immunity. And overuse of antibiotics has led to increasing bacterial resistance.
Rather than learning these lessons, the U.S. government is promoting passage of state emergency health powers acts that would increase the unbridled crisis power of governors and appointed officials-to do harm. The acts provide for forced vaccina-tion, without exemptions for medical contraindications or personal beliefs; large-scale forced isolation or quarantine, despite the indications that less extreme measures would be more effective and less harmful (Barbera et al, JAMA 2001;286: 2711-2717); and power to commandeer or seize property. The acts might also penalize provident stockpiling of useful goods (www.aapsonline.org, ``emergency powers'' and ``forums.'')
What should be done? The human body has a highly dispersed mechanism for detecting and identifying foreign invaders and for manufactur-ing, on demand, custom-made antibodies as well as all-purpose bacteria and virus killers. Socie-tal defense mechanism should be modeled in this way.
Unlike the body, which is always on alert, society tends to mobilize defenses upon the occurrence of an event. But as Steven Koonin pointed out at a Caltech conference on biode-fense, ``if the event is covert, ... then there is no `event'.''
Koonin suggests constant facility sampling, or mobile sensors as on municipal vehicles, looking for increased amounts of nitric oxide or other simple molecules that the body uses to fight disease (Engineering & Science 2001;64(3/4):23-29).
Once an event is detected, we need a surge capability to respond. At present, there is no such capability in our medical system, with ``just in time'' ordering, high occupancy levels in hospitals, and limited capacity of public health laboratories.
Koonin suggests HEPA filters, air scrubbers, and positive pressure inside large buildings-at an estimated cost of only tens of dollars per person per year.
However, all the air everywhere cannot be constantly filtered. In a serious biowarfare attack, ``unthinkable'' numbers of casualties could occur immediately. If Americans can overcome their denial about this fact, they can begin to think about how to protect the rest of the population.
There is no substitute for properly equipped shelter for attack by chemicals, biologicals, nuclear weapons, or conven-tional explosives-but of course warning is essential.
When prevention fails, and no magic bullet is avail-able, the only hope is to aid the body's natural defenses-an ancient idea. The first known chemical hormetic was called Theriac, com-pounded of 71 ingredients including viper flesh and opium, administered in wine. King Mithridates VI developed it in the first century B.C. to protect against the occupational hazard of poisoning; it didn't really counteract all poisons and cure all illnesses, even the Black Death, but the concept is vital.
Ken Alibek, former head of the Soviet biowarfare program, concluded that boosting the nonspecific immune system was the most promising method of containing a crisis, if administered within a few hours of an attack. Possibilities include the use of cytokines (e.g. interferon and interleukin-2), which increase the effec-tiveness of lymphocytes and prompt growth and activation of immune cells-a dramatic shift from current reliance on vaccines. The U.S. Marines obtained preliminary approval in 1998 to test such a program (Alibek, Biohazard 1999).
Risk aversion, centralization, and the dead hand of bureaucracy are sapping our strength and lowering our resistance: a change in direction is vital, and not just for bioweapons.
British Columbia's Liberal Party made an interesting campaign promise in 2001: to reduce the regulatory burden by one-third within three years. This implies a commitment first to measure the burden-a Herculean task. By last December, the provincial government had identified 404,000 provincially imposed rules that place any ``compulsion, obligation, demand, or prohibition on an individual, entity, or activity.'' Such rules are a hidden tax but generally escape the scrutiny that opposition parties apply to tax proposals. The cost is difficult to determine, but one study suggests that for every dollar spent by the public sector in administering the regulations, the private sector spends between $17 and $20 in compliance. The $13,700 per Canadian family of four is only slightly less than the average income tax (Fraser Forum 1/02)-and less than the cost of a steel shelter.
The direct cost of U.S. federal environmental, health, and safety regulation is estimated to be about $200 billion/year, about the same as for all nondefense discretionary spending. However, the total cost to the economy is closer to $800 billion, or $7,410 per two-earner family-18% of the after-tax family budget (10,000 Commandments, 2001, available from the Competitive Enterprise Institute, 1001 Connecticut Ave., Suite 1250, Washington, DC 20036, www.cei.org).
The nontangible cost is ``damage so vast, it's often hard to see,'' writes John Stossel (Imprimis 5/01). ``Nor do regulations only depress the economy. They depress the spirit.'' Small businessmen have to get involved in government-or govern-ment will wreck their business. As for those who are supposedly being protected, ``if we frighten [them] about ant-sized dangers, they won't be prepared when an elephant comes along.''
[Baby steps toward regulatory reform in medicine are being explored by an Advisory Committee appointed by HHS Secretary Tommy Thompson. For public meeting schedules and comments by AAPS, see www.aapsonline.org.]
The seeming triumph of personal and economic freedom symbolized by dancing on the Berlin Wall in 1989 was illusory. Instead, we are witnessing a new age of state tyranny, called the ``Third Way.'' Its most appropriate commentator is Max Weber (1864-1920), who saw bureaucracy as the most dangerous and persistent threat to liberty. He wrote that the ``Iron Cage of Bureaucracy'' killed off spontaneity, depressed liberty, and dehumanized those caught in its system. The New Iron Cage that smothered the free market so quickly at the end of the 20th century is driven by risk aversion, write Mark Neal and John Finlay (Fraser Forum 1/02).
An extensive review of publicly available economic analyses of 500 ``life-saving interventions'' (Tengs et al, op. cit.) revealed startling differences in the cost-effectiveness of regulation. On the whole, medical interventions were the most effective, with a median cost of $19,000/life-year, followed by residential, $36,000/life-year, and transportation, $56,000/life-year. Occupational standards cost a median of $350,000/life-year. The authors conclude that ``where there are investment inequalities, more lives could be saved by shifting resources.''
Costs in $/life-year for some environmental rules-on the whole orders of magnitude more expensive than others:
Arsenic emission standards
Benzene controls, various sites $76,000 - $20,000,000,000
Chlorination of drinking water $3,100
Radionuclide emission controls at uranium fuel
There are huge uncertainties in the estimates, as many toxic effects are extrapolated from animal studies.
Still more stunning than the estimates of Tengs et al: the EPA's 1990 hazardous waste listing for wood-preserving chemicals costs $6.3 trillion per statistical life saved (Science 1996;272:221-222).
The worst atrocity of all: starting in 2004, the EPA intends to create a huge scar on a 40-mile stretch of the Hudson River. General Electric will be billed $500 million to pay for removing 2.65 million cubic yards of silt and mud, spreading it some-where in ``dewatering ponds,'' encasing it in concrete, shipping it to Buffalo or Houston for disposal, digging up 2 billion pounds of sand and gravel from somewhere, and dumping that into the Hudson River in an attempt to restore the aquatic environment. In the process, the economy of towns on the river will be disrupted, farms may be destroyed by resuspended contaminants, and drinking water supplies made unusable.
The purpose: removing 150,000 pounds of PCBs (about 1 tsp per 5 acres) sequestered in the sediment. These compounds are highly useful in keeping electrical transformers from exploding. Called ``suspected carcinogens,'' PCBs are associated with a lower than expected cancer rate in persons with occupational exposure. Perhaps they might cause temporary retardation in learning skills in prenatally exposed infants-if their mothers eat a whole contaminated fish every day.
For an extraordinary exposť of this and other EPA horrors, see William Tucker's article in the Jan/Feb American Spectator
. We need a memorial to dump-truck drivers, bulldozer operaters, and those who work near explosive transformers, whose lives will be sacrificed for a ``clean'' Hudson River.
HECATE. I'll...raise such artificial sprites,
As, by the strength of their illusion,
Shall draw him on to his confusion.
He shall spurn fate, scorn death, and bear
His hopes 'bove wisdom, grace, and fear;
And you all know, security
Is mortals' chiefest enemy.
Shakespeare, Macbeth III,v