Maybe you should elaborate for some of your readers on the difficulty of arguing for null effects. In my experience, when people trying to get peer-reviewed science pubs arguing for null effects they do multiple experiments or the strongest test possible (which seems most relevant here). This study seems to have done neither and instead subjected all inhaler patients to crappier inhalers by showing that the mildest sufferers of asthma did not show a statistically significant difference in their relatively insensitive test.
This is a hugely important point. And there are a lot of ways in which these tests seemed deliberately designed to "prove" that there was no difference:
- Small sample: the smaller the sample, the harder it is to find an adverse effect. That's why drugs like Vioxx made it to market: distinguishing problems from background statistical noise needed a lot of patients. I know more than one analyst who argues that medical studies are generally too small--because humans are so variable, they don't reliably pick up any but the strongest effects. Hence the steady stream of articles proving that antioxidants will kill you/make you live forever/make you fat/make you thin/improve your singing voice/cause your fingers to fall off.
- Short timespan. One study ran for a year. The rest were 6-8 weeks.
- Only mild-to-moderate asthmatics included. These asthmatics are generally well controlled, and don't have crises that often. If you have a 20% increase in the number of crises over a year, but the asthmatics in your study only have a crisis once a week, it will be hard to distinguish that from statistical noise, espeically given the small samples and short timeframes.
- The differences may be hard to quantify, and thus not show up in the study: if your breathing gets 30% worse, the doctor can't tell unless he happens to have you on hand to measure when you're having an attack. Again, if you only have an attack rarely, he probably won't.
Lest you think this is special pleading, I'm pretty much resigned to my CFC-fate. But this sort of thing matters broadly. The FDA used the lightest possible statistical test on a pretty important medication for millions of asthmatics. Do you want Medicare denying your mother a possibly effective treatment for her otherwise terminal cancer with the same kind of test?
The most worrying thing here is the real possibility that the FDA got the result the EPA wanted. Will they be tempted to get the answer Medicare would like to hear about the relative merits of expensive medications?
Again, I'm not saying we shouldn't do CRE. But for all that Democrats are enjoying thinking of themselves as the Party of Guys in White Coats With The Answers, the binary discussion of CRE (we'll find what works!) is borderline religious in the way it treats government researchers. The process of finding out what works is considerably more complicated than giving a scientist some money and a hundred human lab rats. And there is a real danger that a few studies will end up shutting down potentially useful treatments, as first Medicare and then private insurers turn weak or equivocal results into an iron ruling.
Vioxx may only have been a problem when it was tried at higher doses as a cancer preventative. Another issues to consider is that there appears to be some increased risk of MI (myocardial infarction) with the use of various NSAIDs (nonsteroidal antiinflammatory drugs). Given that people were going to be prescribed/take something for pain, what would be the appropriate comparison group, people not taking any of this category? Then you have to consider the comparative risk that people would have from gi bleeding, a side effect I believe less common with Vioxx than with the traditional group of NSAIDs.
The Democrats are certainly not the party of science - don't you believe one word of it. Nothing is more anti-science than the global warming scam, which is in reality the politicization of science.
I am not saying the Republicans are any better.
Regardless of the harm CFCs may cause, I would think there is room for special exceptions for inhalers. It says a lot about our system that it does not accommodate them.
I think you missed (or failed to expound upon) your correspondent's main point, which is that there's a huge logical difference between (1) significant evidence that there's no effect and (2) a lack of significant evidence that there is an effect. It's very difficult to build (1) and very easy to find (2) — after all, simply shrinking your sample size makes (2) more likely. You'd think that this would be an obvious clue that something's wrong with the experimental design, but many people are clueless and confuse the two anyway.
I agree she missed the real points here. The difficulty of proving null effect -- actually a large enough sample size will make any effect statistically significant -- is only academic. It doesn't mean the public should pay for a small difference that is easily buried in human variability. Otherwise someone could do a very large study to prove that a cancer drug can prolong life by 2 days and we are still supposed to pay 100K for that effect?
It is true that even a small effect statistically significant to be seen may imply that a subpopulation could benefit more from it (but by the same argument, another subpopulation must be harmed by it). Until we learned to distinguish between the sub populations, however, it is right to reject drugs based on small effects.
I think you've got it backward.
She's saying the study used a subset of Small sample of Only mild-to-moderate asthmatics and Short timespan. One study ran for a year. The rest were 6-8 weeks.
This selects out as a subset of asthmatics. The decision to pull the previous inhaler for everyone who used it was based on a subset.
People who support changes to combat global warming need to do their part. Every little bit helps when we are talking about the fate of the world. As Spock said, "The needs of the many out way the needs of the few."
Don't resign yourself to your CFC-less state. I've been suffering for a month now, and my HFA inhalers are either worthless or making things worse. Do what I did, and order CFC inhalers from India. And write and call your congressional representatives and insist on a response. My asthma is mild and well-controlled, or was until 2009, as was yours. If our reactions are this unsatisfactory, I can only imagine how those with more severe asthma are reaction. How many people are dying? How many kids are simply giving up on physical activity? How many people are living in fear? This nonsense needs to end.
Megan said,
■Small sample: the smaller the sample, the harder it is to find an adverse effect. That's why drugs like Vioxx made it to market: distinguishing problems from background statistical noise needed a lot of patients. I know more than one analyst who argues that medical studies are generally too small--because humans are so variable, they don't reliably pick up any but the strongest effects.
....
Just curious - Since finding and examining enough patients is the biggest expense behind developing drugs, are you willing to increase the cost of future drugs by 20-30% to have a larger sample size? 40-50%?
I'm intimately involved in this process, and it's unbelievable to watch these study protocols get designed....as an example:
Study X is for Chronic Obstructive Pulmonary Disease. It needs 2000 patients with moderate-to-severe COPD who will fail a POST-bronchodilator breathing test (i.e. even after they get a drug, they still can't breathe at 70% of normal).
The patients can't have any confounding major medical conditions.
Patients in this population tend to have received alot of drugs which start to cause eye problems. But patients in this study can't have any existing eye problems, so that they can study whether the investigational drug causes such problems.
The patients have to agree to several 12-hour long study visits, agree to coming off all of their current medications for at least 4 weeks prior to receiving study drug. Or placebo. Let's not forget that they might be required to take a placebo.
They might have a exacerbation while they stop taking their medication, and the exacerbation might be enough to hospitalize them. But since they haven't started taking the study drug yet, their hospitalization wouldn't be covered by the study sponsor.
They won't really get any compensation for their participation, because it can't be sufficient to make them WANT to participate. That'd be unethical.
And they won't be able to get the study drug after their participation ends, because it's investigational.
So basically, you need to find people with a significant illness who are willing to put themselves through hardship, sacrifice, and possible severe health problems for the sake of altruism.
Do you have any idea how hard it is to find 2000 people fitting that profile? The time and money involved in simply IDENTIFYING those people?
To give you an example, I just spent about $1 million finding 50 such individuals. That doesn't include conducting the actual research. That's just creating awareness, pre-screening them, and connecting them with the doctor's office.
And this is just one study....you need several such studies to get a drug approved. And many more studies before that to show the drug is worth taking into a 2000 person study.
My point is: People have no idea what it takes to conduct such research, and why drugs are so commensurately expensive. If you want less statistical noise, be willing to pay for drugs that are much more expensive.
Joe
Let me add: Being willing to pay more, or be willing to loosen the restrictions on finding patients, or be willing to seriously compensate patients for their time and participation, or allow a much more universal patient population to take part.
You can't have extremely rigid criteria for inclusion in a study and extremely large study populations. In alot of cases, the patients simply don't exist.
Literally, I have been involved in Alzheimer's studies where there are NOT sufficient patients meeting the protocol criteria to actually meet the study N requirements.
this is common for cancer trials, too.
But in the case of inhalers, it's relatively simple because the older technology still exists; it just requires some effort to reinstate it.
"agree to coming off all of their current medications for at least 4 weeks prior to receiving study drug. Or placebo."
I understand the need to control for the placebo effect. But if we're trying to figure out if a new drug is better than existing drugs, why can't our "placebo" be their existing drug? People wouldn't know if they were really getting the new one or getting their old one, and we could get valuable data on the new one at substantially less risk to the participants in the study.
After all, when there are existing drugs, the relevant comparison isn't whether the new drug is better than nothing. It's whether the new drug is better than current alternatives.
The main focus of your ire should not be the EPA or FDA, but it should be the Congressmen and Senators who voted to verify the Montreal Protocol and implement it in the Clean Air Act amendments. EPA didn't just decide it wanted to ban inhalers, it had to at some point, that point being when FDA said their use wasn't essential. Not essential for some people, essential. The people who write our laws like to use words like "ban" and "essential" without any thought to how the law has to be implemented and without a care to people outside the center of the distribution who will be hurt.
Joe said
I agree completely. The faults Megan highlights all basically reduce the statistical power of the test. Increasing statistical power generally costs money. There's a clear trade-off here.
Why, Megan, why?
If a drug has the potential to cure a terminal cancer, most of the problems you highlighted in the inhaler study don't apply anymore. No more testing on small sample sizes of "mild" patients (you'll have on lack of voluntary severe patients), no problem with the duration of the study, etc.
But, to use your elevated rethoric , would you want your mummy to die of cancer because some medicine is too expensive for her to take, or because an effective drug hasn't been released in the market yet?
Again, there's a trade-off.
In general, the Democrats are the guys in white coats because they are the only ones willing to put them on. As long as the other major political party has senators and congressmen who deny climate change or evolution, pelts will suit their members better.
Also, the concept of "government researchers" reveals a profound ignorance of how medical research is actually conducted. What does Megan think is going on? Researchers are party hacks? Research with government funds is not conducted by the best scientists in a given field?
Most importantly, what's the alternative to government researchers? Private ones? Because I can tell you the researchers themselves would probably be exactly the same people doing exactly the same work, only employed by a different boss.
Ah ha! We have a new "litmus test". You have to believe in climate change and evolution. Otherwise, you're wearing a "pelt". Cute.
Climate is changing. Climate has changed previously. Climate will change in the future. We do not understand why climate changed in the past. We do not understand why climate is changing now, although some of us scream loudly that they know.
Man has evolved in the past. Man is devolving in the present. Nobody is yet able to identify the source of the "primordial ooze" from which nature as we know it evolved, except those who accept the concepts of a creator and creation.
Yes, if you're a congressmen or senator, you do. And the test is actually much more extensive than that. Unless you know something the rest of us don't, you also have to believe man went to the moon. You have to believe in the existence of microorganisms invisible to the naked eye. You have to believe that the solar system has 7 more planets (since Pluto's demotion), even if you personally haven't seen them.
There's no such thing as "devolving". You may mean losing previously acquired features. Which are those?
Evolution doesn't deal with the problem of origin of life. It stops there (or starts there, depending on the point of view). Actually you do have some idea of the composition of the primordial ooze, although some "ingredients" are still very speculative.
But your reasoning is peculiar: nobody has solved problem X, except for the ones who choose to believe in an unsupported solution posited some millenia ago.
This has been discussed quite a lot around here. For the">http://meganmcardle.theatlantic.com/archives/2009/05/high_standards.php#comment-197560">the most recent episode, see mine and especially zic's links on this topic (scroll down for a second post of zic).
I don't believe the inhaler example is an apples-to-apples comparison in the comparative effectiveness research (CER, not CRE) debate, but in some respects, efficacy research is already happening in programs like Medicare to determine the least costly alternative for things like medical equipment.
One more thing
I forgot to say: there's really no alternative to this process, unless you are willing to consider the services of augurs and astrologers. Some studies will inevitably turn out to be flawed, but you can bet the people most likely to control and discover the flaws are other scientists, especially if they have more money and human lab rats.
There's a weird suspicion of the scientific process in this passage. Reminds me of a kind of "Scientists are the news priests" lame vibe predominant in the lost culture of X-Files devotees.
I'll assume that the new asthma inhalers are worse than the old ones, and that the research that verified them was inadequate. Let's further assume that the research was inadequate because the funders had in mind a result they wanted to see.
How is that different from drug trials, where the funding drug company wants to see the new drug seeming to be better than an old drug that's about to go out of patent? Right now, undoubtedly, there are some very expensive drugs and treatments we're paying for that aren't any better than older, less expensive drugs and treatments.
Arguing that sometimes COE results are going to be wrong doesn't get us anywhere. Unless we're prepared to abandon all trials of drugs and treatments, on the basis that funders might influence them, we'll have to muddle through, knowing that science isn't perfect.
With electronic medical records, we'll be able to do some dandy retrospective studies with huge data sets.
At least with the new drug scenario you still have the option of continuing with the older, less expensive drug or treatment, if the professionals are wiling to keep providing the old version (as presumably some at least will if their customers complain enough).
A young man, my son's friend, died today. He was a high school student and suffered an asthma attack.
I don't know if a more effective rescue inhaler would have made a difference, but I certainly wish that the FDA would have made sure an effective treatment was available, before banning one that was.
I can not convey the pain I feel watching my son mourn his friend. I can not imagine the pain the young man's parents are in.
Nimed, here's a test for you: will Democrats support efforts to overturn the FDA's determination, and allow me and others access to CFC inhalers? Because if they won't, well, they're just like people who don't believe in evolution and climate change, except, you know, for the fact that they're killing people and ruining my life.
will Democrats support efforts to overturn the FDA's determination, and allow me and others access to CFC inhalers?
If you can prove it based on science and not anecdotal data then they probably would. Drug companies have to report the complaints and deaths to the FDA, so it's not like there won't be decent data in the near future on the inhalers. That's the point of the entire thread is that anecdotal data like "Treatment A cured me, so it's effective" is not a great way to make medical decisions.
Well, that's reassuring. We know, to the extent it can be known, that CFC inhalers are safe and effective. There's 20+ years of experience and data. It's not a fucking anecdote. We also have some really crappy studies done which were used to ban them. And now you say that, if enough people die we may be able to prove up the case.
And, of course, we can tell based on the FDA's response so far that no amount of evidence is going to persuade them. Blaming the patient, pointing to obviously flawed studies, and suggesting a psychological dependency aren't, shall we say, suggestive of an open mind on the question. And why should the FDA's mind (in some collective sense) be open? Balanced against my life is a trivial risk to the ozone layer.
Man, I have no idea what Democrats will do. I don't know how much more/less effective are HFA inhalers relative of old CFC ones. Judging by the opinion of a good share of commenters in this and the other threads, the HFA ones suck for a sizable proportion of asthmatics. Megan also implied that they have a minimum impact on the ozone lair, and, according to wikipedia (a less than perfect source, I know)
Although, from other article
If all the former assertions are true (including the low impact one), and I have no idea if they are, I would agree the reintroduction of CFC inhalers seems a no-brainer.
What I would say is that this is very much a technical matter, and it's not like the parties have an official positions on it. So if you would ask members of the House or Senate about CFC inhalers, they very likely wouldn't know what you were talking about. That's not the case with either evolution or global warming.
On The Origin of Species has been around since 1859, and has since been incredibly consistent with posterior discoveries in molecular and cellular biology, geology, paleontology, etc. The issue of global warming has also been around for a while, and there's a vast consensus in the scientific community for some time now.
Just to give you an idea, inside the scientific circles the global warming denialists are often compared with Duesberg and other AIDS denialists, which still exist, albeit in ever decreasing numbers, even after some of them died from AIDS:
The reason almost nobody knows about these bunch of kooks is because they aren't funded by the likes of AEI of Heritage. But denying anthropogenic global warming is every bit just as stupid.
Hey Nimed,
I consider myself fairly openminded and educated, and your statements come across as quite the opposite...despite you obviously being an intelligent writer.
AIDS is a disease that took years of observation to define (they had to define what HIV did in the body). A man on the moon is an achievement. Seeing microbes under a microscope is an instantaneous observation.
Making the case that A. the globe is on a substantial warming trend that will cause major problems and B. this warming trend is caused by human emissions....that's a far different proposition. And one that, in my mind, hasn't been proven by any means.
Let me be clear though. I feel strongly we should cut down on emissions....emissions are a sign of waste and inefficiency, and advancement means reducing that waste. For things that are true pollutants (i.e. sulfur dioxide), there were steps that needed to (and have been) taken to reduce their output.
But for the actual argument of global warming, many things have not been hashed out...such as:
1. Why is THIS the perfect temperature we should strive to maintain?
2. Since global cooling inarguably has far worse effects for the human race, would it not be better to raise global temperature by a few degrees to have an additional buffer?
3. Any sea rise will be slow and gradual; would it not be better to begin pumping money into reallocation of coastal communities AS THEY begin to rise, as opposed to restricting economic output to prevent a rise in year over year emissions? Even though the current level of output is already said to be increasing global temperatures?
4. What happens if we as a race take all steps to cut CO2 output, and then a massive volcano erupts or a methane hydrate deposit becomes unstable and releases a few billion tons of methane into the atmosphere? Do we then geoengineer?
5. The earth was far warmer than it currently is in the past....was that a bad thing?
The difference between observing something like microbes, AIDS, or a man on the moon, and deciding whether or not the earth is warming due to our emissions and whether or not something needs to be done.....well, those are far different discussions.
Nobody who understands even the basic underpinnings of climate research suggest we should "maintain" this temperature; and that you even ask this questions indicates who little you know.
It's not a specific temperature that's the problem, it's the rate of change that's the problem.
Juneau, AK is rising at a rate of 3" a year; the land is springing up, released from the weight of melting glaciers. This kind of rapid change is likely to induce seismic activity, meaning more earth quakes, more active volcanos. So it's not just "slowly rising sea levels" that are a concern. And last I checked, natural disasters on this kind of scale are expensive.
Finally on AIDS, I lost my youngest brother to AIDS. He was exposed to the virus during the years C. Everett Koop was Surgeon General, and Reagan muzzled him on the topic to prevent a "public panic.' Several years after Koop retired, I watched a broadcast where he wept as he confessed his guilt about this.
I wept, too. Again and again.
You see, the problem with accelerated temperature change is that by the time you can observe it, like the spread of AIDS, it's already too late.
Zic
Thanks for your response. I'm sorry to hear about the loss of your brother. Science & Politics mix to do dark things in the early days of a new controversial discovery.
Thank you for telling me how little i know about a subject because I brought up "this temperature". I appreciate your assumptions.
My argument with global warming is that I believe the science AND the politics are comingled in a dangerous fashion (sometimes on both sides of the table).
Your analogy of juneau Alaska is fine, but the same has been recorded elsewhere....and far in the past. Little Ice Age and all that.
We'll face a quickly changing earth, as we did several hundred years ago, with far more resources.
If this is a very concerning thing, then shouldn't we master climate-engineering so that we don't have to worry about global warming OR cooling?
It seems like the current course of trying to modify global CO2 output is not working, and India and China will continue to grow apace.
So if we are threatened, then it seems the best solution is careful climate engineering combined with becoming more efficient in our power production, industrial manufacturing, and transportation.
Just my .02
Tree Joe, I agree politics/science is a problem. There are also doom-and-gloom environmentalist; like any cause, they're dependent on a crisis for fund raising. As a journalist, I've had them out and out lie to me, and be righteously pissed when I called them on it in print. That doesn't happen often enough.
With climate, change is the norm. Looking out my window right now, I see beautiful glacial cirques, my vegetable garden in the back yard is built on a mineral-rich soil deposit of ground rock left by a melting glacier, and they tell me that between 15,000 there was five miles of ice here, that melted by about 11,000 years ago. That's a 4,000 year spread for melting, not a single century or decade. The time scales were vastly different than what we might now be considering. Remember, the dinosaurs didn't go extinct with a single meteor strike; individual species evolved and died out over millions of years. The extraordinary events, meteor strikes, etc., were exceptions to the rule, not the rule. We're working fast to create another exception.
As to India and China both follow the US footsteps of industrial development. I would hope we can stop devolving the discussion to 'they won't, so we don't have to.' It's as reprehensible as the "it's already too late, so why bother," meme in vogue amongst the AGW crowd. Because our unwillingness to take responsibility is more likely to foster continued development without responsibility in India and China. And it means we're failing to lead in the technological developments spurred by an effort to at least slow down the rate of temperature change. As you pointed out, there's also tremendous payback to developing less wasteful systems, and much of the discharges we make are indicators of waste.
I agree that the focus of CO2 in the global warming debate is misplaced, and have said this many times on this blog. While it's a key component of the discussion and research, it's not the only component. I much rather see a discussion based on discharges, pollutants, etc., with carbon part of the greater discussion. Instead, it's the shorthand for everything, and it's very misleading. Rather like saying the temperature here today is cooler than average, so global warming must be a myth.
Perhaps the best example I can think of is water discharge; where you can have clean water, no contaminates, that is heated several degrees beyond the receiving water body. It may not be polluted, but it's still causing problems such as oxygen depletion to the receiving water body. This leads to algae blooms, fish kills, and a host of other nasty problems. As a result, discharge temperatures have long been regulated.
Btw, anytime someone uses scientific consensus as an argument, I just think they are unfamiliar with history. Examples abound enormously of scientists, in every field, holding onto erroneous beliefs based upon shoddy scientific evidence and a desire not to be ridiculed.
1. That time is constant everywhere
2. Ulcers are caused by stress
2. A low fat diet is better for your heart
Just a few I'm familiar with....
I hate the new inhalers. They taste bad and I have always thought they were less effective. However the biggest problem is the price. The old ones were generic and cost $10-$15. Now the pharma cos had to get new FDA approval so the generics are gone. Now my cost with the insurance discount is over $40. While this does not hurt me financially to a large degree, for many asthmatics it will. The lower cost used to allow me to keep an inhaler at work, home, car and maybe have a extra on hand. Now I have two and sometimes it is not were I need it.
I guess this is just another way that Government is helping the people.
dtt, I'm told that Walmart offers a 60 dose Ventolin inhaler (HFA, of course) for $11. It's not cheaper per dose, but it might allow you to keep them in a variety of places.
Wouldn't comparative effectiveness data for medical treatments and tests already exist based on the medicine we already practice? I know I've certainly read studies that went back and compared various treatments, it's the science of biostatistics. And as we so often hear here, ours is the best medicine in the world.
(Don't insurance companies do these kinds of studies all the time? I know they do for personal property, I learned that from watching Allstate commercials.)
I don't think determining efficacy of treatments always requires the short-term, limited clinical trials Megan describes. Those are to make certain the drug doesn't kill anyone, from the sounds of it. In many cases, you wouldn't need any trials at all; the information you need to analyze is sitting in patient files all across the country. The data is there, we just can't mine it.
Instead, a system that compared an individuals profile to others with similar problems, and analyzed appropriate treatment based on past outcomes would be much more effective. They already do this for cancer treatments in the clinical trial setting. And such a system would go hand in hand with computerized medical records.
There are issues. privacy being one. But we already have to sort that out. And a I would want a doctor should make the final treatment decision. I'd also want to include alternative treatments; though where you draw the line on the side of wacko is a sticky question; but wacko also applies to some of the "traditional" medicine currently practiced.
I think there's more than one way to skin the cat you give us, Megan. You're inhaler would likely be found out this way.
I agree. I've said again and again that I support comparative effectiveness research. My point, and I think it's an important one, is that we need to make sure that the tests are statistically powerful, and that we're conservative about how much we act based on those results. This was not a jeremiad against government research or government researchers, but a warning that when a Certified Government Researcher says something, we probably attribute more weight and certainty to it than we should.
I’d like to draw attention to MM’s penultimate paragraph, because it seems to me that it contains the heart of the problem. The government could straightforwardly state “It is the public policy of the United States to eliminate CFCs, and asthmatics will just have to suck it up.” (Sorry.) Instead it pretends that new inhalers are just as good as old ones, so no trade-off is necessary. This tendency eventually breeds a widespread corrosive distrust not just of the government, but science in general, and poisons public discourse.
Reading the comments seemingly always drives me nuts, but I'm usually okay with the posts. This time, Megan, you seem to be making some of the same errors as the commenters:
"Small sample: the smaller the sample, the harder it is to find an adverse effect. That's why drugs like Vioxx made it to market: distinguishing problems from background statistical noise needed a lot of patients. I know more than one analyst who argues that medical studies are generally too small--because humans are so variable, they don't reliably pick up any but the strongest effects. Hence the steady stream of articles proving that antioxidants will kill you/make you live forever/make you fat/make you thin/improve your singing voice/cause your fingers to fall off."
By saying this, it shows that you are falling victim to the same fallacy that your correspondent was trying to point out. All of those studies 'proving' that antioxidants do things actually found a significant effect. This means that the sample was large enough to pick up the hypothesized effect. The problem with small sample sizes is NOT that you will see something happening that isn't there (that's caused by all sorts of study flaws that have nothing to do with sample size), it's that you will miss something that is actually there. The anti-oxidant example is just plain wrong.
The other study flaws you mention are relevant, but in a strange sort of way. If you can get past the idea that failing to see a difference is nothing at all like proving similarity by convincing yourself that such a failure would be the best available evidence of similarity, then you should set up your test to examine the effect where it should be at its absolute strongest. Find a population of asthmatics who have extraordinarily frequent and/or severe attacks and have had good success managing emergencies through the use of a CFC inhaler. If the investigator fails to find an effect there, a reasonable (though by no means conclusive) argument can be made that an effect may exist, but it is too weak to be of practical significance.
On the very different topics brought in by the commenters... Regarding the Climate Change argument that keeps popping up claiming that there is no a priori reason to prefer our current overall temperature to a warmer one - well, duh, of course not. It's the rapidity of the change that causes the problems. I think it's fine that NYC has gone from 96000 residents to more than 8000000 residents over the psat 200 years, and it would have been fine if NYC stayed around 100k and Providence, R.I. had become our largest city. What would have been bad is if NYC had gone from 96000 people in 1810 to 8000000 in 1820. I imagine that could have been considered "catastrophic."
And a final note on "Goverment Researchers." There are a lot of scientists who work directly for the Federal government, at institutions including the NIH, NASA, DOD, etc., but they represent a small fraction of the scientific community. Most government-sponsored research is done by scientists who are working at public universities, private universities, quasi-public research institutes, hospitals, and even private industry. They engage in a highly contested competition for grant money from the NIH, NSF, DOD, DOE, USDA, etc., with a panel of experts in the particular subfield evaluating and ranking each proposal on its merits. "Near religious faith" in this system is pretty equivalent to "near religious faith" in markets.
On global warming: What if NYC had gone from 96000 to 104000 in 1810 to 1820?
You are describing a massive increase in global temperature as catastrophic....but we've seen similar such increases in similar timeframes while humans were present on earth. The catastrophic times have been when temperatures dramatically decreased for one or more years (i.e. after krakatoa erupted, global temperatures dropped by several degrees celcius for several years, which caused massive problems).
Can you tell me why the current warming trend is catastrophic?
Re: NIH funded research to academia - My exposure to that for ~6 months left me wondering just why in the hell that system is in place. Rarely did it seemed focused on the advancement of the human race, as a system. Though individual projects did and do yield huge improvements.
Well, if you get cancer, you can thank non-profit groups, funded by NIH for not only finding treatments but for comparing treatment to determine which have better quality-of-life, instead of the old binary does the patient live or die.
Or perhaps the teaching hospitals where your doctor likely received her education.
Just little stuff that's not profitable but necessary.
And the funny thing about temperature shifts -- fast ones have only been down; cooling from volcanos, meteor impacts, and very catastrophic, indeed. There's nothing in the fossil, ice, tree-ring or geological imprints to indicate what a quick 5-degree increase would mean, or even a 2-degree increase. We're going blind into this. In fact, we're careening around a blind curve at 100-mph with no brakes and no seatbelts. But hey, it's been a hell of a ride.
Great post, jason.
The CFC vs. HFL inhaler issue is hopefully unusual in that it was a Yes/No kind of problem. With most medical procedures, there is a ranking of Good/Better/Best modified by the fact that the order may vary person to person. Real effectiveness research would identify which procedures/treatments/medications work best in most people and then identify alternatives that usually don't work as well or have worse side effects. Then people could try the "best" one first and move down the ranking to find the one that works best for them. Ideally, insurance would pay for any of the treatments if the doctor could demonstrate that he tried the recommended one and it didn't work.
But government bureaucrats won't like that, it's too subjective and relies on doctor and patient judgment. We can't have that... everything has to fit into a form or schedule.
"Do you want Medicare denying your mother a possibly effective treatment for her otherwise terminal cancer with the same kind of test?
My Mother?
In the immortal words of Jack Benny: "I'm thinking about it."
But I take it that you like your mother and value her continued well being. So, point taken.