Crab Bucket

Terry Pratchett taught me about “crab bucket” in Unseen Academicals [1]. I don’t know if it’s a metaphor of his part of England, or if it’s unique to the Discworld.

… She reached down and picked a crab out of a bucket. As it came up it turned out that three more were hanging on to it…

… ‘Oh that’s crabs for you,’ said Verity … ‘Thick as planks the lot of them. That’s why you can keep them in a bucket without a lid. Any that tries to get out gets pulled back…’

Crab bucket, thought Glenda … That’s how it works. People from the Sisters disapproving when a girl takes the trolley bus … Practically everything me mum ever told me…

I did find a wikipedia entry for “crab mentality”, which led to a 1994 article …

When teachers at Frank W. Ballou … talk about the crab bucket syndrome …

But the author doesn’t describe where the term comes from. It’s a useful concept; reminds me again how much we need to recreate anthropology.

[1] Written when Pratchett was well into his eventually terminal dementia syndrome, so while it’s very enjoyable for fans it’s not his best work.

Those moments when you feel the walls of reality fall away

I’m working through a tedious form that requires me to look up old information from dusty files. I step away to eat and locate some documents.

I then return to the form and open it.

And it’s been filled out.

My eyes bug out.

My jaw drops.

I’ve switched timelines. I have a brain tumor. I’m more demented than I thought.

Then I notice the date - February, 6 months ago. I’d filled the same form out for the same people before. Forgetting that is well within the scope of my congenitally poor and not improving memory.

By chance, on returning to my work, I took a different folder path and found the original document.

A perfectly reasonable explanation. At least that’s what I tell myself. In this timeline.

Creaks and clicks in geriatric bikes

I like a quiet bike as much as the next neurotic guy. So the creaks and clicks in my 20 yo Cannondale T400 have been distracting. Like dental surgery.

I finally clear up the problem. Except it was problems, the plural. Plural recurrent actually, which was why it took a year to get through them all, and why the damned bike seemed haunted. The big tubes on this aluminum touring bike didn't help, they sent the sounds everywhere. Danged hard to localize, as is often true.

I went through a lot of diagnostics and replacements, which sometimes seemed to work but they the creak-click would return — though maybe with a bit different sound. In the end of day these were the obvious culprits:

• The seats: Swapping seats didn’t hep too much. Turned out I had swapped one mediocre old seat for another, both were stretched and creaky. I bought myself a nice (i.e. pricy) Fizik Antares R5 for my birthday and that creak went away.
• The damned Shimano Shimano PD-A530 SPD Dual Platform pedals: WTFShimano?! The worst pedals every made. Five years ago I compared Shimano’s surprising quality to Apple’s. Since then both brands seem to have gone on a bender. One of my creak-clicks was a bad bearing in the first pair I owned. I bought a replacement and they were defective out of the box. I returned those under warranty and 10 months later that one started a creak-click. Hard to diagnose because the seat was creaking too, but in the end these pedals were 80% of the problem. I’m debating switching to Crank Brothers for all of my bikes. Shimano sells a Deore XT dual platform pedal in Europe, but they are hard to find here. I guess I could try those, but I’m loathe to send Shimano any more money.

These were things I replaced that probably didn’t contribute to the problem.

• Seat post: For $25 I picked up a Nashbar replacement post that’s much nicer than my original single-bolt post. Didn’t make any difference but I wanted the better adjustment anyway.
• Bottom bracket bearing unit: This was because I couldn’t believe it was the pedals clicking - again. Original was 20y old, so probably not a bad idea anyway, but didn’t make any difference.

Old bikes are like old men. It’s usually not a weird and exotic disease, it’s more likely two or three common diseases that just coexist.

In defense of Donald Trump.

Trump is more racist and sexist than most 70+ yo white men. He is amoral and a con man. He may be a sociopath and probably has a narcissistic personality disorder. He is living proof that we need drug and dementia testing for presidential nominees. He is dim. Even by the standards of presidential contenders he is a nasty person.

Trump is the anti-Obama. Irrational, impulsive, thoughtless, intemperate … it’s a long list.

Trump makes paranoid H. Ross Perot look good. He exceeds the sum of the worst of GWB and Richard Nixon. I cannot think of a post WW II major party candidate this bad.

He may be worse that Cruz.

Yeah, America’s two leading contenders for the GOP nomination in 2016 were both awful. Two of the worst options in the past 100 years. That means something. It means despite our immense wealth and overall prosperity, despite our social and environmental progress, America is in trouble. Trump isn’t America’s festering abscess, he’s the fever. It’s not enough to treat the fever. We need to drain the abscess.

So where is the abscess? Why did the GOP drift further and further from reality? How did a political party that once supported science become anti-evolution and, most insanely, pro CO2 production?

I think Noah Smith has a part of the answer. The GOP had deep internal divisions and over the past 15 years the glue gave way.  The Party is broken, it has to reform.

Maybe that’s the whole story. I don’t think it is though. I think the abscess is the bottom 40% of white America. The great unwanted. The Left Behind. The new disabled. A cohort that has seen 40 years of shrinking opportunity. The economy has moved on; we don’t have vast office buildings full of thousands of people who move paper from cabinet A to cabinet B.

The odds are we’ll fix the Trump fever. Hell, even the Koch brothers favor Clinton. Obama is in the game and on top of his form. Women are starting to realize sexism is no more dead than racism.

But the abscess will still be there.

Sometimes fever is a friend. It tells you something bad is happening.

Life tip: photograph or photo-scan cards and special correspondence

A few years back, around the time the iPhone camera became very good at close photography, I began to photograph Father's Day cards and the like.

Later, when products like “Scanner Pro.app” made it very easy to create PDFs that went to Google Drive, I began to phone-scan correspondence I wanted to keep.

I store the PDFs on my computer. The photos go into my photo library and become a part of our screensaver slideshows. Most of the originals go to recycling.

It would have been great to save more of my mother's correspondence this way, but that would take time travel. We didn't have the tech back then.

It's a good idea.

Double unders

People come to our gym and in two months they’re doing double unders.

I am not those people. After ****** of practice I do about 5 DU with 2 singles between each as I advance backwards across the floor. (I think this is “piking” and is related to using a longer than desired rope)

As someone who has failed at this for so long I’m well placed to recommend these tutorials….

• 10 Tips on the Double Under
• 10 Common Double Under Mistakes, and How to Fix Them

I’d add …

• If you’re practicing at home a glass of wine might not hurt
• Try a metronome? (free on iPhone)
• Chest has to stay high.
• Warm up with 25 singles, then 10 slow high singles, then to the DUs.
• I like long handles that amplify my poorly coordinated wrist snap
• I think my speed rope is too long
• I might try the beaded rope, they are supposed to help old people. (50 isn’t old …)

I’m on record saying if I ever get 10 consecutive DUs and a single bar muscle up I’ll get a tattoo. Presumably a very small one. I’m not worried.

Signs of progress from O'Reilly and Limbaugh.

Limbaugh says that black Americans really need to stop talking about that unhappy slavery episode. O’Reilly tells us the slaves building the White House were well fed and had good government housing.

I’m going to claim this is progress.

People like Limbaugh and O’Reilly (or at least their listeners, Limbaugh is more cynical, vicious, and venal than ignorant) have lived in blinders all their lives. That’s a lot of people with the white privilege of denying American history. We’re not the only ones who do this of course. Japan has had a bit of trouble with its history too.

Now the blinders are coming off. Americans, especially those who went to high school before 2000, are learning more of the nasty bits of American history. If you’re a white American it’s a disturbing experience. So now we have “get over it” and “the housing was good”.

But this is progress. It’s the difference between, say, Holocaust Denial and “that was long ago”. 

Progress doesn’t mean things turn out well. These are truly scary times. But absence of progress is worse.

Informatics core: US genomic and healthcare standards have a common problem.

My current work means I’ve spent many hours plumbing details of major American and international health care standards, particularly FHIR, HL72, CCDA/HL73 and NCPDP. 

It reminds me of a project from the late 00s when I was exploring genomics database.

There’s too much documentation.

Specifically, there are too many information sources that are not well maintained. There’s always funding to create a repository or database or web app, there’s never funding to sustain it. All the partly implemented solutions create a misleading cloud of chaff.

One has to dig through to the core source — if it exists. The core sources for HL7 3 are, unfortunately, very hard to work with (lots of reasons for that, including the way HL7 used to be funded). FHIR core sources are easier to navigate — but already there are various extensions and fissures. Best not to mention use of the Federal Registry as a reference information source.

The structure and maintenance of knowledge sources is a core informatics problem. We need to get back to our roots in the National Library of Medicine and library science. That would require funding though…

Systemic failure in American medicine: combining ICD-10-CM with "leaf code" reimbursement rules

This is very much “inside baseball”. It’s related to professional work I do. It’s incomprehensible to most people, but it’s having a big impact on your healthcare. An impact that the vast majority of healthcare workers and administrators won’t understand. Only the coding specialists in unlit basement rooms know what’s going on.

For several decades American physicians have used a system of codes to justify procedures and bills. They’re like the occupation codes you might use to fill out your tax form, but there are thousands of them. They are called diagnostic codes, the old system was called ICD-9-CM. (ICD codes are also used in public health, epidemiology, research and information exchange, but that’s not what I’m writing about.)

For various reasons, which I personally think were unwise, the ancient ICD-9-CM system was recently replaced with a less ancient ICD-10-CM system. That was a disruptive change with limited value, but the change in coding systems by itself wasn’t the disaster. Yes, I know many physicians think the coding system change was the disaster, but they’re wrong. There are more codes, but there are ways that software systems could have made that proliferation manageable. The real problem is more subtle.

The disaster was that Medicare (CMS) and payers retained an old ICD-9 rule. A rule that only the “leaf” (most detailed) codes in the ICD-10-CM system could be accepted for payment. If you want to know what I mean by “leaf” check out this example from the ICD-10-CM codes for Type 2 Diabetes Mellitus:

Doesn’t it look a bit like branches of a tree? Only the little green arrow codes can be accepted for payment. They are “most detailed”. They have “no children”. They are “leaves”.

If you’re with me so far, here’s the punchline. ICD-9-CM had “leaf” codes that essentially meant the same as the “root” code, ICD-10-CM doesn’t. (In the example above E11 is a root code.)

I’m simplifying a bit here. ICD-9-CM was a mess. It didn’t always have “unspecified” or “not otherwise specified” leaf codes that meant the same as the root code, but it mostly did. Diabetes Mellitus 250.00 meant the same as 250. 

ICD-10 is more intelligent, it doesn’t have these duplications. If you want to just say a patient has Type 2 Diabetes Mellitus you could just say E11.

Except you can’t get paid for saying E11. Because of the leaf rule. So that’s not an option in health record or billing systems. Instead physicians must choose between:

But what if they don’t know or care if the patient has complications? Maybe they’re seeing them for a cold. Maybe the patient doesn’t know if they have DM complications. They have to choose one at random. It’s the same everywhere.

This is madness. The problem isn’t ICD-10-CM. It isn’t even the leaf code requirement. It’s the combination of the two.

In a sane world the fact that we combined an essential healthcare code system that lacked redundant leaf codes with a payment system that required leaf codes would be treated as a systemic failure. There would be congressional hearings and root cause analysis.

Instead we stagger on into the fog.

Fixing disc brake squeaks - mountain bike.

I found 2 techniques for silence squeaky disk (disc) brakes — all involving rotor cleaning. (If pads are contaminated they need to be replaced.)

• clean with isopropyl alcohol
• Silence That Squeaky Disc Brake - Pinkbike: the big guns

The PinkBike reference claims “weak break in period” is the number 1 sin:

Brake squeal is most commonly caused by a weak initial break-in period, with the introduction of impurities like chain lube or chemical bike cleaners to the braking surfaces as a close second.

 I bet I’m guilty.

break in your disc brakes with a series of very firm stops from a reasonably good speed before you get out on the trail. This properly deposits the pad material on the braking surface of the rotors. Typically, most riders drag their brakes lightly around every corner in the trail, as well as down easy descents. Lightly dragging a new set of brakes is a perfect recipe to create brake howl - which is why you see so many cross-country riders with noisy brakes. 

Rule one: brake like you mean it, then let go.

The PinkBike reference is hard core. Clean with automative brake cleaner, Sand with 11 and 220 grit abrasive cloth (I’d try an orbital sander) then break it in properly.

I’m going to try the easy step first. The big job will wait until it gets really annoying…

Finding yourself in the mathematical universe of pi

I’m reading Tegmark’s Our Mathematical Universe. It’s the layperson version of a 2007 paper (downloadable)

I explore physics implications of the External Reality Hypothesis (ERH) that there exists an external physical reality completely independent of us humans. I argue that with a sufficiently broad definition of mathematics, it implies the Mathematical Universe Hypothesis (MUH) that our physical world is an abstract mathematical structure. I discuss various implications of the ERH and MUH, ranging from standard physics topics like symmetries, irreducible representations, units, free parameters, randomness and initial conditions to broader issues like consciousness, parallel universes and Godel incompleteness. I hypothesize that only computable and decidable (in Godel's sense) structures exist, which alleviates the cosmological measure problem and help explain why our physical laws appear so simple. I also comment on the intimate relation between mathematical structures, computations, simulations and physical systems.

As best as I can tell, Tegmark, more or less like Einstein, thinks of spacetime as a static thing; we relate to spacetime as a tune relates to a CD. It is a bit of an illusion that one thing follows another, or that we seem to have a past and a future, or that things are created and end. Rather as a block of granite contains all sculpture, or the alphabet all knowledge, meaning is just an arrangement that fits. “I think therefore I am” indeed.

Which made me wonder if I could find “I am John” in pi. Seems a bit similar. If pi is random then that string should show up somewhere.

Happily the “National Energy Research Scientific Computing Center” will search pi for strings based on a 5bit English character set encoding.

Alas, “I am John” is not in the span they search…

search string = "i_am_john"
45-bit binary equivalent = 010010000000001011010000001010011110100001110
string does not occur in first 4 billion binary digits of pi

My daughter’s name does turn up:

search string = "brinna"
30-bit binary equivalent = 000101001001001011100111000001
search string found at binary index = 872397609 

binary pi : 0010101000010100100100101110011100000101111010011010101101000011
binary string: 000101001001001011100111000001
character pi : aqyfuc_nj_--yjbrinnaoiuma.fvfkbv.bcfgz
character string: brinna

This essay should be in there too, assuming pi digits really are deterministically random. Somewhere. Which I think has something to do with the Mathematical Universe. Somehow.

PS. From the arXiv paper: “… quantum field theory states such as the Hawking-Hartle wave function or the inflationary Bunch-Davies vacuum have very low algorithmic complexity (since they can be de- fined in quite brief physics papers), yet simulating their time evolution would simulate not merely one universe like ours, but a vast decohering ensemble corresponding to the above-mentioned Level III multiverse. It is therefore plausible that our universe could be simulated by quite a short computer program.”

Desensitization therapy for dogs with fear of thunder, lightning and, of course, firecrackers

This is the season for traumatized dogs. We’ve had two husky mixes, the first (Molly Thunderpaws Squirrelbane) ended up needing oral valium during storms. She wanted under our bed but couldn’t quite fit. Which was why the feet of the bed rested on four hockey pucks.

I often wondered what visitors made of the hockey pucks. It probably livened our reputation.

Kateva Rose Cupcake (young kids did naming by then) isn’t so bad, but as she ages she’s more worried. She’s also having more trouble getting under the bed. So, again, hockey pucks.

So a NYT article caught my attention …

Why Thunder and Fireworks Make Dogs Anxious

… at least 40 percent of dogs experience noise anxiety, which is most pronounced in the summer. Animal shelters report that their busiest day for taking in runaway dogs is July 5…

… the first drug approved by the Food and Drug Administration for canine noise aversion (a term encompassing mild discomfort to phobia) came on the market. The drug, Sileo, inhibits norepinephrine, a brain chemical associated with anxiety and fear response…

…  a micro-amount of a medication approved as a sedative for minor veterinary procedures —- a flavorless gel, measured in a syringe, that is squeezed between the dog’s cheek and gum and absorbed within 30 minutes.

Orion, the Finnish company that developed it, tested it on several hundred noise-averse dogs during two years of New Year’s fireworks. Three-quarters of the owners rated the dogs’ response as good to excellent; their pets remained unperturbed. The drug lasts several hours, after which another dose can be administered.

A syringe costs about $30 and holds several weight-dependent doses. Sileo’s main side effect, in 4.5 percent of dogs, is vomiting…

… The optimal solution, vets say, is catching the response early, and desensitizing the dog with calibrated recordings of the offending noise, and positive conditioning…

You know, they could have mentioned the deconditioning part earlier. I found more on that from a reputable source …

Fear of Thunder and Other Loud Noises : The Humane Society of the United States

Begin by exposing your dog to an intensity level of noise that doesn't frighten her and pairing the noise with something pleasant, like a treat or a fun game. Gradually increase the volume as you continue to offer her something pleasant. Through this process, she'll come to associate "good things" with the previously feared sound.

Example:

Make a tape with firecracker noises on it.
Play the tape at such a low volume that your dog doesn't respond fearfully. While the tape is playing, feed her dinner, give her a treat, or play her favorite game.
In your next session, play the tape a little louder while you feed her or play her favorite game.
Continue increasing the volume through many sessions over a period of several weeks or months. If she displays fearful behavior at any time while the tape is playing, STOP. Begin your next session at a lower volume, one that doesn't produce anxiety, and proceed more slowly.
For some fears, it can be difficult to recreate the fear stimulus. For example, thunder is accompanied by lightning, rain, and changes in barometric pressure; your dog’s fearful response may be to the combination of these things and not just the thunder….

Sounds like the desensitization routine could be tricky, but I’ll give it a gentle try.

There are web sites that sell recordings, but a search on iTunes found several $1 recording from “Nature Sounds”. I’ll buy one, probably one with rain and thunder. It’s easy then to play it softly over the kitchen speakers while Kateva eats a treat-enhanced dinner.

Traffic skills for cyclists: MSP options

Just did some research on bicycle traffic training options for St Paul and Minneapolis (MSP, Twin Cities). I found:

• Bicycle Alliance of Minnesota: “BikeMN uses the Smart Cycling Curriculum developed by the League of American Bicyclists.” Liberal options for rescheduling classes. Their calendar shows some Cycling Savvy and other org classes as well as their Traffic Skills 101.
• Bikeed.org (Bike Ed) has a free online classroom portion of TS 101 - sponsored by City of Houston.
• Cycling Savvy: a national 3 part course, bike skills, classroom video session and a city tour. $95 for three, MSP schedule available. "CyclingSavvy is a program of American Bicycling Education Association, Inc. (ABEA). The course teaches the principles of Mindful Bicycling:”

See also:

• League of American Bicyclists (in my youth was “league of american wheelmen”) Ride Smart program. You can buy a 32 page “Quick Guide” for $3.00.

Update 6/21/2015. I did the Houston City online version of the TS 101 class. It took about 20 minutes (not 5 hours), but I knew the material already. I wrote some quick reactions in an email to a friend who teaches this class…

… I passed so I can now access the reference material on http://bikeed.org/studentDashboard.aspx.

The course is a neat introduction to cycling, but for me it was a bit of an odd mix. The sections on maintenance, bike types and purchase aren't really part of traffic safety. Rock dodge and Instant Turn are neat technical moves, but really almost nobody is going to learn those.

I'd have wanted to see more on visibility issues (fog, dark shadow, use of daytime lights, twilight), identifying and managing distracted drivers, assessing risks of rear ending at stops from distracted drivers, route selection (google maps is good), traffic speed and risk of death, watching for poor/angry/impaired drivers, trail etiquette expansion, specific recommendations on hideous yellow/orange vs. generic "bright colors", more on reflective gear and clothing, more on bike light choice and blinkies, more on reflective helmets, etc.

Single biggest omission was route selection and assessing road risks explicitly. Biggest change in last few years is smartphone-distracted drivers, but probably hasn’t been time to respond to that.

I think some of this material is sensitive because course is a mixture of advocacy (bicycling great!) and risk management (human drivers incompetent). So maybe reluctant to say "You are engaged in a risky activity. To minimize risk stay on bike trails and watch for incompetent cyclists. When you drive with cars you are taking more risks. Here is how to minimize them if you decide you still want to do this..."

Related: Be the Best You Can Be: Special needs urban bicycling - what streets are safe?

Driving under the smartphone influence: changing my bicycling style and changing laws

Emily was waiting to turn left when she was rear-ended. Our Subaru survived with injuries, the distracted driver’s car was badly damaged. At the body shop she was told their rear-end business used to be seasonal, but now it’s year round.

That fits with what I see driving and bicycling, and with my city’s one a day pedestrian and cyclist toll. Humans were never good at driving, but smartphones have made us much worse. Computers are indeed having mixed effects on our economic productivity.

As usual the fix for a technology failure is more technology. One day, maybe twenty years from now, autonomous cars will drive us (until they demand the vote). Today automatic braking systems reduce rear-end collisions 40%. These braking systems should be mandatory on all new cars; but they should also be required to recognize bicycles waiting in a line for a light to change.

That’s because I’m not as tough as our Subaru. If I’d been on my bike, instead of Emily in our Forester, that distracted driver would have killed me. If she couldn’t see a car with a blinking turn signal she definitely wouldn’t see me.

Smartphone-impaired drivers have changed the way I ride my bicycle. Bicycling with cars has always been a matter of calculated risk, and now those risks have shifted. A few years ago it often made sense to move into a line of cars, particularly when turning left or straight but sometimes even when turning right.

It’s still risky to be on the curb side at a light, or to pass stopped cars on the right, but now being the car line is newly dangerous. There are too many impaired drivers on the road.

So I’m changing my strategy. I’m shifting to the curb side more often, moving in front of a car line only when rear-end risks are relatively low. Really I should shift to running the red light when cross traffic is clear — that eliminates much of the rear-end and right turn risks. Unfortunately that angers drivers too much to be a great idea.

We desperately need new approaches to deal with our transition period before the AIs take over, a period when humans are much worse drivers. We need mandated collision avoidance systems that detect pedestrians and cyclists. We need more segregated bike lanes. We need to eliminate right turns on red lights (sorry fellow drivers, we’re the ones with the substance problem). We need to drop speed limits. We need panopticon traffic cameras to automatically cite drivers who violate crosswalk and intersection laws. We need ongoing “sting” operations to generate thousands of traffic citations, because nothing motivates drivers like a ticket.

We’ve got a lot of work to do.

Dissecting drug price leaps: The hydroxychloroquine story

Hydroxychloroquine (HCQ) is an old drug. It’s a descendant of chloroquine, which is as old as dirt:

Chloroquine was discovered in 1934 by Hans Andersag and coworkers at the Bayer laboratories, who named it “Resochin".  It was ignored for a decade because it was considered too toxic for human use. During World War II, United States government-sponsored clinical trials for antimalarial drug development showed unequivocally that chloroquine has a significant therapeutic value as an antimalarial drug. It was introduced into clinical practice in 1947 for the prophylactic treatment of malaria.

HCQ largely replaced chloroquine in the 1940s; when it was on patent it was sold as Plaquenil. Today it’s still used for malaria, but it’s mainstay drug for Lupus (increasingly popular) and rheumatoid arthritis. Some rheumatologists use it for osteoarthritis because it’s thought to slow cartilage erosion (few studies, mixed results).

It has a fascinating 400 year history (emphases mine):

The Nine Lives of Hydroxychloroquine | RheumNow

The HCQ story begins in 1638 when the wife of the Viceroy of Peru, Countess Cinchona, acquired malaria while living in the New World. Rather than getting the “approved” therapy, blood-letting, she was treated by an Incan herbalist with the bark of a tree (eventually, named for the countess-Cinchona Tree). Her response was dramatic; when the Viceroy returned to Spain, he brought with him large supplies of the powder for general use, which at the time was controlled by the Church and was thus called “Jesuit’s Powder”.

It took nearly two centuries for the active substance, Quinine, to be isolated from the bark (and was eventually to make a name for itself as a tonic to be added to gin).

Over the next century, quinine would become a common component in folk medicines and patent remedies for the treatment of malaria in the southern states of America, as well as for generic malaise. By the 1940s, quinine, or rather its derivative chloroquine, was recognized for its anti-malarial properties and found use among troops fighting in the Pacific during WW-II. However, it was noted that this compound had significant toxicities. In 1945, a modification of this compound via hydroxylation led to the development of HCQ, which was found to be less toxic and remains in use, without change, to this day.

Over time, physicians began to experiment with the medication and, in the early 1950s, began to use it for the treatment of SLE. ….. combination therapy [for rheumatoid arthritis], which became popular in the 1980s and has culminated in the recent studies showing the notable efficacy of triple therapy when HCQ was combined with MTX and sulfasalazine.

Most of the science regarding HCQ’s mechanism of action falls in the realm of speculation…

..  has been clearly shown to reduce the number of SLE flares, reduce the severity of SLE flares when they occur, can in some cases lead to “remission” including lupus nephritis, increase the risk of flares when stopped, and decrease the doses of prednisone needed to control the disease. In at least one study, the use of HCQ increased survival in patients with SLE by 70%…

HCQ used to be quite inexpensive — in the range of $30 a month, covered by all insurances. It’s a generic drug and it’s been off patent for decades. Things changed in late 2014 and early 2015 - shortages developed and the price jumped. The 2014-2015 Ebola epidemic disrupted health care systems and led to a surge in malaria and then high demand for HCQ to treat it.

The demand surge ended, and the drug shortage resolved, but the price has stayed high. In the US a month’s supply now costs about $400. Why hasn’t the price come down?

There used to be at least two manufacturers, but now there is only one: Covis Pharmaceuticals. Covis was acquired by Concordia, a company that makes its money by increasing the costs of old drugs. Ranbaxy, an Indian manufacturer, had severe quality issues and has itself been acquired by another similar predator - Sun Pharma. Sun is another Indian multinational with substantial power in the US generic drug market. Sun has also had FDA warnings; it’s likely their competitive edge comes from dodging FDA rules.

With the price increase the most profitable payors, like Aetna, have dropped coverage for HCQ. So the price has gone up ten fold, but Aetna’s patients are paying out of pocket.  Aetna has been more profitable than less unethical competitors like Cigna. So Aetna is growing and Cigna is being acquired. That’s another reason why DOJ should block Aetna and Anthem acquisitions.

Hydroxychloroquine is just one drug, but it’s a classic story. Dodgy manufacturers, globalization and regulatory evasion, monopoly development, price manipulation, ruthless healthcare insurance companies — the same themes appear across the lengthy ASHP drug shortage page.

There are fixes. The DOJ should absolutely block consolidation of US payors. Voters should demand government function — which today means voting against the GOP. Governments should coordinate responses. We need the “public payor” option that had to be dropped from Obamacare to keep a few Dem senators on board (all GOP opposed of course). We need the national formulary price negotiations most other countries have. We need a mixture of regulatory actions, market forces and buyer coordination to drive competition into the drug manufacturing industry. We need to end the monopolies.

It all begins with voters. Fortunately we have a meaningful election coming up. If the GOP is routed they may reform as a “smart-government” rather than “no-government” party — and we’ll have a better chance at intelligent action going forward. Vote accordingly.