Friday, 15 March 2019

Vaccines

Hooray, New Zealand gets a measles outbreak. Whether it's due to middle-class antivaxxers, or kids whose parents just have a hard time getting them to the GP - who knows.

But what doesn't make sense to me is why school-based immunisations aren't comprehensive.

Year 7 and 8 students get immunisations at school - for schools that are participating. The kids there get their tetanus, diptheria and whooping cough booster, and the HPV vaccine. 

There's a national vaccinations register, so the public health nurses going into the schools to deliver vaccinations would know which kids haven't had their measles shots. 

So my dumb questions:
  1. Why aren't vaccinations provided at all schools rather than just at some schools? It seems far more efficient to send one nurse out to vaccinate a year-cohort of 20-100 kids than to send 20-100 families each to the GP for a vaccination. 
  2. Why aren't the public health nurses providing the MMR vaccine along with DPT for Year 7 kids for those kids who missed the shot when they should have had it? The shots are government funded anyway already, via the GP. But it's cheaper and more comprehensive for the government to provide them via the public health nurse who's already at the school than through GP offices. 
What am I missing? Is this a doctor-cartel thing where they really like getting the revenue stream from in-GP-office shots?

Thanks to @mikeythenurse for relevant discussion.

Midwife-led care

Midwife and researcher Ellie Wernham and Prof Diana Sarfati discuss their work showing worse outcomes under midwife-led care, and the Ministry of Health's coordination with the College of Midwives in response to that work.



Government policy might not change, but you can update your practice.

The practice we followed a bit over a decade ago:

  1. Find a midwife the second you think you're pregnant - or even earlier. Get one with proper training, not just the midwife certificate. You want a midwife who had rigorous nurse's training prior to going in for specialisation in midwifery. The ones who have training go very quickly. If you wait, you will be left with a midwife with weaker training. 
  2. Pay for shared care with an obstetrician anyway. In 2008, we paid a fixed price of $2k; in 2010, it was $3k. At the time, it was about the same price as a decent flat-screen TV; we kept the old CRT around for a few more years instead. Having your obstetrician available on-call during delivery to provide a c-section if needed is worth it. 

Previously: The Midwives have a history

Wednesday, 13 March 2019

Reducing harm or barking at cars?

There’s an old joke about the neighbourhood dog that loved to chase cars down the road – what would it ever do if it caught one?

The Government has been a bit like that with tobacco harm reduction. A very promising car has come around the corner and stopped. And the puzzled dog is standing there growling at it.

For decades, government has wanted to reduce smoking rates. Why? Smoking causes cancer, myriad respiratory problems, and shortens lives.

To reduce smoking, government used the tools it had at hand – which have gotten some of the job done, even if it was at a cost.

Tobacco excise collects at least three times more in tax than smoking costs the health care system. The 2001 McLeod Tax Review found the relatively low excise rates then in place to be indefensible – if their purpose was to compensate the Government for smoking’s cost to the health care system. Background documents for the Cullen tax review suggested that continued excise hikes would do relatively little to further reduce smoking rates, while imposing substantial regressive burden on poorer communities that continue to smoke.

Plain packaging regulations with graphic warnings may discourage kids from starting smoking, but the evidence is weaker than you might hope: SmokeFree regulations have made smokers pariahs, increasingly barred from places where decent people might witness their habit.

Even though smoking rates have declined, nothing suggests that current policy will achieve the Government’s goal of getting smoking down to less than 5 percent of the population by 2025.

And so we come to the promising car that has come around the corner – new and safer ways of accessing nicotine.

Spend any time walking around a downtown urban centre and you will notice the clouds of vapour coming from former smokers who have switched to a less harmful alternative. Rather than berating smokers for their habit, vaping offered a way of delivering nicotine without combustion’s nasty consequences.

But vaping is hardly the only alternative out there.

Nicotine gum and patches have long been prescribed as stop-smoking solutions, but simply haven’t worked for a lot of smokers trying to quit.

Swedish snus is a powdered tobacco contained in a small sachet that looks like a teabag; users place the sachet behind their lower lip. Snus is far safer than smoking or traditional chewed tobacco, has been an important part of Sweden’s decline in smoking rates since the 1980s, but has only recently became available in New Zealand. And new technology that heats tobacco rather than burn it, and consequently avoids creating the carcinogens that come with combustion, is now on the market too.

There have to be a wide variety of options available for people wanting to cut down or quit smoking because different things work for different people. And making that work requires regulatory and tax frameworks that are fit for purpose rather than refitting those designed for cigarettes.

Last week’s headlines told us Philip Morris offered to stop selling cigarettes in New Zealand if it received a tax break – along with a rather smug reply from the Prime Minister that the company could feel free to stop selling cigarettes any time it liked and shouldn’t need a tax break to do it.

But the reporting really missed what has been going on.

Philip Morris makes one of the newer reduced harm products. Its Iqos device heats non-combustible tobacco rather than burn it. Iqos is less harmful than smoking, but perhaps not quite as safe as vaping – the science is still being settled on that one. Nevertheless, ‘heets’ (the tobacco sticks used in Iqos) face the same tobacco excise rate as cigarillos. Excise on cigarette tobacco is just over $1,300 per kilogram or about $0.92 per cigarette. Excise on other tobacco products, from cigars and cigarillos to snus and ‘heet’ sticks, runs just over $1,150 per kilogram of tobacco.

In every other aspect of tobacco control policy, the Government has been adamant that price is an effective deterrent. That is why it imposes excise taxes that cost a pack-a-day smoker more than $6,700 per year, despite the regressive effects of that tax regularly highlighted in Statistics New Zealand’s inflation updates.

If the Government wants people to switch from smoking to less harmful alternatives, why does it impose the same tax on combustible tobacco as on tobacco that is used less harmfully? A 10-gram packet of snus selling for $21, containing 15 sachets, draws about $11.50 in excise – or about $0.77 per sachet. A 10-gram packet of cigarillos would draw the same excise.

It gets worse. Iqos sticks are subject to smoked tobacco’s plain packaging rules with graphic warnings about the dangers of cigarettes. It could well be worth having a warning on the packs that while they are safer than cigarettes, they aren’t candy. But how does it encourage uptake of reduced-harm alternatives if their packages look just as dangerous as the actually dangerous products?

The dog just does not know what to do with the car it has caught, so it sticks to what it knows – growling. When the Prime Minister quipped that Philip Morris could simply stop selling cigarettes here, she absolutely missed the point. Other cigarette companies would fill the gap in the market. But if reduced-harm products had a greater price advantage over cigarettes through a risk-proportionate excise regime, more smokers overall might switch.

Vaping is a really important part of tobacco harm reduction. But it is not a solution that will work for all smokers. Making sure the regulatory regime is right for other reduced-harm products matters. That means a much lower excise rate for reduced-harm tobacco products – or even zero excise through 2025 – and a bit of sanity in the rules around product packaging.

Tuesday, 12 March 2019

Morning roundup

This morning's worthies:

Monday, 11 March 2019

YIMBY - local bottle shop edition

The local Khandallah DVD shop finally closed down. We'd rented DVDs there roughly once a month - there's a lot of older stuff that just doesn't stream in New Zealand.* So, it looks like we'll have to drive out to Aro Video a bit more often for those things.

In its place, a bottle shop has applied for permission to open. The Council website provides a lot of ways for people to lodge objections but doesn't make any provision for those, like me, who'd like to say Yes In My Back Yard.

So I've mailed the following letter to their Objections address. I don't know whether it will do any good, but remain ever-hopeful.
Secretary of the District Licensing Committee
PO Box 2199
Wellington 6140

Re: Application of The Bottle-O Khandallah, 5 Ganges Road, Khandallah

Dear DLC,

I am writing in support of the application to open a bottle shop at 5 Ganges Road, Khandallah.

I have lived on Nicholson Road, an 8-minute walk from the proposed location, since 2014 with my young family. I am very happy with the excellent beer and wine selection at the local New World; I will be very happy to also have easier access to a local bottle shop. We otherwise do our spirits shopping at Moore Wilson or at Johnsonville, neither of which are particularly convenient.

I expect a Khandallah-based shop will provide a range and selection that suits the local market, and I will appreciate having access to that within an easy walk. Some might object that Ngaio or Johnsonville bottle shops are close enough and that one in Khandallah isn’t needed. Well, Ngaio has a butcher shop, but the Khandallah butcher shop runs a brisk trade; Johnsonville has two Countdowns but our New World also does well. A bottle shop in the village will do no harm and will be great for those, like me, who like to do our shopping while walking from home.

I also strongly urge that the DLC weigh customer access against the inevitable police or medical officer objections demanding more limited hours. Khandallah town centre runs until about 9pm; the application requests that the shop is open until 9pm. The shop should be allowed to run until 9pm, which matches the hours of the local New World. Professionals like me will often do their shopping after getting the kids to bed – so, in the 8-9pm period. I’m generally rushing through at a quarter to nine. Earlier closing times would be an undue burden.

Since the Council website provides a lot of information about how to object to things and no particular way for those who don’t want to object to make their views known, I thought it worthwhile to send in this note. I hope to be a happy customer of the shop, one of the countless moderate drinkers who impose no harm on anyone, who pay far more in excise than we should, and whose views are rarely heard when these sorts of applications are made.

Yes In My Back Yard, please. And perhaps consider making some changes to your consultation website so you might hear more from those of us who welcome things like this.

Sincerely,

If we all start submitting in support of stuff that usually draws objection, maybe the equilibrium changes a bit.

Previously: For a bigger Khandallah


* We subscribe to Netflix, Amazon Prime, Neon, and Anime Lab. Egads but Neon is terrible.

Trust in Online Markets - Condliffe Memorial Lecture

Berkeley's Professor Steve Tadelis is this year's Condliffe Memorial Lecturer at Canterbury's economics department.

You can register here for the lecture scheduled for 5.30, Monday 1 April, in the Undercroft. Canterbury's blurb:
The growth of online electronic commerce and markets is attributed not only to their ease of use but also to the fact that they provide reputation and feedback systems that help create trust. Recent research has exposed, however, that feedback systems are biased, suffer from “grade inflation”, and do not clearly differentiate between higher and lower quality sellers. This lecture highlights recent research that addresses these concerns and presents ways to increase the effectiveness of online reputation systems and markets.
Tadelis spent time both at Amazon and at eBay's research lab. His bio at Berkeley explains why you might want to fly out to Christchurch for this one, if you're in the industry here in NZ:
These days my research primarily revolves around e-commerce and the economics of the internet. During the 2016-2017 academic year I was on leave at Amazon, where I applied economic research tools to a variety of product and business applications, working with technologists, computer and ML scientists, and business leaders. During the 2011-2013 academic years I was on leave at eBay research labs, where I hired and led a team of research economists who focused on the economics of e-commerce, with particular attention to creating better matches of buyers and sellers, reducing market frictions by increasing trust and safety in eBay's marketplace, understanding the underlying value of different advertising and marketing strategies, and exploring the market benefits of different pricing structures. Aside from the economics of e-commerce, my main fields of interest are the economics of incentives and organizations, industrial organization, and microeconomics. Some of my past research aspired to advance our understanding of the roles played by two central institutions---firms and contractual agreements---and how these institutions facilitate the creation of value. Within this broader framework, I explored firm reputation as a valuable, tradable asset; the effects of contract design and organizational form on firm behavior with applications to outsourcing and privatization; public and private sector procurement and award mechanisms; and the determinants of trust. 
Some of his relevant papers and working papers:




Friday, 8 March 2019

Oh Canada

This week's column in the Initiative's newsletter covers the latest Canadian scandal.
Oh Canada

Partisanship is a powerful and deadly drug. Canada is the latest in a too-lengthy list of places badly in need of rehab.

In response to harsh criticism of his involvement in and handling of a corruption scandal, Canadian Prime Minister Justin Trudeau told his Party’s supporters this week that his policy agenda is too important to risk.

Canadian political parties have been too quick to identify the good of the party with the good of the country. As Canadian columnist Paul Wells put it, “a country gets into trouble when it turns every question into an electoral question.”

So what happened?

Last week, Judy Wilson-Raybould, Mr Trudeau’s former Attorney-General and Minister of Justice, testified that the Liberal Party hierarchy, from the Prime Minister down, pressured her to go easy on politically powerful Quebec-based engineering firm SNC-Lavalin.

Facing Canadian prosecution for bribery in Libya, SNC-Lavalin threatened to shift its headquarters out of Quebec. With a Quebec election in the offing and a federal election to come, the loss of a corporate headquarters and associated jobs was too great a political threat. So the Liberals’ enforcers strongly suggested that the Attorney-General enter into a more accommodating arrangement with the firm.

This week, a second cabinet minister stepped down over the same issue, saying she could not defend the Cabinet’s decisions as required under Cabinet responsibility without compromising herself, or the constitution.

On Monday, Prime Minister Trudeau noted that he regretted her decision, that his government was thinking hard about the SNC-Lavalin case, but that it is vitally important to the national interest that the Liberals be re-elected.

In short, good Liberals should be happy to sweep the matter under the carpet to avoid letting the Conservative Party win the coming election.

No price of power is too high to pay if you have convinced yourself that the entire fate of the country is at stake. What is a little erosion of constitutional norms and the rule of law if the nation hangs in the balance?

The question should really be reversed: what is the nation if its political elite quietly condones gross impropriety in pursuit of partisan interest?

We in New Zealand are fortunate that nobody can credibly pretend that a change in government portends the end of days.

But it is up to all of us never to allow our politicians to let partisan electoral ends justify questionable policy means. 
It has long been considered racist, or at best impolite, for those outside of Quebec to point to the obvious corruption problems in Quebec.

During the sponsorship scandal of the late 1990s and early 2000s, Chretien's Liberal government broke standard financial administration rules to funnel money to parts of Quebec at risk of voting for independence. The fall of Paul Martin's Liberal government and three fraud cases ultimately followed.

Maybe you could have then claimed that the country really was at stake.

But that doesn't explain the 2008 Conservative-led prorogation crisis, in which Harper prorogued Parliament to delay a confidence vote, or Paul Martin's 2005 trick in delaying a confidence vote to give give himself enough time to buy a floor-crosser with a Cabinet slot.

America's in far worse shape, sure. But everybody needs to be on guard.