Run to Stop Cancer

This is not a fundraiser. “Run to stop cancer” is scientifically sound advice.

Unlike diabetes and coronary disease, which predictably prey upon the overweight and out-of-shape, cancer may seem to strike out of the blue, affecting the young and healthy as well as the wanton. And since cancer is fundamentally a genetic disease, it’s easy to feel helpless to combat a potential death sentence inscribed in your DNA.

But as Aaron Carroll points out, science is showing that genes alone do not account for even half of all cancer risk:

Using sophisticated modeling techniques, the researchers argued that less than 30 percent of the lifetime risk of getting cancer was because of intrinsic risk factors, or “bad luck.” (NYT/Nature)

Another study from JAMA Oncology found that 25% of cancers in women and 33% in men were potentially preventable by lifestyle modification: smoking cessation, moderation of alcohol intake, maintenance of healthy body weight, and regular exercise.

So lifestyle choices like diet and exercise seem to play as big a role as genetics in moderating cancer risk at the population level. There are individual cases where genetic mutations wholly predetermine cancer occurrence, but the vast majority of cancer types have a lifestyle-risk element. This should be a message of empowerment. Cancer is not destiny; we can and should use our powerful tools of lifestyle change to prevent cancer before it happens.

For details on the adrenalin theory of how exercise fights cancer, check out this piece in The Economist.

Hospital Consolidation

You may have heard about how the current health care market is all about “consolidation“. Consolidation can be a broad term, but it usually refers to hospitals acquiring other hospitals, physician practices, and even absorbing insurance companies. While some of this is in response to the Affordable Care Act, consolidation was already occurring before 2009. Big Companies have been a Big Thing for a while: agriculture, media, law, and other industries have been undergoing consolidation similar trends, perhaps in an effort to become more resistant to risk.*

http://www.forbes.com/sites/theapothecary/2015/01/12/what-60-minutes-didnt-tell-you-obamacare-will-drive-up-the-cost-of-hospital-care/#328f2bc4b3e4

Some people think of consolidation in a good way, kind of like bundled testing. In theory, it should be administratively simpler. Less hospital systems = less billing, recordkeeping, and bureaucratic burden because patients are less likely to be shifting between health systems when there are fewer of them. Administrative costs are a likely etiology of some of the health care spending growth in the United States in the last two decades.

Others think of consolidation more like… a pneumonia. You know, like when a lobe of your lung gets all fibrotic and stuff. One of the many things I have learned in medical school is that consolidated pneumonias are bad.

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Figure 1: A gross anatomical specimen consolidated lobar pneumonia. (Operative term here is “gross”).

Less hospitals = less competition = higher prices for the same services, whether that be for third party payers or patients themselves. There’s some evidence to show that price inflation is a common adverse effect of hospital mergers. And there is also evidence to suggest that high prices are bad for patients, too.

The Federal Trade Commission is the agency tasked with preventing enormous  hospital mergers from having this effect on the healthcare economy. They recently sued Penn State’s Hershey Medical Center when they attempted to merge with PinnacleHealth System. The FTC’s core assertion was that the merger of these two systems would limit care options for patients in the “Harrisburg area” and that the combination of these two systems would cover 65% of Southern Pennsylvania. The Pennsylvania Office of Attorney General agreed with the FTC, citing nearby UPMC’s similar grip on healthcare delivery in the Pittsburgh region as an example.

While these assertions may not sound all that impressive (especially if you, like most people, know very little about rural Pennsylvania) it was a big blow to the FTC’s recent track record of success when it came to knocking down huge hospital deals.

This decision has interesting implications for a newly minted large hospital system — Vanderbilt Health. Shedding its University trappings, the Vanderbilt Health System is now more poised to be more “agile” in a rapidly evolving healthcare market, ready to start forming “partnerships” and investing in “ventures” in the years to come. I interpret this to mean that they are set to absorb more hospitals, physician practices, and other entities. While improved coordination of care might be one outcome, based on consolidation and price trends for other regions, it also will mean higher prices.

Only time will tell if we are a consolidated pneumonia for Tennessee or not.

*Or maybe, they’re trying to become Too Big to Fail??

Primers on Consolidation:

Alex Tolbert, Health Care Consolidation: What Consumers Need to Know”, The Tennessean (March 8, 2016) http://www.tennessean.com/story/money/industries/health-care/2016/03/08/health-care-consolidation-what-consumers-need-know/81493602/

The Robert Wood Johnson Foundation, The Impact of Health Care Consolidation — Update, The Synthesis Project, June 2012  http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf73261

Top 10: The Best Songs From Hamilton

6358021610526848122095891113_tjLin-Manuel Miranda’s Hamilton will go down as one of the major artistic achievements of the decade (century?) The combination of subject matter (the Founding of the nation), social significance (a non-white cast and composer telling the story of our all-white Founding Fathers), and theatrical greatness (a mix of hip-hop and more traditional numbers) make Hamilton a work that should survive in public consciousness for as long as the United States is a nation – and maybe longer.  Here are some of the highlights:

10. Cabinet Battle #1: Thomas Jefferson vs. Alexander Hamilton in a rap battle representing the nation’s first major political rivalry. Hamilton (Miranda) goes for the throat:

A civics lesson from a slaver. Hey neighbor
Your debts are paid cuz you don’t pay for labor
“We plant seeds in the South. We create.”
Yeah, keep ranting
We know who’s really doing the planting

9. My Shot: An early energy and character builder for the boyish Alexander: Yo I’m just like my country/ I’m young, scrappy, and hungry/ and I’m not throwin’ away my shot.

8. You’ll Be Back: King George (Jonathan Groff ) reigns as the petulant monarch pining for his wayward love, the American colonies, to return to him: When push comes to shove/ I will kill your friends and family/ To remind you of my love.

7. Burn: An appropriately named slow burner. The plaintive violin line gives it a Funeral-era Arcade Fire feel.

6. Alexander Hamilton: The iconic opener introduces the voices of a terrific cast and provides a whirlwind tour through the youth of America’s supreme “bastard, orphan, son of a whore.”

5. History Has Its Eyes On You / Who Lives, Who Dies, Who Tells Your Story: George Washington (Christopher Jackson {what a voice}) waxes eloquent on the Founders’ burden of legacy building in “History.” “Who Lives” picks up the melodic and thematic strand in a stirring closer; its only flaw is the perhaps excessive exposition at the expense of lyrical flow.

4. Guns and Ships: History has never been more fun than the motor-mouthed French-accented rapping by Daveed Diggs. Also a reason why it makes little sense to see this show live without listening ahead of time. No way your ears can keep up with his tongue twisters.

3. Wait For It: High school history books portray Aaron Burr as a bit of a nut. But Miranda turns Hamilton’s ultimate enemy into a compelling and sympathetic foil. Played by Leslie Odom, Jr., Burr gets some of the play’s most memorable lines. And Miranda’s powerful use of the chorus heightens the emotion.

2. Say No To This: The sultry Maria Reynolds (Jasmine Cephas Jones) nails the show’s musical climax with her “STAAAAAY.” The harp glissandos in the chorus give me tingles.

1. Satisfied: A wedding toast warps into a flashback: a love story fraught by jealousy, restlessness, and familial duty. The frustrations of 18th century gender dynamics find expression in Renee Elise Goldsberry’s doubly impressive performance as rapper and balladeer.

Trump’s Health Care Plan Is One Sentence Plus Hand Gestures

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Obamacare, whatever its flaws, has extended insurance coverage to an estimated 16 million people.  Donald Trump promises to repeal it and in return offers no direct support for poor and middle class families who struggle with health costs. His sole substantive proposal on health care is to deregulate insurance companies to make it easier for them to sell insurance across state lines.

Trump summed up his plan in the debate on Thursday: “When you get rid of the lines [around the states] it brings in competition.” Circular hand motions were added to make the point more vivid.

There are two major problems with this proposal: (1) it doesn’t work, and (2) even if it did, it’s nothing close to a complete health care plan for the nation.

In theory driving down costs by encouraging interstate competition is a nice free-market idea. But as the Upshot has detailed, the evidence that this works in practice is nil:

The trouble is that varying or numerous state regulations aren’t the main reason insurance markets tend to be uncompetitive. Selling insurance in a new region or state takes more than just getting a license and including all the locally required benefits. It also involves setting up favorable contracts with doctors and hospitals so that customers will be able to get access to health care. Establishing those networks of health care providers can be hard for new market entrants….

In 2012, Ms. Corlette and co-authors completed a study of a number of states that passed laws to allow out-of-state insurance sales. Not a single out-of-state insurer had taken them up on the offer. As Ms. Corlette’s paper highlighted, there is no federal impediment to across-state-lines arrangements.

The laborious work of setting up a network of providers is not something that out-of-state insurers can easily replicate, and as far as the evidence goes, there’s no sign it would have any effect on the insurance market or costs to consumers.

Even if eliminating state barriers somehow restrained growth in health care costs, repealing Obamacare would toss 10 million+ back into the realm of the uninsured. What would happen to people with pre-existing conditions? That Trump hasn’t even thought about addressing these issues highlights how shallow his approach to policy is. After eight months of running for president all he’s picked up on health care is an irrelevant sound bite on “lines around states.”

In the clip below, when Dana Bash asked Trump if he has any other health policy ideas to add, Trump responded: “There’s nothing to add. What’s to add?” Meanwhile his odds of winning the GOP nomination are approaching 80%.

American Exceptionalism and the 2016 Presidential Election

To chime in on the Hillary-Bernie debate, I just want to say I wholeheartedly support Bernie Sanders’ campaign. He speaks to my heart and what I want for all people in the United States and the World: harmony, freedom, love, compassion, equality, fairness. If I voted with my heart, I would vote for Bernie. I will, however, be voting with my finger; punching through a hanging chad waiting for it to fall to the ground before rejoicing like all Jewish grandmothers across South Florida (I mean my nice neighbors down by the beach.)

Just kidding. This election cycle, I will vote with my head. And in the upcoming Democratic Primary, I’m voting for Hillary. She represents what is great about America. Power, Opportunity, Optimism, and Freedom (though perhaps this one slightly less so than Bernie, I must admit). What’s more she represents what is exceptional about America, and what has, ironically, taken somewhat of a back step during the era of Obama: Diversity.

Her recent pledge to end racism with a $125 billion budget speaks to the transcendence of her candidacy. With her politicking ability, she also represents the most uninterrupted path forward for our country’s less fortunate. Her candidacy is the only logical progression of the Obama presidency, by all sane measures, a success. She is the single most qualified candidate in the entire field for the position and could wield a mighty, yet gentle sword for goodness of our country and our world.

Right now, however, I am less than optimistic about her ability to win the election given the latest trajectory of the national polls. She may have all the ability and connections in the world to bring politicians and lobbyists together in Washington and produce real change, but to get there she needs to inspire her people. Because ultimately, we, the American people, regardless of background, will be the ones implementing and leading her change if she is elected as the next President.

So Hillary Rodham Clinton, you have my primary vote during this election. It’s not November 8th yet, though. I can still vote with my heart.

Scalia’s Healthcare-Related Jurisprudence (and Mic Drops)

Aside from his reputation as a towering conservative legal mind, Antonin Scalia was probably best known for his zingy dissents and equally sassy majority opinions on virtually every legal matter brought before the Supreme Court of the United States. Unsurprisingly, on healthcare issues, Scalia remained staunchly committed to the kind of originalismtextualism, and gloves-off humor he was best known for.

antonin_scalia_2010

The most recent challenge to the Affordable Care Act, King vs. Burwell (2015), centered on the question of whether the ACA’s Exchanges, where subsidized health insurance would be sold, needed to be established “by the State” (as opposed to administered by the federal government) in order for purchasers to qualify for subsidies. If interpreted as written, the ACA would have been gutted of one of its central goals. But true to the text of the law, Scalia insisted that the ACA needed to be interpreted as it was written. “It is bad enough for a court to cross out ‘by the State’ once,” Scalia bemoaned, “But seven times?” While health policy wonks and economists were worried about the practical effects King could have on the viability of the ACA, Scalia worried about the future of the rule of law in a world where laws are conveniently reinterpreted to suit someone’s agenda: “Words no longer have meaning if an Exchange that is not established by a State is ‘established by the State.'”He  remained concerned about the precedent set by this style of interpretation, predicting that “The somersaults of statutory interpretation they have performed […] will be cited by litigants endlessly, to the confusion of honest jurisprudence.”

Scalia was no stranger to controversy, and this remained true on issues pertaining to healthcare, too. He wrote the majority opinion  in District of Columbia vs. Heller (2008), which supported the individual right to bear arms under the Second Amendment. In the face of revisionist arguments about the scope of what the Constitution could protect, Scalia admitted that while it was possible the Constitution could be outmoded, ultimately “[…] what is not debatable is that it is not the role of this court to pronounce the Second Amendment extinct.” Only the Legislature could do that.

In the world of patent law, Scalia also wrote a number of influential opinions that shaped the drug industry’s patent litigation strategies. In Commil v. Cisco (2015), most recently, the Court decided that believing in good faith that a patent was invalid is enough to absolve the defendant of infringing on the patent holder’s rights. Scalia defended that interpretation by writing that “Saying that infringement cannot exist without a valid patent does not ‘conflate the issues of infringement and validity’ any more than saying that water cannot exist without oxygen ‘conflates’ water and oxygen.” Understanding the intricacies of science necessary to making just determinations of law was a source of frustration for Scalia more than once. In Association of Molecular Pathology vs. Myriad Genetics (2013), where the Court needed to decide whether a company could patent a DNA sequence, he said “I am unable to affirm those details [of laboratory DNA synthesis] on my own knowledge or even my own belief. It suffices for me to affirm, having studied the opinions below and the expert briefs presented here, that the portion of DNA isolated from its natural state sought to be patented is identical to that portion of the DNA in its natural state; and that complementary DNA (cDNA) is a synthetic creation not normally present in nature.” Though Scalia probably never developed a coherent theory of intellectual property or patent law for that matter, his disdain for poor logic rang through the diverse opinions he penned in this field.

In an era of Congressional gridlock and dysfunction of the most dangerous branch of government, Scalia stood by his vision of lawmakers who actually wrote laws that made sense on their own terms, and that were true to the words they contained. He held himself to similarly high standards. If he could be faulted for occasional inaccuracies in his opinions and occasionally straying from his textualist roots, he was an inspirational leader when it came to being a vocal supporter of unpopular opinions at times. And perhaps — more importantly — a man who never let his robes disguise a wry sense of humor. He brought life and color to the dry legal battles that shape our rights, obligations, and opportunities as citizens — and healthcare professionals.

 

Other Resources:

  1. A summary of upcoming SCOTUS cases that may be affected by the loss of a well-known conservative thinker on the bench.
  2. SCOTUSBlog‘s coverage of Healthcare cases on the docket.
  3. A 60 Minutes Episode on Justice Scalia.
  4. The immediate impacts of Scalia’s death

Superdelegates Don’t Count. Not Yet.

With respect to my friend and colleague Nikhil, his post earlier this week detailing the “win” Hillary Clinton actually had in New Hampshire this week is based on bad math.

Well, the first part, at least. The contention that a Trump nomination-slash-establishment implosion spells good tidings for the Democrats is certainly a valid one. As the Republicans seem to veer more and more toward nominating a candidate that evokes more Barry Goldwater than Ronald Reagan, any Democratic winner (but especially the establishment candidate) stands to benefit.

Where the Hillary-Actually-Won-That-Night argument falls short is on the delegate count argument. If you Google “Democratic delegate count,” you’ll see this:

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Wow! How did Hillary “earn more New Hampshire delegates” than Bernie Sanders after getting a thorough beatdown in nearly every voting demographic on Tuesday?

The answer is simply that she did not. The only delegates worth counting as actual votes toward a nomination, right now at least, are the pledged delegates – these are the delegates assigned and bound by party rules to vote for one candidate or another according to the outcome of the popular vote in a given state primary. In Iowa, Clinton took 23 pledged delegates to Sanders’ 21; in New Hampshire, Sanders won 15-9.

The rest of that whopping lead Clinton seems to possess actually does not exist. These are the “superdelegates,” who essentially represent the Party Establishment – federal legislators, key party officials, and other prominent Democrats. These superdelegates, who make up about 15% of the total delegate count at the convention, sit wholly outside the voting primary/caucus framework and are free to cast votes however they see fit at the convention.

Why a superdelegate exists and has voting privileges at the convention is a little bit dry and dates back to 1980 after the disastrous nomination of George McGovern. No one wants to hear about George McGovern.  Trust me.

(If you care, though, for a great summary and FAQ on superdelegates see this Paste Magazine piece by Shane Ryan.)

Importantly, a superdelegate from New Hampshire – for example, Jeanne Shaheen, the senior senator from the state, who supports Clinton – can vote at the convention for Clinton, Sanders, or Vermin Supreme if she so chooses.

What some outlets chose to do was to suddenly dump the lump sum of all “committed” superdelegates into their delegate tallies, thus giving the appearance of a huge Clinton lead. Others, like CNN, only added in the superdelegate commitments from New Hampshire, which is silly because superdelegates are as tied to their state as they are to a candidate – which is to say, not at all.

Plus, these superdelegates who say they are committed to one candidate or another mostly declared their support weeks or months before the NH primary – so this is truly old news.

The key to all this, and why it doesn’t matter right now, is that superdelegates are committed to a candidate in the same way that a high school football player may be verbally committed to play for a college. As collegiate coaches know, kids flip their commitments all the time – and superdelegates are no exception.

In 2008, Clinton held a large lead in the “overall” delegate count, which included superdelegates, through the early voting in Iowa and New Hampshire. As Obama gained momentum and started winning primaries, many of the undecided superdelegates – and not just a few of Clinton’s own “committed” superdelegates – flipped to his side. As late as early summer, though, enough factors were in play (including Florida and Michigan’s I’m-taking-my-ball-and-going-home behavior that invalidated their votes for awhile) that the threat of a brokered convention – where party elites would essentially decide the winner of the nomination, despite the outcome of the popular vote – still loomed.

Every time, though, superdelegates mostly go for whoever wins the general popular vote – Clinton or Sanders. Bloomberg’s Jonathan Bernstein said it well six months ago:

…[T]he “supers” have never tilted the nomination; they always line up with the candidate who won the most delegates in the caucuses and primaries. That’s essentially what happened in 2008: Clinton had an early lead in superdelegates, but as Barack Obama started winning caucuses and primaries, he wound up picking up almost all the undecided supers and even some defectors from Clinton.

And the supers will go with the winner in 2016, too. It’s technically possible for Clinton to win the nomination by dominating the superdelegate count even if she (narrowly) loses every state: Thanks to strict proportional allocation on the Democratic side, a candidate only gains a small delegate advantage for a small edge in primary votes. Realistically, however, politicians and formal party leaders would never go against a clear decision by voters. If Clinton lost every state, she would lose her superdelegates, too.

 

A final note: unlike some of the links herein, I don’t actually believe that the mainstream media is engaged in a systematic attempt to cool the Bern. I just think they’re relying on poor form, bad numbers, and maybe a nudge from DNC strategists who aren’t wild about the possibility of nominating a 74-year-old socialist from the Northeast.

How Clinton Won Big in New Hampshire Despite Her Huge Loss to Bernie

Bernie Sanders scored an impressive victory in the New Hampshire Democratic Primary last night, racking up a colossal 60% of the vote to Hillary Clinton’s 38%. And while a Bernie win here is not a huge surprise, this margin of victory (+22) is significantly greater than the run-up polling predicted. He also won among Clinton’s target demographic groups like women and moderates. So Bernie voters understandably see the New Hampshire results as a ray of hope for the “revolution” platform.

Hillary won the delegate count

But if we step back from the raw vote percentages, it’s clear that the bigger winner was actually Hillary Clinton– for two main reasons. First, by virtue of a quirk in the primary system, Clinton ends up getting more DNC delegates from New Hampshire than Bernie does. This is because New Hampshire’s delegation to the DNC includes 8 so-called super-delegates, party officials who are free to vote for whomever they favor regardless of the popular vote in New Hampshire. Six of the eight super-delegates have pledged to support Clinton, while the other two remain uncommitted. Thus, despite a smashing win in the New Hampshire popular vote, Bernie claims only 13 of the state’s delegates to Hillary’s 15 – per CNN. And of course it’s the delegates that ultimately matter for the purposes of winning the nomination!

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So despite Bernie’s great achievement, Hillary – smooth operator that she is – still comes out ahead in the race for the Democratic nomination. And in the upcoming primaries in states like Nevada, South Carolina, and several other southern states, Clinton faces a much more congenial electorate. If Bernie can’t win the delegate tally in independent-minded, heavily white New Hampshire, it’s not clear that he has much of a shot at taking down the Clinton operation in the long haul of the primaries.

Hillary’s GOP opposition just got downgraded

The second reason New Hampshire was a win for Hillary is arguably more important: it shows that the GOP is in shambles. After Rubiobot’s meltdown in Saturday’s debate, the so-called establishment lane of the GOP race went into chaos, with John Kasich emerging as the second place finisher in New Hampshire behind anti-establishment firebrand Trump.

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The problem for the GOP establishment/centrist bloc is that their support continues to be fragmented among Kasich, Rubio, Bush, and Christie. After Iowa it seemed that Rubio might emerge as the champion of this bloc who could challenge Trump and the more hard-right candidate Cruz. But with Rubio tumbling down to a sluggish fifth place finish, it seems more likely than ever the establishment will fail to unite, allowing Trump to divide and conquer and build unstoppable momentum as we head into the heart of primary season.

This is great news for Hillary. Trump has a net favorability rating of -20, and he fares poorly in head-to-head polls against Hillary. By comparison Rubio’s net favorables are -3.5 and he has the best head-to-head ratings against Hillary of any GOP candidate. (For reference, Hillary’s net favorability is around -11.) So Hillary should be delighted to see Trump rather than Rubio emerging as her likely opponent in the general election.

So I’d argue that for Hillary the most significant result of New Hampshire  was neither losing the popular vote nor winning the delegate count but rather watching her most dangerous rival on the GOP side fade to the middle of the pack.

New Hampshire Predictions: In the Wake of Rubiobot

Marco Rubio emerged from Iowa as the momentum candidate in the GOP. His strong third place finish put him close to Trump and decisively ahead of his “establishment” rivals: Bush, Kasich, and Christie. But then came Saturday’s debate and Rubio’s repetition gaffe:

Polls leading up to Saturday’s debate showed Rubio building toward a strong second place showing and another decisive win over his establishment peers, but now Rubio’s stock is dipping back toward the rest of the pack’s. Christie was eager to take down Rubio at the debate, but he came off looking like a bully and probably won’t get much of a bounce out of it. So the immediate beneficiaries of the Rubiobot moment are likely to be the other establishment lane figures: Kasich and Bush. With that in mind, it’s time for predictions for the GOP New Hampshire primary:

Trump: 32  Kasich: 15  Rubio: 14  Cruz: 12  Bush: 12 Christie: 8 Fiorina: 4  Carson: 2

If this plays out, the big picture winner here is also the immediate: Trump. Not only does Trump claim the lion’s share of the delegates but he also benefits from seeing an establishment lane that continues to be fractured and in flux. Will party elites rally around Kasich if he wins? Seems unlikely. But one could imagine them being slower to unify behind Rubio. Meanwhile unless Bush or Christie surprise, they will not have done enough to justify party confidence and might even need to think about exiting the race. If establishment support continues to be splintered among several candidates, Trump’s position will remain relatively strong as the campaign moves into the Southern states.

The Democratic side is much less intriguing in the Granite State. Expect a handy but not race-changing win for Bernie:

Sanders: 54  Clinton: 44

Flint’s Lead Crisis & The Coming Crime Wave

In the wake of Flint, Michigan’s water crisis (check out this timeline for details), it’s worth noting why lead poisoning is so awful not only for the individual families affected but also for the wider community. Kevin Drum’s 2013 reporting on lead as a driver of crime is more important than ever. His work illustrated that rising lead emission was tightly correlated with the crime spike of the 1960s-80s and that declining emissions were tied to falling crime in the 1990s-present:

In a 2000 paper (PDF) [researcher Rick] Nevin concluded that if you add a lag time of 23 years, lead emissions from automobiles explain 90 percent of the variation in violent crime in America. Toddlers who ingested high levels of lead in the ’40s and ’50s really were more likely to become violent criminals in the ’60s, ’70s, and ’80s.

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Similar correlations hold when the data is analyzed at local levels or across countries. Meanwhile neuroscience research has provided a better understanding of what lead does to the brain:

As [public health professor] Reyes summarized the evidence in her paper, even moderately high levels of lead exposure are associated with aggressivity, impulsivity, ADHD, and lower IQ. And right there, you’ve practically defined the profile of a violent young offender.

It’s not hard to connect the dots: lead addles the brain, and the addled brain is prone to crime. Which means that the Flint water crisis of 2014-2016 is not a self-contained fiasco. The water crisis is a lead crisis and thus it plants the seeds for a potential crime crisis in the 2020s and 2030s. For a city that’s already among the nation’s most dangerous, it’s insult to injury.