All I can think of while reading Nilay Patel’s software brain essay, quoted and linked to all over the web, is the slight but dense Metaphors We Live By. Software databases — metaphoric file cabinets and manila folders — now themselves becoming metaphors for physical objects is truly Escherian.
Last week I wrote about the scammy way in which a large hospital system, Johns Hopkins, tried to bully us into paying them money we didn’t owe. The responses to it on Mastodon after a boost from Corey Doctorow were unlike anything I have received before, at least in the English language. There was a period of about a year or two, early 2020 to late 2021, when a thing I tweeted in Serbian ended up in a tabloid. Around the same time a Serbian TV station lifted an annotated covid graph I had been updating, without attribution of course. Crazy times, may they never return. Who knew that American “health” “care” “system” could arouse such strong feelings.
An unexpected turn in the conversation was towards veterinary medicine and how it too is undergoing general enshittification under pressure from private equity and no regulatory barriers. Which got me thinking: could veterinary medicine serve as a proxy for what would happen to human medicine if it were to become deregulated? What would a wholly free-market medicine, a libertarian’s wet dream, look like? Now clearly I have neither the time nor the will to sink hours into this kind of research, but do you know who does?
Yes, I asked Gemini to formulate a research plan, then passed on the plan with the Deep Research toggle on to create a report titled “A Comparative Analysis of Veterinary and Human Medicine: Evaluating Deregulation Proxies in the United States Healthcare System”. The goal was to test whether veterinary medicine could serve as a proxy for deregulated human healthcare and personally I don’t think it achieved that objective — this could be just my anti-AI bias — but it did provide a few juicy quotes, such as:
Theoretical free-market economics suggests that corporate consolidation should benefit the consumer by driving down costs through supply-chain efficiencies, centralized administrative services, and immense economies of scale. The empirical data from the veterinary sector directly contradicts this theory. Instead of utilizing their massive scale to lower consumer costs, corporate consolidators have leveraged their localized monopolies to exercise extreme, unchecked pricing power.
And two paragraphs down:
Furthermore, corporate management fundamentally alters the clinical culture at the ground level. Veterinarians operating within these corporate structures report worsening working conditions, including intense pressure from non-medical corporate managers to “do more and see more patients,” meet specific monthly revenue quotas, and upsell clients on expensive and potentially unnecessary diagnostics to satisfy debt obligations. (21) To protect their market share and ensure high practitioner retention despite these conditions, these corporations frequently deploy aggressive non-compete and non-solicitation agreements, legally preventing veterinarians from opening independent practices nearby and artificially suppressing labor mobility. (21) This data definitively indicates that in a deregulated medical market, institutional capital prioritizes relentless profit extraction and margin expansion over consumer cost-savings or provider well-being.
Reference 21, to save you a click, is a letter from Elizabeth Warren to CEO and President of Mars Inc — which in addition to hocking teeth-numbing treats is also apparently a veterinary behemoth — outlining her concerns about the industry consolidation with ever more references. An actual report would have to dig down into them and find primary sources for Gemini’s claims, but even this is publishable.
And here is the conclusion:
Ultimately, the hypothesis that veterinary medicine serves as a highly accurate proxy for human medical deregulation is remarkably robust. The comprehensive data confirms that stripping away third-party mandates, emergency care obligations, and unlimited tort liabilities yields a highly efficient, point-of-care transaction model that eliminates administrative bloat, enforces total price transparency, and accelerates clinical innovation. Yet, it simultaneously exposes the harsh, unyielding realities of a pure free-market health economy. The veterinary paradigm proves definitively that while deregulation optimizes the speed of scientific advancement and the profitability of specialty providers, it structurally abandons the foundational concept of healthcare as a universal human right, replacing it entirely with a ruthless, capital-gated commodity market.
Woah there, Gemini. With such strong language I do feel obligated to declare that the original prompt was as neutral as possible. I wonder what ChatGPT, Claude or Grok would have to say on the topic, and if Grok in particular would have a different view.
📚 Finished reading: Dark Gods by T. E. D. Klein, a short story collection you’d get if you transported H.P. Lovecraft from 1920s New England to 1980s New York City, then asked him to water down the weirdness and narrow the horror from Cosmic to Upper East Side. Which is to say, I wasn’t impressed.
Another weekend, another free hour to improve Inkling, the 95% Gemini-generated Emacs client for Inkwell. In addition to fixing a couple of annoying bugs — and how great is it that every RSS feed is its own unique snowflake? — I’ve added a bookmark manager for micro.blog’s bookmarks, complete with tagging. Next up: adding drafts to Microbe.
A mere 50 pages in and I can already tell that Inventing the Renaissance will be a banger of a book. Three concepts in particular stood out for there relevance far outside that particular period in history:
No surprise that it has been nominated for a Best Related Work Hugo Award, and kudos to Palmer for compelling me to write the first “currently reading” post in almost two years (the last one was also for a book she wrote).
🕹️ Good write up in today’s FT about Esoteric Ebb, a fantasy RPG which seems to be heavily influenced by Planescape: Tornment, Disco Elysium and Terry Pratchet’s Discworld. Sign me up! Mentioned at the end is Type Help, a free-to-play text adventure that is quite unlike any work of interactive fiction I’ve seen before. Recommended.
Tax Day was a good kick in the rear to clean up all the recurring payments that have accumulated over the years. Here are a few notable cancellations:
So with all of that deadweight removed, I felt that I could splurge on a Digital+Print subscription to Nautilus, an even more lay audience-friendly version of Quanta Magazine. Both of those are, of course, wildflowers growing out of the compost pile that was Scientific American. Thus Nautilus joins the Financial Times as the only print editions we subscribe to, all other magazines that come in the mail being hoisted on us as members of various medical societies.
Apart from looking like he has just been on the losing end of a fistfight, and having occasional bouts of nausea, Ben Sasse seems to be doing as well as someone recently diagnosed with metastatic pancreatic cancer possibly could. Both the nausea and his face peeling off are because of daraxonrasib, a new drug which targets KRAS G12 mutations which are common in many cancers but are found in most pancreatic ductal adenocarcinoma (PDAC). As a reminder, PDAC is the one that Steve Jobs did not have, the one that has the dubious distinction of being both the most common and the most lethal cancer of the pancreas.
Well, daraxonrasib seems to be doing its job and doing it well, based on a company press release. Remember, most press releases should not count as evidence for anything. This particular one, however, is worth reading because it is (1) for a randomized controlled trial with (2) a “hard” endpoint of overall survival OK, putting my pedant hat on, the pre-specified co-primary endpoints are progression-free survival (PFS) and overall survival (OS) in the RAS G12-mutant population. What is reported in the press release is only OS in the “intent-to-treat” which is to say both G12-mutant and wild type populations, which was a secondary endpoint. A bullet point at the beginning says that all primary and key secondary endpoints were met, so why not report both? Probably because one looked better than the other, but would it not be a tad suspicious that a less targeted population did better than the more targeted one? But this is just speculation, let’s see review the actual data once they come out. which will (3) be presented at the ASCO annual meeting, I imagine as a plenary talk, in early June of this year. The thing to look for there will be informative censoring, in particular early censoring of frail participants — the ones more likely to die early of their disease — who were randomized to receive daraxonrasib but then withdrew due to the “manageable” toxicity of a melting face. The fact that there are no participant numbers reported at all in the release makes me suspicious, though information on the number of patients enrolled is readily available: 501. That’s a lot of patients!
The company is certainly feeling optimistic: they have already received a National Priority Voucher from the US FDA and will now submit a New Drug Application. Kudos and congrats for designing and testing a working drug without using AI, because to read both professional and lay media the past two years it is a miracle there were any drugs being discovered until Large Language Models came along.
Yes, I had to invoke AI, because it is becoming exceedingly common for people to give algorithms credit where it is not due. This is what Tyler Cowen wrote yesterday about pancreatic cancer research:
AI and the pancreatic vaccine. More testing is needed, but there is a reasonable chance that we have a good treatment for pancreatic cancer, and AI was instrumental in that. It is mRNA as well, so a double burn on the haters.
The link is to a post on X by one Rotimi Adeoye, a “contributing opinion writer @nytimes” (one guest essay as of today which is one more than I have so congratulations, I guess?) who in true X fashion superimposed a screenshot from an uncredited journal abstract over someone posting a link to an NBC news article about the updated results of a phase 1 trial of an mRNA vaccine for pancreatic cancer. For those not keeping track, you are right now reading a blog post about a blog post about a retweet of a tweet about a news article based on a press release. You’re welcome. These were presented yesterday at the annual meeting of the American Association for Cancer Research but were hinted at in a press release (?) from Memorial Sloan Kettering, where the vaccine — generic name autogene cevumeran which rolls right off the tongue doesn’t it? — was being tested.
Remember how a few paragraphs above I had implied that you should ignore most press releases? Well, news on academic websites should rank even lower as no one there has to answer to the SEC. The primary study was great for what it was, a first-in-human trial with laboratory endpoints meant to test whether the participants’ immune system responded at all to the vaccine. And it seems that it did, as shown in not one but two papers in Nature published two years apart. The number of original participants, all of whom had early-stage, freshly resected and otherwise untreated PDAC upon enrollment, was 19. Three of these did not make it to the vaccine as they had progression, died, or had toxicity from adjuvant chemotherapy before being dosed. Chemotherapy? Yes, in addition to the vaccine everyone also received “adjuvant” (meaning: there to “clean up” any residual cancer after surgery) chemotherapy (FOLFIRINOX, not for the faint of heart) and immunotherapy (atezolizumab which is in comparison to the chemo a walk in the park but even that has its side effects). There was no control.
Of the 16 participants, 8 were “responders” to the vaccine as measured by some highly sophisticated laboratory tests — not that the patients would care what their blood work showed — and in 7 of those the cancer hasn’t come back for 3 years as noted in the follow-up Nature paper or for 4-6 years as noted in yesterday’s update. This compares to 2 of 8 who were “non-responders” to the vaccine.
If you don’t have your calculator handy let me do the math for you: 9 of 16 patients, or 56.25%, with newly resected PDAC who received chemotherapy, immunotherapy and the vaccine were still alive more than 3 years after treatment. You may not know this, and I didn’t until I looked it up just now as it has been a while since I have treated patients with newly diagnosed early-stage pancreatic cancer, but the median OS after (modified) FOLFIRINOX alone in a recent large, randomized Phase 3 trial was 53.5 months, with 43.2% of patients still alive 5 or more years. Did the addition of atezolizumab and the vaccine change anything? I can’t tell and neither can anyone else until there is a randomized controlled trial, which isn’t to cast shade on the investigators — kudos to them as well for a successful first-in-human study — but let’s curb our enthusiasm.
So we have some updated results from a tiny trial that didn’t really move the needle one way or another, and yet Cowen et al. feel the need to push AI into the narrative. To be clear, there is absolutely no mention of LLMs, machine learning, algorithms or artificial intelligence of any kind anywhere in the autogene cevumeran literature. Granted, it is a “personalized” vaccine, meaning that every potential participant had their tumor sequenced and up to 20 vaccine targets identified among the newly mutated proteins. I am sure there was a lot of computation involved. But not every sophisticated computer analysis is AI, let alone an LLM, so I truly don’t see how they could legitimately be brought into the conversation.
And in case you were wondering, no, the screenshotted abstract did not in fact back up Adeoye’s claim. Best as I can tell this was the paper in question, a speculative review article in an obscure journal written by a Shanghai-affiliated group of authors who had nothing to do with BioNTech whose purpose was to be a never-looked-at reference for a false claim, that “AI played a critical role in advancing the vaccine”. Anything for the clicks, am I right?
Adeoye’s behavior was regrettable but Cowen’s is detestable, especially when paired with his look-at-the-sheeple attitude towards humans. The linked to article from Cowen is particularly wrongheaded if you realize who the Luddites really were and that the label should in fact be a positive one. Cory Doctorow had warned about AI companies over-promising their capabilities for a short-term gain. But they don’t really need to: there are plenty of useful fools willing to promise on their behalf, giving it credit even where there is none.