Results for “tabarrok rapid test” 18 found
Testing Freedom
I did a podcast with Brink Lindsey of the Niskanen Center. Here’s one bit on the FDA’s long-history of banning home tests:
Brink Lindsey: …it’s on the rapid testing that we had inexplicable delays. Rapid tests, home tests were ubiquitous in Europe and Asia months before they were in the United States. What was going on?
Alex Tabarrok: So I think it’s not actually inexplicable because the FDA has a long, long history of just hating people testing themselves. So the FDA was against pregnancy tests, they didn’t like that, they said women they need to consult with a doctor, only the physician can do the test because literally women could become hysterical if they were pregnant or if they weren’t pregnant, this was a safety issue. There was no question that the test itself was safe or worked. Instead what the FDA said, “We can regulate this because the user using it, this could create safety issues because they could commit suicide or they could do something crazy.” So they totally expanded the meaning of safety from is the test safe to can somebody be trusted to use a pregnancy test?
Then we had exactly the same thing with AIDS testing. So we delayed personal at-home tests for AIDS for literally 25 years. 25 years these tests were unavailable because the FDA again said, “Well, they’re dangerous.” And why are they dangerous? “Well, we don’t know what people will do with this knowledge about their own bodies.” Now, of course, you can get an HIV test from Amazon and the world hasn’t collapsed. They did the same thing with genetic tests from companies like 23andMe. So I said, “Our bodies ourselves, our DNA ourselves.” That people have a right to know about the functioning of their own bodies. This to me is a very clear violation of the Constitutions on multiple respects. It just stuns me, it just stuns me that anybody could think that you don’t have a right to know, we’re going to prevent you from learning something about the operation of your own body.
Again, the issue here was never does the test work. In fact, the labs which produce these tests, those labs are regulated outside of the FDA. So whether the test actually works, whether yes, it identifies this gene, all issues of that nature, what is the sensitivity and the specificity, are the tests produced in a proper laboratory, I don’t have a lot of problem with that because that’s all something which the consumers themselves would want. What I do have a problem with is then the FDA saying, “No, you can’t have access to this test because we don’t know what you’re going to do about it, what you’re going to think about it.” And that to me is outrageous.
Here’s the full transcript and video.
FDA Approves American Rapid Antigen Test
What makes the FDAs failure to approve more rapid antigen tests even more galling is that the test being sold cheaply in the Amsterdam supermarket is the Flowflex, an American test made by Acon Labs in San Diego.
Well the FDA has finally approved the Acon test! Apparently it is good enough for the Germans and for US citizens. Hoorah! USA Today notes:
ACON expects to make 100 million tests per month by the end of this year. Production could double to 200 million monthly tests by February, according to the FDA.
…The United Kingdom and Germany have made significant purchases of home tests and widely distributed them to their residents to slow the spread of coronavirus. Such large government purchases allowed manufacturers to continue making tests even when demand softened as cases dropped.
The Biden administration will spend nearly $1.2 billion to purchase up to 187 million home tests from Abbott Laboratories and Celltrion Inc., company officials confirmed. The Department of Defense announced additional contracts totaling $647 million to buy 60 million kits from Abbott and three other testing vendors: OraSure Technologies, Quidel and Intrivio Holdings.
The FDA has authorized seven antigen-based tests that can be used at home without a prescription. The EU has authorized 21 tests beginning with the letter A (I am not sure all of these are authorized for home use but you get the idea.) Turtle slow. Still this is a big improvement.
Frankly, I think all the pressure from people like Michael Mina amplified by myself and others over 18 months and culminating in David Leonhartd’s NYTimes article Where Are the Tests? finally pushed them over the edge.
The NYTimes on the FDA and Rapid Tests
In July of 2020 I wrote in Frequent, Fast, and Cheap is Better than Sensitive:
A number of firms have developed cheap, paper-strip tests for coronavirus that report results at-home in about 15 minutes but they have yet to be approved for use by the FDA because the FDA appears to be demanding that all tests reach accuracy levels similar to the PCR test. This is another deadly FDA mistake.
…The PCR tests can discover virus at significantly lower concentration levels than the cheap tests but that extra sensitivity doesn’t matter much in practice. Why not? First, at the lowest levels that the PCR test can detect, the person tested probably isn’t infectious. The cheap test is better at telling whether you are infectious than whether you are infected but the former is what we need to know to open schools and workplaces.
It’s great that other people including the NYTimes are now understanding the problem. Here is the excellent David Leonhardt in Where are the Tests?
Other experts are also criticizing the Biden administration for its failure to expand rapid testing. Even as President Biden has followed a Covid policy much better aligned with scientific evidence than Donald Trump’s, Biden has not broken through some of the bureaucratic rigidity that has hampered the U.S. virus response.
In the case of rapid tests, the F.D.A. has loosened its rules somewhat over the past year, allowing the sale of some antigen tests (which often cost about $12 each). But drugstores, Amazon and other sellers have now largely run out of them. I tried to buy rapid tests this weekend and couldn’t find any.
The F.D.A.’s process for approving rapid tests is “onerous” and “inappropriate,” Daniel Oran and Dr. Eric Topol of Scripps Research wrote in Stat News.
For the most part, the F.D.A. still uses the same cumbersome process for approving Covid tests that it uses for high-tech medical devices. To survive that process, the rapid tests must demonstrate that they are nearly as sensitive as P.C.R. tests, which they are not.
But rapid tests do not need to be so sensitive to be effective, experts point out. P.C.R. tests often identify small amounts of the Covid virus in people who had been infected weeks earlier and are no longer contagious. Rapid tests can miss these cases while still identifying about 98 percent of cases in which a person is infectious, according to Dr. Michael Mina, a Harvard epidemiologist who has been advocating for more testing
Identifying anywhere close to 98 percent of infectious cases would sharply curb Covid’s spread. An analysis in the journal Science Advances found that test frequency matters more for reducing Covid cases than test sensitivity.
As I said on twitter what makes the FDA’s failure to approve more rapid antigen tests especially galling is that some of the tests being sold cheaply in Europe are American tests just ones not approved in the United States. If it’s good enough for the Germans it’s good enough for me!
My Congressional Testimony
I thought the meeting went well. I made four points.
- It is not too late to do more.
- We should invest in nasal and oral vaccines.
- We should vaccinate the world.
- We should stretch doses through fractional dosing and delaying the second dose, this will be important to vaccinate the world quickly.
One observation. Lots of people are talking about vaccine hesitancy but I am one of the few people who have been talking about nasal and oral vaccines which are the only really solid approach to the issue that I have seen.
My best line:
The unvaccinated are the biggest risk for generating mutations and new variants. You have heard of the South Africa and Brazilian variants, well the best way to protect your constituents from these and other variants is to vaccinate South Africans and Brazilians.
I also got in the last word in Q&A when discussing the pause of J&J:
For the rest of the world it is important to underline that it is most important to get vaccinated now. Use the AstraZeneca vaccine, use the Johnnson & Johnson vaccine…don’t wait for Moderna or Pfizer, it is going to take too long…start your vaccination program early…vaccinate as quickly as possible, that is the route to health and wealth.
See Western Warnings Tarnish Vaccines the World Badly Needs for the beginnings of a disaster. Note that if J&J and AZ are tarnished or knocked out of the vaccine arsenal then dose stretching and investing in more capacity are going to be even more important.
I also submitted five excellent and important pieces to Congress:
Canadian statement on delaying the second dose.
National Advisory Committee on Immunization (NACI) Canada. 2021. “COVID-19 Vaccine Extended Dose Interval for Canadians: NACI Recommendation.” Government of Canada. March 3, 2021. https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/rapid-response-extended-dose-intervals-covid-19-vaccines-early-rollout-population-protection.html.
Value of vaccine capacity and additional investments.
Castillo, Juan Camilo, Amrita Ahuja, Susan Athey, Arthur Baker, Eric Budish, Tasneem Chipty, Rachel Glennerster, et al. 2021. “Market Design to Accelerate COVID-19 Vaccine Supply.” Science, February. https://doi.org/10.1126/science.abg0889.
Efficacy of the first dose from NEJM.
Skowronski, Danuta, and Gaston Serres De. 2021. “Letter to the Editor on Safety and Efficacy of the BNT162b2 MRNA Covid-19 Vaccine.” New England Journal of Medicine, February 17, 2021. https://doi.org/10.1056/NEJMc2036242.
Overview of dose stretching policies (with links in the online version).
Tabarrok, Alex. 2021. “What Are We Waiting For?” Washington Post, February 12, 2021, sec. Outlook. https://www.washingtonpost.com/outlook/2021/02/12/first-doses-vaccine-rules-fda/
A plan to vaccinate the world.
Agarwal, Ruchir, and Tristan Reed. 2021. “How to End the COVID-19 Pandemic by March 2022” SSRN. 2021. https://documents.worldbank.org/en/publication/documents-reports/documentdetail/181611618494084337/how-to-end-the-covid-19-pandemic-by-march-2022
Testing and the NFL
NYTimes: The Centers for Disease Control and Prevention and the National Institutes of Health announced a new initiative on Wednesday to help determine whether frequent, widespread use of rapid coronavirus tests slows the spread of the virus.
The program will make rapid at-home antigen tests freely available to every resident of two communities, Pitt County, N.C., and Hamilton County, Tenn., enough for a total of 160,000 people to test themselves for the coronavirus three times a week for a month.
“This effort is precisely what I and others have been calling for nearly a year — widespread, accessible rapid tests to help curb transmission,” said Michael Mina, an epidemiologist at Harvard University who has been a vocal proponent of rapid, at-home testing programs.
I guess this is good news it just feels like something that in a different time line, happened long ago. Here is Derek Thompson in an excellent piece making exactly that point:
Imagine a parallel universe where Americans were tested massively, constantly, without care for cost, while those who tested negative continued more or less about their daily life.
In fact, that parallel universe exists. It’s the National Football League.
..After an October outbreak, the NFL moved to daily testing of all its players and instituted new restrictions on player behavior and stricter rules on ventilation and social distancing. The league also used electronic tracking bracelets to trace close contacts of people who tested positive. Throughout the season, the NFL spent about $100 million on more than 900,000 tests performed on more than 11,000 players and staff members. In January, the CDC published an analysis of the league that concluded, “Daily testing allowed early, albeit not immediate, identification of infection,” enabling the league to play the game safely.
You could write off the NFL’s season as the idiosyncratic achievement of a greedy sport with nearly unlimited resources. But I can think of another self-interested institution with nearly unlimited resources: It’s the government of a country with a $20 trillion economy and full control over its own currency. Unlike the NFL, though, the U.S. never made mass testing its institutional priority.
“The NFL was almost like a Korea within the United States,” Alex Tabarrok told me. “And it’s not just the NFL. Many universities have done a fabulous job, like Cornell. They have followed the Korea example, which is repeated testing of students combined with quick isolation in campus dorms. Mass testing is a policy that works in practice, and it works in theory. It’s crazy to me that we didn’t try it.” Tabarrok said we can’t be sure that a Korean or NFL-style approach to national testing would have guaranteed Korean or NFL-style outcomes. After all, that would have meant averting about 500,000 deaths. Rather, he said, comprehensive early testing was our best shot at reducing deaths and getting back to normal faster.
In praise of Alex Tabarrok
Here’s a question I’ve been mulling in recent months: Is Alex Tabarrok right? Are people dying because our coronavirus response is far too conservative?
I don’t mean conservative in the politicized, left-right sense. Tabarrok, an economist at George Mason University and a blogger at Marginal Revolution, is a libertarian, and I am very much not. But over the past year, he has emerged as a relentless critic of America’s coronavirus response, in ways that left me feeling like a Burkean in our conversations.
He called for vastly more spending to build vaccine manufacturing capacity, for giving half-doses of Moderna’s vaccine and delaying second doses of Pfizer’s, for using the Oxford-AstraZeneca vaccine, for the Food and Drug Administration to authorize rapid at-home tests, for accelerating research through human challenge trials. The through line of Tabarrok’s critique is that regulators and politicians have been too cautious, too reluctant to upend old institutions and protocols, so fearful of the consequences of change that they’ve permitted calamities through inaction.
Tabarrok hasn’t been alone. Combinations of these policies have been endorsed by epidemiologists, like Harvard’s Michael Mina and Brown’s Ashish Jha; by other economists, like Tabarrok’s colleague Tyler Cowen and the Nobel laureates Paul Romer and Michael Kremer; and by sociologists, like Zeynep Tufekci (who’s also a Times Opinion contributor). But Tabarrok is unusual in backing all of them, and doing so early and confrontationally. He’s become a thorn in the side of public health experts who defend the ways regulators are balancing risk. More than one groaned when I mentioned his name.
But as best as I can tell, Tabarrok has repeatedly been proved right, and ideas that sounded radical when he first argued for them command broader support now. What I’ve come to think of as the Tabarrok agenda has come closest to being adopted in Britain, which delayed second doses, approved the Oxford-AstraZeneca vaccine despite its data issues, is pushing at-home testing and permitted human challenge trials, in which volunteers are exposed to the coronavirus to speed the testing of treatments. And for now it’s working: Britain has vaccinated a larger percentage of its population than the rest of Europe and the United States have and is seeing lower daily case rates and deaths.
FDA Allows Pooled Tests and a Call for Prizes
The FDA has announced they will no longer forbid pooled testing:
In order to preserve testing resources, many developers are interested in performing their testing using a technique of “pooling” samples. This technique allows a lab to mix several samples together in a “batch” or pooled sample and then test the pooled sample with a diagnostic test. For example, four samples may be tested together, using only the resources needed for a single test. If the pooled sample is negative, it can be deduced that all patients were negative. If the pooled sample comes back positive, then each sample needs to be tested individually to find out which was positive.
…Today, the FDA is taking another step forward by updating templates for test developers that outline the validation expectations for these testing options to help facilitate the preparation, submission, and authorization under an Emergency Use Authorization (EUA).
This is good and will increase the effective number of tests by at least a factor of 2-3 and perhaps more.
In other news, Representative Beyer (D-VA), Representative Gonzalez (R-OH) and Paul Romer have an op-ed calling for more prizes for testing:
Offering a federal prize solves a critical part of that problem: laboratories lack the incentive and the funds for research and development of a rapid diagnostic test that will, in the best-case scenario, be rendered virtually unnecessary in a year.
…We believe in the ability of the American scientific community and economy to respond to the challenge presented by the coronavirus. Congress just has to give them the incentive.
The National Institutes of Health (NIH) have already begun a similar strategy with their $1.4 billion “shark tank,” awarding speedy regulatory approval to five companies that can produce these tests. Expanding the concept to academic labs through a National Institute of Science and Technology (NIST)-sponsored competition has the added benefit ultimately funding more groundbreaking research once the prize money has been awarded.
This is all good but frustrating. I made the case for prizes in Grand Innovation Prizes for Pandemics in March and Tyler and I have been pushing for pooled testing since late March. We were by no means the first to promote these ideas. I am grateful things are happening and relative to normal procedure I know this is fast but in pandemic time it is molasses slow.
Conditional Approval for Human Drugs
Recently a new drug to extend lifespan was granted conditional approval by the FDA–the first drug ever formally approved to extend lifespan! (By the way, the entrepreneur behind this breakthrough, Celine Halioua, is an emergent ventures winner for her earlier work rapidly expanding COVID testing. Tyler knows how to spot Talent!)
Great news, right? Yes, but there are two catches. First catch: the drug is for extending the lifespan of dogs. Second catch: Conditional approval is only available for animal drugs. Conditional approval was permitted for animal drugs beginning in 2004 for minor uses and/or minor species (fish, ferrets etc.) and then expanded in 2018 to include major uses in major species. What does conditional approval allow?
Conditional Approval (CA) allows potential applicants (referred to from this point as “sponsors”) to make a new animal drug product commercially available after demonstrating the drug is safe and properly manufactured in accordance with the FDA approval standards for safety and manufacturing, but before they have demonstrated substantial evidence of effectiveness (SEE) of the conditionally approved product. Under conditional approval, the sponsor needs to demonstrate reasonable expectation of effectiveness (RXE). A drug sponsor can then market a conditionally approved product for up to five years, through annual renewals, while collecting substantial evidence of effectiveness data required to support an approval.
Here is where it gets even more interesting. Why does the FDA say that conditional approval is a good idea?
First, it’s very expensive for a drug company to develop a drug and get it approved by FDA. Second, the market for a MUMS [Minor Use, Minor Species, AT] drug is too small to generate an adequate financial return for the company. The combination of the expensive drug approval process and the small market often makes drug companies hesitant to spend a lot of resources to develop MUMS drugs when there is so little return on their investment.
By allowing a drug company to legally market a MUMS drug early (before it is fully approved), conditional approval makes the drug available sooner to be used in animals that may benefit from it. This early marketing also helps the company recoup some of the investment costs while completing the full approval.
…Similar to conditional approval for MUMS drugs, the goal of expanded conditional approval is to encourage drug companies to develop drugs for major species for serious or life-threatening conditions and to fill treatment gaps where no therapies currently exist or the available therapies are inadequate.
Sound familiar? These are exactly some of the points that I have been raising about the FDA approval process for years. In particular, by bringing forward marketing approval by up to 5 years, conditional approval makes it profitable to research and develop many more new drugs.
Conditional approval is very similar to Bart Madden’s excellent idea of a Free to Choose Medicine track, with the exception that Madden makes the creation of a public tradeoff evaluation drug database (TEDD) a condition of moving to the FTCM track. Thus, FTCM combines conditional approval with the requirement to collect and make public real-world prescribing information over time.
But why is conditional approval available only for animal drugs? Conditional approval is good for animals. People are animals. Therefore, conditional approval is good for people. QED.
Ok, perhaps it’s not that simple. One might argue that allowing animals to use drugs for which there is a reasonable expectation of effectiveness but not yet substantial evidence of effectiveness is a good idea but this is just too risky to allow for humans. But that cuts both ways. We care more about humans and so don’t want to impose risks on them that we are willing to impose on animals but for the same reasons we care more about improving the health of humans and should be willing to risk more to save them (Entering a burning building to save a child is heroic; for a ferret, it’s foolish.)
I think that the FDA’s excellent arguments for conditional approval apply to human drugs as well as to (other) animal drugs and even more so when we recognize that human beings have rights and interests in making their own choices. The Promising Pathways Act would create something like conditional approval (the act calls it provisional approval) for drugs treating human diseases that are life-threatening so there is some hope that conditional approval for human drugs becomes a reality.
Dare I say it, but could the FDA be lumbering in the right direction?
How the NSF Moved Faster than the NIH During COVID-19
The NSF is a much smaller organization than the NIH but during the pandemic it moved more quickly. Why? Maxwell Tabarrok explains:
The NSF relied on its special congressional authority to skip peer review to bootstrap its pandemic-related granting. Two pre-existing programs which use this authority enabled the NSF’s speedy response. The RAPID (Rapid Response Research) and EAGER (EArly-concept Grants for Exploratory Research) programs focus on “proposals having a severe urgency,” and “exploratory work in its early stages on untested, but potentially transformative, research ideas,” respectively. Both turn applications around quickly: while typical federal science grants take 9-12 months of review, RAPID and EAGER grants usually provide funding to researchers in less than a month.
…The NSF funded valuable research through its RAPID grants program, including the development of the first COVID-19 test to get FDA approval, the Johns Hopkins COVID-19 data dashboard, and both inhaled and micro-needle patch vaccines, the latter of which is currently being scaled up for use in HPV vaccines. These examples don’t conclusively show that the NSF avoided sacrificing quality control for speed, but they suggest that the NSF’s internal team of reviewers funded multiple effective projects that benefited from faster turnarounds. The benefits of speeding up these big successes when they were urgently needed outweighed the hypothetical costs of approving some below-average projects.
In crises generally, the success of a science funder is determined by its biggest wins, not by the average quality of the projects it approves. Science’s impact on the pandemic was dominated by a single technology: the mRNA vaccine. The next most important contributions, likely testing or pharmaceutical treatments, were less important than the vaccine, and the average COVID-19 research project may have had minimal impact. External peer review slows down the funding of all projects to make sure that low-quality research is not funded. This kind of bottom-end quality control is less important in a crisis environment. At crisis-response margins, it’s probably better for science funding agencies to anchor less on quality control and instead take more shots on goal.
The NIH, to be fair, also responded more rapidly than usual and it used some special “shark-tank” like programs to do so which also worked well.
Read the whole thing for more recommendations.
Our Regulatory State Isn’t Learning
Delta is the fourth wave of covid, and amazingly the US policy response is even more irresolute than the first time around. Our government is like a child, sent next door to get a cup of sugar, who gets as far as the front stoop and then wanders off following a puppy.
The policy response is now focused on the most medically ineffective but most politically symbolic step, mask mandates. An all-night disco in Provincetown turns in to a superspreader event so… we make school kids wear masks in outdoor summer camps? Masks are several decimal places less effective than vaccines, and less effective than “social distance” in the first place.* Go to that all night disco, unvaccinated, but wear a mask? Please.
If we’re going to do NPI (non pharmaceutical interventions), policy other than vaccines, the level of policy and public discussion has tragically regressed since last summer. Last summer, remember, we were all talking about testing. Alex Tabarrok and Paul Romer were superb on how fast tests can reduce the reproduction rate, even with just voluntary isolation following tests. Other countries had competent test and tracing regimes. Have we built that in a year? No. (Are we ready to test and trace the next bug? Double no.)
What happened to the paper-strip tests you could buy for $2.00 at Walgreen’s, get instant results, and maybe decide it’s a bad idea to go to the all night dance party? Interest faded in November. (Last I looked, the sellers and FDA were still insisting on prescriptions and an app sign up, so it cost $50 and insurance “paid for” it.) What happened to detailed local data? Did anyone ever get it through the FDA’s and CDCs thick skulls that even imperfect but cheap and fast tests can be used to slow spread of disease?
…And then we indulge another round of America’s favorite pastime, answers in search of a question. Delta is spreading, so… extend the renter eviction moratorium. People who haven’t paid rent in a year can stay, landlords be damned.
All true. I got dispirited on testing. It’s insane that we don’t have cheap, rapid testing and good ventilation ready for a new school year. As I wrote about earlier, even the American Academy of Pediatrics is shouting from the rooftops that the FDA is deadly slow. The eviction moratorium is a sick joke. Just a backhanded way to redistribute wealth without a shred of justice or reason. Disgusting.
Here’s one more bit (but read the whole thing there is more.)
To learn from the mistakes, and institutionalize better responses would mean to admit there were mistakes. One would think the grand blame-Trump-for-everything narrative would allow us to do that, but the mistakes are deeply embedded in the bureacracies of the administrative state. Unlike bad admirals in WWII, nobody less than Trump himself has lost their job over incompetent covid response. The institutions have an enormous investment in ratifying that they did the best possible job last time. So, as in so many things (financial bailouts!) we institutionalize last time’s mistakes to keep those who made them in power in power — which means we do not learn from mistakes.
Self Recommending Links
1. I had a fun and wide-ranging conversation with Jonah Goldberg on the Remnant. We covered the economy, immigration, cyborgs and the Baumol effect among other topics.
2. Tim Harford covers fractional dosing at the FT:
The concept of a standard or full dose is fuzzier than one might imagine. These vaccines were developed at great speed, with a focus on effectiveness that meant erring towards high doses. Melissa Moore, a chief scientific officer at Moderna, has acknowledged this. It is plausible that we will come to regard the current doses as needlessly high.
3. The Brunswick Group interviews me:
Act like you’re in a crisis. That has been economist Alex Tabarrok’s advice since the start of the COVID-19 pandemic. Tabarrok was among the earliest and loudest voices arguing for urgency and risk-taking when it came to increasing rapid testing, investing in vaccine capacity, and employing flexible vaccine dosing. In hindsight, he has been proven regularly right when most health experts were wrong.
A Solution if We Act
Many simulations have been run in recent weeks using standard epidemiological models and the emerging consensus, as I read it, is that test, trace and isolate can be very effective. Paul Romer’s simulations are here and he notes that a COVID-19 test does not have to be especially accurate for the test, trace and isolate strategy to work. Indeed, you don’t even need to trace, if you test enough people. Linnarsson and Taipale agree writing:
We propose an additional intervention that would contribute to the control of the COVID-19 pandemic and facilitate reopening of society, based on: (1) testing every individual (2) repeatedly, and (3) self-quarantine of infected individuals. By identification and isolation of the majority of infectious individuals, including the estimated 86% who are asymptomatic or undocumented, the reproduction number R0 of SARS-CoV-2 would be reduced well below 1.0, and the epidemic would collapse….Unlike sampling-based tests, population-scale testing does not need to be very accurate: false negative rates up to 15% could be tolerated if 80% comply with testing, and false positives can be almost arbitrarily high when a high fraction of the population is already effectively quarantined.
Similarly, Berger, Herkenhoff and Mongey conclude:
Testing at a higher rate in conjunction with targeted quarantine policies can (i) dampen the economic impact of the coronavirus and (ii) reduce peak symptomatic infections—relevant for hospital capacity constraints.
This is exactly the strategy I discussed in, Mass Testing to Fix the Labor Market, where I wrote “Testing, isolating and tracing will [get the economy back on track] much faster and cheaper than dealing with a prolonged recession.”
I want to expand on the costs because it’s clear that a mass testing regime will require millions of tests. Is that cost-effective? Yes. The two types of tests we have are a RT-PCR test for COVID-19 (there are several versions) which costs something like $100 but could probably be much less as we ramp up. (We can cut costs and greatly increase throughput, for example, by pooled testing.) The second test, a blood test for antibodies, is, as best as I can tell, in the realm of $10. Both types are useful. I am going to be very conservative and say that we use a combination of tests at $75 per test. To test the entire US population, therefore, it would cost on the order of $25 billion dollars. Coincidentally, $25 billion is about what we spent on the Manhattan Project in current dollars. Thus, I am proposing a Manhattan Project for testing.
Twenty five billion dollars to test the entire US population. Now suppose the pandemic knocks 5% off US GDP over the next year or two, that’s roughly a trillion dollars lost. Or to put it differently, $3 billion a day. Thus, if mass testing reduces the number of days we are away from work by 9, it pays for itself. Let’s again be conservative and say that testing will also require a $25 billion fixed cost to build the enzyme factories and so forth, for a total cost of $50 billion. 18 days and it’s worth it.
We would also save medical costs by suppressing the virus. (The focus on ventilators has perhaps been overdone given that ventilators in no way guarantee survival–better to stop people needing ventilators.) We would also save lives. Thus, a program of mass testing seems like a no-brainer. Yet, there is no direct funding for anything like this in the $2.2 trillion CARES bill which is stunning. Here’s Austan Goolsbee:
We literally put in a tax break for retailers and restaurants to expand their capacity but not money for production of more COVID tests.
Here’s Paul Romer:
We have an economic crisis because it is not safe for people to work or consume. Our Congress just passed a bill that will spend $2.2 trillion to deal with the crisis. Can anyone identify any spending in this bill devoted to making it safe for people to work and consume?
As I wrote:
We need to attack the virus with test, isolate, and trace. More money for counter-attack!
Objections will no doubt be raised. Isn’t there a shortage of reagents? Do we have the personnel to test everyone? To which I answer, $50 billion solves a lot of problems. We won’t know how many till we try. We don’t need all of final testing capacity at once and even poor tests like simple temperature checks will help but we need to move rapidly in the right direction. The main constraint is time. Social distancing and lock downs are starting to have an effect. I expect the emergency will peak in mid-April and then things will slowly start to get improve. Even when the worst of the emergency passes, however, we will still need lots of testing. This virus will be with us and the world for some time. Let’s get on it.
MRU and the Coronavirus
Many universities are moving rapidly to teach online. Tyler and I and the entire team at MRU want to do everything we can to help make the process as successful as possible not just to improve education but to help to reduce the threat from COVID-19.
First, we have created a Resources Page on Teaching Online at that page you can also find a Facebook Community Page where educators are providing lots of tips and resources not just on videos but on how to use Zoom and other tools. Here, for example, is an excellent twitter thread on teaching online from Luke Stein that covers hardware, software, and techniques.
Second, If you are using Modern Principles, our textbook, and want to move online, Macmillan will do that for you for free, very rapidly, and including online tests, homework etc. If you want to move online from a different book, send Tyler or myself an email and we can discuss the best ways to do that.
Third, MRU has hundreds of videos which are free for anyone to use. Most notably our courses on Principles of Microeconomics and Principles of Macroeconomics but a lot more as well. You can search for MRU videos here. Here is a “greatest hits” list.
MRU is, of course, not the only source of excellent teaching material. Here are some others:
- Mary McGlasson has a micro playlist (54 videos) and macro playlist (38 videos). These are great and can be used in both university/high school.
- The St. Louis Fed provides a variety of great resources, including 14 videos on popular micro and macro topics.
- If you’re looking for pop culture references to embed into an econ class, check out https://econ.video/, http://www.bazinganomics.com/ (Big Bang Theory clips), https://breakingbadecon.com/.
- Jacob Clifford is a popular option among AP Econ teachers. He has micro playlists (93 videos) and macro playlists (85 videos).
- Planet Money Shorts also has good material.
One place to begin might be to explain to your students the mathematics of why universities and schools are closing despite relatively few deaths to date in the United States. As always, this 3Blue1Brown video is excellent.
Addendum: See also Tyler’s important announcement on EV Prizes.
Should we censor porn?
In 1971 Irving Kristol said yes, today Ross Douthat says yes. I am sympathetic with the notion that porn in the “I know it when I see it sense” is a net negative bad for society, even if it helps some people revitalize their sex lives (Alex differs). That said, I cannot find an attractive way of censoring it.
Ross tweeted:
I think you start with the rules we have, and think about how they might be applied to ISPs.
Yet playing whack-a-mole with ISPs does not always go well, a truth to which a number of emotionally well-balanced MR commentators can attest. And porn users and suppliers I think would be especially willing to find workarounds, including VPNs. So I don’t think porn would end up all that ghettoized. My fear is that the American internet would evolve rather rapidly toward Chinese-style institutions of control (though they would not used right now), without stopping porn very much, but leading to increasing calls to censor many other things too.
Keep in mind also that porn has been a major driver of innovation, not just for the VCR but for the internet too, including for means of payment, methods of streaming, and anti-piracy. Might porn drive the demand to build networks of virtual reality? So I’m not ready to ban it just yet.
Off Label Prescribing as Good as On Label
Once a drug has been approved for some use it may be legally prescribed for any use. New uses for old drugs are discovered quite often so off-label uses can be very different from FDA approved uses. Mitomycin, for example, was approved to treat stomach and pancreatic cancer but is used off-label in laser-eye surgery. Drugs prescribed off-label have not been through FDA-approved efficacy trials for the off-label use. In Assessing the FDA via the Anomaly of Off-Label Drug Prescribing I pointed out that off-label prescribing, therefore, gives us a window onto a world with much less FDA regulation.
Since off-label prescribing is common and in rapidly progressing areas of medicine often the gold-standard, I argued that the behavior of physicians validated off-label prescribing and demonstrated that physicians were willing and able to draw upon non-FDA sources of information to make rational prescribing decisions. Dan Klein and I also showed that physicians are supportive of off-label prescribing saying, for example, that it would be “crazy” to require FDA approval for off-label uses.
The support of physicians for off-label prescribing is telling but not dispositive. Perhaps physicians make hubristic mistakes in prescribing off-label. A new paper by Ladanie et al. (including John Ioannidis) provides important information. The authors search the literature for all the RCTs when an off-label drug was pitted against an on-label drug. They conclude:
Our meta-epidemiological analysis of 25 different treatment indications for off-label drug use provides no empirical evidence supporting any assumption of generally inferior treatment
effects associated with off-label use. On the contrary, the summary effect estimates across all indications would even be compatible with more favorable effects, on average, of the off-label
treatment. However, the heterogeneity is substantial and the on-label comparators are not necessarily the best approved treatment option in all 25 topics. While some off-label
treatments are clearly better, others are clearly not.
The finding is especially impressive because although off-label treatments are sometimes the gold standard they are also often used when standard treatments have failed. Thus, in an RCT, off-label treatments could be worse on average and yet still provide a very useful weapon in the medical armory.
One might argue that if off-label treatments are as good as FDA-approved treatments then the FDA should have higher standards. FDA required clinical trials, however, already cost hundreds of millions of dollars and years of effort, creating drug lag and drug loss. Rather than condemning the FDA, what these results indicate is that the medical system–physicians, hospitals, insurers, scientists–does a good job at evaluating new uses for old drugs. As Dan Klein and I noted in our precis on off-label prescribing:
The off-label experience testifies to the fact that much knowledge about efficacy and safety is produced outside the FDA regulatory apparatus. The Pharmacopoeia’s recognition of off-label
indications years ahead of the FDA demonstrates that physicians and scientists have certified thousands of drug indications quite independently of the FDA, even when those indications are not
very closely related to the original indications. In addition to the Pharmacopoeia, there are several other forms of professional certification, including the American Hospital Formulary Service Drug Information, HMO formularies, and a wide array of specialist professional periodicals and information services. NIH studies, clinical results and determinations from other countries, and other professional, science-based judgments are examples of nongovernmental, non-mandatory certification.
Hat tip: Michelle Dawson.