Category: Medicine

Economics in One Virus

Here is John Cochrane, Megan McArdle, Ryan Bourne and myself on the pandemic. Lots of good material. John Cochrane was excellent on testing in a pandemic and why it’s different than medical testing, starting around 22:00. My follow-up also had some good material, our antibodies, our selves.

Ryan Bourne’s book Economics in One Virus is very good.

 

Atul Gawande and Zeke Emanuel Now Support Delaying the Second Dose

Many people are coming around to First Doses First, i.e delaying the second dose to ~12 weeks. Atul Gawande, for example, tweeted:

As cases and hospitalizations rise again, we can’t count on behavior alone reversing this course. Therefore, it’s time for the Biden admin to delay 2nd vax doses to 12 weeks. Getting as many people as possible a vax dose is now urgent.

Now urgent??? Yes, I am a little frustrated because the trajectory on the new variants was very clear. On January 1, for example, I wrote about The New Strain and the Need for Speed (riffing off an excellent piece by Zeynep Tufekci).  Still, very happy to have Gawande’s voice added to the cause. Also joining Gawande are the power trio of Govind Persad, William F. Parker and Ezekiel J. Emanuel who in an important op-ed write:

If we temporarily delay second doses …that is our best hope of quelling the fourth wave ignited by the B.1.1.7 variant. Because we did not start this strategy earlier, it is probably too late for Michigan, New York, New Jersey and the other Northeastern states. But it might be just in time for the South and California — the next places the more infectious strain will go if historical patterns repeat.

…Drug manufacturers selected the three- or four-week interval currently used between doses to rapidly prove efficacy in clinical trials. They did not choose such short intervals based on the optimal way of using the vaccines to quell a pandemic. While a three- or four-week follow-up is safe and effective, there is no evidence it optimizes either individual benefit or population protection.

…Some complain that postponing second doses is not “following the science.” But the scientific evidence goes far beyond what was shown in the original efficacy trials. Data from the United Kingdom, Israel and now the Centers for Disease Control and Prevention shows that first doses both prevent infection and reduce transmission. In people with prior infection, experts are beginning to recognize that a second dose could provide even less benefit. Following the science means updating policies to recognize new evidence rather than stubbornly maintaining the status quo.

Emanuel is on Biden’s COVID-19 task force so consider this op-ed running the flag up the flagpole. I predict Topol will fall next.

I would be surprised, however, if the US changes course now–too many people would then ask why didn’t we do this sooner?–but dose stretching is going to be important for the rest of the world. Why aren’t we doing more to investigate fractional dosing? Even if we went to half-doses on the second dose–the full second dose appears to be strong–that would still be a significant increase in total supply.

Addendum: I have argued for sending extra doses to Michigan and other hot spots such as NJ. Flood the zone! The Biden administration says no. Why? Production is now running well ahead of distribution as more than 50 million doses have been delivered but not administered. It would be a particularly good idea to send more single-shot J&J to reach hard to reach communities–one and done.

Vaccine passport sentences to ponder

From New York State:

Using Excelsior Pass is entirely voluntary, but it requires learning about the state’s system and mastering a few different websites and apps. It took me 20 minutes over Zoom to help an octogenarian set up his pass, though it was certainly simpler than mastering vaccine-appointment websites. And even when we thought we understood the system, Excelsior Pass didn’t always work: My tech-reporter colleague tried to use it to enter Yankee Stadium, but the system didn’t update with his clearance until after the game was over…

Testing Excelsior Pass, what surprised me most was how easy it is to fake. When you first sign up for your QR code on the state website, it asks a handful of questions based on your vaccination and testing records. But after that, you’re on the honor system — you can add the QR code to any phone without any more challenge questions.

Designed by IBM, here is the full story.  I get that different parts of the country (Michigan…surge vaccine supply!) may need to proceed at different speeds, but basically it is time to plan a full reopening, and it seems that vaccine passports are more likely to hinder than to help achieve that end.

From the comments, on Covid and our response

It is simply not a tenable policy to oppose pandemic lockdowns on the premise that COVID-19 only negatively affects a certain portion of the population. First, the fact that COVID-19 disproportionately killed the elderly was not something that was readily apparent right out of the box, when the virus was spreading rapidly. Hindsight is 20-20. Second, focusing solely on mortality is short-sighted given that approximately one-third of all people who get over COVID-19 suffer “long haul” symptoms that persist for months and may even be permanent in some. We cannot simply claim that the non-elderly have no reason to fear COVID-19.

So far, COVID-19 has killed more Americans than we lost in World War II, and it took the war five years to do what the virus did in one year. Even though the majority of the deaths were 65+, these are staggering numbers. Losing well over 100,000 people under the age of 65 in one year alone is nothing to sneeze at, and that’s with lock-downs and other harsh measures being taken. A “let them live their lives” approach would doubtlessly have escalated those numbers greatly.

The best early policy for any pandemic is to ramp up rapid testing as fast as possible, and test people constantly. A widespread testing regime (like in South Korea) would allow uninfected people to live more or less normally, while stifling the spread of the virus by identifying infected people quickly so they can immediately quarantine and prevent further spread. [Alex’s] earlier post on Testing and the NFL is instructive on that point. Such a testing regime could have enabled us to avoid harsher measures later on. But, unfortunately, America was led at the time by a president who did not prioritize testing (and in fact discouraged it to hide the spread of the virus) and sought to pooh-pooh its danger, shrugging off even the slightest mitigation efforts, like masks. Even after he got it, and was hospitalized, almost put on a ventilator, he acted as though it was nothing. That leadership caused a dangerous cognitive dissonance in public perceptions of COVID-19 — a dissonance that is causing people to take unreasonable risks, refuse to get vaccinated, and otherwise take actions that will make it even harder for us to get out from under this pandemic.

Focusing on the Great Barrington Declaration itself, the big problem with its approach is that it presumes that “herd immunity” will naturally occur with COVID-19 at some point. The evidence indicates, however, that natural infection does not lead to permanent immunity. The worse a person’s symptoms from COVID-19, the longer their immunity lasts, but that’s it. The only immunity that is possible now is through vaccination, and even that will require yearly updates as the virus mutates as it is already doing. Eventually we will have it under control. But the suggestion that people under 65 can just safely infect themselves into herd immunity is likely an impossibility, and certainly not a good enough foundation to rest any pandemic policy on. https://www.nature.com/articles/d41586-021-00728-2

None of this is meant to minimize or challenge the obvious economic and mental health effects of certain pandemic policies. There are a great many costs being imposed by lock-downs and other policies. Businesses are failing and not coming back, jobs are being permanently lost, people are feeling isolated, on and on. All of that is tragic, and could have been largely avoided had we aggressively pursued testing (especially rapid-result testing) from the outset. When the next pandemic comes, I hope our descendants remember that lesson. Because once the pandemic started spreading because we didn’t get a testing regime in place, it was too late, and then the harsher policies became inevitable. The horse was out of the barn, and the game changed for good.

That is from James N. Markels, responding to Don Boudreaux in these comments.

Here is another way to put the broader argument, not my preferred first-order response, but I think significant nonetheless.  Given the way government and public choice work, anything that kills over half a million Americans is going to be a big deal for policy, whether we like it or not (Don should be the first to recognize that government will restrict your liberties for far less than 500k deaths!).  You want the best feasible version of a response, as there isn’t really a stable libertarian response pattern out there.  Trying partial but non-sustainable libertarian approaches will in the end get you more and more statism as the virus keeps on defeating you, deaths rise, and calls for ever-greater state action increase.  A lot of what libertarians don’t like about lockdowns in part stems from the “do nothing” response of the first two months of notice that we Americans had when Covid first appeared in China.

Wohin economics?

Mammograms and Mortality: How has the Evidence Evolved?

Surviving a Mass Shooting

Representation is Not Sufficient for Selecting Gender Diversity

Back to School: The Effect of School Visits During COVID-19 on COVID-19 Transmission

The Public Health Effects of Legalizing Marijuana

Those are all new NBER working papers, issued today.  To be clear, I do not intend this list as criticism, either of these papers or of the NBER (for one thing, I have not read them).  But surely it is worth pointing out that something has changed.  If you think economists should be doing these papers, does that translate into a relatively low opinion of the quantitative standards in those fields proper?  Or maybe the economists are better at spotting interesting questions and seeing the work through?  Yes or no?  How exactly should we imagine the (possible) comparative advantage of economists with these topics?  I mean these as genuine questions, not snarky ones.  I have never been a per se opponent of economic imperialism.

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.

Failure is the Mother of Success

New paper from Jeffrey E. Harris:

The decades-long effort to produce a workable HIV vaccine has hardly been a waste of public and private resources. To the contrary, the scientific know-how acquired along the way has served as the critical foundation for the development of vaccines against the novel, pandemic SARS-CoV-2 virus. We retell the real-world story of HIV vaccine research – with all its false leads and missteps – in a way that sheds light on the current state of the art of antiviral vaccines. We find that HIV-related R&D had more than a general spillover effect. In fact, the repeated failures of HIV vaccine trials have served as a critical stimulus to the development of successful vaccine technologies today. We rebut the counterargument that HIV vaccine development has been no more than a blind alley, and that recently developed vaccines against COVID-19 are really descendants of successful vaccines against Ebola, MERS, SARS-CoV-1 and human papillomavirus. These successful vaccines likewise owe much to the vicissitudes of HIV vaccine development.

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.

Here is more from Ezra Klein at the New York Times.

The mortality of scholars

After recovering from a severe mortality crisis in the seventeenth century, life expectancy among scholars started to increase as early as in the eighteenth century, well before the Industrial Revolution. Our finding that members of scientific academies—an elite group among scholars—were the first to experience mortality improvements suggests that 300 years ago, individuals with higher social status already enjoyed lower mortality. We also show, however, that the onset of mortality improvements among scholars in medicine was delayed, possibly because these scholars were exposed to pathogens and did not have germ theory knowledge that might have protected them. The disadvantage among medical professionals decreased toward the end of the nineteenth century.

Here is more from Robert Stelter, David de la Croix, and Mikko Myrskylä.  Via the excellent Kevin Lewis.

Are Americans getting worse?

Maybe so:

Morbidity and mortality have been increasing among middle-aged and young-old Americans since the turn of the century. We investigate whether these unfavorable trends extend to younger cohorts and their underlying physiological, psychological, and behavioral mechanisms. Applying generalized linear mixed effects models to 62,833 adults from the National Health and Nutrition Examination Surveys (1988-2016) and 625,221 adults from the National Health Interview Surveys (1997-2018), we find that for all gender and racial groups, physiological dysregulation has increased continuously from Baby Boomers through late-Gen X and Gen Y. The magnitude of the increase is higher for White men than other groups, while Black men have a steepest increase in low urinary albumin (a marker of chronic inflammation). In addition, Whites undergo distinctive increases in anxiety, depression, and heavy drinking, and have a higher level than Blacks and Hispanics of smoking and drug use in recent cohorts. Smoking is not responsible for the increasing physiological dysregulation across cohorts. The obesity epidemic contributes to the increase in metabolic syndrome, but not in low urinary albumin. The worsening physiological and mental health profiles among younger generations imply a challenging morbidity and mortality prospect for the United States, one that may be particularly inauspicious for Whites.

Here is the full article, via an excellent loyal MR reader.

Trypanophobia or How to Alleviate Vaccine Hesitancy

A significant share of vaccine hesitancy is driven by fear of needles, trypanophobia. Adults don’t like to admit a fear of needles and less so that they would avoid a vaccine for fear of a needle. But trypanophobia is common and does reduce flu immunizations:

Avoidance of influenza vaccination because of needle fear occurred in 16% of adult patients, 27% of hospital employees, 18% of workers at long‐term care facilities, and 8% of healthcare workers at hospitals. Needle fear was common when undergoing venipuncture, blood donation, and in those with chronic conditions requiring injection.

Aside from fear of the needle, I think there is also a perception that needles are “serious medicine” and thus anything that comes in needle form must be serious or dangerous. In fact, vaccines are safer than many commonly used drugs that are taken orally.

Needle hesitancy is bad for the hesitant who don’t get protection from COVID and bad for everyone else who are further subject to transmission from unvaccinated carriers.

The best way to alleviate needle hesitancy is to get rid of the needle. Operation Warp Speed made smart investments in a fairly widely range of vaccines (we advised going wider) including a pill vaccine from VaxArt. The VaxArt vaccine has completed a Phase I trial with modest results and is moving into Phase II. Nasal vaccines are in development. The RadVac open science vaccine, for example, is a nasal vaccine available to anyone with a scientific bent willing to give an unapproved vaccine a try. CodaGenix has a nasal vaccine in Phase I trials as does Altimmune.

Aside from ease of delivery, a COVID nasal or oral vaccine may also be better than intramuscular injection because it stimulates the immune system at the first point of viral attack, the mucosal tissues in the nose, mouth, lungs and digestive tract. In addition, the mucosal immune system has some unique elements so you get a potentially stronger immune response more capable of neutralizing the virus quickly.

Operation Warp Speed investments generated trillions in value for billions in cost, a few additional smart investments in accelerating nasal and oral vaccines could pay off highly in mopping up vaccine hesitancy and moving us more quickly to herd immunity. We could even do a human challenge trial with nasal vaccine v. intramusucalar injection. Oral and nasal vaccines will also be great for kids and for booster shots.

Even at this late stage we are spending trillions on stimulus/relief and not enough on investment, especially on highly successful investment in vaccines.

Addendum: I know it probably won’t help but fyi, it’s a painless shot. Nothing to fear! Get a superpower and a donut afterwards. It will be memorable.

Power Up!

Two weeks ago I was bitten by the equivalent of a radioactive spider and now I have superpowers! Including the power of immunity and the power to fly! Awesome. As I said earlier, the SARS-COV-2 virus killed more people this year than bullets “so virus immunity is a much better superpower than bullet immunity!”

I got the J&J vaccine–one of the first in the world to do so–which seemed appropriate as I have been calling for first doses first and the J&J vaccine is single dose. I will probably supplement with Novavax at a later date when supplies are plentiful.

Addendum: Also, I can get free donuts at Krispy Kreme.

The EU Vaccine Bungling

The EU vaccine rollout has been remarkably bungled even by the standards we have come to expect from Western governments. In advising governments I and the AHT team argued that vaccines were the world’s easiest cost-benefit test because Billions<<Trillions. Yet when manufactures offered the EU vaccines worth thousands of dollars a dose for just $5-$40 a dose the EU foolishly shouted “price gouging” and wasted weeks in dickering. I leave it to you as an exercise to calculate the value EU governments implicitly placed on European lives.

The latest bungling was the halt by over a dozen European governments of vaccination with the AstraZeneca vaccine due to fears that it might cause very rare blood clots (wisely Belgium and Great Britain continued vaccinations). After a review, the EMA has now cleared the vaccine:

The European Union’s drug regulator said on Thursday that the AstraZeneca vaccine was safe and effective, a finding that officials hope will alleviate concerns about possible rare side effects involving blood clots and allow more than a dozen countries that halted its use to add it back into their arsenal against the resurgent coronavirus.

The halt, however, was never justified. The EMA press release make this clear because it hasn’t added much more information it only underlines what we already knew. Namely, there was no increase in the overall risk of blood clots. There might be an increase in a very rare type of blood clot but that wasn’t obvious, especially when one takes into account that when you are monitoring hundreds of rare side effects it’s bound to be the case that some show statistically significant effects even if there are no true effects. As a result, the more conditions you test the higher standards you should apply to judge a difference as statistically significant (ala Bonferroni Correction which the EMA does not appear to have done). Moreover, even assuming that the rare vaccine effects were real they were thousands of times less than the effects of blood clotting from COVID itself so if you wanted to avoid blood clots the way to do so was to take the vaccine. Moreover, even assuming that the rare effects were real, they were not larger than those from other common activities such as flying or taking contraceptive pills. Moreover, and this point does not seem to have been made prominent, the most plausible argument for the vaccine creating blood clots is through the generation of the spike protein, which all the vaccines do, so there is little reason to believe that the Pfizer or Moderna vaccine would not also have the same problems (which they might). Thus, the focus on AZ seemed oddly misplaced. Draw your own conclusions on that.

The end result is that more people will die from the halt than could possible have been saved by the halt. Why did this happen? One reason is the absurd focus on doing anything to alleviate “vaccine hesitancy.” To alleviate vaccine hesitancy we have repeatedly sent the message that the vaccines are “safe, safe, safe.” When we should have said the vaccines pass a cost-benefit test (with flying colors!) and are much safer than many drugs people take for less serious conditions. But every drug or vaccine has side-effects. Tradeoffs are everywhere.

Unfortunately, vaccine hesitancy seems to have become a catch-all excuse for never having to show your work with a cost-benefit analysis. As I said in my post Don’t Delay a Vaccine to Allay Fear (should have said don’t halt one either!):

We should not let public policy be guided by the most risk averse, fearful, and scientifically illiterate among us.

[And]… rather than alleviating fear, delay may increase fear. People may reason, if the FDA is taking this long to review the evidence when thousands of people are dying every day it must be a hard decision.

The latter point, of course, is exactly what has happened. The EU halt has increased vaccine hesitancy rather than alleviating it.

Addendum:

  • Feb. 2: France restricts AstraZeneca vaccine to those aged less than 65 years of age.
  • March 2: France approves AZ vaccine for all ages.
  • March 19: France recommends AstraZeneca vaccine only to those aged more than 55 years.

I guess 55-65 years of age is the sweet spot.

How bad is EU bungling? So bad, Paul Krugman and I are in agreement. He almost quotes me on “Progressivism: The haunting fear that someone, somewhere, may be making a profit.”