Category: Medicine

Toward a short history of Operation Warp Speed

Link here, do read the whole thread.  So which of you is going to write the definitive book on this?  That is a serious question.

Why we should be optimistic about various vaccines

I’ve been a long-time reader of your blog, and I have enjoyed your analyses of how the pandemic could play out in the US.

I saw that you gave some space to Arnold Kling’s pessimistic take on the vaccines. I’m a volunteer in the J&J Phase 3 vaccine trial, and my experience of the trial design makes me more optimistic about the vaccines than even the headline numbers in the so-far announced trials would suggest. I think the trial set-ups particularly for J&J have some biases that would lead to understated effectiveness results:

First, these trials are effectively unblinded. The placebos are saline solution in J&J, AstraZeneca, Pfizer and Moderna. Per the Phase 2 results for J&J, >60% of participants had significant side effects, with flu-like symptoms the most common; I believe other vaccine trials had similarly intense side effects. When I got a shot, I was nearly bedridden for 24 hours; it felt as if I had the flu, and the effect was far more pronounced than for any other vaccine I’ve had. If I got the placebo, I need a psychotherapist. Though I plan to remain generally responsible and not take too many incremental risks, given I’m only mostly sure I got a vaccine that is still unproven, I’m sure my assumption that I’ve been vaccinated will influence my behavior, and the behavior of anyone else who has had significant side effects from their injection too.

Second, upcoming trials are likely going to suffer from a “too much COVID effect” on an absolute basis, and relative to prior trials in particular. J&J counts any infection more than 14 days after injection toward its efficacy calculation. If full immunity takes longer (and my understanding is that antibodies build after infections for 3+ weeks in many cases), then there will be people out there getting infected before the vaccine has taken full effect. That wasn’t particularly likely to happen in the summer when there were fewer cases overall. This is particularly going to affect 1-shot vaccines, as other trials have their effectiveness measured only after the second dose (but I could still imagine this dynamic having some impact, if full immunity builds gradually after the second dose).

Anyway, hope this is of some interest. I found it encouraging to conclude that study bias could understate, not overstate, the effectiveness of vaccines.

That is from my email, identity of the author is redacted.

Bryan Caplan on the cost of Covid

Here is Bryan’s post, here is one bit:

Taking quality of life into account, how many life-years has the reaction to COVID destroyed?…

Upshot: The total cost of all COVID prevention has very likely exceeded the total benefit of all COVID prevention.

I don’t agree with Bryan’s numbers, but the more important point is one of logic.  The higher the costs of reaction to Covid, the stronger the case for subsidizing vaccines, therapeutics, and other corrective measures.  Would you accept this Bryan?  You have numerous posts about risk overreaction, but not one (if I recall correctly) calling for such subsidies.  Furthermore we just did some of those subsidies, through Operation Warp Speed, and they worked and they will fix the relevant incentives and lead to a resumption of normal life.  So the “subsidies will prove counterproductive” argument doesn’t seem strong here.  The subsidies are the (much) quicker path back to what you desire.

A second question is whether moral suasion — “don’t overreact to Covid!” — is likely to prove effective.  As I’ve already linked to, risk explains mobility reductions far more than do lockdown policies.  Or consider Sweden, which had a relatively non-panicky Covid messaging, no matter what you think of their substantive policies.  Sweden didn’t do any better on the gdp front, and the country had pretty typical adverse mobility reactions.  (NB: These are the data that you don’t see the “overreaction” critics engage with — at all.  And there is more where this came from.)

How about Brazil? While they did some local lockdowns, they have a denialist president, a weak overall response, and a population used to a high degree of risk.  The country still saw a gdp plunge and lots of collateral damage.  You might ponder this graph, causality is tricky and the “at what margin” question is trickier yet, but it certainly does not support what Bryan is claiming about the relevant trade-offs.

I keep on hearing this point again and again, about overreaction.  What kinds of reaction are you expecting or viewing as feasible and attainable?  If overreacting is indeed a public bad, why think you can talk people down out of it?  How much do you think you can talk them out of it?  What if someone suggested that we try to talk people out of their irrational voting patterns, as analyzed by Bryan’s The Myth of the Rational Voter?  How sanguine would he be about that enterprise?  I believe he instead stressed changes in relative prices.

And this is the huge flaw behind so much of the discourse about the “costs of lockdowns” — they can cite the stupidity of closing the parks in March, yes, but they don’t and indeed can’t tell you how most of those costs were to be avoided, given how the public reacts to risk.

If we instead look to the relevant changes in relative prices, that means subsidies for vaccines and tests, most of all through advance market commitments, but not only.  And a full-scale commitment to implementing testing and masks and therapeutics.

The more you push home points about overreaction, the more you ought to favor these subsidies.  Libertarians out there, do you?  This chicken has come home to roost, so please fess up and give the right answer here.  Do you favor these subsidies, not just murmured into your closet at night but in plain black and white for the world to read?  Moral suasion against risk overreaction is a red herring, fine enough for cutting back on one part of the problem by maybe a few percentage points, but serving mainly to distract from the very real economic questions at hand and the need to admit that one’s libertarian ideology doesn’t fit around this problem as nicely as one might wish.

How good has media coverage of Covid-19 been?

We analyze the tone of COVID-19 related English-language news articles written since January 1, 2020. Ninety one percent of stories by U.S. major media outlets are negative in tone versus fifty four percent for non-U.S. major sources and sixty five percent for scientific journals. The negativity of the U.S. major media is notable even in areas with positive scientific developments including school re-openings and vaccine trials. Media negativity is unresponsive to changing trends in new COVID-19 cases or the political leanings of the audience. U.S. major media readers strongly prefer negative stories about COVID-19, and negative stories in general. Stories of increasing COVID-19 cases outnumber stories of decreasing cases by a factor of 5.5 even during periods when new cases are declining. Among U.S. major media outlets, stories discussing President Donald Trump and hydroxychloroquine are more numerous than all stories combined that cover companies and individual researchers working on COVID-19 vaccines.

Emphasis added by me.  That is the abstract of a new NBER working paper by Bruce Sacerdote, Ranjan Sehgal, and Molly Cook.

The case for geographically concentrated vaccine doses

Here goes:

A central yet neglected point is that vaccines should not be sent to each and every part of the U.S. Instead, it would be better to concentrate distribution in a small number of places where the vaccines can have a greater impact.

Say, for the purposes of argument, that you had 20,000 vaccine doses to distribute. There are about 20,000 cities and towns in America. Would you send one dose to each location? That might sound fair, but such a distribution would limit the overall effect. Many of those 20,000 recipients would be safer, but your plan would not meaningfully reduce community transmission in any of those places, nor would it allow any public events to restart or schools to reopen.

Alternatively, say you chose one town or well-defined area and distributed all 20,000 doses there. Not only would you protect 20,000 people with the vaccine, but the surrounding area would be much safer, too. Children could go to school, for instance, knowing that most of the other people in the building had been vaccinated. Shopping and dining would boom as well.

Here is one qualifier, but in fact it pushes one further along the road to geographic concentration:

Over time, mobility, migration and mixing would undo some of the initial benefits of the geographically concentrated dose of vaccines. That’s why the second round of vaccine distribution should go exactly to those people who are most likely to mix with the first targeted area. This plan reaps two benefits: protecting the people in the newly chosen second area, and limiting the ability of those people to disrupt the benefits already gained in the first area.

In other words, if the first doses went (to choose a random example) to Wilmington, Delaware, the next batch of doses should go to the suburbs of Wilmington. In economics language [behind this link is a highly useful Michael Kremer paper], one can say that Covid-19 infections (and protections) have externalities, and there are increasing returns to those externalities. That implies a geographically concentrated approach to vaccine distribution, whether at the federal or state level.

Here is another qualifier:

…there will be practical limits on a fully concentrated geographic distribution of vaccines. Too many vaccines sent to too few places will result in long waits and trouble with storage. Nonetheless, at the margin the U.S. should still consider a more geographically concentrated distribution than what it is likely to do.

Do you think that travel restrictions have stopped the spread of the coronavirus? (Doesn’t mean you have to favor them, all things considered.)  Probably yes.  If so, you probably ought to favor a geographically concentrated initial distribution of the vaccine as well — can you see why it is the same logic?  Just imagine it spreading out like stones on a Go board.

Of course we are not likely to do any of this.  Here is my full Bloomberg column.

The pandemic is indeed a big deal

In our estimation, and with standard preference parameters, the value of the ability to end the pandemic is worth 5-15% of total wealth. This value rises substantially when there is uncertainty about the frequency and duration of pandemics. Agents place almost as much value on the ability to resolve the uncertainty as they do on the value of the cure itself.

That is from a new NBER working paper by Viral V. Acharya, Timothy Johnson, Suresh Sundaresan, and Steven Zheng.  Their analysis also shows that preventing or limiting future pandemics may be a bigger deal yet.

Rapid Antigen Tests in Europe

Image‘If rapid antigen tests are so good how come other countries aren’t using them’? is a question I get asked a lot. In fact, India authorized these tests months ago. Slovakia tested most of their population using antigen tests. Germany is using them to protect nursing home residents. Lufthansa is trialing rapid antigen tests on special flights. Rapid antigen tests are now beginning to be available more widely in Europe. Here from a twitter thread is a picture of what they look like, it’s just a paper strip inside. You swab your nose (no need for deep cleaning), swirl the swab in a tube with some liquid and then squeeze a few drops of the liquid onto the end of the tester. Results in 15 minutes. They cost about $8 a test.

Why are these tests important? The CDC now says that asymptomatic or pre-symptomatic people account for a majority of infections. Do you get it? How many people without symptoms will get a COVID PCR test, which can be time consuming and expensive? (And how many PCR tests can we run in a timely fashion if people without symptoms get many more tests?) Not that many. But many people without symptoms would get a $8 or less, at-home, 15 minute test. And if some of those people discover that they are infectious and self-isolate for a few days we can drive infection rates down.

We should have had an Operation Warp Speed for tests. We still need funding for a mass rollout and, of course, the FDA needs to approve these tests! (Here is Michael Mina in Time fulminating at the FDA holdup.)

By the way, more than 2800 Americans have died of COVID since Pfizer requested an Emergency Use Authorization for their vaccine. The FDA meets Dec. 10.

Addendum: Here’s me explaining why Frequent, Fast, and Cheap is Better than Sensitive and the difference between infected and infectious.

Externalities and Covid

I am getting a little ornery with all of the people citing Covid externalities, and then not going a step deeper.  To be clear, I agree we should subsidize preventive measures (most of all vaccines and testing, but more too), and close down high-risk indoor gatherings in many locales.  No more Democratic Party fundraisers in New York State, not indoors at least.

What is being neglected is that many of the American people are voting with their feet when it comes to externalities, and we may not always like the answers we are seeing.  Take all of the pending Thanksgiving travel — the biggest risk is to parents and grandparents, but mostly they are receiving their children voluntarily.  Now I get that there is a higher-order risk to friends of the parents and grandparents, and that externality is not internalized, but still…much of the externality is in fact internalized.

I haven’t seen many (any?) jurisdictions in this country where the median voter wants to shut down Thanksgiving travel.  Do please note it is in fact my personal preference that no one travel for Thanksgiving, but I’m not going to confuse that preference with the Coasean outcome or for that matter the democratic outcome.  It might be the Coasean outcome in northern Jutland, it does not seem to be here.

Or consider mobility.  The people of means I know have been moving to Austin and Miami, two locales that are both quite open in the sense of having relatively few Covid-related restrictions on commerce.  These individuals do not have to work as a cashier in the Safeway, and so they can enjoy the openness while avoiding most of the corresponding risk.  They can work at home and socialize outside.  Maybe the weather, the time zone, the “coolness” of the locale, and other factors are more important than the stores being open.  Still, the “loose” Covid policies have not scared them away.

One might expect that front-line workers would be less keen to move to Austin and Miami, but I have not seen data to that effect and I am not convinced that is true on net.  I genuinely would like to know, and in the meantime am agnostic on the question.

I don’t see many people moving into Vermont or San Francisco, two locales that have done a good job minimizing Covid risk.

Analytically, you might put it this way.  There always have been positive externalities from human contact through commerce, and at the margin, even with Covid risk, for many people those externalities still are positive.  Thus if you limit or tax those interactions, the policies will be unpopular.

I genuinely do think many of our failings are those of prudence rather than externalities.  That is one reason why I am reluctant to recommend large-scale coercive lockdowns, while still regarding the positive fight against Covid with extreme urgency.  Three of our prudence failings are the following:

1. We are not good at intertemporal substitution in this context, and

2. The risks of Covid are sufficiently stressful that many people instead prefer to self-deceive and minimize the risks, rather than deal with the stress (NB: this is one instance where higher stakes and decisive choice lead to a worse rather than a better outcome, contra Caplan).

3. Many individuals are bad at grasping the multi-week reporting lags and also the “Blitzkrieg” nature of the struggle.

I am reluctant to smush together the externalities argument and the paternalism argument for policy activism, and instead prefer to unpack the two, even though that weakens the case for major restrictions.  It disturbs me that few public health commentators or for that matter commenting economists are willing to consider even this simple analytic division.  Talking about all the deaths does not in fact settle the matter, as it remains necessary to ask what Americans really want, and how much we ought to be willing to respect those preferences.

Vaccination economic resumption sentences to ponder

If you think of state governments as basically being as permissive as possible consistent with not overwhelming their hospital systems then even vaccinating 20% of the population has a huge economic impact as long as it’s targeted in a halfway plausible way.

That is from Matt Yglesias.  I would stress also the bad news that in the meantime many Americans (other citizens too!) are becoming infected.  I haven’t seen recent serological results, but quite some time ago the range already was 10-15% of America infected.  It seems entirely plausible to think that many parts of the country (not SF, not Vermont) will be at 30% or higher infected by February.  Plus 20% getting vaccinated, and still likely a residue of the population with above average protective immune response, and by that I mean relative to age group.

So overalI I am more optimistic about the spring than are many of the people I am talking to.  And the United States may well be the first country to arrive at a semblance of herd immunity, albeit not the way we might have preferred.

The political economy of Swine flu vaccine allocation

Previous research has isolated the effect of “congressional dominance” in explaining bureaucracy-related outcomes. This analysis extends the concept of congressional dominance to the allocation of H1N1, or swine flu, vaccine doses. States with Democratic United States Representatives on the relevant House oversight committee received roughly 60,000 additional doses per legislator during the initial allocation period, though this political advantage dissipated after the first 3 weeks of vaccine distribution. As a result political factors played a role in determining vaccine allocation only when the vaccine was in particularly short supply. At-risk groups identified by the Centers for Disease Control (CDC), such as younger age groups and first responders, do not receive more vaccine doses, and in fact receive slightly fewer units of vaccine.

That is from an Economic Inquiry paper by Matt E. Ryan.  Via Henry Thompson.

Progress against HIV-AIDS hasn’t been reported enough

While an effective vaccine against HIV may still be a long way off, a new HIV prevention technique has proven remarkably effective at protecting women against the virus.

A single injection of a drug called cabotegravir every two months was so successful in preventing HIV in a clinical trial among women in sub-Saharan Africa that the study was wrapped up ahead of schedule.

The study, run by the HIV Prevention Trials Network, was looking at two forms of pre-exposure prophylaxis or (PrEP) aimed at women. PrEP is a technique of administering low doses of anti-AIDS drugs to people who are HIV negative as a way to protect them from infection. The study compared the effectiveness of the new long-acting injectable against the current form of PrEP, a daily pill of Truvada.

The findings were announced by the study’s researchers on Monday.

“This is a major, major advance,” said Dr. Anthony Fauci in a briefing. The director of the National Institute of Allergy and Infectious Diseases, which was involved in the study, Fauci has spent much of his career working on HIV/AIDS.

Here is the full NPR report, here is NYT coverage. Yes, it still needs to be easier to deliver.  But how many Americans, right now, could identify what cabotegravir is?  As I said earlier this morning, the great stagnation may be ending.