Category: Medicine

The British approach to coronavirus

Not sure how aware you are of what’s happening here but the British government is taking a decidedly different approach to most other nations. They are not shutting schools or cancelling large gatherings or recommending self-isolation. They’re taking a longer view and saying if that happens it will be a way off yet. The policy is led by the scientists.

It’s a very bold approach, the govt is coming under a lot of pressure to do what other nations are doing, there’s a lot of shouting to DO MORE, but so far they’re ignoring it. It’s kind of fascinating to see it play out. If you have time, today’s press conference is really worth a watch, the chief scientific and health advisers give a pretty detailed explanation of what they’re doing (Johnson introduces and then the scientists start talking at 31.50). They don’t say this explicitly but their bet is that what China and South Korea are doing is not economically or psychologically sustainable and will just lead to another peak. (My friend has drawn a cute visual explanation of the thinking here).

In this press conference they also make a pretty persuasive case that cancelling large gatherings is pointless and may be counter-productive.

…One more thing – good summary of the arguments the govt scientists made in that press conference, in this Guardian report. eg “closures would have to be at least 13 weeks long to reduce the peak of Covid-19 by 10-15%. Measures such as self-isolation for seven days for those with symptoms … have been modelled and are shown to be much more effective”

That is from an Ian Leslie email.  I am skeptical about this approach (is it politically sustainable?), but we will know more soon.  Here is another good explanation, by another guy named Ian:

3. A UK starting assumption is that a high number of the population will inevitably get infected whatever is done – up to 80%. As you can’t stop it, so it is best to manage it. There are limited health resources so the aim is to manage the flow of the seriously ill to these.

4. The Italian model the aims to stop infection. The UKs wants infection BUT of particular categories of people. The aim of the UK is to have as many lower risk people infected as possible. Immune people cannot infect others; the more there are the lower the risk of infection

And here is a polemic critique of the British strategy.  Continuing…

A new proposal for coronavirus rebound

The $8 billion emergency spending bill to deal with coronavirus includes $3 billion that can be used for the research and development of a coronavirus vaccine or treatment. There’s a better way: The U.S. government should take advantage of the recent stock market plunge to incentivize firms to develop a coronavirus cure, vaccine, or other approaches.

We call this proposal the Epidemic Market Solution or EMS. The government should offer each of 10 firms stock options worth ten billion dollars if the Dow Jones increases by 15 percent over the next six months, and maintains that average increase over a month.

A coronavirus cure or vaccine would generate such an increase. For example, if a firm has $10 billion in options based on index funds, and a new cure or progress towards a cure causes the stock market to rise by 15 percent, the firm would make a profit of $1.5 billion. An even better response might be an increase in the market by 20 percent; in this case, the firm would make a profit of $2 billion.

That is from my old colleagues Linda Cohen and Ami Glazer at UC Irvine, and yes that is the Ami Glazer of Glazer’s Law.  Here is the full proposal.

$1 million plus in Emergent Ventures Prizes for coronavirus work

I believe that we should be using prizes to help innovate and combat the coronavirus. When are prizes better than grants? The case for prizes is stronger when you don’t know who is likely to make the breakthrough, you value the final output more than the process, there is an urgency to solutions (talent development is too slow), success is relatively easy to define, and efforts and investments are likely to be undercompensated. All of these apply to the threat from the coronavirus.

We do not know who are the most likely candidates to come up with the best tests, the best remedies and cures, the best innovations in social distancing, and the best policy proposals. Anyone in the world could make a contribution to the anti-virus effort and it won’t work to just give a chunk of money to say Harvard or MIT.

Progress is urgent. I am still keen on talent development for this and other problems, but the situation is worse every week, every day. It is important to incentivize those who are working on these problems now.

The innovators, medical professionals and policy people at work on this issue are unlikely to receive anything close to the full social value of their efforts.

I therefore am grateful that I have been able to raise a new chunk of money for Emergent Ventures — a project of the Mercatus Center — for ex post prizes (not grants) for those who make progress in coronavirus problems.

Here are the newly established prizes on offer:

1. Best investigative journalism on coronavirus — 50k

2. Best blog or social media tracking/analysis of the virus — 100k

3. Best (justified) coronavirus policy writing — 50k

4. Best effort to find a good treatment rapidly — 500k, second prize 200k

5. Best innovation in social distancing — 100k

6. Most important innovation or improvement for India — 100k

What might be an example of a winning project?  What if this attempt to build scalable respirators succeeded?  That would be a natural winner.  Or a social distancing innovation might be the roll out of more meals on wheels, little libraries, online worship, easier ways to work from home, and so on.  The vision is to give to people whose work actually will be encouraged, not to give to Amazon (sorry Jeff!), no matter how many wonderful things they do.

These are not prizes you apply for, they will be awarded by Emergent Ventures when a significant success is spotted.  (That said, you still can propose a coronavirus-related project through normal channels, with discretionary amounts to be awarded as grants per usual procedures.)  And typically the awards will apply to actions taken after the release of this announcement.

I would love to be able to offer more second and third prizes for these efforts, and also to increase the amounts on offer, and perhaps cover more countries too. Or perhaps you have an idea for an additional category of prize. So if you are a person of means and able to consider making a significant (tax-deductible) contribution, please email me and we can discuss.

In the meantime, the rest of you all need to get to work.

Massive US Government Failure

NPR: Ashish Jha, who runs the Harvard Global Health Institute, says the response to the coronavirus has varied dramatically around the world.

…So how has the United States’ response been?

“Our response is much, much worse than almost any other country that’s been affected,” Jha says.

He uses the words “stunning,” “fiasco” and “mind-blowing” to describe how bad it is.

“And I don’t understand it,” he says incredulously. “I still don’t understand why we don’t have extensive testing. Vietnam! Vietnam has tested more people than America has.” (He’s citing data from earlier this week. The U.S. has since started testing more widely, although exact figures still aren’t available at a national level.)

…Jha believes that the weekslong delay in deploying tests — at a time when numerous other tests were available around the world — has completely hampered the U.S. response to this crisis.

“Without testing, you have no idea how extensive the infection is. You can’t isolate people. You can’t do anything,” he says. “And so then we’re left with a completely different set of choices. We have to shut schools, events and everything down, because that’s the only tool available to us until we get testing back up. It’s been stunning to me how bad the federal response has been.”

I too am stunned .

Michael Strain and Scott Gottlieb have policy proposals for coronavirus

Congress should make direct cash payments—mailed checks or direct deposits—to low-income households in places with severe outbreaks. Hourly wage workers should not feel compelled to show up to work sick because they need to pay bills. Congress can help these Americans recover and keep other people healthy by financing their time away from work.

In states experiencing severe outbreaks, Congress should waive the requirement that people receiving unemployment insurance payments look for work. Better that such unemployed workers receive financial assistance for rent, mortgages and groceries than to risk spreading the virus by applying and interviewing for jobs. Congress should also waive work requirements in the food-stamp program.

Children in low-income families will miss subsidized meals if schools are closed. Federal subsidies to those households should be increased to account for lost breakfasts and lunches. This might help relieve some of the pressure on low-income parents, who might otherwise feel the need to go to work even if ill.

Cash-strapped states may be reluctant to divert spending from other priorities toward health care, especially as more people use services. States that experience outbreaks may also lose tax revenue. Congress should increase the share of Medicaid spending financed by the federal government to alleviate the budget pressure.

So far the best proposals I have seen, here is more from the WSJ.  Note that paid sick leave can place a high burden on small and medium-sized businesses, here is a Yelowitz and Saltsman critique of paid sick leave, also WSJ.

What is the proper fiscal response to the coronavirus?

A number of you have been asking me this question, and unfortunately I still do not know.  Here is why:

1. I still am not sure how much we want to keep people on the job, as opposed to keeping them away from the workplace (but still being paid?).

2. I am not sure if this will be a rapid, bounce-back recovery, or a tortuous supply-bottlenecked, high risk premium non-recovery.  It matters a good deal for our policy choices and also for their timing.

3. Will aggregate supply or aggregate demand end up being the binding constraint, after the two have interacted for a while?  Or is that the wrong framework altogether?

3b. Can you build tunnels and bridges with quarantined workers?

4. I see a good chance that the coronavirus will affect regions of the country differently, with climate, temperature, humidity, and population density being possible factors.  (Where are the overloaded hospitals in Jakarta?  Surely at this point it is not just a data collection issue.)  So where exactly should the aid and the fiscal stimulus go?  And for what exactly?  It seems we will know much more soon, but we don’t know it yet.

5. Do you want to give people cash if they will just go out and spend it on entertainment or in large, crowded stores?  Is that what you are hoping they will do?  To what extent do we want the “transmitting sectors” to be contracting right now?  Does it do much good to send consumers money they will spend on Amazon or pizza deliveries, two sectors that may do fine or even prosper during the tough times?

I do not think we should bail out shale oil producers or cruise lines.  Presumably we wish to support businesses with an income gap for coronavirus reasons, but what exactly should we do?  I am puzzled by the degree of certainty people seem to exhibit about this issue.  I am not arguing we should do nothing, but simply noting I am not yet sure what to recommend.  My intuition is to opt for well-targeted federal aid for the most heavily affected regions — Washington state, the Bay Area, and parts of New York — and then take another bite at the apple soon as the numbers develop.

In the meantime, let’s do everything we can on the public health front.  Much of that will end up being fiscal policy as well.

How big a hit will the U.S. economy take?: two scenarios

That is the topic of my latest Bloomberg column, here is one pastiche:

First, consider the relatively optimistic view: Covid-19 will have affects akin to what economists call a seasonal business cycle — which is to say, it will be over quickly and without much lasting damage.

…in this scenario there is also a rapid path back to recovery. At some point the terror of Covid-19 will lift, just as cases in many parts of China now seem to be declining. Once public health conditions improve, retail, entertainment and services can gear back up. Both production and purchasing power will bounce back, similar to how they normally do after the first-quarter doldrums.

Or:

But there is a much more worrying scenario. Rather than drawing an analogy with temporary seasonal cycles, an alternative model draws a parallel with cascading disruptions. Have you ever tried building a sand pile and noticed that, at some point, adding a few more handfuls of sand causes a kind of avalanche, leaving just an amorphous heap?

This less sanguine option might look like this: The Chinese economic slowdown leads to a permanent loss of momentum and a global recession. At the same time, with Lombardy closed down, the Italian government defaults, but the European Union is unable to resolve the matter (and the associated bank failures) in a timely and resolute manner. Governments vacillate between policies that make it easier for people to stay at home to limit the spread of the disease and policies designed to get them back in the workplace.

The U.S. would be caught up in the general loss of confidence, as well as the contagion from European banks. But that is only the beginning. As schools close to limit the spread of Covid-19, single parents would have to stay home, and the resulting production bottlenecks would plague the U.S. economy. Maybe New York City would have to cut back on the number of subway trains it runs, and much of the city’s economy would grind to a halt. Supply chain problems from China would persist, hitting everything from medicines to the ordinary goods found in a Walmart.

The problems of missing goods in the supply chain, workplace absenteeism, family health emergencies, and investor uncertainty would compound each other. Any individual act of spending or production, rather than jump-starting further economic activity, would run up against another bottleneck and fade to insignificance. The confidence boost would fail to materialize. Untangling this mess of problems is much harder than just getting people to go back out to dinner and the movies again, and could take years. Traditional demand-side stimulation from the Fed or from the fiscal side would not itself reverse the stagnation.

Recommended.

The Lasting Effects of the 1918 Influenza Pandemic

[I’ve never put a trigger warning on a post before but given the current situation the information here is potential upsetting to anyone expecting a child. I do not think that the current pandemic will be as bad as the 1918. I am also hopeful that the weather will work in our favor and that, as Tyler argued, America will start to work. Do also read my post, What Worked in 1918-1919 for a more positive message.]

The 1918 influenza pandemic struck the United States with most ferocity in October of 1918 and then over the next four months killed more people than all the US combat deaths of the 20th century. The sudden nature of the pandemic meant that children born just months apart experienced very different conditions in utero. In particular, children born in 1919 were much more exposed to influenza in utero than children born in 1918 or 1920. The sudden differential to the 1918 flu lets Douglas Almond test for long-term effects in Is the 1918 Influenza Pandemic Over?

Almond finds large effects many decades after exposure.

Fetal health is found to affect nearly every socioeconomic outcome recorded in the 1960, 1970, and 1980 Censuses. Men and women show large and discontinuous reductions in educational attainment if they had been in utero during the pandemic. The children of infected mothers were up to 15 percent less likely to graduate from high school. Wages of men were 5–9 percent lower because of infection. Socioeconomic status…was substantially reduced, and the likelihood of being poor rose as much as 15 percent compared with other cohorts. Public entitlement spending was also increased.

At right, for example, are male disability rates in 1980, i.e. for males around the age of 60, by year and quarter of birth. Cohorts born between January and September of 1919 “were in utero at the height of the pandemic and are estimated to have 20 percent higher disability rates at age 61…”.

Figure 3 at right shows average years of schooling in 1960; once again the decline is clear for those born in 1918 and note that not all pregnant women contracted influenza so the actual effects of influenza exposure are larger, about a 5 month decline in education, mostly coming through lower graduate rates.

Higher disability and lower education translate into greater government payments as show in the final figure below. Almond labels these welfare payments which might be slightly misleading–these are Social Security Disability payments in 1970. Here’s Almond:

Average payments to women and nonwhites in 1970 are plotted in figure 8. The average welfare payment was 12 percent higher for both women and nonwhites born in 1919, or approximately one-third higher for children of mothers who contracted influenza. When we focus on quarter of birth, it is apparent that these increased payments are generated by high payments to those born between April and June of 1919.

Note that men and women who were especially disabled could have died before 1970 and so these are lower bounds on the disability impact.

Fetal exposure seems to be the key as Almond tests for and rejects other possibilities. The 1918 kids, for example, seem about the same as the 1920 kids so it’s not that the flu killed off the weak kids in 1918.

Almond was interested in the 1918 pandemic not simply as a historical episode but to make the case that infant health and infant health programs have high benefit to cost ratios, a still relevant lesson.

Hat tip: Wojtek Kopczuk.

Solve for the reporting equilibrium?

The district governments of the metropolis that comprises Wuhan — the epicenter of the coronavirus outbreak in China — have announced plans to give cash rewards to local residential areas that have successfully curbed the spread of COVID-19.

The incentive rules stipulate that regions and large facilities, such as rural villages and apartment complexes, will receive up to 500,000 yuan ($72,000) for reporting no new cases of infection. Per the Beijing News (in Chinese), the policies were in line with a high-level initiative launched by the Wuhan municipal government on March 1 that mandates every resident to be thoroughly examined.

Here is more, via Slow Thinker.

America is historically slow to mobilize, but eventually quite effective

That is the theme of my latest Bloomberg column, and Pearl Harbor, terrorism risk, and the financial crisis stand among the notable examples.  Here is one excerpt:

It is no accident that America is so often so slow out of the starting gate. The federal government is large and complex, and the American people do not always elect the most intellectual or science-minded of leaders. Federalism means American politics has many moving parts, and the government tends to work closely with the private sector, heightening coordination problems and slowing response times. For all America’s reputation as the land of laissez-faire, it is in fact highly bureaucratized, with the health-care sector an especially bad offender.

And:

As time passes, the number of discrete decision points in the U.S. system goes from being a drawback to a strength. For instance, it turns out that the University of Washington had been developing an effective testing kit several months ago, for fear that Covid-19 would spread widely. Washington State is now in the testing lead, and virologists there are working very hard to collect and interpret data, setting an example for others. Commercial companies such as Quest Diagnostics and LabCorp are now developing tests as well, with further interest likely to follow. American institutions are some of the most productive and flexible in the world, at least once they are allowed to operate.

America also has one of the strongest traditions of civil society and volunteerism, and those resources too will be mobilized to help fight the coronavirus as appropriate. The Gates Foundation will soon fund free home-testing kits, initially in the Seattle area.

There is much more at the link.  Of course it is indeed time we got our act together, starting at the very top but by no means limited to that position.

The FDA and Coronavirus

The failure of the FDA/CDC to adequately prepare for coronavirus, despite weeks of advance notice from China is one of the most shocking and serious examples of government failure that I have seen in my lifetime. After being prevented from doing so, private laboratories are now allowed to offer coronavirus tests and Bill and Melinda Gates’s Foundation is working on an at home swab and test.

But what happens when people get sick? What drugs will patients be allowed to try given that there is no standard treatment available? One experimental antiviral, Remdesivir, was given to the first US patient who was on a downward spiral but seemed to recover after receiving the drug. Gilead, the manufacturer says:

Remdesivir is not yet licensed or approved anywhere globally and has not been demonstrated to be safe or effective for any use. At the request of treating physicians, and with the support of local regulatory agencies, who have weighed the risks and benefits of providing an experimental drug with no data in 2019-nCoV, Gilead has provided remdesivir for use in a small number of patients with 2019-nCoV for emergency treatment in the absence of any approved treatment options.

If Gilead is willing to supply, should patients have a right to try? This seems like a good case for the dual tracking approach proposed by Bartley Madden–let patients try unapproved drugs but collect all information in a public database for analysis. Clinical trials for Remdesivir and other potential drugs are currently underway in China.

Chloroquine, might also be useful against Covid-19. Chloroquine was approved long ago to treat malaria and physicians are allowed to prescribe old drugs for new uses. New uses for old drugs are discovered all the time and they do not have to go through long and costly FDA approval procedures before being prescribed for the new uses. Since chloroquine has never been tested for efficacy against coronovirus, allowing physicians to prescribe it is similar to allowing physicians to prescribe an unapproved drug like Remdesivir. The difference in how new drugs and old drugs for new uses are treated is something of a regulatory anomaly but a fortunate one as I argue in my paper on off-label prescribing.

I suspect that my arguments for less FDA regulation will be relatively well received during the current climate of fear. Bear in mind, however, that for the patient who is dying it’s always an emergency.

Hat tip: Balaji Srinivasan, who really would make a great FDA commissioner.

A simple proposal for boosting health care workers

One recent report suggests that 10% of the doctors in northern Italy are infected with coronavirus.  No matter what the exact figure, that is clearly a problem.  In response, Italy is opting for at least two reforms.  First, health care workers who are retired are being lured back to work:

Italy on Saturday began recruiting retired doctors as part of urgent efforts to bolster the healthcare system with 20,000 additional staff to fight the escalating viral epidemic.

Second, the government is giving accelerated treatment to those studying for health care jobs:

In addition, nursing students who were due to take their final exams next month are now expected to graduate in the coming days so they can be immediately put to work

The United States should consider measures in the same direction.

My avian flu blog days

Circa 2004 or so, it seemed to me that America was grossly underprepared for a possible pandemic.  I started reading up on the topic, and I produced a very basic, simple Mercatus policy paper on avian flu.  For obvious reasons, much of it is out of date and some of the recommendations have been adopted, but here is the first part of the Executive Summary:

1. The single most important thing we can do for a pandemic—whether avian flu or not—is to have well-prepared local health care systems. We should prepare for pandemics in ways that are politically sustainable and remain useful even if an avian flu pandemic does not occur.

2. Prepare social norms and emergency procedures which would limit or delay the spread of a pandemic. Regular hand washing, and other beneficial public customs, may save more lives than a Tamiflu stockpile.

3. Decentralize our supplies of anti-virals and treat timely distribution as more important than simply creating a stockpile.

4. Institute prizes for effective vaccines and relax liability laws for vaccine makers. Our government has been discouraging what it should be encouraging.

5. Respect intellectual property by buying the relevant drugs and vaccines at fair prices. Confiscating property rights would reduce the incentive for innovation the next time around.

6. Make economic preparations to ensure the continuity of food and power supplies. The relevant “choke points” may include the check clearing system and the use of mass transit to deliver food supply workers to their jobs.

7. Realize that the federal government will be largely powerless in the worst stages of a pandemic and make appropriate local plans.

8. Encourage the formation of prediction markets in an avian flu pandemic. This will give us a better idea of the probability of widespread human-to-human transmission.

9. Provide incentives for Asian countries to improve their surveillance. Tie foreign aid to the receipt of useful information about the progress of avian flu.

10. Reform the World Health Organization and give it greater autonomy from its government funders.

And also from later on:

4. We should not expect to choke off a pandemic in its country of origin. Once a pandemic has started abroad, we should shut schools and many public places immediately.

5. We should not obsess over avian flu at the expense of other medical issues. The next pandemic or public health crisis could come from any number of sources. By focusing on local preparedness and decentralized responses, this plan is robust to surprise and will also prove useful for responding to terrorism or natural catastrophes.

Still relevant today.  For a while I also wrote an avian flu blog with Silviu Dochia, archived here.

What Worked in 1918-1919?

The influenza pandemic of 1918 was the most contagious calamity in human history. Approximately 40 million individuals died worldwide, including 550 000 individuals in the United States...[C]an lessons from the 1918-1919 pandemic be applied to contemporary pandemic planning efforts to maximize public health benefit while minimizing the disruptive social consequences of the pandemic as well as those accompanying public health response measures?

That’s the question Markel et al. analyzed in 2007 by gathering historical data on outcomes and what 43 US cities, covering about 20% of the US population, did to combat influenza in 1918-1919.

Nonpharmaceutical interventions were considered either activated (“on”) or deactivated (“off”), according to data culled from the historical record and daily newspaper accounts. Specifically, these nonpharmaceutical interventions were legally enforced and affected large segments of the city’s population. [1] Isolation of ill persons and quarantine of those suspected of having contact with ill persons refers only to mandatory orders as opposed to voluntary quarantines being discussed in our present era. [2] School closure was considered activated when the city officials closed public schools (grade school through high school); in most, but not all cases, private and parochial schools followed suit. [3] Public gathering bans typically meant the closure of saloons, public entertainment venues, sporting events, and indoor gatherings were banned or moved outdoors; outdoor gatherings were not always canceled during this period (eg, Liberty bond parades); there were no recorded bans on shopping in grocery and drug stores.

The authors define “public health response time” as the number of days from the day the excess death rate was double baseline to the day that at least one of their three key public health measures was implemented. Cities that responded very early have a negative public health response time. The basic result is shown in the figure below. The longer the public health response time the greater the total excess deaths (the arrow is my least squares eyeball).

Moreover, although it’s difficult to control for other factors, cities that combined school closures, isolation and quarantining, and public gathering bans tended to do better. Some cities let up on their public health interventions and these cities seem to correlate well with bi-modal distributions in excess death rates, i.e. the death rate increased. Denver was an example where the public gathering ban was dropped and the school ban was lifted temporarily and the excess death rate rose after having fallen.

The authors conclude:

…the US urban experience with nonpharmaceutical interventions during the 1918-1919 pandemic constitutes one of the largest data sets of its kind ever assembled in the modern, post germ theory era.

…Although these urban communities had neither effective vaccines nor antivirals, cities that were able to organize and execute a suite of classic public health interventions before the pandemic swept fully through the city appeared to have an associated mitigated epidemic experience. Our study suggests that nonpharmaceutical interventions can play a critical role in mitigating the consequences of future severe influenza pandemics (category 4 and 5) and should be considered for inclusion in contemporary planning efforts as companion measures to developing effective vaccines and medications for prophylaxis and treatment. The history of US epidemics also cautions that the public’s acceptance of these health measures is enhanced when guided by ethical and humane principles.

Addendum: Another way of putting this is that China has largely followed the US model. Can the US do the same?

From a scientist, coronavirus pictures to ponder

Figure legend
– Plotted in log scale!
– US cases based on deaths: estimated number of real cases using SK‘s current death rate of 0.6%
– US prediction 1a: predicted lower lower bound trajectory based on SK and China (assumes containment and large amount of testing )
– US 2a: upper bound, same assumptions as 1a
– US prediction 1b: no serious containment, trajectory similar to flu, lower bound
– 2b: Higher bound for flu-like trajectory

As I read this picture, it seems to suggest that the returns to properly done containment can be high.  What do you all think?