Category: Medicine

Patrick Collison on vaccines

Pan-variant vaccines are a $1 trillion dollar bill on the sidewalk. Some combination of a lack of basic institutional seriousness and self-imposed straightjackets mean that we will probably get these vaccines much later (perhaps years later) than we otherwise could. It is intellectually internally consistent to believe that COVID doesn’t matter and that we consequently shouldn’t care about any of this. But it is not consistent to think that COVID matters and that this situation is anything other than crazy.

Here is the full piece, written for Slow Boring (which you should subscribe to and pay for, as I do), excellent throughout.  One lesson is that management really matters, public sector management most of all for a case like this.

The FDA is Increasing Skin Cancer

Americans who travel to the beaches in France, Spain, or Italy routinely do something that is illegal in the United States–they buy and use European sunscreens to protect themselves from sunburn and skin cancer. Suncreens in Europe and Asia are better than in the United States because more ingredients are allowed and these create more effective and more pleasing suncreens. I’ve been writing about this since 2013! My view hasn’t changed:

My rule is very simple. I don’t think the FDA is better than the EMA so if any drug or device is approved in Europe it ought to be available for purchase in the United States with a label saying “Approved by the EMA. Not approved by the FDA.” (By the way, we do have reciprocity type agreements with Canada and New Zealand for food so this would not be unprecedented.)

Here’s the latest from Amanda Mull writing in the Atlantic:

Newer, better UV-blocking agents have been in use in other countries for years. Why can’t we have them here?

In formal statements and position papers, doctors and cancer-prevention advocates express considerable interest in bringing new sunscreen ingredients to the American market, but not a lot of optimism that any will be available soon.

…In 2014, Congress passed a law attempting to speed access to sunscreen ingredients that have been in wide use in other countries for years, but it hasn’t really worked. “The FDA was supposed to be fast-tracking these ingredients for approval, because we have the safety data and safe history of usage from the European Union,” Dobos said. “But it seems to continually be stalled.” According to Courtney Rhodes, a spokesperson for the FDA, manufacturers have submitted eight new active ingredients for consideration. The agency has asked them to provide additional data in support of those applications, but none of them has yet satisfied the agency’s requirements.

“In the medical community, there is a significant frustration about the lack of availability of some of the sunscreen active ingredients,” Henry Lim, a dermatologist at Henry Ford Health, in Michigan, told me. The more filters are available to formulators, the more they can be mixed and matched in new ways, which stands to improve not just the efficacy of the final product, but how it feels and looks on your skin, and how easy it is to apply. On a very real level, making sunscreen less onerous to use can make it more effective. “The best sunscreen is going to be the one you’re going to use often and according to the directions,” Dobos said. Skin cancer is the most common type of cancer in the United States, and by one estimate, one in five Americans will develop it in their lifetime.

Hat tip: Joe.

Marijuana Legalization and Fertility

State-level marijuana legalization has unintended consequences, including its effect on fertility. Marijuana use is associated with behaviors that increase fertility as well as physical changes that lower fertility. In this paper, I use a difference-in-differences design that exploits variation in medical and recreational marijuana legalization across states and over time to study the effects of marijuana legalization on fertility. This paper is the first to study the effects of recreational marijuana legalization on fertility. I find that legalizing recreational marijuana decreases a state’s birth rate by an average of 2.78% while increasing the probability that an individual is sexually active by 3.6 percentage points. [emphasis added by TC] Together, my findings show that the physical effects of marijuana use have the dominant effect on fertility. By contrast with the existing literature, I find that medical marijuana legalization does not affect the birth rate, although it increases the frequency of sexual activity by 1.6 sexual encounters per month. Neither type of marijuana legalization affects male gonorrhea cases or the probability of having sex with a stranger.

That is from a new paper by Sarah Papich, via the excellent Kevin Lewis.  And note that in this paper marijuana legalization predicts lower auto insurance premia.

The marginal value of informal access to health care

To assess the importance of unequal access to medical expertise and services, we estimate the causal effects of having a child who is a doctor on parents’ mortality and health care use. We use data from parents of almost 22,000 participants in admission lotteries to medical school in the Netherlands. Our findings indicate that informal access to medical expertise and services is not an important cause of differences in health care use and mortality.

That is from “Do Doctors Improve the Health Care of Their Parents? Evidence from Admission Lotteries,” by Elisabeth Artmann, Hessel Oosterbeek, and Bas van der Klaauw, in the new American Economic Journal: Applied Economics.  Here are earlier, ungated versions.

Successful People are also Happy and Well-Adjusted

It’s perhaps a consequence of the just-world hypothesis that we think beautiful people can’t be smart, wealthy people must have few friends, and people with greatly successful careers must have sacrificed a happy home. There are, of course, many such examples but alas there are also many people who are ugly and dumb, poor and friendless and unsuccessful and dysfunctional. So, is there any correlation? Probably not.

We examined the wrecked-by-success hypothesis. Initially formalized by Sigmund Freud, this hypothesis has become pervasive throughout the humanities, popular press, and modern scientific literature. The hypothesis implies that truly outstanding occupational success often exacts a heavy toll on psychological, interpersonal, and physical well-being. Study 1 tested this hypothesis in three cohorts of 1,826 high-potential, intellectually gifted individuals. Participants with exceptionally successful careers were compared with those of their gender-equivalent intellectual peers with more typical careers on well-known measures of psychological well-being, flourishing, core self-evaluations, and medical maladies. Family relationships, comfort with aging, and life satisfaction were also assessed. Across all three cohorts, those deemed occupationally outstanding individuals were similar to or healthier than their intellectual peers across these metrics. Study 2 served as a constructive replication of Study 1 but used a different high-potential sample: 496 elite science/technology/engineering/mathematics (STEM) doctoral students identified in 1992 and longitudinally tracked for 25 years. Study 2 replicated the findings from Study 1 in all important respects. Both studies found that exceptionally successful careers were not associated with medical frailty, psychological maladjustment, and compromised interpersonal and family relationships; if anything, overall, people with exceptionally successful careers were medically and psychologically better off.

China depredation of the day

People who have arrived in Zhengzhou to withdraw money from embattled regional banks said they have found their health codes turn red — a label mostly reserved for potential COVID-19 carriers or those infected with the virus — after arriving in Henan province’s provincial capital, prohibiting them from accessing transportation networks, public services, and even going to the banks to lodge their grievances.

Who needs deposit insurance?  Here is the full story, via B.

Is the NIH still broken?

David Putrino, a neurophysiologist at the Icahn School of Medicine at Mount Sinai, labored through his holiday last Christmas to write a grant application for urgently needed Long Covid research. With colleagues, he hoped to tap into $1.15 billion in funding that Congress granted the National Institutes of Health (NIH) in 2020, as Long Covid emerged as a major public health problem. NIH had solicited grant applications in December 2021, just weeks before their January due date. The agency said it planned to issue decisions by late March.

But as of today, Putrino was still waiting to hear whether NIH will fund his effort to discover whether microclots might be a meaningful diagnostic biomarker for many types of Long Covid. “Maybe they should hire people who are dedicated to accelerating these programs,” says Putrino, who specializes in rehabilitation medicine. “[Long Covid] is a national crisis. This does not deserve to be somebody’s second or third job. What we need from the NIH right now is their full attention.”

The article, via N., offers further details and examples.

A Bloody Waste

Image by Satheesh Sankaran from Pixabay

Hemochromatosis is a disorder in which extra iron builds up in the body. A potential treatment is phlebotomy so patients with hemochromatosis want to donate blood and donate regularly. The American Red Cross, however, does not permit people with hemochromatosis to donate blood. Why not? The blood is safe and effective. The blood of these patients doesn’t have much, if any, extra iron (the iron builds up in the body not so much in the blood per se). The “problem” is that people with hemochromatosis benefit themselves by giving blood and for this reason their blood is considered tainted by the American Red Cross.

The American Red Cross, which controls about 45% of the nation’s blood supply, does not currently accept donations from people with known hemochromatosis. Everyone agrees that the blood is safe and of high quality. There is no risk of passing on a genetic disease through blood transfusions. But the Red Cross has a long-standing policy that potential donors are not allowed to receive direct compensation for their donation (beyond the usual orange juice and cookie). Because people with hemochromatosis would otherwise have to pay for their therapeutic phlebotomies, they would in effect be getting something of value for being able to donate for free. Thus the Red Cross has ruled that such donations violate their policy.

The FDA does allow patients with hemochromatosis to donate blood so long as there is no charge for phlebotomy (i.e. so long as patients don’t have an incentive to lie to obtain free phlebotomy via donation.) Some countries and some blood banks within the US do accept donations from people with hemochromatosis as do some Kaiser locations. But the American Red Cross is the biggest collector of blood and so it is very often the case that when people with hemochromatosis get a phlebotomy their blood is simply thrown away.

Once a week, Dan Gray pays to have a pint of blood taken at Franklin Memorial Hospital. And once a week, that blood is thrown out rather than donated to someone in need.

It frustrates him.

“You could take a pint out of me, a pint out of you and a pint out of somebody else and play three-pint monte with it and they wouldn’t know whose is whose,” Gray said. “As far as the analysis of it, no one would know.”

and here:

The Cape Fear Valley Blood Donor Center put out a desperate call this past week for blood donations.

…Every time Carol Barbera hears of such pleas, she gets upset. She was once an avid blood donor and would be one still.

She also has plenty of blood to give.

A medical condition requires her to have a pint of blood drawn at least every two months. The blood is perfectly usable as donor blood. Instead, it goes straight into medical waste.

The Red Cross’s antipathy towards donations from people with hemochromatosis appears to stem from a confused ethical view that incentivized donations are either “coerced” or “non-altruistic” and an old bias against paid donations coming from Titmuss. Actual studies of paid donation, however, show that incentives increased donations without reducing quality.

Thus, as far as the evidence is concerned, there are no good reasons to prohibit people with hemochromatosis from donating blood and given the repeated shortages of blood in the United States there are many good reasons for allowing them to donate.

Hat tip: The tireless Peter Jaworski.

When should rhetoric be racially salient?

Utilizing a correlational design (N = 498), we found that those who perceived COVID-19 racial disparities to be greater reported reduced fear of COVID-19, which predicted reduced support for COVID-19 safety precautions. In Study 2, we manipulated exposure to information about COVID-19 racial disparities (N = 1,505). Reading about the persistent inequalities that produced COVID-19 racial disparities reduced fear of COVID-19, empathy for those vulnerable to COVID-19, and support for safety precautions. These findings suggest that publicizing racial health disparities has the potential to create a vicious cycle wherein raising awareness reduces support for the very policies that could protect public health and reduce disparities.

Here is more from Skinner-Dorkenoo et.al.  Via D.  There may be broader lessons as well.

Italy is Open

Italy has dropped all of its COVID entry requirements joining Austria, Belgium, Czechia, Croatia, Denmark, Greece, Hungary, Iceland, Ireland,  Lithuania, Norway, Poland, Sweden, Switzerland, and the United Kingdom among many others. The US in contrast still has a vaccination requirement for non-citizens and a costly, annoying and near useless test requirement for everyone.

Planes are not especially dangerous for COVID transmission–people are in close quarters but the filtration systems are excellent. That does not mean the risks are zero but rather that there are no strong reasons to treat planes differently than buses, subways, taxis, bars, churches, mosques and concert halls and there is certainly no strong reason to treat foreign flights differently than domestic flights. By all means, wear a mask if you wish to reduce your risk.  But let’s not pretend that testing international travelers is protecting America’s borders.

The test requirement should be dropped forthwith.

The FDA should make Paxlovid easier to get

Pharmacists still cannot prescribe the medication themselves, a step that would cut the time it takes patients to secure the drug.

The Food and Drug Administration “is looking at this and thinking about it,” Dr. Jha said. “Whether they’re going to make a change, when and how, etc., is totally in their wheelhouse.”

Many patients are still handling the sometimes-cumbersome steps on their own: locating a virus test, then securing a Paxlovid prescription from a health provider, then finding a pharmacy that carries the pill, all within days of first showing symptoms.

Dr. Jha described being frustrated by physician colleagues who have told him they still limit Paxlovid to patients 65 years and older.

But no they still will not do this.  I repeat myself, but you need to keep in mind the only time panel members have resigned from the FDA is when the Biden administration pushed through the booster shots.

Here is the full NYT article, via Rich Berger.

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.

Let’s eliminate the Covid test entry requirement for the U.S.

That is the topic of my latest Bloomberg column, you ought to be able to guess most of my arguments.  Here is the very end:

I am not arguing for passivity in the face of danger. It is distressing that US policymakers do not seem interested in spending big for pandemic preparedness. America needs a new Operation Warp Speed for pan-coronavirus vaccines and nasal spray vaccines. It should be gathering more data on Covid and improving its system of clinical trials for anti-Covid remedies, among other measures.

I am simply saying that removing the Covid test for entry to the US would bring an end to one of the more egregious instances of “hygiene theater.” And it would send a signal that America is welcoming the world once again.

Recommended.  And note that the most responsible European countries do not impose such tests.

The new Covid equilibrium

Many people have stopped keeping track of where Covid is headed, if only because it is such a stressful and unpleasant topic.  To be clear, under current circumstances I favor complete “Covid laissez-faire,” though with subsidies for new and better vaccines.  Overall, things are not so peachy keen (NYT):

The central problem is that the coronavirus has become more adept at reinfecting people. Already, those infected with the first Omicron variant are reporting second infections with the newer versions of the variant — BA.2 or BA2.12.1 in the United States, or BA.4 and BA.5 in South Africa.

Those people may go on to have third or fourth infections, even within this year, researchers said in interviews. And some small fraction may have symptoms that persist for months or years, a condition known as long Covid.

“It seems likely to me that that’s going to sort of be a long-term pattern,” said Juliet Pulliam, an epidemiologist at Stellenbosch University in South Africa…

“If we manage it the way that we manage it now, then most people will get infected with it at least a couple of times a year,” said Kristian Andersen, a virologist at the Scripps Research Institute in San Diego. “I would be very surprised if that’s not how it’s going to play out.”

I know many of you like to say “No worse than the common cold!”  Well, the thing is…the common cold imposes considerable costs on the world.  Imagine a new common cold, which you catch a few times a year, with some sliver of the population getting some form of Long Covid.  One 2003 estimate suggested that the common cold costs us $40 billion a year, and in a typical year I don’t get a cold even once.  That 2003 estimate also does not include the sheer discomfort of having a cold.

With a pinch of Long Covid in the distribution surely the current virus is a wee bit worse than that?  While many cases of Long Covid are malingerers and hypochondriacs, at this point it is clear that not all of them are.  Toss in some number of immunocompromised individuals (how many?).

Even under mild conceptions of current Covid, it is entirely plausible to believe that the costs of Covid will run into the trillions over the next ten years.

Death rates are not up, but more of the unvaccinated will die off with time and the rest of us will face this steady risk and planning annoyance for — how long?  Plus we’ll get lots of “colds,” some of them considerably worse than a cold.  And with what risk that it might mutate again and get worse? The next generation of vaccines probably will not be directly subsidized.  Which will mean much lower rates of uptake.  The point of maximum Covid immunity may well be behind us.  And you won’t be able to blame it all on lockdowns.

Please keep in mind that when it comes to your reactions I will read many of them as not much better than “I just don’t want to think about this, I am still in denial.”