Category: Medicine
Why the defenses of Australia do not persuade me
Alex laid out some complaints about Covid policy down under, I have been receiving emails and tweets arguing the following:
1. Australia is choosing a perfectly acceptable point on the liberty vs. safety frontier.
2. The Australian decision to do extreme lockdowns is democratic, and most Australians support it.
And sometimes I see a third point, which as far as I can tell is true:
3. Australia doesn’t have much in the way of ICU excess capacity, so a Covid surge would hit the country especially hard.
I think those responses, however, are missing the point of the critique. I would stress that if Covid risk has you with your back against the wall and the government is forcing extremely restrictive measures on your citizenry, you should be implementing the following in an urgent manner:
a. Twice a week rapid antigen tests for everyone. (Plenty of time to prep for this one.)
b. Much stronger incentives to vaccinate people more rapidly, including with the large stock (six million or so?) of AstraZeneca vaccines. Demand side incentives, supply side incentives, whatever can be done. Let’s throw the kitchen sink at this one. But as it stands, I just don’t see the urgency.
c. Mobile monoclonal antibody units, as they are used in Florida (modest progress here).
d. Maybe other emergency measures too? I’ve been hearing for decades that Australia has such a great health care system so surely they can make lots of progress on these and other fronts?
As far as I can tell from this great distance, Australia is doing none of these. And, while there is some disquiet about lockdowns, few of its citizens are demanding that they do any of those positive measures. Not many of its well-known politicians are proposing those ideas either. (Please feel free to correct me if that is wrong!…but I just don’t see word of it on-line.)
If Australia implemented all of those policies, or even just one of them, they could attain a much better “liberty vs. lives” frontier, no matter where you think the government should end up on that frontier. They could save lives, and enjoy more liberty.
And that is the great shame and indeed I would say crime. There seems to be an incredible complacency that people in some parts of the country will put up with the current measures and not demand the government look for more practical measures to boost both liberty and security.
So when you write me and suggest “this is democratic and the people approve,” yes that is exactly the problem.
Our anti-science science advisors, yet again
Top federal health officials have told the White House to scale back a plan to offer coronavirus booster shots to the general public later this month, saying that regulators need more time to collect and review all the necessary data, according to people familiar with the discussion.
Dr. Janet Woodcock, the acting commissioner of the Food and Drug Administration, and Dr. Rochelle P. Walensky, who heads the Centers for Disease Control and Prevention, warned the White House on Thursday that their agencies may be able to determine in the coming weeks whether to recommend boosters only for recipients of the Pfizer-BioNTech vaccine — and possibly just some of them to start.
Here is more from the NYT. I’ll say it again simply: they refuse to apply scientific reasoning under the heading of expected value theory. I should note, however, that if they recommend it all be sent to Brazil I will agree, but even that decision they should be able to reach within the end of business day.
How is nursing evolving? (from my email)
From Andrew K. Stein, MR reader:
There’s a massive and massively underreported shift going on right now in hospital nurse staffing that is interesting from a health and labor economics POV.
In normal times, hospitals pride themselves on having little or no use of “agency” nurses — i.e., not relying on nursing staffing companies to fill their bedside nursing slots. But it seems now that most hospitals can’t escape using agency (e.g., travel nurses) for a large plurality of their nursing staff. (In my day job, I talk to hospital Chief Nursing Officers somewhat regularly.)
Agency nurses are very expensive (high wages + agency markup) and also rather disruptive — every new travel nurse needs to learn the local hospital care processes (e.g., IV dressing changes). What you’re paying for as a CNO is the convenience of an on-tap nursing workforce. Pre-COVID, you’d hear agency labor described as an addictive drug — once you get hooked, it’s hard to wean yourself off.
What’s happening in the labor market, I think, is that there are two paths for a bedside nurse in the COVID era — keep working for a hospital or go work for an agency. Agency pay has gotten ridiculously high, so more and more nurses are quitting the local hospital, signing on with the agency, and then going to work for any hospital that can pay the agency’s rates. In exchange for going wherever the highest bidder is, they get huge increases in their take-home pay. No shame in that.
The net effect, I suspect, is that the bargaining power of nursing labor is going way up, though with unequal gains; to benefit, you have to quit your hospital-employed job and be willing to go wherever the agency sends you.
And then your open slot gets backfilled by another agency nurse from somewhere else!
It’s a reinforcing cycle: As nursing shortages rise, nurses increasingly “work short” — i.e., caring for more patients per shift than is reasonable — or work more shifts per week than typical. That daily stress spurs many nurses to either leave the bedside for something more 9-to-5 (think outpatient clinics) or jump into travel nursing to at least get paid for the extra load everyone is being forced to bear right now.
Agencies and travel nurses win, hospitals and hospital-employed nurses lose.
You could also tell the story that the labor supply of nursing has historically already been constrained (though of course now more so), and that nurses have historically been underpaid from a supply-demand perspective, and that now it’s a more liquid market (with agencies acting as market makers), so the price for labor is rising.
I’d be interested if any MR readers have seen data on how big of an effect this is (e.g., hospitals’ average % of agency staff).
I suspect that high use of agency staffing is the new normal, at least until the nursing labor supply grows to meet it — emergency authorization of 100,000 work visas for immigrant nurses? — or we invent robot nurses.
State capacity libertarianism, in a nutshell
New fluvoxamine results from McMaster University (and Fast Grants)
In a large, randomized clinical trial conducted with thousands of patients over the past six months, researchers at McMaster University tested eight different Covid-19 treatments against a control group to figure out what works.
One drug stood out: fluvoxamine, an antidepressant that the Food and Drug Administration has already found to be safe and that’s cheap to produce as a generic drug.
…This study, called the TOGETHER study, is a lot bigger — more than 3,000 patients across the whole study, with 800 in the fluvoxamine group — and supports the promising results from those previous studies. The authors released it this week as a preprint, meaning that it is still under peer review.
Patients given fluvoxamine within a few days after testing positive for Covid-19 were 31 percent less likely to end up hospitalized and similarly less likely to end up on a ventilator. (Death from Covid-19 is rare enough that the study has wide error bars when it comes to how much fluvoxamine reduces death, meaning it’s much harder to draw conclusions.) It’s a much larger effect than any that has been found for an outpatient Covid-19 treatment so far.
The role of Fast Grants is discussed toward the end, note that for us this was a major investment and done on very short notice, as befits the name Fast Grants.
My Conversation with Zeynep Tufekci
Here is the audio and transcript. Here is part of the summary:
Zeynep joined Tyler to discuss problems with the media and the scientific establishment, what made the lab-leak hypothesis unacceptable to talk about, how her background in sociology was key to getting so many things right about the pandemic, the pitfalls of academic contrarianism, what Max Weber understood about public health crises, the underrated aspects of Kemel Mustapha’s regime, how Game of Thrones interested her as a sociologist (until the final season), what Americans get wrong about Turkey, why internet-fueled movements like the Gezi protests fizzle out, whether Islamic fundamentalism is on the rise in Turkey, how she’d try to persuade a COVID-19 vaccine skeptic, whether public health authorities should ever lie for the greater good, why she thinks America is actually less racist than Europe, how her background as a programmer affects her work as a sociologist, the subject of her next book, and more.
Here is one excerpt:
COWEN: Max Weber — overrated or underrated as a sociologist?
TUFEKCI: Underrated.
COWEN: Why?
TUFEKCI: Part of the reason he’s underrated is because he writes in that very hard-to-read early 19th-century writing, but if you read Max Weber, 90 percent of what you want to understand about the current public health crisis is there in his sociology. Not just him, but sociology organizations and how that works. He’s good at that. I would say underrated, partly because it’s very hard to read. It’s like Shakespeare. You need the modern English version, conceptually, for more people to read it.
I would say almost all of sociology is underrated in how dramatically useful it is. Just ask me any time. Early on, I knew we were going to have a pandemic, completely based on sociology of the moment in early January, before I knew anything about the virus because they weren’t telling us, but you could just use sociological concepts to put things together. Max Weber is great at most of them and underrated.
COWEN: Kemal Mustafa — overrated or underrated?
TUFEKCI: Underrated.
COWEN: Why?
TUFEKCI: Why? My grandmother — she was 12 or 13 when she was in the Mediterranean region — Central Asia, but Mediterranean region, very close to the Mediterranean. She was born the year the Turkish Republic had been founded, 1923, and she was 13 or so. She was just about to be married off, but the republic was a little over a decade — same age as her. They created a national exam to pick talented girls like her. The ones that won the exam got taken to Istanbul to this elite, one of the very few boarding high schools for girls.
The underrated part isn’t just that such a mechanism existed. The underrated part is that the country changed so much in 13 years that her teacher was able to prevail upon the family to let her go. To have a 13-year-old be sent off to Istanbul, completely opposite side of the country, to a boarding school for education — that kind of flourishing of liberation.
I’m not going to deny it was an authoritarian period, and minorities, like Kurds, during that period were brutally suppressed. I can’t make it sound like there was nothing else going on, but in terms of creating a republic out of the ashes of a crumbling empire — I think it’s one of the very striking stories of national transformation, globally, within one generation, so underrated.
There are numerous interesting segments, on varied topics, to be found throughout the dialog.
Why Doesn’t the United States Have Test Abundance?!
We have vaccine abundance in the United States but not test abundance. Germany has test abundance. Tests are easily available at the supermarket or the corner store and they are cheap, five tests for 3.75 euro or less than a dollar each. Billiger! In Great Britain you can get a 14 pack for free. The Canadians are also distributing packs of tests to small businesses for free to test their employees.
In the United States, the FDA has approved less than a handful of true at-home tests and, partially as a result, they are expensive at $10 to $20 per test, i.e. more than ten times as expensive as in Germany. Germany has approved over 50 of these tests including tests from American firms not approved in the United States. The rapid tests are excellent for identifying infectiousness and they are an important weapon, alongside vaccines, for controlling viral spread and making gatherings safe but you can’t expect people to use them more than a handful of times at $10 per use.
We ought to have testing abundance in the US and not lag behind Germany, the UK and Canada. As usual, I say if it’s good enough for the Germans it’s good enough for me.
Addendum: The excellent Michael Mina continues to bang the drum.
Is the scolding equilibrium shifting, and if so why?
As the pandemic evolves, so is the tendency of people to take moral positions they would not normally endorse. Most notably, many left-wing commentators are becoming moral scolds, stressing ideals of individual responsibility.
Consider these words:
“So it’s time to stop being diffident and call out destructive behavior for what it is. Doing so may make some people feel that they’re being looked down on. But you know what? Your feelings don’t give you the right to ruin other people’s lives.”
If I had read that paragraph two years ago, I might have thought it was a conservative columnist lamenting inner-city crime, or perhaps complaining about the behavior of homeless people in San Francisco. But no: It is Paul Krugman discussing those who will not get vaccinated or wear masks. He calls it “the rage of the responsible,” and it is emblematic of a broader set of current left-wing attitudes, most of all toward the red state responses to the pandemic.
To be clear, I agree with Krugman’s point, and I frequently express similar sentiments. All the same, I wonder about the rules here. When exactly are “the responsible” allowed to express their quiet rage, on which issues and on which terms?
The alternative to this rage is the language of victimhood. For example, many on the left tend to portray the homeless as hostages to circumstances largely beyond their control: the high cost of housing, unjust eviction policies, a tattered social welfare state, perhaps mental illness or drug addiction.
There is some truth in all those hypotheses. Still, when it comes to the homeless, am I also allowed to express the quiet rage of the responsible? Or is only the rhetoric of victimhood allowed?
There is no doubt that homeless people suffer very real injustices. But it could be argued that allowing oneself to become homeless is a greater abdication of responsibility than refusing to be vaccinated. It is also worse for your health and bad for the community, as anyone from San Francisco can tell you.
One rejoinder might be that a pandemic is different. Maybe so, but if this were the 1980s, during the peak of the HIV-AIDS epidemic, one could imagine a Moral Majority advocate expressing sentiments similar to Krugman’s about gay men who engage in unsafe sex. Today such a view would be considered uncouth, at least in the mainstream media, and that’s not only because there are now effective treatments against HIV-AIDS. This kind of scolding has mostly gone out of fashion, especially when the recipients have been victims of prior or current social discrimination.
Or consider the question of suicide. There was a time in America when it was common to view suicide as a violation of Christian doctrine. Now there is largely sympathy for those who have killed themselves. Is this change for the better? Maybe, but it’s not clear that this issue has been given serious evidence-based consideration. Scolding sometimes helps to limit the number of wrong deeds, and everyone does it to some degree, even when it is sometimes not appropriate.
Then there are alcohol and drug abuse, which have some features of epidemics in that they exhibit social contagion. Your drunkenness, for example, on average encourages some of your friends to experiment with the same. But scolding alcoholics also is out of fashion, even though the social costs of alcohol abuse are extremely high, especially when considered cumulatively. As a teetotaler, I sometimes express my own quiet rage of the responsible, and my reaction is mostly considered a strange curiosity.
It is not only left-wing thinkers who have ended up in strange ideological positions. Governor Ron DeSantis of Florida, a conservative Republican and one of America’s leading right-wing politicians, has essentially expanded public health-care coverage in his state by setting up mobile units to administer monoclonal antibodies to Covid-19 sufferers. I’m all for that. At the same time, I notice he continues to oppose Medicaid expansion in Florida.
What explains the attitudinal shifts we are seeing? One possibility is that left-wing thinkers are getting more puritanical and are more comfortable in their new role as scolds, including with respect to sex and vaccination and mask-wearing. That would leave Trumpist Republicans as the defenders of medical choice and the sexual libertinism of the 1960s and 1970s.
Another possibility, not mutually exclusive, is that few of us are intellectually consistent, and so our scolding is increasingly shaped by affective political polarization. The left will scold the practices of Trump supporters, while the right will scold the woke, and views on any particular issue will be adjusted to fit into this broader pattern. If an issue is not very partisan, such as alcohol abuse or suicide, scolding simply will decline.
Here is an article on the movement to treat vaccinated patients first. Fine by me! But what exactly are the egalitarians supposed to say? Is meritocracy now allowed to rear its ugly head? Or do no other social outcomes have anything to do with your merit? Only this one? Really?
More on Australia, from an MR reader
“A random observation, in four sentences:
- I continue to see huge numbers of Australians (e.g. politicians like Dan Andrews, the Victorian Premier, and also huge numbers of random people on my facebook) say “if we don’t continue to lockdown, the health system will be overwhelmed; we have no choice”.
- Most of the at-risk population in Australia has already been vaccinated with at least one dose, which reduces hospitalisation/mortality risk by something like 70% (or perhaps even better in practice; the SMH today reports 94 people in ICU, 83 unvaccinated, 11 have one dose, and ~50% of adults have 1 dose and obviously are very negatively selected on age)
- The US never saw widespread overwhelming of the hospital system (lots of media reports of “hospitals in X about to hit capacity”, but it to date has always been one of those “just wait two weeks” things)
- People in Australia widely believe the quality of the US hospital/healthcare system is substantially inferior to the single payer hospital/healthcare system in Australia
It would seem extremely difficult for these four things to mutually coexist.”
TC again: Here is a short video from Australia, how about some AstraZeneca and a bit of testing regime instead? GG is right that the video resembles a bad dystopian science fiction movie from past decades. You will note that some segments of the American intelligentsia are so invested in criticizing the U.S. “red state” approach, and so warm toward collectivist mandates, that they won’t raise a peep about what is going on here.
Thailand and The WHO on Fractional Dosing
Thailand will study fractional dosing:
Thailand is studying the possibility of injecting coronavirus vaccines under the skin to try to stretch its limited supply, a health official said on Thursday, as the country races to inoculate the public faster amid a worsening epidemic.
“Our previous experience shows that intradermal injections uses 25% of a muscular injection, but triggers the same level of immunity,” head of the medical science department, Supakit Sirilak told reporters.
I am also pleased that the WHO’s SAGE has issued an interim statement on fractional doses:
WHO, with support of the Strategic Advisory Group of Experts (SAGE) on Immunization and its COVID-19 Vaccines Working Group, is reviewing the role of fractionating doses as a dose-sparing strategy in light of global vaccine supply constraints. SAGE is continuously reviewing the literature and has reached out to vaccine manufacturers and the research community for available information.
….While SAGE acknowledges the potential public health benefits of dose-sparing strategies to increase vaccine supply and accelerate population-level vaccination coverage, and possibly also a reduction in reactogenicity, SAGE considers there is currently insufficient evidence to recommend the use of fractional doses. Any use of a fractional dose at this point in time constitutes an off-label use of the vaccine. SAGE encourages research in the area, with a particular emphasis on research into using fractionated doses as potential boosters and fractional doses in children and adolescents. Programmatic and operational considerations should be considered from the start.
The statement is reasonable but could have used some cost-benefit analysis. Given shortages, I’d push for a challenge trial or some field trials. I agree that if we are to have boosters and to vaccinate young children we should be looking very hard at fractional doses as they are likely to be sufficient for purpose and to preserve as much supply as possible for the rest of the world.
By the way, I think you can also see some status quo bias in the WHOs position on boosters: they are not (yet) enthusiastic about increasing supply with fractional doses but they are very negative about reducing supply with boosters. What a miracle that the status quo is just right!
In the context of ongoing global vaccine supply constraints, administration of booster doses will exacerbate inequities by driving up demand and consuming scarce supply while priority populations in some countries, or subnational settings, have not yet received a primary vaccination series.
The WHO also doesn’t note that if developed countries go for boosters then the case for fractional doses elsewhere to make use of the even more limited supply is likely even stronger.
Here’s my paper with co-authors on fractional doses.
Hat tip: Witold.
Fortschritt
Germany has decided to stop using the coronavirus infection rate as its yardstick for deciding if restrictions should be in force to contain the spread of the virus, Chancellor Angela Merkel said on Monday.
The seven-day incidence rate was a key measure in determining whether restrictions could be imposed or lifted, with infection thresholds of 35, 50 and 100 per 100,000 people triggering the opening or closure of different parts of society.
But as the number of people who are fully vaccinated rises, calls have grown for the incidence rate to be dropped as a measure to determine whether lockdowns are necessary.
“We decided today that we no longer need comprehensive protective measures when the number of cases or incidence is 50, because a large proportion of the people are vaccinated,” Merkel said.
When will California do the same? Here is the full story.
The problem with fitting third doses into a regulatory structure
That is a key theme of my latest Bloomberg column, here is one excerpt:
In the U.S., President Joe Biden’s administration is now pushing third booster shots for people who already have been vaccinated. That might be a good idea, but it too creates additional uncertainty for travel and migration — and for social interaction more broadly. If three doses are so important, should people be allowed to travel (or for that matter interact indoors) with only two doses? The bar is raised yet again.
Of course the issues do not end with the third dose. If the efficacy of the second dose declines significantly in less than a year, might the same happen with the third dose? How long before four doses are necessary, or maybe five? Or what if yet another significant Covid variant comes along, and only some people have a booster dose against that strain? What then counts as being “sufficiently vaccinated”?
Many Americans seem to be keen to get their third dose, but by the nature of counting that number is fewer than the number willing to get two doses. Furthermore, many people might just tire of the stress of dealing with an ongoing stream of obligatory booster shots and stop at one or two.
The sad reality is that the “two-dose standard” may not last very long, whether abroad or domestically (the same is true of the even weaker one-dose standard with Johnson & Johnson and AstraZeneca). Vaccine mandates will become harder to define and enforce, will be less transparent, and will probably be less popular.
If you tell people that three doses are needed for safety, but two doses are enough to get you into a concert or government building, how are they supposed to sort out the mixed messages? It is not obvious that enough people will get the third dose in a timely manner to make that a workable standard for vaccine passports.
Add to that the problems with the Johnson & Johnson vaccine, which originally the government urged people to get. Now those people are not being given comparable chances to obtain boosters — in fact, they are not yet being given specific guidance at all. Are they orphaned out of any new vaccine passport system, or will (supposedly dangerous?) exceptions be made for them? Or do they just have to start all over?
The big international winner from all this is likely to be Mexico, which has remained an open country and is not relying on vaccine passports. In general I do not admire Mexico’s lackadaisical Covid response, but the country may end up in a relatively favorable position, most of all when it comes to tourism and international business meetings.
As for the U.S. and Europe, the temptation to escalate required safety measures is understandable. But the previous vaccine standards were largely workable ones. If they are made tougher, they might break down altogether.
Recommended.
Covid markets in everything, certified air ambulance regulatory arbitrage edition
“We weren’t sure what was going to happen … if they were going to separate us or put us in a hospital,” said McElroy. “I didn’t know if I was going to need a respirator.”
None of that happened. Within 72 hours, the couple was on a Learjet back to Arizona.
Before they left, Underwood purchased memberships with Covac Global, a medical evacuation company launched by the crisis response firm HRI in the spring of 2020. It meant the couple didn’t pay a dime for their repatriation, said McElroy.
Commercial airlines and private jets can’t fly travelers with Covid-19 home, but certified air ambulances staffed with medical teams can.
While some companies evacuate travelers who require hospitalization, Covac Global retrieves travelers who test positive for Covid-19 and have one self-reported symptom. About 85% of evacuees are returned home, while the rest need hospital attention, said CEO Ross Thompson.
When CNBC first spoke with the company in March, it was performing about two to three medical evacuations every month. Now, that number has climbed to about 12 to 20.
Here is the full story, via Shaffin Shariff.
They had better hurry up and distribute those AstraZeneca doses
Movement data from last weekend show Melburnians engaging in what experts have called thousands of small transgressions with the potential to drive COVID-19 infections higher, as the effect of 200 days of lockdown takes an emotional toll.
Google mobility data compiled by The Age reveals that across the state last Friday and Saturday, people were moving more than at any time since mid-July last year when complacency prompted Premier Daniel Andrews to plunge the state into stage-four lockdown and mandatory mask-wearing.
Last weekend saw a spate of breaches including an organised takeaway pub crawl in Richmond and an engagement party in Caulfield North attended by 69 guests. The couple involved in the illegal party have received $5400 fines. Two of their parents were also fined and other guests are being interviewed.
Some metropolitan municipalities including Glen Eira and Bayside recorded their highest lockdown movement levels last week, ahead of a number of mystery cases appearing in St Kilda.
Professor Mike Toole from Melbourne’s Burnet Institute, who lives in a mobility hotspot in the inner south, said he was shocked to witness large groups of people gathering in parks at the weekend.
Here is the full article, via Rich Dewey. And the Sydney lockdown is now extended until the end of September, with masks mandated for outside as well. Elsewhere:
Walmart, Target and Lowe’s, by contrast, all lifted sales forecasts this week after beating expectations for the three months to the end of July. While demand for toilet paper and cleaning supplies has cooled after 2020s pantry hoarding, the appetite for other products was broad-based. Party supplies, apparel and travel gear flew off Walmart’s shelves. At Home Depot, an early cache of Halloween decorations sold out almost immediately. Swimsuits and children’s clothing were similarly popular at Target and, in another sign of confidence, more customers returned to Walmart and Target store aisles after a year of browsing online.
Here is the associated FT article. Which set of values do you prefer? Which do most people prefer?