Category: Medicine
Why vaccine passports are a welfare-dominated approach
Use monetary rewards (or penalties) if need be. Here is Joshua Gans applying some game theory to the vaccine passport idea:
Vaccine hesitancy is modelled as an endogenous decision within a behavioural SIR model with endogenous agent activity. It is shown that policy interventions that directly target costs associated with vaccine adoption may counter vaccine hesitancy while those that manipulate the utility of unvaccinated agents will either lead to the same or lower rates of vaccine adoption. This latter effect arises with vaccine passports whose effects are mitigated in equilibrium by reductions in viral/disease prevalence that themselves reduce the demand for vaccination.
A “utility tax” is rarely a good idea. Besides what happens if you lose your smart phone? Don’t have one to begin with? Arrive from another country with an incompatible information/verification system?
With cases falling in both the UK and Netherlands, the vaccine passport idea, at the governmental level, is looking worse and worse. That said, I am all for private entities making their own decisions on these issues, and generally I am happy when I see employers require vaccination.
Addendum: Here is a Gans tweet storm on the paper.
Swedish study will pay people to get vaccinated
Swedish volunteers will be paid £17 each to be immunised in Europe’s largest test of whether small cash incentives can improve vaccine uptake…
The Swedish study, led by Erik Wengstrom, an economics professor at Lund University, uses gentler methods.
Over the next few weeks 8,200 unvaccinated people under the age of 60 will be split into different groups. Some will be given a voucher worth 200 Swedish kronor (£17) that can be used in most shops if they are vaccinated.
The money is a fraction of the sums being discussed in other countries, but Wengstrom said there was evidence from the US that as little as $25 (£18) was enough to persuade people.
He said: “People might have the intention to get vaccinated, but maybe there’s a little bit of hassle involved and something always gets in the way, so a small incentive might help.”
Other participants will be subjected to “nudge” techniques — attempts to influence people’s behaviour by guiding them towards a particular choice.
Some will be given leaflets about the vaccines’ benefits and side effects; others will be asked to think of the best argument to persuade others to have the vaccine. A third group will be told to draw up a list of their loved ones. “That’s basically encouraging them to think about how the vaccination might protect others,” Wengstrom said.
Here is the full London Times story. Here is further information from Sweden.
Electric shock devices on humans now allowed once again
A Massachusetts school can continue to use electric shock devices to modify behavior by students with intellectual disabilities, a federal court said this month, overturning an attempt by the government to end the controversial practice, which has been described as “torture” by critics but defended by family members.
In a 2-to-1 decision, the judges ruled that a federal ban interfered with the ability of doctors working with the school, the Judge Rotenberg Educational Center, to practice medicine, which is regulated by the state. The Food and Drug Administration sought to prohibit the devices in March 2020, saying that delivering shocks to students presents “an unreasonable and substantial risk of illness or injury.”
Although the F.D.A.’s ban was national, the school in Canton, Mass., appears to be the only facility in the United States using the shock devices to correct self-harming or aggressive behavior…
The treatment, in which students wear a special fanny pack with two protruding wires, typically attached to the arm or leg, can deliver quick shocks to the skin when triggered by a staff member with a remote-control device.
Here is the full NYT story. You might argue this treatment can be useful in many cases, but what exactly is the error rate here? How high an error rate should we be willing to accept? What recourse do the victims have, noting that many probably live under guardianship? How might you model the incentives of the staff at the facility who use this? How well do “prison guards” behave more generally?
As a side note, I think this matter should be handled by legislation rather than the FDA.
Excess Deaths in India
Abhishek Anand, Justin Sandefur, and Arvind Subramanian calculate excess mortality in India since April 2020 based on three different datasets (each with their own challenges.) Each estimate indicates that excess mortality is more likely around 4 million than the official figure of 400,000. These figures accord with what everyone on the ground has been telling me. Nearly all my Indian friends report deaths among their family or friends.
…the most critical take-away is that regardless of source and estimate, actual deaths during the Covid pandemic are likely to have been an order of magnitude greater than the official count. True deaths are likely to be in the several millions not hundreds of thousands, making this arguably India’s worst human tragedy since partition and independence.
Photo Credit: REUTERS/ADNAN ABIDI
Vaccines Dramatically Reduce Deaths
A very good graph from the New Statesman. The vaccines give the body a huge advantage in fighting the virus so even when there are infections the number of deaths is dramatically reduced. This is UK data but the same type of relationship should hold everywhere.
Why should they call us “professors”?
I’ve long wondered about this, and explore that question in my latest Bloomberg column. I’ve discouraged this for a long time:
…I have insisted that my graduate students call me “Tyler.” My goal has been to encourage them to think of themselves as peer researchers who might someday prove me wrong, rather than viewing me as an authority figure who is handing down truth.
And:
Some of the strongest norms are around the title “Doctor.” Just about everyone calls their physician “Doctor,” though the esteemed profession of lawyer does not receive similar treatment. As a Ph.D.-toting academic, I’ve even had people say to me — correctly — “You’re not a real doctor.”
I fear that by ceding this unique authority status to doctors we are making it easier for them to oversell us medical care, a major problem in the U.S. If your doctor suggests that you need a procedure done, it can be hard to say no, especially if you have been deferring to that person for years through the use of an honorific title. On the upside, perhaps all that deference has encouraged many people to get their vaccinations.
There are some arguments for titles:
Sometimes a title can be used to suggest a subordinate position, such as the use of Nurse. It can be an honorific, but it also places the person below the Doctor. The advantage, however, is one of greater anonymity and remove. A woman in particular might prefer “Nurse Washington” over the use of her real full name, given the potential risk of harassment.
Title issues and gender issues intersect in tricky ways. A title such as doctor or professor can give a woman newfound respect, but perhaps the practice hurts respect for women as a whole, since they are titled at lower rates than men.
What I expect we will see is that “established” women and minorities will insist on title usage all the more, to command respect, and under the guise of societal feminization we will evolve a new set of non-egalitarian hierarchies, presented and marketed to us under egalitarian pretenses. On related ideas, see my earlier post on the first date book walk out meme.
Biden, COVID and Mental Health in America
Using US Census Household Pulse Survey data for the period April 2020 to June 2021 we track the evolution of the mental health of nearly 2.3 million Americans during the COVID pandemic. We find anxiety, depression and worry peaked in November 2020, coinciding with the Presidential election. The taking of prescription drugs for mental health conditions peaked two weeks later in December 2020. Mental health improved subsequently such that by April 2021 it was better than it had been a year previously. The probability of having been diagnosed with COVID did not rise significantly in the first half of 2021 but COVID infection rates were higher among the young than the old. COVID diagnoses were significantly lower in States that had voted for Biden in the Presidential Election. The probability of vaccination rose with age, was considerably higher in Biden states, and rose precipitously over the period among the young and old. Anxiety was higher among people in Biden states, whether they had been diagnosed or not, and whether they were vaccinated or not. The association between anxiety and depression and having had COVID was not significant in Biden or Trump states but being vaccinated was associated with lower anxiety and depression, with the effect being larger in Biden states. Whilst being in paid work was associated with lower anxiety, worry and depression and was associated with higher vaccination rates, it also increased the probability of having had COVID.
That is a new NBER working paper from the highly regarded David G. Blanchflower and Alex Bryson. Model that!
Second Doses Are Better at 8 Weeks or Longer
In Britain people are now being warned *not* to get their second dose at 3 or 4 weeks because this offers less protection than waiting 8 weeks or longer.
Warnings over the lack of long-term protection offered by jab intervals shorter than eight weeks come as scores of under 40s continue to receive second doses early at walk-in clinics, contrary to Government guidance.
…“There is very good immunological and vaccine effectiveness evidence that the longer you leave that second dose the better for Pfizer and eight weeks seems to be a reasonable compromise.”
Professor Harnden emphasised that “you’re definitely less protected against asymptomatic disease if you have a shorter dose interval”.
I’m so old I can remember when first doses first wasn’t “following the science.”
Covid protection in Oaxaca
On the flight from Houston to Oaxaca, not everyone took off their masks to eat and drink, as they would on most internal U.S. flights, even if only for “faux mask removal-motivated drinking” [FMRMD].
You have to fill out some forms, through an app, on your smart phone in advance. When you arrive they ask: “Did you fill out the forms?” Say yes if you did.
They let you in, no test required, no other questions asked. They do check your baggage tag against the bag you take away.
Nearly everyone in central Oaxaca city wears a mask all the time in public, including outside. It is like San Francisco at its mask-wearing peak.
They spray the sides of the parks with something that smells like hand sanitizer.
If you wish to enter a store, you have to accept some hand sanitizer. This is perhaps an efficient tax on browsing. Toward the end of the day, however, they dispense with the tax.
Some establishments spray your clothes when you enter, maybe it is water? Some spray you front and back. Staff compliance does not seem to be grudging, rather the “Mexican petty bureaucracy” seems to be mobilized and out in force and with real enthusiasm.
There is a place along the local highway where they stop all cars, and have everyone get out to accept a dose of hand sanitizer.
I wonder how the equilibrium operates. Of all the above measures, perhaps only the masks stand a chance of helping? Does the rest of the security theater make it easier for them to largely stay open?
What is going on with Covid right now?
Here is a very good thread from William Hoenig, recommended.
Supported decision-making vs. guardianship
In the last decade, and especially after the 2013 Virginia court case of Ross and Ross v. Hatch, there has been a dramatic increase in knowledge, use, and legal recognition of supported decision-making (SDM) in the United States. SDM is a methodology in which people work with trusted friends, family members, and professionals who help them understand their situations and choices so they may make their own decisions and direct their lives. After the Hatch case, in which a young woman with Down syndrome defeated a petition for permanent guardianship by demonstrating that she uses SDM, this methodology has increasingly been considered and used as an alternative to guardianship to enable people to retain their legal rights and make life choices to the maximum extent possible. This article reviews the guardianship laws of the 50 U.S. states and the District of Columbia. Using criteria we developed, in light of the findings and values expressed in Hatch, we assessed the extent to which those laws recognize or encourage the use of SDM as an alternative to guardianship and as a means to enhance self-determination for people in guardianship. We then offer recommendations for future SDM research, policy, education, and advocacy efforts.
That is from a recent paper by Jonathan Martinis, et.al., via the excellent Kevin Lewis. Guardianship is not the only alternative to “chaos,” now is the time to be truly Woke.
John Aubrey’s account of his own life
In part:
Born at Easton Piers, march twelfth, 1621, about sun-rising: very weak and like to die, and therefore christened that morning before prayer. I think I have heard my mother say I had an ague [fever] shortly after I was born.
1629: about three or four years old, I had a grievous ague. I can remember it. I got not health till eleven, or twelve: but had sickness of vomiting for thirteen hours every fortnight for…years…This sickness nipped by strength in the bud.
1633: eight years old, I had an issue (natural) in the coronal suture of my head, which continued running till twenty-one.
1634: October: I had a violent fever that was like to have carried me off. ‘Twas the most dangerous sickness that ever I had.
About 1639 (or 1640) I had the measles, but that was nothing: I was hardly sick.
1639: Monday after Easter week my uncle’s nag ran away with me, and gave a very dangerous fall.
1643: April and May, the small-pox at Oxford; and shortly after, left that ingenious place; and for three years led a sad life in the country…
1646: April — admitted of the Middle Temple. But my father’s sickness, and business, never permitted me to make any settlement to my study…
1655 (I think) June fourteenth, I had a fall at Epsom, and broke one of my ribs and was afraid it might cause an apostumation [abscess]…
1656: December: Veneris morbus [venereal disease]
1657: November, twenty-second, obiit domina [died Lady] Katherine Ryves, with whom I was to marry; to my great loss
Nor were those the end of his troubles…
That is all from John Aubrey’s Brief Lives, the autobiographical section, an excellent book more generally. Progress Studies!
Towards a COVAX Exchange
Israel had vaccine that was about to expire before it could be administered. South Korea needed vaccine immediately to stop a surge. They arranged a deal.
South Korea said it will receive 700,000 doses of Pfizer-BioNTech’s coronavirus vaccine from Israel on loan this week, in an attempt to speed up immunisation following a surge in infections around the capital Seoul.
…Under the vaccine swap arrangement announced by both governments on Tuesday, South Korea will give Israel back the same number of shots, already on order from Pfizer, in September and October.
South Korea has quickly distributed the COVID-19 vaccines it has, but has struggled to obtain enough doses in a timely manner as global supplies are tight, particularly in Asia.“This is a win-win deal,” [Israeli Prime Minister Naftali Bennett] said in an earlier statement.
One of the weaknesses of the COVAX facility for distributing vaccines is that distribution is primarily based on population with all countries guaranteed that “no country will receive enough doses to vaccinate more than 20% of its population until all countries in the financing group have been offered this amount.” That’s equitable, but it has dynamic challenges: different countries may have different needs and capabilities at different points in time. A country may be given vaccines, for example, when it may not yet be ready to administer them — and that can potentially lead to waste. The Israel-South Korea deal, for example, only narrowly averted 700,000 Pfizer doses from being tossed. Countries may also have different preferences for vaccines, as different vaccines may fit better with their healthcare systems. A fixed distribution schedule doesn’t adapt to the unique circumstances of time and place, as Hayek might have said.
It’s not surprising that COVAX chose a fixed distribution rule as many people wouldn’t trust a centralized authority to decide who gets what vaccines when. But what about guaranteeing each country a right to vaccine but allowing them to trade? Trade wouldn’t be vaccines for dollars which could introduce ethical and agency issues but vaccine at time 1 for vaccine at time 2 as in the Israel-South Korea exchange or across other factors such as vaccine type. My colleagues on the Kremer team, most notably Eric Budish, Scott Duke Kominers and Canice Prendergast, have been helping think through the design of just such a system. Prendergast designed the now-famous distribution system for Feeding America, Budish helped to design Wharton’s Course Match system and Kominers has worked on mechanisms for allocating convalescent plasma, vaccines and many other goods.
A suitably designed exchange can increase efficiency while maintaining equity. The Israel-South Korea deal reminds us that this is a priority. Greater efficiency in this context means fewer vaccine doses wasted, and more lives saved.
Alternative Dosing
Alternative dosing is finally getting some attention. This story in Nature recounts some of the recent arguments and evidence:
Two jabs that each contained only one-quarter of the standard dose of the Moderna COVID vaccine gave rise to long-lasting protective antibodies and virus-fighting T cells, according to tests in nearly three dozen people1. The results hint at the possibility of administering fractional doses to stretch limited vaccine supplies and accelerate the global immunization effort.
Since 2016, such a dose-reduction strategy has successfully vaccinated millions of people in Africa and South America against yellow fever2. But no similar approach has been tried in response to COVID-19, despite vaccine shortages in much of the global south.
“There’s a huge status quo bias, and it’s killing people,” says Alex Tabarrok, an economist at George Mason University in Fairfax, Virginia. “Had we done this starting in January, we could have vaccinated tens, perhaps hundreds, of millions more people.”
…Sarah Cobey, an infectious-disease researcher at the University of Chicago in Illinois and a co-author of a 5 July Nature Medicine commentary supporting dose ‘fractionation’, disagrees about the need for time-consuming data collection.
“We shouldn’t wait that long,” she says. “People are dying, and we have historical precedent for making very well-reasoned guesses that we think are going to save lives.”
…According to a modelling study published by Tabarrok and other economists, such an approach would reduce infections and COVID-linked deaths more than current policies.
Addendum: The reason for doing the modeling study is precisely to take into account variants like Delta. Our modeling suggests that even with efficacy significantly lower than that suggested by Figure 1 in our paper, alternative doses of more effective vaccines would still provide significant reductions in mortality, even when new variants dominate. The benefits derive from vaccinating more quickly.
Tabarrok on RADVAC, the DIY Vaccine
The RadVac vaccine, as you may recall, is the open-source, do-it-yourself vaccine. Here’s Technology Review from one year ago (July of 2020):
Preston Estep was alone in a borrowed laboratory, somewhere in Boston. No big company, no board meetings, no billion-dollar payout from Operation Warp Speed, the US government’s covid-19 vaccine funding program. No animal data. No ethics approval.
What he did have: ingredients for a vaccine. And one willing volunteer.
Estep swirled together the mixture and spritzed it up his nose.
…Estep and at least 20 other researchers, technologists, or science enthusiasts, many connected to Harvard University and MIT, have volunteered as lab rats for a do-it-yourself inoculation against the coronavirus. They say it’s their only chance to become immune without waiting a year or more for a vaccine to be formally approved.
Among those who’ve taken the DIY vaccine is George Church, the celebrity geneticist at Harvard University, who took two doses a week apart earlier this month. The doses were dropped in his mailbox, and he mixed the ingredients himself.
Church say…he believes the vaccine designed by Estep, his former graduate student at Harvard and one of his protégés, is extremely safe. “I think we are at much bigger risk from covid considering how many ways you can get it, and how highly variable the consequences are,” he says.
I’m a big fan of the RadVac vaccine and was recently asked to give a talk about the vaccine and the pluses and minuses of the open source approach. In my talk I cover patents, when it was rational to take an unapproved vaccine, the FDA, paternal medicine versus the Consumer Reports model and more. I’m especially pleased with this talk.
Addendum: Great set of posts from johnswentworth from LessWrong on making the vaccine and then testing it.