Category: Medicine

Did crazy Republican tax-cutters defund the regulatory state for decades?

Minton is the author of a newly released study showing just how far the CDC has strayed from its core mission. In addition to combating dangerous infectious diseases like HIV and malaria, the CDC now also studies alcohol and tobacco use, athletic injuries, traffic accidents, and gun violence. While those things can indeed be important factors to public health, Minton notes, they don’t seem to fall within the agency’s original mission.

They do, however, explain why the CDC’s budget has ballooned from $590 million in 1987 to more than $8 billion last year. If the agency had grown with inflation since 1987, it would have a budget of about $1.3 billion today. Total federal spending, meanwhile, has grown from a hair over $1 trillion in 1987 to $4.4 trillion last year—which means that the CDC’s budget has grown faster the government’s overall spending.

That is by Eric Boehm at Reason.  Via J.

Emergent Ventures prize winners, third cohort

I am happy to announce two further winners of the Emergent Ventures prizes to fight Covid-19.

The first is to Statnews.com for their excellent and intelligent reporting on public health, including the coronavirus, with the latter articles being ungated.

This is not only a prize for past achievement, but also resources to allow them to continue into the future.  As most of you know, journalism is a highly precarious enterprise these days.

And to be clear, this is a one-time prize and it involves absolutely no editorial control or influence over what they publish.

Here is a recent NYT article on Statnews.com.  the headline reads: “The Medical News Site that Saw the Coronavirus Coming Months Ago.”

The second winner is Tina White and Covid Watch, for their work on track and trace apps, you will note that Tina and her group were earlier winners of a (smaller) Emergent Ventures fellowship.  This is an Early Response prize, for their critical and timely work to boost the quality of these apps and to make them more privacy-friendly and more palatable to civil liberties concerns.  Here is some coverage:

This App Protects Privacy While Tracing Covid-19 Infections

Here is the second cohort of prize winners, here is the first cohort.  And here is an update from Celine, from Curative Inc., from the very first cohort of winners:

Emergent Ventures is pleased to have been their very first funder, and to have consummated the entire grant process, including the wire of funds (at the time critical for materials purchase), in less than 24 hours.

How bad is Covid-19 risk compared to other risks?

I’ve had about five of you write me about this point in the last day.  Hundreds of thousands of people worldwide die from falls each year, what about car accidents, cancer, heart attacks, etc.?  Why is this new risk so special?

I think you need to keep clear monthly vs. yearly rates of death.  Covid-19 very likely has killed over 100,000 Americans over the last two months or so.

It either will continue at that pace or it won’t.  Let’s say that pace continues (unlikely in my view, but this is simply a scenario, at least until the second wave).  That is an ongoing risk higher than other causes of death, unless you are young.  You don’t have to be 77 for it to be your major risk worry.

Alternatively, let’s say the pace of those deaths will fall soon, and furthermore let’s say it will fall by a lot.  The near future will be a lot safer!  Which is all the more reason to play it very safe right now, because your per week risk currently is fairly high (in many not all parts of America).  Stay at home and wear a mask when you do go out.  If need be, make up for that behavior in the near future by indulging in excess.

A few of you also have asked me how all this Covid history has changed my view of the world.  If nothing else, I am realizing that people are worse at intertemporal substitution than I had thought.

Good critique of the herd immunity strategy

Herd Immunity sounds promising for a once-in-a-lifetime disease. But if immunity only lasts 12 to 24 months, that’s a, several time per decade disease, which sounds like a less attractive deal.

Let’s say the Infection Fatality Rate is just 0.5% per run to Herd Immunity, which would be achieved at, say, 60% of the US population of 330 million or about 1,000,000 deaths each time.

Let’s say it takes one year of widespread illness and dying to reach herd immunity and then the whole process starts over again 18 months later. That’s four times per decade. But it could be even more frequent than that.

That raises the question of how bad the next several runs to herd immunity would be. My guess is the IFR would decline because you are progressively killing off the the most vulnerable so the disease faces diminishing returns the next several times through. Perhaps people even get more resistant to the disease each time they have it.

Plus, obviously huge resources will be devoted to improving therapy each time. If a million plus people die in America the first run to herd immunity, we will attain a huge sample size of data of how to treat people, which should prove useful in lowering the death toll in subsequent waves.

But then again maybe not. Maybe people get progressively more worn down each time they catch it?

Now it could be that the timing of a vaccine works out perfectly and we get to Herd Immunity the first time about a year before a vaccine arrives so we don’t have to do it all over again and again.

But then again, how do we know herd immunity will happen all that fast? You want it to arrive slowly enough that the hospitals aren’t overwhelmed, but not so slowly that the economy never gets to revive from most people being (briefly) immune. But what if lots of people want to hunker down and avoid being a sacrificial lamb? This sounds like a Herd Immunity strategy might blunder into a worst of both worlds, with huge numbers being made deeply ill but the economic downturn dragging on for several years as scores of millions hunker down and don’t spend a lot of money pursuing an active social life.

Advocates of a Herd Immunity strategy really need to get out their spreadsheets and do the math of how this would turn out to be a good thing. Perhaps it is the best alternative, but, please, show your work.

Here is the link from Steve Sailer.  Via Kyle.

Why the FDA is banning the Gates-connected testing kits

Now we know:

An F.D.A. spokesperson said home collection kits raised additional concerns about safety and accuracy that required the agency’s review. The issue in the Seattle case appears to be that the test results are being used not only by researchers for surveillance of the virus in the community but that the results are also being returned to patients to inform them.

The two kinds of testing — surveillance and diagnostic — fall under different F.D.A. standards. In a pure surveillance study, the researchers may keep the results just for themselves. But coronavirus testing has largely revolved around getting results returned to doctors who can share the results with patients.

Here is the full NYT story, via Paul Novosad.  Just stunning.  Here is Alex’s earlier post on the episode.

On the all too frequent split between theory and practice

I know some people who react very fearfully each time a package comes to the door, or when a jogger passes ten feet away.

Maybe those people are right to have that response!  (Suspend judgment for the time being.)  But if they are right, and the risk is real rather than truly tiny, it is hard to imagine lockdown working.  We can’t eliminate all risk, and we will end up with a fairly high percentage of the population infected fairly quickly.  After all, danger is almost everywhere (in this view).  If you run a pretty high risk of getting infected over the next month or two anyway, you might as well go buy some shoes at Nordstrom for your trouble.

What is noteworthy is that these fearful people tend to be very supportive of lockdown.

On the other side of the coin, some individuals defend the Swedish model.  Presumably they believe that herd immunity can be achieved relatively quickly, and with a high upfront cost the medium- and long-term can be fairly safe, with a net gain overall.

Yet if you accept those presuppositions (suspend judgment for the time being), in fact you ought to behave in a very fearful manner.  Just stay at home and wait until herd immunity arrives in late summer or whenever, and then go out and have all of your fun.  Let the Nordstrom shoes wait!

Yet advocates of the Swedish model also seem quite interested in going out and frolicking in the shorter run.

In reality, mood affiliation may be playing a role here.  People side with either “caution and fearfulness,” or with “openness and boldness,” and then both their theories and behavior follow accordingly.

In reality, the Swedish model advocates ought to behave quite cautiously and lockdown advocates should be willing to take more chances.

The F.D.A. halts a virus testing program backed by Bill Gates

An innovative coronavirus testing program in the Seattle area — promoted by billionaire Bill Gates and local public health officials as a way of conducting wider surveillance on the invisible spread of the virus — has been ordered by the federal government to stop its work pending additional reviews.

Researchers and public health authorities already had tested thousands of samples, finding dozens of previously undetected cases in a program based on home test kits sent out to both healthy and sick people in the hope of conducting the kind of widespread monitoring that could help communities safely reopen from lockdowns.

But the research groups and the public health department of Seattle and King County, which had been operating under authorization from the state, was notified this week that it now needs approval directly from the federal government. Officials with the U.S. Food and Drug Administration directed the partnership to cease its testing and reporting until the agency grants further approval.

Here is the NYT link, ahem.

Small steps toward a much better world

After mounting criticism and thousands of deaths in New York nursing homes—including several individual facilities that have lost more than 50 residents—the state on Sunday reversed the mandate, which said nursing homes couldn’t refuse to accept patients from hospitals who had been diagnosed with Covid-19. New York now says hospitals can send patients to nursing homes only if they have tested negative for the virus.

Here is the WSJ article, via John F.

How to think about uni-disciplinary advice

Let’s say its 1990, and you are proposing an ambitious privatization plan to an Eastern bloc county, and your plan assumes that the enacting government is able to stay on a non-corrupt path the entire time.

While your plan probably is better than communism, it probably is not a very good plan.  A better plan would take sustainability and political realities into account, and indeed many societies did come up with better plans, for instance the Poland plan was better than the Russia plan.

It would not do to announce “I am just an economist, I do not do politics.”  In fact that attitude is fine, but if you hold it you should not be presenting plans to the central government or discussing your plan on TV.  There are plenty of other useful things for you to do.  Or the uni-disciplinary approach still might be a useful academic contribution, but still displaced and to be kept away from the hands of decision-makers.

Nor would it do to claim “I am just an economist.  The politicians have to figure the rest out.”  They cannot figure the rest out in most cases.  Either stand by your proposed plan or don’t do it.  It is indeed a proposal of some sort, even if you package it with some phony distancing language.

Instead, you should try to blend together the needed disciplines as best you can, consulting others when necessary, an offer the best plan you can, namely the best plan all things considered.

That might fill you with horror, but please recall from Tetlock that usually the generalists are the best predictors.

Ignoring other disciplines may be fine when there is no interaction. When estimating the effects of monetary policy, you probably can do that without calculating how many people that year will die of air pollution.  But you probably should not ignore the effects of a major trade war, a budgetary crisis (“but I do monetary policy, not fiscal policy!”), or an asteroid hurtling toward the earth.

If that is too hard, it is fine to announce your final opinion as agnostic (and explain how you got there).  You will note that when it comes to blending economics and epidemiology, my most fundamental opinion is an agnostic one.

This is all well-known, and it has been largely accepted for some time now.

If a public health person presents what is “only an estimate of public health and public health alone” to policymakers, I view it as like the economist in 1990 who won’t consider politics.  Someone else should have the job.  Right now public health, politics, and economics all interact to a significant extent.

And if you present only one of those disciplines to a policymaker, you will likely confuse and mislead that policymaker, because he/she cannot do the required backward unthreading of the advice into its uni-dimensional component.  You have simply served up a biased model, and rather than trying to identify and explain the bias you are simply saying “ask someone else about the bias.”

If an economist claims he is only doing macroeconomics, and not epidemiology (as Paul Krugman has said a few times on Twitter), that is flat out wrong.  All current macro models have epidemiology embedded in them, if only because the size of the negative productivity and negative demand shock depends all too critically on the course of the disease.

It is fine to be agnostic, preferably with structure to the opinion.  It is wrong to hide behind the arbitrary division of a discipline or a field.

We need the best estimates possible, and presented to policymakers as such, and embodying the best of synthetic human knowledge.  Of course that is hard.  That is why we need the very best people to do it.

Addendum: You might try to defend a uni-disciplinary approach by arguing a decision-maker will mainly be fed other, biased uni-disciplinary approaches, and you have to get your discipline into the mix to avoid obliteration of its viewpoint.  But let’s be clear what is going on here: you are deliberately manipulating with a deliberately non-truthy approach (I intend those words as a description, not a condemnation).  If that’s what it is, I wish to describe it that way!  I’ll also note I’ve never done that deliberately myself, and that is along many years of advising at a variety of levels.  I’d rather give the best truthful account as I see it.

The general lesson still has yet to sink in

Apple Store’s Temperature Checks May Violate EU Privacy Rules, Says German Data Protection Office

Of course they do.  And yes, I know that is a small thing, and furthermore temperature checks may not even be effective.

The general point is this: you cannot over the longer run have a society based on such inflexible rules of adjustment.  For decades it may seem possible, due to underlying stasis, but eventually the truth will be revealed.  No single anecdote will be so convincing, and it will take a long time for the failures to pile up.  And in the meantime this will breed disrespect for the more valuable laws.

Why aren’t we talking about forcible quarantine more?

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

There has been surprisingly little debate in America about one strategy often cited as crucial for preventing and controlling the spread of Covid-19: coercive isolation and quarantine, even for mild cases. China, Singapore and South Korea separate people from their families if they test positive, typically sending them to dorms, makeshift hospitals or hotels. Vietnam and Hong Kong have gone further, sometimes isolating the close contacts of patients.

I am here to tell you that those practices are wrong, at least for the U.S. They are a form of detainment without due process, contrary to the spirit of the Constitution and, more important, to American notions of individual rights. Yes, those who test positive should have greater options for self-isolation than they currently do. But if a family wishes to stick together and care for each other, it is not the province of the government to tell them otherwise.

What I observe is people citing those other countries as successes, wishing to “score points,” but without either affirming or denying their willingness to engage in coercive quarantine.  Here is another bit:

Furthermore, all tests have false positives, not just medically but administratively (who else has experienced the government making mistakes on your tax returns?). Fortunately, current Covid-19 tests do not have a high rate of false positives. But even a 1% net false positive rate would mean — in a world where all Americans get tested — that more than 1 million innocent, non-sick Americans are forcibly detained and exposed to further Covid-19 risk.

And this:

Coercive containment was tried during one recent pandemic — in Castro’s Cuba, from 1986 to 1994, for those with HIV-AIDS. It is not generally a policy that is endorsed in polite society, and not because everyone is such an expert in Cuban public health data and epidemiological calculations. People oppose the policy because it was morally wrong.

And what about uncertainty? Is it really a safe bet that America’s quarantine policy would be executed successfully and save many lives? What if scientists are on the verge of discovering a cure or treatment that will lower the Covid-19 death rate significantly? Individual rights also protect society from the possibly disastrous consequences of its own ignorance.

Here are a few points that did not fit into the column:

1. I am not opposed to all small number, limited duration quarantine procedures, such as say holding Typhoid Mary out of socializing.  This same point also means that a society that starts coercive quarantine very early might be able to stamp out the virus by coercing relatively small numbers of people.  (It is not yet clear that the supposed successes have achieved this, by the way.)  That is very different from the “mass dragnet” to be directed against American society under current proposals.

2. I am familiar with the broad outlines of American quarantine law and past practice.  I don’t see that history as necessarily authorizing how a current proposal would have to operate, and on such a scale.  In any case, I am saying that such coercive quarantines would be wrong, not that they would be illegal.  I believe it is a genuinely open question how current courts would rule on these matters.

3. From my perch from a distance, it seems to me that Human Challenge Trials for vaccines are more controversial than is mass forced quarantine.  I could be wrong, and I would gladly pursue any leads on the current debate you might have for me.  Who are the philosophers or biomedical ethicists or legal scholars who have spoken out against such policies?

“Our regulatory state is failing us”

A number of commentators suggest that the real problem is President Trump, rich people overly concerned with tax cuts, a Republican Party with a deregulatory ideology, and so on.

Instead I have been repeating insistently that “our regulatory state is failing us.”  The FDA and CDC, for instance, have through their regulations made it harder for testing and also widespread mask supply to get off the ground.

I don’t see how you can blame (supposed) deregulatory fervor for the presence of too many regulations, as we have been observing in these instances.

I do think you can blame President Trump, along multiple dimensions, for a poor response to the pandemic, see my grades here.  (If there were a separate risk communication grade, Trump would get an F minus for that.)  Nonetheless a regulatory state cannot be said to work well if it requires such extraordinary attention from a sitting president.

It can be the case that both Trump and the permanent bureaucracy are at fault.  If something takes a long time to get done for reasons relating to preexisting rules, regulations, and laws, usually the current president is not directly at fault for that particular problem.  Was it only Trump’s fault, for instance, that the permits to build a mask factory can take months to acquire?  Or that the HHS did not respond to inquiries about gearing up mask production in Texas?  Or that a law had to be changed to allow industrial companies to sell quality masks to hospitals?  Or that so many a-legal or extra-legal activities (e.g., rich people arranging deliveries by plane, etc.) had to occur to sneak masks into this country?  That the trade barriers on masks persisted for so long? (And yes likely the Trump administration is at fault for de facto toughening restrictions on masks from China.)

It is fine to say “the buck stops here,” and to criticize Trump for not having erected processes to be more aware of these problems and to dissolve them more quickly.  I would agree with some of those criticisms, while noting the Trump administration also has tried to ease many of the regulations hampering adjustment.

This is more something on the horizon, but how do these apples make you feel?  Comforted?  The fault of plutocratic Republicans most of all?

And in both cases, vials and stoppers, a vaccine manufacturer cannot just switch to a slightly different product or another brand. They typically have to run manufacturing changes by FDA first, which could make quick supplier changes to curb shortages a difficult prospect.

The FDA can decide how flexible it will be about this type of change, says Sklamberg. The agency said in a December 2017 draft guidance that companies could note some changes in their annual reports rather than waiting for approval, but it has not finalized the policy.

The ability to switch products could be crucial as the entire world readies for a possible vaccine and vies to secure their supplies.

If you wish, consider a simple question.  When the CDC pooh-poohed masks early on, or botched their testing kit thereby delaying U.S. testing by weeks or maybe months, did the permanent staff of the CDC rise up and rebel and leak howling protests to the media, realizing that thousands of lives were at stake?  That is surely what would happen if say the current FDA announced it was going to approve thalidomide.

Those are still cases of our regulatory state failing us.

Germany R estimate of the day

Germany is being closely watched worldwide as the most successful large European country in curbing the spread of the virus, partly thanks to massive testing, which has prompted a partial reopening of the economy. Merkel has frequently said the reproduction rate of the new coronavirus must be held below 1 to prevent the health system from being overwhelmed.

But the Robert Koch Institute for public health said the rate hovered above this critical threshold for the third consecutive day with an estimated value of 1.07 on Monday, after 1.13 on Sunday.

That Germany does not have its R below one is, in a nutshell, why short-run measurements of coronavirus responses are not very reliable.  And why “we need to lock down until full testing is up and running” is not necessarily convincing.  Here is the full story.

Some reflections on GRE scores

The evidence indicates that GRE scores predict graduate school success, general intelligence, and also that SAT scores predict later success in science.  Here is further evidence, and here is yet further evidence.

You don’t have to think that “high GRE score fields” are better than “low GRE score fields.”  Many of my friends, for instance, think string theory is intellectually bankrupt, despite many of its proponents being very, very smart.  I don’t have an opinion on string theory per se, but my friends might be right, and in any case I would rather read books from cultural studies, a lower GRE score field.

If you wish to understand the relative strengths and pathologies of theoretical physics and cultural studies, you cannot do that without knowing that the former is a relatively high GRE score field (or the equivalent) and that the latter is a relatively low GRE score field (or the equivalent).

There are many top economists on Twitter, most of them Democrats, who would never ever utter a word about GRE scores in a blog post or on Twitter.  Yet when on an admissions committee, they will ruthlessly enforce the strictest standards for math GRE scores without hesitation.  Not only in top ten programs, but in top thirty programs and even further down the line in many cases.  It is very, very hard to get into a top or even second-tier economics program without an absolutely stellar math GRE score, and yes that is enforced by the same humans who won’t talk about the issue.

Just in case you didn’t know that.

Personally, I feel it has gone too far in that direction, and economics has overinvested in one very particular kind of intelligence (I would myself put greater stress on the old GRE subject test scores for economics, thus selecting for those with an initial interest in the economy rather than in mathematics).

When I did graduate admissions for George Mason University, I very consciously moved away from an emphasis on GRE scores, and for the better.  My first goal was simply to take in more students, and a more diverse group of students, and in fact many of the later top performers were originally “marginal” students by GRE standards.  Looking back, many of our top GRE-scoring students have not done better than the peers, though they have done fine.  For GMU these admission criteria are (in my view) more like the Rosen-Roback model than anything else, though I would readily grant Harvard and MIT are not in the same position.

If you are afraid to talk about GRE scores, you are afraid to talk about reality.

Human Challenge Trials

What if we develop a vaccine for COVID-19 but can’t find enough patients to run a randomized clinical trial? It sounds absurd, but this problem has happened in the past. Ebola was identified in 1976, and candidate vaccines were proven safe and effective in mice and primates in 2004 and 2005, respectively. But no human vaccine was produced [at that time] because it was extremely difficult, bordering on impossible, to trial an Ebola vaccine. The problem? Ebola is so deadly that people take precautionary measures long before a vaccine can be tested.

A few pieces have been written about human challenge trials, clinical trials in which healthy people are infected with a disease in order to see if a treatment or vaccine works, but most of them focus on the ethical issues. I don’t think there are serious ethical issues so writing at The National Interest I focus on why challenge trials are useful statistically and why they may even be necessary.

Even health care workers, however, have a low enough infection rate that you either need many months to determine if there is a significant effect, or you need large populations. In Italy, about 6,000 doctors were infected over two months, out of a population of about 241,000 Italian doctors. This is a monthly infection rate of 1.2 percent. If the vaccine is 50 percent effective, then to detect this within a month, you need a sample size of 7,776 people equally divided between a vaccinated group and a non-vaccinated group. You could run the test in a smaller sample of 1,322 but then the trial would take six months. A more effective vaccine would make detecting an effect easier, but flu vaccines work at 40 to 60 percent effectiveness, so an assumption of 50 percent is not unreasonable.

But will Italian doctors still be getting infected at a rate of 1.2 percent per month when a vaccine becomes available for trial in six months or a year? We hope not. The hope is that social distancing and the use of personal protective equipment will have greatly lowered the infection rate. A low infection rate is great, unless you want to properly test a vaccine.

…The virtue of a challenge trial is that the results would be available very quickly, within a few weeks, and using only a small population. If the vaccine is 50 percent effective, for example, then we would need around 100 volunteers or perhaps even fewer depending on how many people exposed to the virus in laboratory conditions contract the disease.

By advancing a vaccine by many months, a challenge trial could save many thousands of lives and spare the world the huge economic costs of the lockdowns and social distancing that we will be using to combat the virus.

Challenge trials, however, don’t solve all problems. In particular, to limit the risk we would want to restrict the patients in a challenge trial to be young and healthy. But that raises a problem of external validity. We also want the vaccine to be safe and effective in less healthy and elderly people which requires secondary challenge trials or field testing in that population. Nevertheless, as Athey, Kremer, Synder and myself argue in our NYTimes op-ed, the high risk of vaccine failure means that we would like 15-20 vaccine candidates and challenge trials could help us whittle this number down to the best two to three substantially speeding up the vaccine discovery process.

One more point is worth bearing in mind.

[A]n ordinary vaccine trial is not without risk—a vaccine could backfire and make the disease worse—so exposing fifty or so volunteers to the virus in a challenge trial must be balanced against exposing thousands to a potentially dangerous vaccine in an ordinary clinical trial.

Thus, the total risk may be lower with a combination of challenge trials and longer, larger field trials.

Challenge trials have a long history in medicine and their statistical advantages make them powerful and even necessary. As The Guardian notes:

Scientists, however, increasingly agree that such trials should be considered, and the WHO is the latest body to indicate conditional support for the idea.

“There’s this emerging consensus among everyone who has thought about this seriously,” said Prof Nir Eyal, the director of Rutgers University’s Center for Population-Level Bioethics in the US.