Category: Medicine

The petty narcissism of small vaccine differences

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

My survey of the cultural vaccine landscape in the U.S. includes the four major vaccines — from Pfizer, Moderna, AstraZeneca and Johnson & Johnson.

Pfizer, distributed by one of the largest U.S. pharmaceutical firms, is the establishment vaccine. Since it initially had a significant “cold chain” requirement, it was given out at established institutions such as big hospitals and public-health centers with large freezers. It is plentiful, highly effective and largely uncontroversial.

Moderna — the very name suggests something new — is the intellectual vaccine. The company had no product or major revenue source until the vaccine itself, so it is harder to link Moderna to “Big Pharma,” which gives it a kind of anti-establishment vibe. Note also that the last three letters of Moderna are “rna,” referring to the mRNA technology that makes the vaccine work. It is the vaccine for people in the know.

Moderna was also, for a while anyway, the American vaccine. It was available primarily in the U.S. at a time when Pfizer was being handed out liberally in the U.K. and Israel. As a recipient of two Moderna doses myself, I feel just a wee bit special for this reason. You had to be an American to get my vaccine. Yes, the European Union had also approved it, but it failed to procure it in a timely manner. So the availability of Moderna reflects the greater wealth and efficiency of the U.S.

Then there are the AstraZeneca and Johnson & Johnson vaccines…

And:

To the extent vaccines turn into markers for a cultural club, vaccine hesitancy may persist.

It might be better, all things considered, if vaccines were viewed more like paper clips — that is, a useful and even necessary product entirely shorn of cultural significance. Few people refuse to deploy paper clips in order to “own the libs” or because they do not trust the establishment. They are just a way to hold two pieces of paper together.

To be clear, the primary blame here lies with those who hesitate to get vaccinated. But behind big mistakes are many small ones — and we vaccinated Americans, with our all-too-human tendency to create hierarchies for everything, are surely contributing to the mess.

Recommended!

The petition that is French

A survey of more than 2,600 industry professionals by the Union of Oenologists showed that among those who had caught COVID-19, more than a third said the disease had affected their ability to do their work. Some student wine tasters had dropped out of courses after falling ill with the virus, the union said.

Union boss Didier Fages said the body had written to President Emmanuel Macron and Prime Minister Jean Castex to ask that wine tasters be moved to the front of the queue for anti-COVID shots to safeguard livelihoods.

Here is the full story.

When doctors stay in their lane

Here is the paper, showing massive overdiagnosis, even following testing.  If you don’t wish to click through, here is a nice summary:

 

“RCTs for me but not for thee”?

Zeke Emanuel, a professor of healthcare management at the University of Pennsylvania and a former coronavirus adviser to US president Joe Biden, said: “I understand they wanted to be transparent, but did they really have to announce a complete pause? “My concern is this will unnecessarily undermine confidence in the vaccine, and possibly all [Covid-19] vaccines. Are people going to know the difference?”

Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security in Baltimore, said: “The damage is done, this is going to be hard to resume. All [the CDC] can do is say how rare this is, show how safe and efficacious the J&J vaccine is. But this action is going to be hard to reverse.”

Here is the full FT piece.  Since lives are at stake, how about this for a proposal?  The FDA is allowed to suspend the use of any positive expected value vaccine only after running an RCT on their underlying theory of credibility and public risk communication in the relevant context.  (NB: asking about attitude change is not nearly good enough!)  And after they run the RCT, they have to wait three weeks to schedule the meeting on evaluating the data.  After all, that is how long it takes, right?

Estamos de acuerdo?

By the way, one reader wrote to me: “I submit to you that the credibility of the FDA on the relative safety of various vaccines may be a minor issue in the pool of issues that prevent the level of vaccinations we would like to see.”  Do we even know if that is true or false?

From the comments, on FDA credibility

This maybe a violation of Cowen’s second law, but my cursory examination turns up no useful hits in PubMed about FDA credibility. We have the odd op-ed, some drivel about people thinking the FDA is more credible about cigarettes when they learn that FDA regulates cigarette manufacture, and precious little else of remote utility.

Almost as though senior FDA leadership have not bothered, after over a year of pandemic to even commission a rigorous survey of which action(s) the public would view as credible. Certainly what they are doing is not coherent with any of the effective medical communication techniques I was taught nor with any of my training for dealing with public responses to calamity.

But maybe I’m wrong. Maybe somewhere the FDA dumped a couple of grand into even a Mechanical Turk survey to justify actions that will have billions in cost implications and might lead to the death of thousands of folks (particularly overseas).

I mean, the civil servants at the FDA surely are not just LARPing as pop psychologists, somewhere I’ve missed they have actual peer reviewed literature guiding any of their moves regarding communication, credibility, and risk management, right?

That is from Sure.  So what is the best piece on FDA credibility?  (Yes, I know the work of Daniel Carpenter and have a CWT with him coming out and we do address this directly.)  And what has the FDA itself done to study the issue of its own credibility?

The Covid culture that is Australia

Health Minister Greg Hunt has refused to guarantee Australia’s borders will open even if the whole country has been vaccinated against COVID-19.

Australia’s borders have been shut since March 2020 and will remain closed until at least the middle of June, leaving more than 36,000 Australians trapped overseas, unable to return due to caps on the number of quarantine spaces.

The closure also bans citizens from leaving the country unless they have an exemption or are travelling to New Zealand.

Mr Hunt suggested at a news conference in Canberra on Tuesday the international border closures could last much longer and stay in place even if the entire population had been vaccinated against the coronavirus.

“Vaccination alone is no guarantee that you can open up,” Mr Hunt said.

“If the whole country were vaccinated, you couldn’t just open the borders.”

“We still have to look at a series of different factors: transmission, longevity [of vaccine protection] and the global impact – and those are factors which the world is learning about,” he said.

Really people?  Via Chris.

Hearing: “Vaccinations and the Economic Recovery”

I will be testifying to the JEC of Congress today at 2:30 pm est.

Witnesses:       

Dr. Paul Romer
Nobel Prize Winning economist and NYU Professor
New York, NY

Dr. Céline Gounder, MD, ScM, FIDSA
Clinical Assistant Professor of Medicine & Infectious Diseases, NYU School of Medicine & Bellevue Hospital
CEO of Just Human Productions
New York, NY

Dr. Alexander Tabarrok
Bartley J. Madden Chair in Economics at the Mercatus Center and Professor of Economics George Mason University
Fairfax, VA

Dr. Belinda Archibong
Assistant Professor, Economics
Barnard College, Columbia University
New York, NY

Link here.

“Free-floating credibility” is underrated

The presence of a minuscule risk for some of the adenovirus platform Covid vaccines means that the FDA has put a hold on J&J and still won’t approve AstraZeneca.

In response to critics, the FDA says that their credibility is on the line.  If they allow vaccine use to proceed, and a modest number of people die as a result (with a big increase in net lives saved), the FDA and its defenders claim that people will lose faith in the FDA.  Yet that is exactly the wrong thing to say, it is self-serving, and it exacerbates the problem at hand.

When the FDA announces that they have to ban a vaccine because its credibility is on the line, that very announcement puts their credibility on the line.  It is a simple two-line proof.  Either they are lying about whether their credibility is on the line, in which case they have wrecked their credibility with the lie.  Or they are telling the truth, in which case by definition their credibility is indeed on the line.

One lesson is that you should not try to extend your credibility too far, because you will end up unduly constrained.

For purposes of contrast, consider alcoholic beverages.  At the federal level they are regulated by the Alcohol and Tobacco Tax and Trade Bureau (who are they again?), and also various state and local authorities.

As a result of this unusual, Prohibition-rooted distribution of authority, alcohol does not come with nutritional labeling.

Now, in that setting, if a bunch of kids die from binge drinking, the credibility of the Bureau is not much damaged.  The Bureau does not have to ban alcohol on the grounds that if it does not, the credibility of the Bureau will be ruined.  The Bureau simply never put its credibility on the line in this manner.

Now you might favor a tighter regulation of alcohol for some reason, but you could achieve such regulation without tying up the credibility of the ATTT Bureau in knots.  Similarly, the Department of Transportation regulates road safety (again with state and local authorities as well), but it has not put its credibility on the line when 40,000 or so Americans die each year on the roads.  Again, maybe they should enforce tougher safety standards, but they shouldn’t tie their credibility to getting road deaths down to one hundred, and indeed they do not.  They end up with more degrees of regulatory freedom.

Let’s say I were to announce that my credibility as a public intellectual were to depend at how I would fare at darts on British pub night.  That would be a big mistake, for multiple reasons.  It is like with the FDA.  If I am lying about that credibility tie, I hurt my credibility as a public intellectual.  If somehow I am telling the truth, well let’s just hope everyone else stays home that evening because my credibility is going to take a beating.

What I call “free-floating credibility” is underrated.

And that is precisely what defenders of the FDA destroy when they…defend the FDA.  They make the FDA worse.

NB: You are “out of your lane” commenting on this analysis unless you have studied game theory with Thomas Schelling.

Vaccine fact of the day

Moderna and BioNTech shares jumped 10.5 per cent and 6.1 per cent, respectively, on Tuesday as the vaccine makers benefited from news of the J&J pause.

Norway’s health authorities estimated that their vaccination plans could be delayed by eight to 12 weeks if they could not use either the J&J or the Oxford/AstraZeneca vaccine.

The biggest short-term loser here is Europe, not the United States.  Nor will this help Australia reopen.  But does the American median voter or median FDA senior bureaucrat care?  What will the CVS liability lawyers advise from here on out?  What will the French anti-vaxxers think?

Here is the full FT article.

Why I am not entirely keen on the Great Barrington Declaration and AIER

More people are asking me about my attitudes toward Great Barrington and AIER, including David Henderson in this post (which also has a good transcript of my remarks to Russ Roberts).  Earlier I wrote a conceptual critique of the Great Barrington Declaration, but today I would like to make some more targeted remarks.  I didn’t do this when speaking to Russ because I feel they require direct quotation and documentation, which one cannot easily do in a podcast.  And in general I don’t like to write posts “attacking people” (way oversupplied on the internet), but in this case libertarian sympathies are so split that a kind of a wake-up call is needed.

Let me first say that if you are libertarian, and would like a libertarian response to the pandemic, and you find Alex and me not libertarian enough, read the Ryan Bourne book from the Cato Institute.  You may not agree with everything in there, but it has no “gross errors” and no “biomedical weirdness.”  And people, the Cato Institute really is libertarian.  They once hired David Henderson as chief economist.

As for the AIER, read this Jeremy Horpedahl thread and click through appropriately, here is the Sam Bowman-produced part of the thread.  Conspiracy theorist and shall we say “speculative thinker” Naomi Wolf is now a senior researcher at AIER, please do read her tweets.  5G conspiracy theories?  Vaccine nanoparticles that make you travel back in time?  “Not kidding” she wrote, and the general weirdness extends far beyond that, to some of her books as well.  Or try this “externality denialism” from just a few days ago: “Your vaccine status makes no difference to others.”  Her pinned tweet casts suspicion on Bill Gates, and refers to “global treason.”

I say it is a mistake to let such a group set the libertarian agenda or indeed any agenda, even if you favor very rapid reopenings and are very critical of lockdowns.  I implore you to think very seriously about what is going on here.

Going back to the GBD proper, which again is sponsored by AIER, here is co-author Sunetra Gupta:

“What we’ve seen is that in normal, healthy people, who are not elderly or frail or don’t have comorbidities, this virus is not something to worry about no more than how we worry about flu,”  professor Gupta told HT.

Nope, almost 600,000 U.S. deaths later.  Or how does this Gupta claim look?:

‘Why would you arrest transmission?’ she asks. ‘To wait for a vaccine? You cannot get rid of it.’

What would Benjamin Netanyahu say?  Or Gupta in May: “Covid-19 is on the way out.”

The best of them is probably Jay Bhattacharya, with whom I often agree, and who, as far as I can tell, has no track record of blatantly false predictions.  Yet even he cannot avoid a tinge of biomedical weirdness.

Why was Bhattacharya on the advisory board of the anti-vax group Panda?  I am reluctant to play the “guilt by association” game here, but I think there is a broader pattern of these writers simply being wrong about the science, and their associations reflecting that.

I agree with his WSJ critique (with Kulldorff) of vaccine passports.  Still, he comes up with some literally true but misleading sequences such as:

The idea that everybody needs to be vaccinated is as scientifically baseless as the idea that nobody does. Covid vaccines are essential for older, high-risk people and their caretakers and advisable for many others.

I wonder why cannot he bring himself to say that “the average social value of a 16-year-old getting vaccinated is strongly positive”?  (And we are running significant tests to lower the remaining uncertainty, and if it is merely adenovirus platforms you worry about well say that.)  Instead he has to walk around the issue and play down the value of near-universal Covid vaccination.  You might think that is all the fault of the editorial chopping board, but it seems to be a broader and more consistent pattern with this group.

Take Hulldorff’s now-famous tweetThose with prior natural infection do not need it [Covid vaccines]. Nor children.”  “Need?” — OK, I get it, demand curves slope down.  But again, his tweet is not nearly as good or as accurate a message as “the average social value of a 16-year-old getting vaccinated is strongly positive.”  There is good evidence that the vaccines provide better protection than does natural infection, especially against the Covid variants, and it is established that infected younger persons can carry Covid to the unvaccinated, of which there will always be quite a few, most of all globally.  Furthermore, non-vaccine methods of achieving herd immunity are looking worse, due to the spread of variants and areas such as Manaus, which seem to have high rates of reinfection.  And have I mentioned that hospitalization rates for the young are rising?  (We are not sure why.)

Is it so great that 38.9% of Marines are refusing to take the vaccine? (no).  Or have these writers looked into the huge success that is Gibraltar?

Why take this weird, hinky attitude toward the science for no good reason?  It’s as if — when it comes to vaccines — they deliberately talk in an Alice in Wonderland universe without self-awareness of that fact.

No matter what your associations may or may not be, getting people vaccinated with quality vaccines is the #1 issue right now and it is the path back to liberty most likely to succeed and prove sustainable.  If you are not really enthusiastic about that, I think, frankly, that you are out to lunch.

My Conversation with Lex Fridman

2 hours 9 minutes long, Lex is one of the very best interviewers/discussants in the sector.  Here is the video, here is the audio.  Plenty of new topics and avenues, including the political economy of Russia (note this was recorded before the massing of Russian forces on the Ukraine border).  Lex’s tweet described it as follows:

Here’s my conversation with @tylercowen  about economic growth, resisting conformity, the value of being weird, competition and capitalism, UFO sightings, contemporary art, best food in the world, and of course, love, death, and meaning.

https://www.youtube.com/watch?v=7Grseeycor4

Recommended.

Economics in One Virus

Here is John Cochrane, Megan McArdle, Ryan Bourne and myself on the pandemic. Lots of good material. John Cochrane was excellent on testing in a pandemic and why it’s different than medical testing, starting around 22:00. My follow-up also had some good material, our antibodies, our selves.

Ryan Bourne’s book Economics in One Virus is very good.

 

Atul Gawande and Zeke Emanuel Now Support Delaying the Second Dose

Many people are coming around to First Doses First, i.e delaying the second dose to ~12 weeks. Atul Gawande, for example, tweeted:

As cases and hospitalizations rise again, we can’t count on behavior alone reversing this course. Therefore, it’s time for the Biden admin to delay 2nd vax doses to 12 weeks. Getting as many people as possible a vax dose is now urgent.

Now urgent??? Yes, I am a little frustrated because the trajectory on the new variants was very clear. On January 1, for example, I wrote about The New Strain and the Need for Speed (riffing off an excellent piece by Zeynep Tufekci).  Still, very happy to have Gawande’s voice added to the cause. Also joining Gawande are the power trio of Govind Persad, William F. Parker and Ezekiel J. Emanuel who in an important op-ed write:

If we temporarily delay second doses …that is our best hope of quelling the fourth wave ignited by the B.1.1.7 variant. Because we did not start this strategy earlier, it is probably too late for Michigan, New York, New Jersey and the other Northeastern states. But it might be just in time for the South and California — the next places the more infectious strain will go if historical patterns repeat.

…Drug manufacturers selected the three- or four-week interval currently used between doses to rapidly prove efficacy in clinical trials. They did not choose such short intervals based on the optimal way of using the vaccines to quell a pandemic. While a three- or four-week follow-up is safe and effective, there is no evidence it optimizes either individual benefit or population protection.

…Some complain that postponing second doses is not “following the science.” But the scientific evidence goes far beyond what was shown in the original efficacy trials. Data from the United Kingdom, Israel and now the Centers for Disease Control and Prevention shows that first doses both prevent infection and reduce transmission. In people with prior infection, experts are beginning to recognize that a second dose could provide even less benefit. Following the science means updating policies to recognize new evidence rather than stubbornly maintaining the status quo.

Emanuel is on Biden’s COVID-19 task force so consider this op-ed running the flag up the flagpole. I predict Topol will fall next.

I would be surprised, however, if the US changes course now–too many people would then ask why didn’t we do this sooner?–but dose stretching is going to be important for the rest of the world. Why aren’t we doing more to investigate fractional dosing? Even if we went to half-doses on the second dose–the full second dose appears to be strong–that would still be a significant increase in total supply.

Addendum: I have argued for sending extra doses to Michigan and other hot spots such as NJ. Flood the zone! The Biden administration says no. Why? Production is now running well ahead of distribution as more than 50 million doses have been delivered but not administered. It would be a particularly good idea to send more single-shot J&J to reach hard to reach communities–one and done.

Vaccine passport sentences to ponder

From New York State:

Using Excelsior Pass is entirely voluntary, but it requires learning about the state’s system and mastering a few different websites and apps. It took me 20 minutes over Zoom to help an octogenarian set up his pass, though it was certainly simpler than mastering vaccine-appointment websites. And even when we thought we understood the system, Excelsior Pass didn’t always work: My tech-reporter colleague tried to use it to enter Yankee Stadium, but the system didn’t update with his clearance until after the game was over…

Testing Excelsior Pass, what surprised me most was how easy it is to fake. When you first sign up for your QR code on the state website, it asks a handful of questions based on your vaccination and testing records. But after that, you’re on the honor system — you can add the QR code to any phone without any more challenge questions.

Designed by IBM, here is the full story.  I get that different parts of the country (Michigan…surge vaccine supply!) may need to proceed at different speeds, but basically it is time to plan a full reopening, and it seems that vaccine passports are more likely to hinder than to help achieve that end.