Category: Medicine

No Respect for Diversity of Opinion or Choice

David Zweig notes an important correlation:

The colleges with the most stifling atmospheres for speech also have the most aggressive Covid vaccine policies. The colleges that most welcome and protect a free exchange of ideas, in turn, have the least intrusive vaccine requirements.

Number 1 ranked [on Fire’s Free Speech Index, AT] Chicago has no vaccine mandate at all. The university merely “strongly recommends” Covid vaccination. Numbers 2, 3, 4, and 5 on the list – Kansas StatePurdueMississippi State, and Oklahoma State – do not require any Covid vaccination either. They do each highly encourage vaccination, though.

At the bottom, Columbia not only requires the primary series for its students, but also requires the most recent bivalent booster. Ditto for second-to-last place Penn. For the many students who received an initial booster early on, this means a requirement of four doses. Rounding out the worst five colleges for free speech, Rensselaer Polytechnic InstituteGeorgetown, and Skidmore also mandate all students be boosted. Though compared to Columbia and Penn they are relatively lax, only requiring “a booster,” meaning the third shot could have been from a long while ago, and not necessarily the bivalent.

Why are the colleges with the worst limits on free speech also the worst for limiting bodily autonomy?

Columbia and its ilk had a history of liberalism which, as is well-known now, has recently morphed into a more stifling form of modern progressivism that doesn’t tolerate dissent. The political tribalism that demands in-group thinking also demands in-group behavior — during, and now exiting the pandemic, the more extreme that one reacted toward Covid, the more one demonstrated their membership in the left wing. (Being double masked and triple vaxxed was for a long time a progressive identity marker.) Quite simply, an extreme vaccination policy, out of step with much of the world yet perfectly accepted in progressive America, announces one’s institution as an unimpeachable member of the tribe.

That there is an association between respect toward free speech and respect toward bodily autonomy — or a lack thereof for each — at academic institutions shouldn’t surprise anyone. Both reflect attitudes either in agreement with or against a libertarian ideal of individual freedom. But the degree of correlation is still disheartening.

…It is an embarrassment that policies at many of our most elite institutions of higher education are the most divorced from scientific evidence, and are now, finally, even alienating mainstream liberals. FIRE’s free speech rankings, alas, help explain how we got to this place.

We live in a diverse society and that requires respect. Unfortunately, at some of our nation’s top universities there is no respect for diversity of opinion or choice.

Emergent Ventures winners, 24th cohort

Shakked Noy, MIT economics, to do RCTs on GPTs as teaching and learning tools.

Gabriel Birnbaum, Bay Area, from Fortaleza, Brazil, to investigate lithography as a key technology used in the manufacturing of microchips.

Moritz Wallawitsch, Berkeley. RemNote is his company, educational technology, and to develop a complementary podcast and for general career development.

Katherine Silk, Boston/Cambridge, general career support and to support advice for early-stage startups.

Benjamin Schneider, Brooklyn.  To write a book on the new urbanism.

Joseph Walker, Sydney, Australia, to run and expand the Jolly Swagman podcast.

Avital Balwit, Bay area, travel grant and general career development.

Benjamin Chang, Cambridge, MA. General career support, “I will develop novel RNA riboswitches for gene therapy control in human cells using machine learning.”

Daniel Kang, Berkeley/Champagne-Urbana, biometrics and crypto.

Aamna Zulfifiqar, Karachi, Pakistan, to attend UK higher education to study economics.

Jeremy Stern, Glendale, CA, Tablet magazine.  To write a book.

James Meech, PhD student, Cambridge, UK, to work on a random number generator for better computer architectures.

Arthur Allshire, University of Toronto, background also in Ireland and Australia, robotics and support to attend conferences.

Jason Hausenloy, 17, Singapore, travel and general career development, issues surrounding artificial intelligence.

Sofia Sanchez, Metepec, Mexico, biology and agricultural productivity, to spend a summer at a Stanford lab.

Ukraine tranche:

Andrey Liscovich, eastern Ukraine, formerly of Harvard, to provide equipment for public transportation, communication and emergency power generation to civilian authorities of frontline-adjacent areas in Ukraine which have lost vital infrastructure.

Chris Nicholson, Bay area, working as a broker to maintain internet connectivity in Ukraine.

Andrii Nikolaiev, Arsenii Nikolaiev, Zarina Kodyrova, Kvanta, to advance Ukrainian mathematics, help and train math Olympiad winners.

As usual, India and Africa/Caribbean tranches will be reported separately.

Pegylated interferon lambda

A new drug quashes all coronavirus variants. But regulatory hurdles and a lack of funding make it unlikely to reach the U.S. market anytime soon.

So starts the NYT article.  Have we learned nothing?  As for the drug itself, the news is good:

…a new class of variant-proof treatments could help restock the country’s armory. Scientists on Wednesday reported in The New England Journal of Medicine that a single injection of a so-called interferon drug slashed by half a Covid patient’s odds of being hospitalized.

The results, demonstrated in a clinical trial of nearly 2,000 patients, rivaled those achieved by Paxlovid. And the interferon shots hold even bigger promise, scientists said. By fortifying the body’s own mechanisms for quashing an invading virus, they can potentially help defend against not only Covid, but also the flu and other viruses with the potential to kindle future pandemics.

We will see if this has the opportunity to progress.  Fast Grants, working in conjunction with Rainwater Foundation, was a key early funder here.

Oh, and do note this:

As it stands, Eiger executives said that they might seek authorization for the interferon shot outside of the United States. China, for example, has been looking for new treatment options.

And here is an Eric Topol thread on the results.

Yglesias on Operation Warp Speed and the Republicans

Here’s Yglesias on Operation Warp Speed and the Republicans:

The debate over Operation Warp Speed wasn’t just a one-off policy dispute. Long before the pandemic, there was a conservative critique that the Food and Drug Administration is too slow and too risk-averse when it comes to authorizing new medications. Alex Tabarrok, a George Mason University economist, wrote about the “invisible graveyard” that could have been avoided if the FDA took expected value more seriously and considered the cost of delay in its authorization decisions.

The pandemic experience validated this criticism, which came to be embraced by some on the left as well — and it was about more than just vaccines. When it came to home Covid tests, Ezra Klein noted in the New York Times in 2021, “the problem here is the Food and Drug Administration. They have been disastrously slow in approving these tests and have held them to a standard more appropriate to doctor’s offices than home testing.” 

And yet, just as the invisible graveyard was becoming seen and the debate was being won and just as a historical public-private partnership had sped vaccines to the public and saved millions, the Republicans abandoned the high ground:

…it’s not surprising that Democrats are comfortable with the bureaucratic status quo and hesitant to ruffle feathers at federal regulatory agencies. What’s shocking is that Republicans — the traditional party of deregulation, the party that argued for years that the FDA is too slow-footed, the party that saved untold lives by accelerating vaccine development under Trump — have abandoned these positions.

At the cusp of what should have been a huge policy victory, Republicans don’t brag about their success, and they have no FDA reform legislation to offer. Instead, they’ve taken up the old mantle of hard-left skepticism of modern science and the pharmaceutical industry. 

It’s been painful to see all that has been gained now being lost. Libertarian economists and conservatives argued for decades that the FDA worried more about approving a drug that later turns out to be unsafe than about failing to approve a drug that could save lives; thus producing a deadly caution. But now the FDA is being attacked for what they did right, quickly approving safe vaccines. I hope that he is wrong but I fear that Yglesias is correct that the FDA may now get even slower and more cautious.

The irony of the present moment is that there is substantial backlash to the FDA’s approval of vaccines that haven’t turned out to be dangerous at all.

That’s only going to make regulators even more cautious. Right now the entire US regulatory state is taking essentially no heat for the slow progress on the next generation of vaccines, and an enormous amount of heat for the perfectly safe vaccines that it already approved. And the ex-president who pushed them to speed up their work on those vaccines is not only no longer defending them, he’s embarrassed to have ever been associated with the project.

Like I said, it’s a comical moment of Republican infighting. But it’s a very grim one for anyone concerned with the pace of scientific progress in America.

Medical markets in everything?

Or will they be thwarted?

To Nina McCollum, Cleveland Clinic’s decision to begin billing for some email correspondence between patients and doctors “was a slap in the face.”

She has relied on electronic communications to help care for her ailing 80-year-old mother, Penny Cooke, who is in need of specialized psychiatric treatment from the clinic. “Every 15 or 20 dollars matters, because her money is running out,” she said.

Electronic health communications and telemedicine have exploded in recent years, fueled by the coronavirus pandemic and relaxed federal rules on billing for these types of care. In turn, a growing number of health care organizations, including some of the nation’s major hospital systems like Cleveland Clinic, doctors’ practices and other groups, have begun charging fees for some responses to more time-intensive patient queries via secure electronic portals like MyChart.

…a new study shows that the fees, which some institutions say range from a co-payment of as little as $3 to a charge of $35 to $100, may be discouraging at least a small percentage of patients from getting medical advice via email. Some doctors say they are caught in the middle of the debate over the fees, and others raised concerns about the effects that the charges might have on health equity and access to care.

Demand curves do slope downward.  And yet:

But a recent study led by Dr. Holmgren of data from Epic, a dominant electronic health records company, showed that the rate of patient emails to providers had increased by more than 50 percent in the last three years.

Perhaps there is a smidgen of room for AI here?  But not under the current legal regime, I suspect.  Here is the full Benjamin Ryan NYT article.

The medical culture that is Britain

Universities have been told they must limit the number of medical school places this year or risk fines, a move attacked as “extraordinary” when the NHS is struggling with staff shortages.

Medical schools have been told to curtail offers to ensure that there is “no risk” of them accepting more would-be doctors than permitted by a government cap, with universities saying they are likely to offer fewer places than normal to sixth-formers this year.

Ministers have been criticised for holding firm to a 7,500 cap on new medical students in England while also acknowledging that a chronic shortage of doctors and nurses is contributing to long delays for NHS treatment.

Robert Halfon, the universities minister, wrote to vice-chancellors last week telling them to limit their offers to sixth-formers, causing frustration among universities, which face fines of £100,000 per student for persistent over-recruitment. Universities say that in the summer, they were forced to reject students for administrative reasons such as submitting vaccine certificates late to stay within permitted numbers.

Here is more from the Times of London (gated).  Perhaps Tyrone approves!

Is the NHS the UK’s biggest problem?

UK ambulances took an average of 1 hour & 32 minutes to respond to heart attacks & strokes last month. 5 X higher than target, double the average in November. Feels like the NHS is falling apart

That is from Matt Goodwin.

Some Ukrainian refugees in the UK are returning back home to get medical care, because their pledge of NHS coverage has turned out to be very meaningful.

I think one has to face the possibility that the NHS has fallen apart, and “all the King’s horses and all the King’s men…” etc.  To make it all much worse, the British citizenry is convinced that it can get a great product for nearly free.  How will the news be broken to voters?

I don’t see much coverage of this in the MSM, but here is Bloomberg reporting on Peter Thiel:

[Thiel] has described British people’s affection for the state-backed health service as “Stockholm syndrome.”

The venture capitalist’s comments came during a Q&A session after a speech at the Oxford Union, a 200-year-old debating society, on Monday. He also said that the crisis-stricken health service, currently grappling with strikes and long wait times for emergency care, was making people sick and needs “market mechanisms” to fix it. Such mechanisms include privatizing parts of it, avoiding rationing and loosening regulations…

“In theory, you just rip the whole thing from the ground and start over,” Thiel said after an address in which he argued that a perceived fear of disruption was holding back technological and scientific developments. “In practice, you have to somehow make it all backwards-compatible in all these ridiculous British ways.”

The first step to fixing the NHS was, he said, to break away from the view that it is “the most wonderful thing in the world” and understand it as an “iatrogenic” institution, which means it makes people sick.

Ouch.  What will it cost to recapitalize the thing?  How long will it take?  I am more optimistic about England than most commentators these days, but this is perhaps problem number one?

To be clear, I nonetheless recognize the recent successes of the NHS in collecting data and testing hypotheses.  It is patient care at the retail level that is the problem.

Is it Possible to Prepare for a Pandemic?

In a new paper, Robert Tucker Omberg and I ask whether being “prepared for a pandemic” ameliorated or shortened the pandemic. The short answer is No.

How effective were investments in pandemic preparation? We use a comprehensive and detailed measure of pandemic preparedness, the Global Health Security (GHS) Index produced by the Johns Hopkins Center for Health Security (JHU), to measure which investments in pandemic preparedness reduced infections, deaths, excess deaths, or otherwise ameliorated or shortened the pandemic. We also look at whether values or attitudinal factors such as individualism, willingness to sacrifice, or trust in government—which might be considered a form of cultural pandemic preparedness—influenced the course of the pandemic. Our primary finding is that almost no form of pandemic preparedness helped to ameliorate or shorten the pandemic. Compared to other countries, the United States did not perform poorly because of cultural values such as individualism, collectivism, selfishness, or lack of trust. General state capacity, as opposed to specific pandemic investments, is one of the few factors which appears to improve pandemic performance. Understanding the most effective forms of pandemic preparedness can help guide future investments. Our results may also suggest that either we aren’t measuring what is important or that pandemic preparedness is a global public good.

Our results can be simply illustrated by looking at daily Covid deaths per million in the country the GHS Index ranked as the most prepared for a pandemic, the United States, versus the country the GHS Index ranked as least prepared, Equatorial Guinea.

Now, of course, this is just raw data–maybe the US had different demographics, maybe Equatorial Guinea underestimated Covid deaths, maybe the GHS index is too broad or maybe sub-indexes measured preparation better. The bulk of our paper shows that the lesson of Figure 1 continue to apply even after controlling for a variety of demographic factors, when looking at other measures of deaths such as excess deaths, when  looking at the time pattern of deaths etc. Note also that we are testing whether “preparedness” mattered and finding that it wasn’t an important factor in the course of the pandemic. We are not testing and not arguing that pandemic policy didn’t matter.

The lessons are not entirely negative, however. The GHS index measures pandemic preparedness by country but what mattered most to the world was the production of vaccines which depended less on any given country and more on global preparedness. Investing in global public goods such as by creating a library of vaccine candidates in advance that we could draw upon in the event of a pandemic is likely to have very high value. Indeed, it’s possible to begin to test and advance to phase I and phase II trials vaccines for every virus that is likely to jump from animal to human populations (Krammer, 2020). I am also a big proponent of wastewater surveillance. Every major sewage plant in the world and many minor plants at places like universities ought to be doing wastewater surveillance for viruses and bacteria. The CDC has a good program along these lines. These types of investments are global public goods and so don’t show up much in pandemic preparedness indexes, but they are key to a) making vaccines available more quickly and b) identifying and stopping a pandemic quickly.

Our paper concludes:

A final lesson may be that a pandemic is simply one example of a low-probability but very bad event. Other examples which may have even greater expected cost are super-volcanoes, asteroid strikes, nuclear wars, and solar storms (Ord, 2020; Leigh, 2021). Preparing for X, Y, or Z may be less valuable than building resilience for a wide variety of potential events. The Boy Scout motto is simply ‘Be prepared’.

Read the whole thing.

The decline of religion, and the rise of deaths of despair

In recent decades, death rates from poisonings, suicides, and alcoholic liver disease have dramatically increased in the United States. We show that these “deaths of despair” began to increase relative to trend in the early 1990s, that this increase was preceded by a decline in religious participation, and that both trends were driven by middle-aged white Americans. Using repeals of blue laws as a shock to religiosity, we confirm that religious practice has significant effects on these mortality rates. Our findings show that social factors such as organized religion can play an important role in understanding deaths of despair.

That is from a new NBER working paper by Tyler Giles, Daniel M. Hungerman, and Tamar Oostrom.  Ross Douthat, telephone!

Testing Freedom

In the latest Discourse Magazine I discuss the FDA’s long-standing fear and antipathy toward personalized medical tests and how this violates the 1st Amendment.

In 1972, the FDA confiscated thousands of home pregnancy tests, declaring that they were “drugs” meant to diagnose a “disease” and thus fell under the FDA’s regulatory dominion. The case went to the U.S. District Court for the District of New Jersey, and Judge Vincent P. Biunno ruled that the FDA had overstepped. “Pregnancy,” he said, “is a normal physiological function of all mammals and cannot be considered a disease … a test for pregnancy, then, is not a test for the diagnosis of disease. It is no more than a test for news….” As a result of Judge Biunno’s ruling, home pregnancy tests are easily available today from pharmacies, grocery stores and online shops without a prescription.

These days, debates over home pregnancy tests from the 1970s seem anachronistic and paternalistic. Yet the same paternalistic arguments appear again and again with every new testing technology. In the late 1980s, for example, the FDA simply declared that it would not approve at-home HIV tests, regardless of their safety or efficacy. As with pregnancy tests, the concern was that people could not be trusted with information about their own bodies…the first rapid at-home HIV test was developed and submitted to the FDA in 1987 [but] it took 25 years before the FDA would approve these tests. (Now, you can easily buy such a test on Amazon.)

…The FDA has a vital role in ensuring that tests are clinically accurate—tests should do what they say they do. Tests don’t need to be perfectly accurate to be useful (think of thermometers, personality tests and tire pressure gauges), but if a test advertises that it measures HDL cholesterol, it should do that within the tolerances the firm promises. The FDA has the technical knowledge to ensure that tests work, and that’s a skill that Americans value from the agency.

What Americans don’t want is to be told they can’t handle the truth. Yet when it came to at-home tests such as pregnancy tests, HIV tests and genetic tests, that’s exactly the reasoning the FDA used—and continues to use—to suppress information. The FDA should ensure that tests are safe, but “safety” means physical safety. The FDA may not declare a product unsafe because it might produce dangerous knowledge. Patients have a right to know about their own bodies. Our antibodies, ourselves. The FDA has authority over drugs and devices but not over patients.

Judge Biunno had it right back in 1972 when he said that diagnostic tests produce “news.” Test results, therefore, are a type of speech that fall under the First Amendment right to freedom of speech. The Supreme Court has repeatedly rejected restrictions on freedom of speech based on “a fear that people would make bad decisions if given truthful information”; thus, FDA restrictions on tests based on such fears are unconstitutional. The question of whether consumers will respond “safely” to test results is no more relevant to the FDA’s regulatory authority than the question of whether readers will respond safely to political news published in The New York Times. The FDA does not have the constitutional authority to regulate news.

How much did pre-ACA Medicaid expansions matter?

This paper examines the impact of Medicaid expansions to parents and childless adults on adult mortality. Specifically, we evaluate the long-run effects of eight state Medicaid expansions from 1994 through 2005 on all-cause, healthcare-amenable, non-healthcare-amenable, and HIV-related mortality rates using state-level data. We utilize the synthetic control method to estimate effects for each treated state separately and the generalized synthetic control method to estimate average effects across all treated states. Using a 5% significance level, we find no evidence that Medicaid expansions affect any of the outcomes in any of the treated states or all of them combined. Moreover, there is no clear pattern in the signs of the estimated treatment effects. These findings imply that evidence that pre-ACA Medicaid expansions to adults saved lives is not as clear as previously suggested.

That is a new NBER working paper from Charles J. Courtemanche, Jordan W. Jones, Antonios M. Koumpias, and Daniela Zapata.

Here are some relevant pictures.  Now, would you expect subsequent Medicaid expansions to have higher, lower, or the same marginal value?

David Wallace-Wells on the pandemic

Rather than quote the parts where he says nice things about Alex and me, how about a wee excerpt on the GBD crowd:

Dr. Bhattacharya, for instance, proclaimed in The Wall Street Journal in March 2020 that Covid-19 was only one-tenth as deadly as the flu. In January 2021 he wrote an opinion essay for the Indian publication The Print suggesting that the majority of the country had acquired natural immunity from infection already and warning that a mass vaccination program would do more harm than good for people already infected. Shortly thereafter, the country’s brutal Delta wave killed perhaps several million Indians. In May 2020, Dr. Gupta suggested that the virus might kill around five in 10,000 people it infected, when the true figure in a naïve population was about one in 100 or 200, and that Covid was “on its way out” in Britain. At that point, it had killed about 45,000 Britons, and it would go on to kill about 170,000 more. The following year, Dr. Bhattacharya and Dr. Kulldorff together made the same point about the disease in the United States — that the pandemic was “on its way out” — on a day when the American death toll was approaching 600,000. Today it is 1.1 million and growing.

It has fallen down the memory hole a bit just how um…”off” these people were, and that is the polite word.  That said, I don’t think they should have been banned from any social media platforms.  Here is the full NYT piece, excellent throughout, and mostly about other topics.  For the pointer I thank Alex T.

Shruti Rajagopalan and Janhavi Nilekani podcast

In this episode, Shruti speaks with [the excellent] Janhavi Nilekani about India’s high rate of C-sections compared with vaginal births, problems with maternal healthcare, the present and future of Indian midwifery and much more. Nilekani is the founder and chair of the Aastrika Foundation, which seeks to promote a future in which every woman is treated with respect and dignity during childbirth, and the right treatment is provided at the right time. She is a development economist by training and now works in the field of maternal health. She obtained her Ph.D. in public policy from Harvard and holds a 2010 B.A., cum laude, in economics and international studies from Yale.

Here is the link.

Retrospective look at rapid Covid testing

To be clear, I still favor rapid Covid tests, and I believe we were intolerably slow to get these underway.  The benefits far exceed the costs, and did earlier on in the pandemic as well.

That said, with a number of pandemic retrospectives underway, here is part of mine.  I don’t think the strong case for those tests came close to panning out.

I had raised some initial doubts in my podcasts with Paul Romer and also with Glen Weyl, mostly about the risk of an inadequate demand to take such tests.  I believe that such doubts have been validated.

Ideally what you want asymptomatic people in high-risk positions taking the tests on a frequent basis, and, if they become Covid-positive, learning they are infectious before symptoms set in (remember when the FDA basically shut down Curative for giving tests to the asymptomatic?  Criminal).  And then isolating themselves.  We had some of that.  But far more often I witnessed:

1. People with symptoms taking the tests to confirm they had Covid.  Nothing wrong with that, but it leads to a minimal gain, since in so many cases it was pretty clear without the test.

2. Various institutions requiring tests for meet-ups and the like.  These tests would catch some but not all cases, and the event still would turn into a spreader event, albeit at a probably lower level than otherwise would have been the case.

3. Nervous Nellies taking the test in low-risk situations mainly to reassure themselves and others.  Again, no problems there but not the highest value use either.

So the prospects for mass rapid testing — done in the most efficacious manner — were I think overrated.

I recall the summer of 2022 in Ireland, which by the way is when I caught Covid (I was fine, though decided to spend an extra week in Ireland rather than risk infecting my plane mates).  Rapid tests were available everywhere, and at much lower prices than in the United States.  Better than not!  But what really seemed to make the difference was vaccines.  The availability of all those tests did not do so much to prevent Covid from spreading like a wildfire during that Irish summer.  Fortunately, deaths rose but did not skyrocket.

The well-known Society for Healthcare Epidemiology just recommended that hospitals stop testing asymptomatic patients for Covid.  You may or may not agree, but that is a sign of how much status testing has lost.

Some commentators argue there are more false negatives on the rapid tests with Omicron than with earlier strains.  I haven’t seen proof of this claim, but it is itself noteworthy that we still are not sure how good the tests are currently.  That too reflects a lower status for testing.

Again, on a cost-benefit basis I’m all for such testing!  But I’ve been lowering my estimate of its efficacy.