Scott Gottlieb’s Uncontrolled Spread

Scott Gottlieb’s Uncontrolled Spread is superb. I reviewed it for the WSJ. Here’s one bit:

If there’s one overarching theme of “Uncontrolled Spread,” it’s that the Centers for Disease Control and Prevention failed utterly. It’s now well known that the CDC didn’t follow standard operating procedures in its own labs, resulting in contamination and a complete botch of its original SARS-CoV-2 test. The agency’s failure put us weeks behind and took the South Korea option of suppressing the virus off the table. But the blunder was much deeper and more systematic than a botched test. The CDC never had a plan for widespread testing, which in any scenario could only be achieved by bringing in the big, private labs.

Instead of working with the commercial labs, the CDC went out of its way to impede them from developing and deploying their own tests. The CDC wouldn’t share its virus samples with commercial labs, slowing down test development. “The agency didn’t view it as a part of its mission to assist these labs.” Dr. Gottlieb writes. As a result, “It would be weeks before commercial manufacturers could get access to the samples they needed, and they’d mostly have to go around the CDC. One large commercial lab would obtain samples from a subsidiary in South Korea.”

At times the CDC seemed more interested in its own “intellectual property” than in saving lives. In a jaw-dropping section, Dr. Gottlieb writes that “companies seeking to make the test kits described extended negotiations with the CDC that stretched for weeks as the agency made sure that the contracts protected its inventions.” When every day of delay could mean thousands of lives lost down the line, the CDC was dickering over test royalties.

In the early months of the pandemic the CDC impeded private firms from developing their own tests and demanded that all testing be run through its labs even as its own test failed miserably and its own labs had no hope of scaling up to deal with the levels of testing needed. Moreover, the author notes, because its own labs couldn’t scale, the CDC played down the necessity of widespread testing and took “deliberate steps to enforce guidelines that would make sure it didn’t receive more samples than its single lab could handle.”

Read the whole thing.

Addendum: My previous reviews of Michael Lewis’s The Premonition, Slavitt’s Preventable and Abutaleb and Paletta’s Nightmare Scenario.

Covid markets in everything

A pastor is encouraging people to donate to his Tulsa church so they can become an online member and get his signature on a religious exemption from coronavirus vaccine mandates. The pastor, Jackson Lahmeyer, is a 29-year-old small-business owner running in the Republican primary challenge to Sen. James Lankford in 2022.

Lahmeyer, who leads Sheridan Church with his wife, Kendra, said Tuesday that in the past two days, about 30,000 people have downloaded the religious exemption form he created.

And:

Some institutions request a signature from a religious authority, but Charles Haynes, senior fellow for religious freedom at the Freedom Forum in Washington, said that those institutions could be on a shaky ground constitutionally. Haynes said that if a person states a sincere religious belief that they want to opt out of vaccination, that should be enough.

“He’s not really selling a religious exemption,” said Haynes, who compared Lahmeyer’s exemption offer to televangelists who sell things like prayer cloths. “He’s selling a bogus idea that you need one.”

Here is the full story, via Brett D.

My January 2020 Bloomberg column on Covid

I thought this one worthy of a redux, here are a few segments:

First, most emergency rooms are not equipped to handle a very high volume of cases, especially infectious diseases…The general economic problem is that emergency rooms typically are not equipped with full surge capacity, nor are there enough emergency room add-ons or substitutes available on very short notice.

And:

Very often, when a pandemic breaks out, talk turns to macro remedies such as air travel bans and quarantines, as China is instituting. Yet often the more important factor is the strength, resilience and flexibility of local public health institutions, and those qualities cannot be created overnight. Just as the Chinese health-care system is undergoing a major test right now, there is a good chance that the U.S. will too.

And:

An additional test could concern child-care and telecommuting. Will U.S. schools need to be shut? At the very least it is something officials should have been planning for. Even if schools are not closed, some number of parents will keep their children at home, whether out of rational fear or not. Anti-vaccine sentiment is fairly high and rising, after all, and even the wisest parents will prefer to be safe than sorry.

Keeping one’s children at home means that fewer people will go to work. Even those with external child-care options, such as day care, may be reluctant to leave their children outside the home for the same reasons they fear the schools. The new question then becomes how robust are work plans, and U.S. supply chains, to a higher than usual rate of workplace absenteeism. There also may be an especially high level in China, which could strain U.S. and other supply chains relying on Chinese producers. Many businesses may need to amend their plans on the fly.

Once again, pandemic preparation is about the flexibility of decentralized institutions. These are not problems that can be solved by top-down planning. Instead, they rely on longstanding institutional capacities, high levels of social trust and improvisational skill.

If and when a good vaccine becomes available for the virus, that will again be about the improvisation and flexibility that will allow for scalability and eventual production and distribution. It is usually difficult to solve such problems quickly, but still there is better and worse performance — and that can make a big difference.

And:

The very first problem the U.S. is likely to face is one of risk communication. Of course the correct message will depend on how the data evolve, but in general there is tension between warnings that get people to take notice, and those that scare them underground or into counterproductive forms of panic.

If you tell people how terrible things are, they feel a loss of control. Many will retreat into conspiracy theories, spread mistrust of health-care institutions, or withdraw altogether from social or professional activity. Those who are sick may be afraid to seek medical attention, for fear of having their movements constrained, driving the disease further underground and distorting the data. Again, trust is of paramount importance.

Recommended.

What’s the Right Dose for Boosters?

The Biden administration says booster shots are coming, but the FDA hasn’t decided on the dose. Moderna wants a half-shot booster. Pfizer a full shot. But could the best dose for Americans and for the world be even less?

COVID-19 vaccines are the first successful use of mRNA vaccine technology, so a lot remains unknown. But identifying the smallest dose needed to provide effective boosting is critical to protect Americans from adverse effects, increase confidence in vaccines, and mitigate global vaccine inequity.

We’ve known since earlier this year that a half-dose of the Moderna vaccine produces antibody levels similar to the standard-dose and newer information suggests that even a quarter-dose vaccine may do the same. If a half or quarter dose is nearly as effective as a standard dose for first and second shots then a full dose booster may well be an overdose. The essential task of a booster is to “jog” the immune system’s memory of what it’s supposed to fight. Data from the world of hepatitis B suggest that the “reminder” need not be as intense as the initial “lesson.” And in the cases of tuberculosis, meningitis, and yellow fever vaccines, lower doses have been as good or better than the originals.

Lower doses could also reduce risks of adverse effects.

That’s myself and physicians Garth Strohbehn and William F. Parker on the Med Page Today. Strohbehn is an oncologist and specialist in optimizing doses for cancer drugs. William Parker is a pulmonologist and professor of medicine at the University of Chicago.

China campaign of the day

But a shift in investor sentiment suggests the days of China’s youth going under the knife in pursuit of perfection might be numbered, as President Xi Jinping tries to reshape the country’s cultural and business landscape as part of a “common prosperity” drive. S

ince the start of July, the market value of the country’s three biggest publicly traded medical aesthetics companies has fallen by a third, representing a collective loss of more than $17bn, despite the popularity of cosmetic procedures. Investment bank Citic estimated sales revenues in China’s aesthetic medicine market were more than Rmb330bn ($51bn) in 2020.

But analysts warn that the industry could suffer a heavy blow if Beijing concludes that the sector’s negative social influence is on a par with private tutoring and online gaming — industries where strict regulations have crushed the market values of dominant groups in recent months.

“It is perfectly possible we may see another industry disappear,” said Mark Tanner, managing director of China Skinny, a marketing company.

Here is more from the FT.

Covid and intertemporal substitution

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

Before the vaccines came along, it made great sense to enforce masking norms. If infections could be shifted into the future, an eventually vaccinated citizenry would be much better protected.

There is a less obvious corollary: Those same mask norms make less sense when large numbers of people are vaccinated. Masking still will push infections further into the future, but if the vaccines become marginally less effective over time, as some data suggest, people may be slightly worse off later on (they’ll also be a bit older). The upshot is that the case for masking is less strong, even if you still think it is a good idea overall.

Still, many people prefer to abide by fixed rules and principles. Once they learn them and lecture others about them, they are unlikely to change their minds. “Masking is good!” is a simple precept. “Exactly how good masking is depends on how much safer the near future will be!” is not. Yet the latter statement is how the economist is trained to think.

And this:

Some of the consequences of intertemporal substitution are a bit ghastly, and you won’t find many people willing to even talk about them.

For example: Say you are immunocompromised, and you either can’t or won’t get vaccinated. You might be justly mad about all the unvaccinated knuckleheads running around, getting Covid, and possibly infecting you. At the same time, you wish to minimize your required degree of intertemporal substitution.

So if you are (perhaps correctly) afraid to go out very much, you are better off if those same knuckleheads acquire natural immunity more quickly. Yes, it would be better if they got vaccinated. But barring that, a quick pandemic may be easier for you to manage than a long, drawn-out pandemic, which would require heroic amounts of intertemporal substitution.

Recommended.  And yes there is a “don’t overload your health system” qualifier (most of the U.S. is OK on this front right now), which I’ve written about multiple times including as early as January 2020.

Understanding the onset of hot streaks in careers

By Lu Liu, et.al., in Nature:

Across a range of creative domains, individual careers are characterized by hot streaks, which are bursts of high-impact works clustered together in close succession. Yet it remains unclear if there are any regularities underlying the beginning of hot streaks. Here, we analyze career histories of artists, film directors, and scientists, and develop deep learning and network science methods to build high-dimensional representations of their creative outputs. We find that across all three domains, individuals tend to explore diverse styles or topics before their hot streak, but become notably more focused after the hot streak begins. Crucially, hot streaks appear to be associated with neither exploration nor exploitation behavior in isolation, but a particular sequence of exploration followed by exploitation, where the transition from exploration to exploitation closely traces the onset of a hot streak. Overall, these results may have implications for identifying and nurturing talents across a wide range of creative domains.

For the pointer I thank Alice Evans.

What to Watch

A few things I have watched recently:

The Courier–a taut, spy drama about the true story of Greville Wynne, an ordinary British businessman who was recruited by the British and American spy services to courier information in the 1960s from Russian agent Oleg Penkovsky–information that proved crucial to the United States during the Cuban Missile Crisis. Stars Benedict Cumberbatch and Rachel Brosnahan. On Amazon Prime.

The Hitman’s Wife’s Bodyguard–I thought this action-comedy was hilarious (in the spirit of Deadpool). The plot makes no sense but who cares? It stars Ryan Reynolds, Samuel Jackson, Morgan Freeman, Antonio Banderas and Salma Hayek all of whom are clearly having a good time. Salma Hayek’s over-the-top performance makes the film. It even has an attack on occupational licensing. Saw it on a plane.

Worth–who would have thought that debates about estimating the value of a life would make a good movie? Michael Keaton plays Kenneth Feinberg, the lawyer who headed the September 11th Victim Compensation Fund. How much for a waiter? How much for a Wall Street trader? This is the philosophical question that gets the movie going but more practical problems also intercede. What do you do when the wife and the mistress both file for compensation? In the end, the movie bails on the big questions but succeeds on the quality of the performance by Michael Keaton. The tort system is a very expensive way to compensate victims. The Victim Compensation fund was a successful application of no-fault rules. On Netflix.

Billions–I will finish out the the fifth season but the plots are now repetitive and while I wouldn’t say it has jumped the shark it will never rise again to the heights of The Third Ortolan. I did appreciate the Neil Peart reference but it should never have been explained. Love Jason Isbell but it feels like the writers are reaching for relevance. On Showtime.

Only Murders in the Building–An old-time murder mystery starring Steve Martin, Martin Short, and Selena Gomez. It’s fun but will they pull off a satisfying ending? I hope so. A show I can watch with my wife. On Hulu.

Tuesday assorted links

1. Mike Makowsky good career advice for those economists (and others?) coming out of non-elite schools.

2. Bryan Caplan on his home schooling experience.

3. BBC covers EV India winner and his fight against air pollution.

4. Why young Koreans are doing so well in classical music.

5. Art Blakey and Lee Morgan in concert.

6. Guardian Fall books preview.  And Vulture Fall books preview.

Derry notes, Northern Ireland’s second largest city

People in Derry are still talking about the 1680s…it is bad to be a “Lundy,” namely a traitor to your cause but the bar here has become a high one.  You are either with them or against them.

The 17th century city wall seems fully intact, the buildings are splendid, and the green, wet, and hilly natural setting is a perfect fit.  The town is long on history, short on things to do.  It is perfect for a two-day trip.

I witnessed a Loyalist parade — the men were not feminized, nor did they seem happy. It is now so much “common knowledge” that Britain really does not care about them.  So what is their future and with whom?  Given differential birthrates, Catholics seem headed to become a majority in NI as well.

Most of the city centre is Catholic, and unlike Belfast it is not difficult to imagine Derry rather easily being swallowed up by the Republic of Ireland, some of which even lies to the north of Derry.

I went to see where Bloody Sunday occurred in 1972, and it shocked me how small the “contested territory” is/was.  It feels as if you can count each and every home, and one’s mind starts wandering to the Coase Theorem and Hong Kong real estate billionaires and Special Enterprise Zones.

Real estate in Northern Ireland seems dramatically underpriced, though along a thirty-year rather than a ten-year time horizon.  But should you buy closer to Belfast?

In some ways Derry reminded me of parts of West Virginia, including the Scots-Irish faces, the bygone glories, and also the “every family has an addiction” signs in the center of town.

One hundred years ago, in 1921, who would have thought that joining with the Irish Republic would lead to more prosperity than joining with Britain?  Therein lies a cautionary note for us all.

Why I am reluctant to endorse preschool

A few of you asked for follow-ups, given my discussion with Ezra Klein.  Here is one paper that makes me skeptical:

Exploiting admission thresholds in a Regression Discontinuity Design, we study the causal effects of daycare at age 0–2 on cognitive and non-cognitive outcomes at age 8–14. One additional month in daycare reduces IQ by 0.5% (4.5% of a standard deviation). Effects for conscientiousness are small and imprecisely estimated. Psychologists suggest that children in daycare experience fewer one-to-one interactions with adults, which should be particularly relevant for girls who are more capable than boys of exploiting cognitive stimuli at an early age. In line with this interpretation, losses for girls are larger and more significant, especially in affluent families.

That is sometimes called the Bologna preschool paper, and it is by Fort, Ichina, and Zanella.  More generally, there is the question of whether a society will produce more top performers with the state as nanny, or with the parents as nanny.  Maybe we don’t know, but my intuition suggests with the parents.  Here are some other reservations, and here are more yet.  It is difficult to show lasting benefits from preschool.  Here is the most extensive study I have seen, and it shows negative results for preschool.  Or consider this RCT.  Symbolically I am not crazy about the idea of building systems that imply human life is about “schooling” almost from the get go.  I don’t think the literature to date is conclusive, but I do think the case for preschool still remains to be made.

Monday assorted links

1. You can now buy a $475 NFT ticket to see Beeple’s $69 million NFT at an IRL party.  The ticket also includes one drink.

2. “We find that young players benefited at the expense of older players and that the disruptive effects of the new [tennis] racquets persisted over two to four generations.

3. In the early stages of pandemics, do they spread more amongst people of higher status?

4. The exclusionary history of the FHA.

5. Excerpts from me on how to read.

6. The Japanese are better at reading Twitter.

7. Tensions between the CDC and Biden administration mount.  Which one do you think is coming closer to trying to maximize expected value?  It turns out even the FDA thinks the CDC is too slow.

Operation Warp Speed: A Story Yet to be Told

Operation Warp Speed was by far the most successful government program against COVID. But as of yet there is very little discussion or history of the program. As just an indication I looked for references in a bunch of pandemic books to General Perna who co-led OWS with Moncef Slaoui. Michael Lewis in The Premonition never mentions Perna. Neither does Slavitt in Preventable. Nor does Wright in The Plague Year. Nor does Gottlieb in Uncontrolled Spread. Abutaleb and Paletta in Nightmare Scenario have just two index entries for Perna basically just stating his appointment and meeting with Trump.

Yet there are many questions to be asked about OWS. Who wrote the contracts? Who chose the vaccines? Who found the money? Who ran the day to day operation? Why was the state and local rollout so slow and uneven? How was the DPA used? Who lifted the regulations? How was the FDA convinced to go fast?

I don’t know the answer to these questions. I suspect when it is all written down, Richard Danzig will be seen as an important behind the scenes player in the early stages (I was involved with some meetings with him as part of the Kremer team). Grogan at the DPC seems under-recognized. Peter Marks at the FDA was likely extremely important in getting the FDA to run with the program. Marks brought people like Janet Woodcock from the FDA to OWS so you had a nominally independent group but one completely familiar with FDA policy and staff and that was probably critical. And of course Slaoui and Perna were important leaders and communicators with the private sector and the logistics group but they have yet to be seriously debriefed.

It’s also time for a revisionist account of President Trump’s Council of Economic Advisors. Michael Kremer and I spoke to the DPC and the CEA early on in the pandemic and argued for a program similar to what would later be called OWS. The CEA, however, was way ahead of the game. In Sept of 2019 (yes, 2019!) the CEA produced a report titled Mitigating the Impact of Pandemic Influenza through Vaccine Innovation. The report calculates the immense potential cost of a pandemic and how a private-public partnership could mitigate these costs–all of this before anyone had heard the term COVID. Nor did that happen by accident. Thomas Philipson, the CEA chair, had made his reputation in the field of economic epidemiology, incorporating incentives and behavioral analysis in epidemiological models to understand HIV and the spread of other infectious diseases. Eric Sun, another CEA economist, had also written with Philipson about the FDA and its problems. Casey Mulligan was another CEA chief economist who understand the danger of pandemics and was influenced by Sam Peltzman on the costs of FDA delay. So the CEA was well prepared for the pandemic and I suspect they gave Trump very good advice on starting Operation Warp Speed.

In short, someone deserves credit for a multi-trillion-dollar saving government program! More importantly, we know a lot about CDC and FDA failure but in order to know what we should build upon we also need to know what worked. OWS worked. We need a history of how and why.

Immigration to the U.S. is correlated with quite high life expectancy

We find that immigration increases US life expectancy by 1.5 years for men and 1.4 years for women. Over half of these contributions occur at the prime working ages of 25–64. The difference between foreign-born and US-born mortality has grown substantially since 1990, with the ratio of US-born to foreign-born mortality rates nearly doubling by 2017. In that year, foreign-born life expectancy reached 81.4 and 85.7 years for men and women, respectively—7.0 and 6.2 years higher than their US-origin counterparts. These life expectancy levels are remarkable by most standards. Foreign-born male life expectancy exceeds that of Swiss men, the world leaders in male life expectancy. Life expectancy for foreign-born women is close to that of Japanese women, the world leaders in female life expectancy. The widening mortality difference between the US-born and foreign-born populations, coupled with an increase in the share of the population born abroad, has been responsible for much of the increase in national life expectancy in recent years. Between 2007 and 2017, foreign-born men and women were responsible for 44% and 60% of national life expectancy improvements. Between 2010 and 2017, immigrants experienced gains while the US-born experienced declines in life expectancy. Thus, nearly all of the post-2010 mortality stagnation is due to adverse trends among the US-born. Without immigrants and their children, national life expectancy in 2017 would be reduced to its 2003 levels. These findings demonstrate that immigration acts to bolster American life expectancy, with particularly valuable contributions at the prime working ages.

I will repeat what is to me the most striking excerpt:

Foreign-born male life expectancy exceeds that of Swiss men, the world leaders in male life expectancy. Life expectancy for foreign-born women is close to that of Japanese women, the world leaders in female life expectancy.

Many interesting results in there, for instance those immigrants sure are mighty!  I strongly suspect much of that is selection, and another big part lifestyle, but yet another implication is that the U.S. health care system maybe isn’t as terrible as what you have been hearing.  And that living in the U.S., over the generations, screws people up.

Here is the full piece by Arun S. Hendi and Jessica Y. Ho, via the excellent Kevin Lewis.