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ProPublica on FDA Delay

If you have been following MR for the last 18 months (or 18 years!) you won’t find much new in this ProPublica piece on FDA delay in approving rapid tests but, other than being late to the game, it’s a good piece. Two points are worth emphasizing. First, some of the problem has been simple bureaucratic delay and inefficiency.

In late May, WHPM head of international sales Chris Patterson said, the company got a confusing email from its FDA reviewer asking for information that had in fact already been provided. WHPM responded within two days. Months passed. In September, after a bit more back and forth, the FDA wrote to say it had identified other deficiencies, and wouldn’t review the rest of the application. Even if WHPM fixed the issues, the application would be “deprioritized,” or moved to the back of the line.

“We spent our own million dollars developing this thing, at their encouragement, and then they just treat you like a criminal,” said Patterson. Meanwhile, the WHPM rapid test has been approved in Mexico and the European Union, where the company has received large orders.

An FDA scientist who vetted COVID-19 test applications told ProPublica he became so frustrated by delays that he quit the agency earlier this year. “They’re neither denying the bad ones or approving the good ones,” he said, asking to remain anonymous because his current work requires dealing with the agency.

Recall my review of Joseph Gulfo’s Innovation Breakdown.

Second, the FDA has engaged in regulatory nationalism–refusing to look at trial data from patients in other countries. This is madness when India does it and madness when the US does it.

For example, the biopharmaceutical giant Roche told ProPublica that it submitted a home test in early 2021, but it was rejected by the FDA because the trials had been done partly in Europe. The test had compared favorably with Abbott’s rapid test, and received European Union approval in June. The company plans to resubmit an application by the end of the year.

A smaller company, which didn’t want to be named because it has other contracts with the U.S. government, withdrew its pre-application for a rapid antigen test with integrated smartphone-based reporting because it heard its trial data from India — collected as the delta variant was surging there — wouldn’t be accepted. Doing the trials in the U.S. would have cost millions.

Photo credit: MaxPixel.

The Promising Pathway Act

Operation Warp Speed showed that we can move much faster. FDA delay in approving rapid tests shows that we should move much faster. There is a window of opportunity for reform. The excellent Bart Madden and Siri Terjesen argue for the Promising Pathways Act.

One particularly exciting development is the Promising Pathway Act (PPA), recently introduced in Congress. PPA would reduce bureaucracy via legal changes and provide individuals with efficient early access to potential new drugs.

Under PPA, new drugs will receive provisional approval five to seven years earlier than the status quo via a two-year provisional approval. Drugs that demonstrate patient benefits could be renewed for a maximum of six years, and the FDA could grant full approval at any time based on real-world as opposed to clinical trial data documenting favorable treatments results.

The PPA allows patients, advised by their doctors, to choose early access to promising but not-yet-FDA -approved drugs. Patients and doctors would make informed decisions about using either approved or new medicines that demonstrate safety and initial effectiveness compared to approved drugs.

…Patients and doctors can log into an internet registry database for early access drugs that would contain treatment outcomes, side effects, genetic data, and biomarkers. Scientific researchers, as well as patients, will also benefit from the identification of subgroups of patients who do exceptionally well or fail to respond.

Data from the registry will open knowledge pathways to improve the biopharmaceutical industry’s research outlays to benefit future patients.

With radically lower regulatory costs plus heightened competition as more companies participate, expect substantially lower prescription drug prices for provisional approval drugs.

Here is the text of the PPA.

The TGA is Worse than the FDA, and the Australian Lockdown

I have been highly critical of the FDA but in Australia the FDA is almost a model to be emulated. Steven Hamilton and Richard Holden do not mince words:

At the end of 2020, as vaccines were rolling out en masse in the Northern Hemisphere, the TGA [Therapeutic Goods Administration, AT] flatly refused to issue the emergency authorisations other regulators did. As a result, the TGA didn’t approve the Pfizer vaccine until January 25, more than six weeks after the US Food and Drug Administration (FDA), itself not exactly the poster child of expeditiousness.

Similarly, the TGA didn’t approve the AstraZeneca vaccine until February 16, almost seven weeks after the UK.

In case you’re wondering “what difference does six weeks make?“, think again. Were our rollout six weeks faster, the current Sydney outbreak would likely never have exploded, saving many lives and livelihoods. In the face of an exponentially spreading virus that has become twice as infectious, six weeks is an eternity. And, indeed, nothing has changed. The TGA approved the Moderna vaccine this week, eight months after the FDA.

It approved looser cold storage requirements for the Pfizer vaccine, which would allow the vaccine to be more widely distributed and reduce wastage, on April 8, six weeks after the FDA. And it approved the Pfizer vaccine for use by 12 to 15-year-olds on July 23, more than 10 weeks after the FDA.

And then there’s the TGA’s staggering decision not to approve in-home rapid tests over reliability concerns despite their widespread approval and use overseas.

Where’s the approval of the mix-and-match vaccine regimen, used to great effect in Canada, where AstraZeneca is combined with Pfizer to expand supply and increase efficacy? Where’s the guidance for those who’ve received two doses of AstraZeneca that they’ll be able to receive a Pfizer booster later?

In the aftermath of the pandemic, when almost all of us should be fully vaccinated,there will be ample opportunity to figure out exactly who is to blame for what.

But the slow, insular, and excessively cautious advice of our medical regulatory complex, which comprehensively failed to grasp the massive consequences of delay and inaction, must be right at the top of that list.

You might be tempted to argued that the TGA can afford to take its time since COVID hasn’t been as bad in Australia as in the United States but that would be to ignore the costs of the Australian lockdown.

Article 13 of the Universal Declaration of Human Rights states that

  1. Everyone has the right to freedom of movement and residence within the borders of each state.
  2. Everyone has the right to leave any country, including his own, and to return to his country.

Australia has now violated each and every clause of this universal human right and seemingly without much debate or objection. It is deeply troubling to see people prevented from leaving or entering their own country and soldiers in the street making sure people do not travel beyond a perimeter surrounding their homes. The costs of lockdown are very high and thus so is any delay in ending these unprecedented infringements on liberty.

Our Regulatory State Isn’t Learning

Outsourced to John Cochrane:

Delta is the fourth wave of covid, and amazingly the US policy response is even more irresolute than the first time around. Our government is like a child, sent next door to get a cup of sugar, who gets as far as the front stoop and then wanders off following a puppy.

The policy response is now focused on the most medically ineffective but most politically symbolic step, mask mandates. An all-night disco in Provincetown turns in to a superspreader event so… we make school kids wear masks in outdoor summer camps? Masks are several decimal places less effective than vaccines, and less effective than “social distance” in the first place.* Go to that all night disco, unvaccinated, but wear a mask? Please.

If we’re going to do NPI (non pharmaceutical interventions), policy other than vaccines, the level of policy and public discussion has tragically regressed since last summer. Last summer, remember, we were all talking about testing. Alex Tabarrok and Paul Romer were superb on how fast tests can reduce the reproduction rate, even with just voluntary isolation following tests. Other countries had competent test and tracing regimes. Have we built that in a year? No. (Are we ready to test and trace the next bug? Double no.)

What happened to the paper-strip tests you could buy for $2.00 at Walgreen’s, get instant results, and maybe decide it’s a bad idea to go to the all night dance party? Interest faded in November. (Last I looked, the sellers and FDA were still insisting on prescriptions and an app sign up, so it cost $50 and insurance “paid for” it.) What happened to detailed local data? Did anyone ever get it through the FDA’s and CDCs thick skulls that even imperfect but cheap and fast tests can be used to slow spread of disease?

…And then we indulge another round of America’s favorite pastime, answers in search of a question. Delta is spreading, so… extend the renter eviction moratorium. People who haven’t paid rent in a year can stay, landlords be damned.

All true. I got dispirited on testing. It’s insane that we don’t have cheap, rapid testing and good ventilation ready for a new school year. As I wrote about earlier, even the American Academy of Pediatrics is shouting from the rooftops that the FDA is deadly slow. The eviction moratorium is a sick joke. Just a backhanded way to redistribute wealth without a shred of justice or reason. Disgusting.

Here’s one more bit (but read the whole thing there is more.)

To learn from the mistakes, and institutionalize better responses would mean to admit there were mistakes. One would think the grand blame-Trump-for-everything narrative would allow us to do that, but the mistakes are deeply embedded in the bureacracies of the administrative state. Unlike bad admirals in WWII, nobody less than Trump himself has lost their job over incompetent covid response. The institutions have an enormous investment in ratifying that they did the best possible job last time. So, as in so many things (financial bailouts!) we institutionalize last time’s mistakes to keep those who made them in power in power — which means we do not learn from mistakes.

Self Recommending Links

1. I had a fun and wide-ranging conversation with Jonah Goldberg on the Remnant. We covered the economy, immigration, cyborgs and the Baumol effect among other topics.

2. Tim Harford covers fractional dosing at the FT:

The concept of a standard or full dose is fuzzier than one might imagine. These vaccines were developed at great speed, with a focus on effectiveness that meant erring towards high doses. Melissa Moore, a chief scientific officer at Moderna, has acknowledged this. It is plausible that we will come to regard the current doses as needlessly high.

3. The Brunswick Group interviews me:

Act like you’re in a crisis. That has been economist Alex Tabarrok’s advice since the start of the COVID-19 pandemic. Tabarrok was among the earliest and loudest voices arguing for urgency and risk-taking when it came to increasing rapid testing, investing in vaccine capacity, and employing flexible vaccine dosing. In hindsight, he has been proven regularly right when most health experts were wrong.

From the comments, on Covid and our response

It is simply not a tenable policy to oppose pandemic lockdowns on the premise that COVID-19 only negatively affects a certain portion of the population. First, the fact that COVID-19 disproportionately killed the elderly was not something that was readily apparent right out of the box, when the virus was spreading rapidly. Hindsight is 20-20. Second, focusing solely on mortality is short-sighted given that approximately one-third of all people who get over COVID-19 suffer “long haul” symptoms that persist for months and may even be permanent in some. We cannot simply claim that the non-elderly have no reason to fear COVID-19.

So far, COVID-19 has killed more Americans than we lost in World War II, and it took the war five years to do what the virus did in one year. Even though the majority of the deaths were 65+, these are staggering numbers. Losing well over 100,000 people under the age of 65 in one year alone is nothing to sneeze at, and that’s with lock-downs and other harsh measures being taken. A “let them live their lives” approach would doubtlessly have escalated those numbers greatly.

The best early policy for any pandemic is to ramp up rapid testing as fast as possible, and test people constantly. A widespread testing regime (like in South Korea) would allow uninfected people to live more or less normally, while stifling the spread of the virus by identifying infected people quickly so they can immediately quarantine and prevent further spread. [Alex’s] earlier post on Testing and the NFL is instructive on that point. Such a testing regime could have enabled us to avoid harsher measures later on. But, unfortunately, America was led at the time by a president who did not prioritize testing (and in fact discouraged it to hide the spread of the virus) and sought to pooh-pooh its danger, shrugging off even the slightest mitigation efforts, like masks. Even after he got it, and was hospitalized, almost put on a ventilator, he acted as though it was nothing. That leadership caused a dangerous cognitive dissonance in public perceptions of COVID-19 — a dissonance that is causing people to take unreasonable risks, refuse to get vaccinated, and otherwise take actions that will make it even harder for us to get out from under this pandemic.

Focusing on the Great Barrington Declaration itself, the big problem with its approach is that it presumes that “herd immunity” will naturally occur with COVID-19 at some point. The evidence indicates, however, that natural infection does not lead to permanent immunity. The worse a person’s symptoms from COVID-19, the longer their immunity lasts, but that’s it. The only immunity that is possible now is through vaccination, and even that will require yearly updates as the virus mutates as it is already doing. Eventually we will have it under control. But the suggestion that people under 65 can just safely infect themselves into herd immunity is likely an impossibility, and certainly not a good enough foundation to rest any pandemic policy on. https://www.nature.com/articles/d41586-021-00728-2

None of this is meant to minimize or challenge the obvious economic and mental health effects of certain pandemic policies. There are a great many costs being imposed by lock-downs and other policies. Businesses are failing and not coming back, jobs are being permanently lost, people are feeling isolated, on and on. All of that is tragic, and could have been largely avoided had we aggressively pursued testing (especially rapid-result testing) from the outset. When the next pandemic comes, I hope our descendants remember that lesson. Because once the pandemic started spreading because we didn’t get a testing regime in place, it was too late, and then the harsher policies became inevitable. The horse was out of the barn, and the game changed for good.

That is from James N. Markels, responding to Don Boudreaux in these comments.

Here is another way to put the broader argument, not my preferred first-order response, but I think significant nonetheless.  Given the way government and public choice work, anything that kills over half a million Americans is going to be a big deal for policy, whether we like it or not (Don should be the first to recognize that government will restrict your liberties for far less than 500k deaths!).  You want the best feasible version of a response, as there isn’t really a stable libertarian response pattern out there.  Trying partial but non-sustainable libertarian approaches will in the end get you more and more statism as the virus keeps on defeating you, deaths rise, and calls for ever-greater state action increase.  A lot of what libertarians don’t like about lockdowns in part stems from the “do nothing” response of the first two months of notice that we Americans had when Covid first appeared in China.

Pandemic sentences to ponder

Of course, there are national health systems in Canada, Mexico, England, and France, among many others, and the uniformity of failure across this heterodox group suggests that structure may have made less of a difference than culture.

“One of the common features is that we are a medical-centric group of countries,” says Michael Mina, a Harvard epidemiologist who has spent the pandemic advocating for mass rollout of rapid testing on the pregnancy-kit model — only to meet resistance at every turn by those who insisted on a higher, clinical standard for tests. “We have an enormous focus on medicine and individual biology and individual health. We have very little focus as a group of nations on prioritizing the public good. We just don’t. It’s almost taboo — I mean, it is taboo. We have physicians running the show — that’s a consistent thing, medical doctors across the western European countries, driving the decision-making.” The result, he says, has been short-sighted calculations that prioritize absolute knowledge about everything before advising or designing policy about anything.

…in East Asia, countries didn’t wait for the WHO’s guidance to change on aerosols or asymptomatic transmission before masking up, social-distancing, and quarantining. “They acted fast. They acted decisively,” says Mina. “They made early moves. They didn’t sit and ponder: ‘What should we do? Do we have all of the data before we make a single decision?’ And I think that is a common theme that we’ve seen across all the Western countries—a reluctance to even admit that it was a big problem and then to really act without all of the information available. To this day, people are still not acting.” Instead, he says, “decision-makers have been paralyzed. They would rather just not act and let the pandemic move forward than act aggressively, but potentially be wrong.”

This, he says, reflects a culture of medicine in which the case of the individual patient is paramount.

Here is more from David Wallace-Wells, interesting throughout and with a cameo from yours truly.

Most Popular MR Posts of the Year

Here is a selection of the most popular MR posts of 2020. COVID was a big of course. Let’s start with Tyler’s post warning that herd immunity was fragile because it holds only “for the current configuration of social relations”. Absolutely correct.

The fragility of herd immunity

Tyler also predicted the pandemic yo-yo and Tyler’s post (or was it Tyrone?) What does this economist think of epidemiologists? was popular.

Tyler has an amazing ability to be ahead of the curve. A case in point, What libertarianism has become and will become — State Capacity Libertarianism was written on January 1 of last year, before anyone was talking about pandemics! State capacity libertarianism became my leitmotif for the year. I worked with Kremer on pushing government to use market incentives to increase vaccine supply and at the same repeatedly demanded that the FDA move faster and stop prohibiting people from taking vaccines or using rapid tests. As I put it;

Fake libertarians whine about masks. Real libertarians assert the right to medical self-defense and demand access to vaccines on a right to try basis.

See my 2015 post Is the FDA Too Conservative or Too Aggressive for a good review of ideas on the FDA. A silver lining of the pandemic may be that more people realize that FDA delay kills.

My historical posts the The Forgotten Recession and Pandemic of 1957 and What Worked in 1918? and the frightening The Lasting Effects of the the 1918 Influenza Pandemic were well linked.

Outside of COVID, Tyler’s 2005 post Why did so many Germans support Hitler? suddenly attracted a lot of interest. I wonder why?

Policing was also popular including my post Why Are the Police in Charge of Road Safety? which called for unbundling the police and my post Underpoliced and Overprisoned revisited.

Tyler’s great post The economic policy of Elizabeth Warren remains more relevant than I would like. On a more positive note see Tyler’s post Best Non-Fiction Books of the Year.

One of the most popular posts of the year and my most popular post was The Gaslighting of Parasite.

But the post attracting the most page views in 2020 by far, however, was Tyler’s and it was…

  1. John Brennan on UFOs.

You people are weird. Don’t expect more UFO content this year. Unless, well you know.

Thursday assorted links

1. The immediate immigration policy dilemmas faced by Biden.  And humans in Mexico 30,000 years ago?

2. Kerfluffle surrounding Philip Lane, chief ECB economist, about making calls privately to banks.

3. Good Dube thread on new wage stickiness paper.

4. Don Boudreaux on Walter Williams (WSJ).  And Jayme Lemke.  And David Henderson.  And Thomas Sowell.

5. The culture that is San Francisco what is up with you people?

6. US vs. UK vaccine review procedures.

7. Delta: “Our partners at Mayo Clinic have advised that virus spread could be reduced by 90 percent with weekly testing, reducing asymptomatic transmission. We’re achieving this expansion of our testing by increasing onsite rapid testing, providing testing kits at workplaces with smaller employee populations, and offering at home testing kits to all U.S. employees.”

8. Some new corporate and banking stuff (WSJ).

Our Antibodies, Our Selves

In 2013 I wrote, Our DNA, Our Selves, arguing against the FDA’s crackdown on genetic readouts from firms like 23andMe. The FDA, however, proved succesful in its crackdown and that is why rapid at-home antigen tests are not available today and why tens of thousands of people are dying from COVID unnecessarily. Regulations have unintended consequences.

Let’s recap:

Consider, I swab the inside of my cheek and send the sample to a firm. The idea that the FDA can rule on what the firm can and cannot tell me about my own genes is absurd–it’s no different than the FDA trying to regulate what my doctor can tell me after a physical examination or what my optometrist can tell me after an eye examination (Please read the first line. “G T A C C A…”).

The idea that the FDA can regulate and control what individuals may learn about their own bodies is deeply offensive and, in my view, plainly unconstitutional.

Let me be clear, I am not offended by all regulation of genetic tests. Indeed, genetic tests are already regulated. To be precise, the labs that perform genetic tests are regulated by the Clinical Laboratory Improvement Amendments (CLIA) as overseen by the CMS (here is an excellent primer). The CLIA requires all labs, including the labs used by 23andMe, to be inspected for quality control, record keeping and the qualifications of their personnel. The goal is to ensure that the tests are accurate, reliable, timely, confidential and not risky to patients. I am not offended when the goal of regulation is to help consumers buy the product that they have contracted to buy.

What the FDA wants to do is categorically different. The FDA wants to regulate genetic tests as a high-risk medical device that cannot be sold until and unless the FDA permits it be sold.

Moreover, the FDA wants to judge not the analytic validity of the tests, whether the tests accurately read the genetic code as the firms promise (already regulated under the CLIA) but the clinical validity, whether particular identified alleles are causal for conditions or disease. The latter requirement is the death-knell for the products because of the expense and time it takes to prove specific genes are causal for diseases. Moreover, it means that firms like 23andMe will not be able to tell consumers about their own DNA but instead will only be allowed to offer a peek at the sections of code that the FDA has deemed it ok for consumers to see.

Ten years later we now need rapid antigen tests but the issue, as Michael Mina points out in an excellent interview with Malcolm Gladwell, is that we have medicalized all tests and readouts. Instead of thinking about the individual as having a right to know about their own body, we treated every test or readout as if the only user were a physician. Thus, instead of thinking about the value of these tests for individuals and for public health, the FDA failed to approve rapid antigen tests because it regarded them as inferior to PCR tests, for a physician diagnosing disease.

Here’s Mina (roughly transcribed and lightly edited)

The only pathway that we have to evaluate tests like this are medical diagnostic pathways, pathways designed specifically to ensure that a physician like a detective is getting all the information they need to diagnose a sick person… We have so devalued and defunded public health…that we don’t have a regulatory pathway to approve a test whose primary objective is stopping an epidemic versus diagnosing a sick person. And that has held everything up. All the companies that could be producing these rapid tests in the millions and millions, they have been sitting on these tests trying to hone them so they can pass FDA standards as a medical diagnostic.

It’s not just slowing down their approval it’s actually bottle necking the companies into creating tests that are not going to be as scalable as they are having to use more expensive reagents and packing the tests with instruments so they can pass FDA review when in reality they are just these little pieces of papers. If we can do the cheap version they can be made very fast but the just won’t get through the FDA.

Gladwell: I find your explanation unconvincing. How dumb is the FDA?…If you make the exact argument you made to me…the FDA is not going to see your logic?

It’s not that they are not smart it’s that this is a regulatory body, they just don’t have a pathway. You can’t apply for approval for a public health test tool…In our country the medical establishment is extremely strong, you can’t go to get a cholesterol test without getting a prescription from your doctor. Why can’t we know that? It’s all through this very heavy medical lens and changing that, getting that big ship to turn is turning out to be a very, very difficult task but leading to potentially tens or hundreds or thousands of deaths that don’t need to be happening.

Infected versus Infectious

As I said in my post Frequent, Fast, and Cheap is Better than Sensitive we shouldn’t be comparing virus tests head-to-head, as if all tests serve the same purpose. Instead, we should recognize that tests have comparative advantages and a cheap, fast, frequent testing regime can be better in some respects than a slow, infrequent but more sensitive testing regime. Both regimes can be useful when used appropriately and especially when they are used in combination.

Eric Topol has a good graphic.

Image

As Topol also notes:

In order to get this done, we need a reboot at @US_FDA, which currently requires rapid tests to perform like PCR tests. That’s wrong. This is a new diagnostic category for the *infectious* endpoint, requiring new standards and prospective validation.

The FDA has sort-of indicated that they might be open to this.

Much, much too slow, of course. Matching a virus that grows exponentially against a risk-averse, overly-cautious FDA has been a recipe for disaster.

Frequent, Fast, and Cheap is Better than Sensitive

A number of firms have developed cheap, paper-strip tests for coronavirus that report results at-home in about 15 minutes but they have yet to be approved for use by the FDA because the FDA appears to be demanding that all tests reach accuracy levels similar to the PCR test. This is another deadly FDA mistake.

NPR: Highly accurate at-home tests are probably many months away. But Mina argues they could be here sooner if the FDA would not demand that tests for the coronavirus meet really high accuracy standards of 80 percent or better.

A Massachusetts-based startup called E25Bio has developed this sort of rapid test. Founder and Chief Technology Officer Irene Bosch says her firm has field-tested it in hospitals. “What we learned is that the test is able to be very efficient for people who have a lot of virus,” she says.

The PCR tests can discover virus at significantly lower concentration levels than the cheap tests but that extra sensitivity doesn’t matter much in practice. Why not? First, at the lowest levels that the PCR test can detect, the person tested probably isn’t infectious. The cheap test is better at telling whether you are infectious than whether you are infected but the former is what we need to know to open schools and workplaces. Second, the virus grows so quickly that the time period in which the PCR tests outperforms the cheap test is as little as a day or two. Third, the PCR tests are taking days or even a week or more to report which means the results are significantly outdated and less actionable by the time they are reported.

The fundamental issue is this: if a test is cheap and fast we shouldn’t compare it head to head against the PCR test. Instead, we should compare test regimes. A strip test could cost $5 which means you can do one per day for the same price as a PCR test (say $35). Thus, the right comparison is seven cheap tests with one PCR test. So considered a stylized example. If a person gets infected on Sunday and is tested on Sunday then both tests will likely show negative. With the PCR test the infected person then goes to work, infecting other people throughout the week before being the person is tested again next Sunday. With the cheap test the person gets tested again on Monday and again comes up negative and they go to work but probably aren’t infectious. They are then tested again on Tuesday and this time there is enough virus in the person’s system to show positive so on Tuesday the infected person stops going to work and doesn’t infect anyone else. Score one for cheap tests. Now consider what happens if the person gets tested on another day, say Tuesday? In this case, both tests will show positive but the person doesn’t get the results of the PCR test until next Tuesday and so again goes to work and infects other people throughout the week. With the cheap test the infected person learns they are infected and again stops going to work and infecting other people. Score two for cheap tests.

Indeed, when you compare testing regimes it’s hard to come up with a scenario in which infrequent, slow, and expensive but very sensitive is better than frequent, fast, and cheap but less sensitive.

More details in this paper.

HIV detection on demand

Ms. Brown would get her results in just 20 minutes, thanks to one of
two new tests that AIDS workers say have revolutionized testing for
H.I.V…

On Thursday, the Food and Drug Administration’s Blood Products Advisory
Committee heard testimony on whether to recommend over-the-counter
sales of the rapid test for home use. The agency approved a home
testing kit in 1996, but users have to mail a blood sample to a
laboratory and wait for results by telephone.

Proponents say
rapid testing in the home will reduce the stigma and other obstacles
that prevent many people, including one in four of the nearly one
million Americans who are infected with H.I.V., from getting tested and
starting treatment. Research shows that people who learn they are
infected are less likely to infect others.

Here are the details, note that test is an easy oral swab.  I am not much worried about immediate suicides ("The most emotional responses come from negatives," says the article).  But what are the further ramifications?

1. The test is in the hands of the individual, and the kit presumably does not issue a credible AIDS-free certificate.  So perhaps we return to a greater reliance on trusting the word of the individual — "don’t worry, I tested negative a few weeks ago."  Formal certificates of health might become less expected.

2. Will lovers-to-be ask for an on-the-site test?  There is a stigma attached to asking a partner about his or her status.  It suggests you often sleep with people whose health status you are unsure about; the alternative impression is "of course I’ve never done this before, and I bet you haven’t either.  I’m not used to asking.  HIV, what’s that?"  And how much fun is it to watch a potential partner waiting for the results?  Do you bring little consolation cards in case the test turns out badly?  The resulting unwillingness to pry may further increase the reliance on verbal assurances.  Again, the presence or lack of a certificate — however dated — may provide a clearer focal point and thus greater information and clarity.

3. How often should you test yourself?  Given the signaling point from #2, what should you tell your next partner?  That you test yourself every year?  Every month?  Every day?  Which frequency would you find most reassuring in a potential partner?  Keep in mind the probability of a lie or false result. 

You can spin this one either way.  You might assume that someone who self-tests every day has dangerous habits.  Alternatively, you might assume (at least in pure theory) that the previous partners have been monitoring the test results, and that you don’t need to.  "Hey, if two hundred people have slept with you in the last year, a few of them must have checked you out."  Don’t you usually find the presence of other "customers" reassuring?

4. Say you test yourself after every new partner.  You have a better sense of who infected you, which in turn identifies a greater number of infected agents in advance and also deters self-recognized infectors.  Therefore people will test themselves less often than is socially optimal.  The main benefits from testing may accrue to others, not to yourself.

Hmm…it’s not so simple after all.  But I still believe this test is likely a positive development.  Comments are open…

p.s. We thank Robin Hanson for his guest blogging!

Two all-purpose pieces of advice: small groups and mentors

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

The first piece of advice stems from what has been dubbed in Silicon Valley “the small group theory.” It goes like this:

  • When working on any kind of problem, task or question, embed yourself in a small group of peers with broadly similar concerns.

And:

The second near-universal piece of advice is this:

  • Get mentors.

Those two pieces of advice, unlike most advice, hold for a very broad variety of contexts.  Do read the column, but here is some further detail:

Mentorship can be general or specialized. I have had classical-music mentors, art-market mentors, country-specific mentors when I lived in Germany and New Zealand, foreign-language mentors, chess mentors, economics mentors, philosophy mentors, writing mentors and friendly mentors to help with the basic emotional issues of life. I’ve tried to find mentors for just about everything. Sometimes the relationship lasts only a week or a month, other times for years.

Aside from providing teaching and advice, the mentor, like the small group, helps make an issue or idea more vivid: A living, breathing exemplar of success stands before you. The mentor makes a discipline feel more real and the prospect of success more realistic.

As a corollary, in addition to trying to find mentors, you should be willing to become a mentor yourself. Even if you do not have advanced understanding in some particular area, almost certainly there is someone who knows less than you do and who could use assistance. Being a mentor also helps you understand how to learn and appreciate your own mentors.

A mentor doesn’t have to be older than you, and in fact some of your mentors probably should be younger, especially since technologies are starting to change more rapidly. If you are 50 years old, the idea of an 18-year-old crypto mentor isn’t crazy. If the metaverse turns into a reality, don’t look to the graybeards for tutelage.

Recommended.

Carlsen vs. Nepo

Here is my Bloomberg column on that topic:

He [Carlsen] recently opined that he is lucky to be facing Nepo rather than two other potential challengers, Fabio Caruana or Ding Liren. That’s the kind of trash talk most sports competitors frown upon for fear of motivating opponents.

Carlsen also has been engaging in online marathons of “bullet chess,” exactly the kind of attention-disrupting, energy-draining stunt contenders are supposed to avoid. In a bullet game, each player has only one minute for all the moves. The pace is so rapid the games are hard to watch, much less play. Carlsen also made a recent appearance in Dortmund, Germany, in part to pose for a photo with a Norwegian soccer player. Nepo, in contrast, claims to have done an “insane amount of work” for the event.

Will the fast thinking of bullet chess help Carlsen see more moves during the much slower time controls of the match with Nepo? (A championship game can easily last four hours or more.) Or maybe the bullet success will intimidate Nepo?

Carlsen also is making it clear that for him, chess is a business proposition. His parents set up a company in his name when he was 16, and the commercial empire since has expanded. Carlsen has worked as a fashion model, endorsed an online sports betting site, and worked with a Norwegian water company. He sponsors a leading chess app and has organized his own series of online chess tournaments, played with more rapid time controls, during the pandemic. Those events arguably have attracted more attention than any of the mainstream tournaments.

Carlsen is probably at the point where even a loss in the match would barely affect his income stream, and that is a dangerous motivational place to be…

Nepo is considered a super-talented but inconsistent player, one who does not bounce back well from adversity. But if he stays focused he could pose a formidable challenge. He was never expected to be a challenger in the first place, so he may feel he has little to lose and, in accord with his naturally aggressive style, he can take all the chances he wants. Carlsen is considered the superior player, perhaps the greatest ever, and remains a heavy favorite with the sports betting sites.

I am picking Carlsen to win.  And on the future of chess:

Carlsen has argued that the mainstream matches of classical chess are too slow and yield too many draws. He would prefer a time limit of around 25 minutes per game per player to become the default. Why shouldn’t the world of chess switch over to a system that spectators seem to prefer?

If Carlsen retains his title, he may well lead such a switch, and it would be hard for the chess establishment to resist. If Nepo wins the match, Carlsen might secede from the current system, causing the chess world to splinter.

What we are seeing in the lead-up to this match is this: A healthy chess world is going to be a more diversely organized chess world, with a lot of disagreement over which forms of chess are most important. Twitch streaming and YouTube already have joined the mix. Chess is likely to retain its recent popularity, but in doing so it will fully realize its destiny as the esport it has already become. The good news is that if you don’t like the outcome of the upcoming chess drama, you can find another one to watch the next day.

Recommended.