Friday, October 2, 2020

Beat Covid Without a Vaccine

Beat Covid Without a Vaccine, with "frequent rapid at-home testing" write Larry Kotlikoff and Michael Mina in the Oct 2 WSJ. I've made this point many times before, as have Larry, Michael, and many others (Paul Romer especially) but this one is well written and concise, and the issue is so important it bears a bit of repetition and efforts to package the message. 

How would you like the recession to be over in a month? Here's the ticket. A vaccine is a technology for stopping the spread of a virus.  Frequent rapid at-home testing is a technology for stopping the spread of a  virus. And it is one we have now, if only the government will let us use it. 

"At least one such test, Abbott Labs ’ BinaxNOW, is already being produced for the government....

... each is simple enough to be self-administered. With the BinaxNow test, you swab the front of your nose, insert the swab into one side of a small card, add saline to the other side, close the card, and see if the reader on the front lights up green or red. A phone app records a negative result for use as a digital passport."

No doctor visit, no referral, no insurance, no lab, no do you fit the criteria. Just test and see if you're sick. 

"Asking those presumed to be infectious to stay home would cut transmission chains, ending Covid outbreaks within weeks. Each transmission stopped may prevent hundreds more. .... Like vaccines, the tests don’t have to be perfect. It’s enough to drop the virus’s reproductive number (the average number of people each infected person infects) below 1."

The tests don't have to be perfect and what we do with them doesn't have to be perfect. We don't need intrusive contact tracing, government imposed isolation, and so on. So long as a bit more than half of the people who are infected stay home and don't infect one other person (on average -- it's really about super spreaders) the pandemic ends. 

"Cornell University’s quick defeat of its Covid cluster shows the power of frequent testing. Cornell tests all undergraduates twice a week and quarantines those who are positive. After an unauthorized party, Cornell had 60 positive cases a week before starting surveillance testing. It now has about three a week."

How fast can it work? 

Our models show outbreaks can be driven down in weeks even if only half a community uses rapid tests every four days. Fifteen million tests a day could stop outbreaks across the U.S. 

How to get this going? Here I think Mina and Kotlikoff are a bit too polite and a lot too dirigiste: 

Based on data from symptomatic Covid patients, the Food and Drug Administration has approved BinaxNOW for use in a doctor’s office or clinic. This will help, but such “point of care” tests are too cumbersome to use on the scale needed to reopen the economy.

Rapid tests need to be tested with asymptomatic infected patients. If they work as well, particularly on those with high viral load, the FDA will be closer to approving them for home use. The agency is highly focused on bringing safe and effective Covid testing into the home. 

I do not see evidence for the latter two sentences. Let us rewrite these paragraphs. "Lacking what it considers enough data, The Food and Drug Administration continues to ban the sale and use of BinaxNOW outside doctor's offices or clinics, destroying its value for stopping the pandemic. A test is not a drug, and cannot cause any medical harm to individual who takes it. By what right does the FDA ban me from learning about what's going on in my own body, in a way that cannot possibly harm me, even if like all information that knowledge is sometimes false? The FDA must allow its home use immediately, with big warning labels about false positive and negative rates, while collecting data on its efficacy for asymptomatic people. We have an economy-destroying pandemic going on, and cannot wait for perfect knowledge of these tests an all classes of people. If the FDA refuses, the politically accountable administration should over-ride its refusal by executive order." 

Likewise, offering an analogy to B-24 bombers, 

The administration should organize a Manhattan Project, run by the Defense Department, to produce and provide free at-home rapid tests to all Americans, starting in hot spots.

Where is the market failure here? Let's work on the FDA allowing home tests before we jump to the conclusion that they need to be produced by the defense department and paid for (at about triple market prices) by taxpayers. There are multiple competing tests by extremely competent private companies.  How about (heavens) start by allowing the companies to sell them to the public at whatever price they want and (heavens) make a profit by doing so; the quicker they ramp up production the more profit they make before competitors come in and drive the price to $5? If we then need a subsidy to get people to buy them, give people money to buy them. The Manhattan project produced three nuclear bombs at immense cost, not 300 million simple low-cost easy-to use tests. I cannot think of a worse metaphor. The Soviet Union had Manhattan projects too, and could never produce toilet paper. 

Covid-19 is ravaging the land, but there’s a clear way to fight back quickly and safely.

President Trump: Here is one last chance to do something big, daring and effective.  Force the FDA to allow the sale of these tests. Stop the pandemic. Senator, presumably president elect Biden: Here is one first chance to do something big, daring, competent, and obviously nonpartisan. Same advice. 


Update

There is a lot of political rhetoric about letting "science" settle these questions, and letting "professional scientists" at agencies such as the FDA make all the decisions. But there is no biology at all, and precious little social science, behind a decision whether to allow a test which causes no medical danger at all at home or in a doctor hospital setting. The only possible justification is an astounding paternalism that we might do something ill advised with better (than nothing) but still imperfect information. The FDA has no scientific basis at all to make such a decision. Moreover, the biological scientists at FDA have no training whatsoever to make the tradeoff between the anguish of a few people who get false test results and the economic carnage of continued lockdown. This is a policy decision, and properly made by politically accountable politicians. President Trump is getting a lot of heat for his covid decisions. That is entirely how the system is supposed to work. 

A practical example. My large extended family would like to get together for thanksgiving. We each have our own protocols for just how much contact we are engaging in, and like all families not everyone is happy with everyone else's decisions. Why not, 9 am thanksgiving morning, everyone takes the 5 minute household covid test? Even if not perfect, 98 out of 100 families will avoid a super spreading thanksgiving this way. You may say, cancel thanksgiving, and we are for now. But many families are not, and it sure would be a healing moment for the country to have a safe thanksgiving. But you cannot get a test for this purpose under the current system. 

Bring back Thanksgiving.  

Marginal revolution links to this nice thread explaining the Doctor point of view, heavens don't let them test themselves. MR's comment

doctors hate highly beneficial but somewhat inaccurate testing methods that lower their status and good feelings about themselves.

I might add, doctors, hospitals, and the insurance establishment, and their friends in the regulatory establishment hate highly beneficial but somewhat inaccurate testing methods that people can purchase for $5 at the pharmacy and lower the flow of business to the former in these cash-strapped times. Never underestimate regulatory capture.  

Update:

Rapid testing does not justify super-spreader activity. See the White House. If you cut the number of infected wandering around by 1/20, and but everyone goes out to see 100 people, here we go. 

 

28 comments:

  1. The market failure that suggests providing free tests is exactly the one you point out before: the epidemiological externality. And, the plausible cost to providing the tests for free fade to insignificance relative to the benefits. So, yes, the government should provide the tests for free. I agree though that I see no reason to produce them by the government.

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    1. Sure. But before we worry about people being to cheap to buy tests -- "people" includes businesses and schools who want to buy them for employees, and grandpas who want to buy them for the kids -- let's ALLOW people to buy them.

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  2. "A vaccine is a technology for stopping the spread of a virus. Frequent rapid at-home testing is a technology for spreading the virus."? This what you meant to write?

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    1. I am cursed by typos. Thanks for pointing it out.

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  3. I worry a bit about non-perfect tests and incentives. If everyone who received a negative took that as an invitation to ``party'', and among those negatives were a sufficient number of false negatives, non-perfect tests might actually be counterproductive.

    My main point is the existence of such channel. In other words, I can't really say whether or not the costs of non-perfect tests actually outweigh the benefits of greater testing. (I don't think it does, but I obviously don't know for sure)

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    1. I worry about that too. So does the FDA. But why is the benchmark that we are forbidden to have a test until the FDA is convinced that R will not increase by false negatives going out to party? It would also require an astounding elasticity. If there are 2% false negatives, then a negative test would have to lead to 50x more partying. And there will be big warning labels on the tests about false positives and negatives.

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    2. There are (potentially negative) externalities here unlike other at-home tests (i.e. pregnancy test), and so that might justify regulatory response. The key word is might. As you correctly point out, the necessary elasticity seems to be implausibly large.

      But to be fair, we (or at least, I) don't really know what that elasticity would be. For instance, at University of Illinois, students continued to go to parties even after testing positive! You can find tons of other inexplicable examples like this. Now, I know data is not the plural of anecdote, but anecdotes like this lead me to believe the public response would be less ``rational'' and more ``behavioral''. And so I wouldn't be surprised if the elasticity turned out to be sufficiently large.

      To be clear, I'm not a fan of the FDA policy either. My point is really that the FDA decision is a bit more than ``what right does the FDA ban me from learning about what's going on in my own body''. In any case, you're probably right that the upside outweighs any downside, which probably can't be any worse than what we've already experienced.

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    3. Why does no one bring up the "invitation to party" argument when it comes to masks? No one says it should be illegal to sell masks because wearing a mask might give someone a false sense of confidence to go out when they would have otherwise stayed home. Quite the contrary, many people actually call for masks to be mandatory. Both masks and tests are imperfect ways of slowing spread, masks by preventing some but not all transmission and tests by preventing some but not all people from attending spreading events. No argument against tests doesn't equally apply to masks.

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  4. I believe your sentence beginning with the word "Frequent" contains a critical typo.

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  5. How did testing work out for Trump?

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    1. Missing the point. Testing confined to the Trump bubble has no impact on virus spread in the general population. Given how many risks he has taken, it's amazing he didn't catch COVID sooner.

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  6. "Our models show outbreaks can be driven down in weeks even if only half a community uses rapid tests every four days. Fifteen million tests a day could stop outbreaks across the U.S."

    Abbott Labs is starting production of BinaxNOW. By the end of October Abbott Labs expects to producing BinaxNOW kits at a rate of 50 million per month.

    Larry Kotlikoff's and Michael Mina's gedankenexperiment relies on a production rate of 450 million BinaxNOW kits per month--nine times the rate that Abbott Labs is targeting.

    Let's look at the economics of the private sector actor in this little drama. The capital cost of the factory and machinery to produce BianxNOW is not trivial. Some parts of the factory and machinery may be repurposed once the need for BinaxNOW kits passes away, as it will when the coronavirus is no longer a source of pandemic. Build one plant to produce BinaxNOW and Abbott Labs can probably recoup its sunk costs. Build nine plants to produce BinaxNOW kits and demand for the kits will be large initially and then drop to zero. Abbott Labs would be unlikely to recoup its sunk costs in that case, especially if the government is buying the kits and then providing the kits for free.

    Another cost that is not being considered is product liability. Abbott Labs is a private company. If the BinaxNOW kits are improperly used in a houshold situation, there will be a host of claims and class action lawsuits facing the company soon after home-testing commences. Why?--because the consumer cannot be relied upon to follow the instructions correctly in every case. A false negative, or a false positive, is more likely if the test is performed in the home rather than in a doctor's office by a trained nurse. False negatives give rise to liability--the consumer is misled and infects others rather than self-isolating (others may be family members). False positives may lead to dismissal from the individual's place of work, or may result in the individual losing income and opportunity when he would otherwise not have lost that income or opportunity. An action at law is inevitable, almost surely.

    Sure, the ideal is enticing to think about. But if it's Ivory Tower stuff, then throw it out because it's just day-dreaming. Don't go blaming the FDA or the CDC, just because the Utopian vision-thing ain't about to happen in a Texas heart-beat. Private capital is not going to take the risk, no matter what the professors of economics and epidemiology come up with as a 'model'.

    If you want 450 million test kits made in one month and then zilch thereafter, be prepared to pay the full economic cost of that at the private cost of capital, not at the phoney manipulated rate of interest the FOMC produces to save the government from itself.

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    1. Long-winded way of saying there needs to be government subsidy and/or provision. Sometimes externalities are consequential. The FOMC tangent is irrelevant.

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    2. BinaxNOW production is so low because FDA authorization was obtained only at the end of August. The 50M/mo rate is a ramp-up, not final, rate. Also, other similar rapid tests haven't been approved yet. The FDA has been the bottleneck.

      If the lack of tests were due to economics rather than FDA, then companies wouldn't be waiting for the FDA to approve their tests. They wouldn't have bothered developing the tests to begin with.

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  7. You go ahead and buy a test kit for $5.

    Per HHS:

    "COVID-19 tests are available at no cost nationwide at health centers and select pharmacies. The Families First Coronavirus Response Act ensures that COVID-19 testing is free to anyone in the U.S., including the uninsured. Additional testing sites may be available in your area. Contact your health care provider or your state or local public health department for more information."

    You can just make an appointment at CVS, like getting a flu shot.

    AND there are 9 companies offering home test kits so you DO have 2 ways to know what's in your body without seeing a doctor. Most seem to be PCR based so there is turn-around time with the lab. However, PCR is probably a better test.

    "doctors hate highly beneficial but somewhat inaccurate testing methods that lower their status and good feelings about themselves."

    Good Lord what color is the sky on MR's planet? Do you think ordering tests gives a warm fuzzy feeling? Data?

    Meanwhile the evil doctors want their patients to do home blood sugar testing, home BP checks and home oxygen level testing, and have no objection to home pregnancy testing. We have no interest in cornering the market on simple home testing.

    Whoever wrote this is completely ignorant about the physician-led movement in the 1980s to decrease testing. On the scale of uninformed doctor-bashing its right up there with Obama's idiotic tonsillectomy remarks.

    When I was 26 I had minor surgery. It was a brief minimally invasive procedure. I was admitted to the hospital the night before and underwent a huge battery of blood tests, chest xray, EKG, etc. They kept me in the hospital for two days.

    Today, thanks to extensive analysis and studies by DOCTORS (not economists) a healthy 26 year old would probably have NO testing done, show up for the procedure on the day of surgery and GO HOME.

    The amount of money saved by physician-led initiatives to decrease testing is incalculable.

    The FDA has bypassed its usual testing protocols by enacting an emergency use option. I think that's hardly being obstructive.

    The FDA also prevented the use of thalidomide in pregnant women, sparing the US from the ravages of phocomelia, which affected 10,000 children in other countries. The prohibition was based on the simple fact that thalidomide had never been tested in pregnant women. Not a huge fan of the FDA but the extraordinary waiver of protocol is incompatible with accusations of obstruction.

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    1. Michael Gorback's reply is one of the best I've read.

      Here, in his blog, John Cochrane has long presented us a range of highest-level scholarship and anger-driven polemics across a broad quality spectrum. It's an intriguing aspect of his blogging but one that I think has contributed to confusion and rancor in the blogosphere over the years.

      Paul Romer nailed it with this crystal-clear reasoning:

      "The people who achieve prominence in science are generally reasonable people with good intensions, so all it might take to keep things on track might be a few small corrections–a reminder that to criticize something, you have to take it seriously; or that anger from a nursed grievance takes away IQ points."

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    2. CVS and the 9 companies are *NOT* offering rapid 15-min tests. Those are traditional PCR tests with results delivered in 2-3 days, sometimes longer.

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  8. I worry that the same who state it is a breach of their freedom to request mask wearing, will fail to do their test daily if at all.

    When do you take away someone's right to do what they want and when do you leave the freedom of choice.

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    1. Let's start with business, airports, airlines, schools, restaurants before worrying about these individuals.

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    2. That's what I was thinking. A place of gathering would have a gatekeeper requiring the test to be passed before entrance. I think that would be more involved in time, stress, and health compared to pointing a temperature sensor at foreheads.

      Then again, possibly technology could be developed that would reliably affirm an entrant having passed the test in the last 12 hours.

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  9. I'm afraid that COVID is the beginning of a very long war between the elderly who would like to live forever by extracting medical resources from the young and the young who would like to minimize their social commitments to their own immediate offspring. Solve for equilibrium.....acknowledging that fertility rates below replacement can't continue forever.

    The young lost this war for now,.....
    What happens when young people simply refuse to fund Medicare or lose their jobs to protect elderly in nursing homes. The Feds paid them off, this time, by borrowing trillions of dollars and sending out checks....The young will have to pay off this bill eventually as well.

    We MIGHT be able to avoid intergenerational conflict (Bernie Bros is just the start...they are only mad about their student loans) by making medicine cheaper. Cheaper in economic terms means minimizing (eliminating) credentialism, inventing alternative competitive regulatory schemes, and substituting market-based individual choices for those of public health czars whose grip on the economy is stunning both in its magnitude and ineptitude.

    The public health czars are living in a fantasy world. Management of dementia of the immune system with age is just as difficult a problem as Alzheimers. In medical school, we were taught that pneumonia was the "old man's friend." It would be nice to think that 18% of GDP currently invested in medical care would allow us to better protect our parents and friends but that is unlikely in the long run. So sorry. Do we lockdown for every flu from now on? Do we create an expense bureaucracy to "test" and quarantine involuntarily from now? This is a public choice nightmare where narrow risk minimization is the goal rather than balanced tradeoffs in individual values.

    The seen and unseen...11% of young people have considered suicide in the last month, double the baseline prevalence according to CDC. 9% of ongoing clinical trials have stopped completely according to clincialtrials.gov. etc. etc. etc.

    John keep preaching free market solutions please and then preach even harder. We are running out of time.....




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  10. Well, I read this:

    "How would you like the recession to be over in a month? Here's the ticket. A vaccine is a technology for stopping the spread of a virus. Frequent rapid at-home testing is a technology for stopping the spread of a virus. And it is one we have now, if only the government will let us use it."

    Testing only provides information. It has to be acted upon properly. Information alone won't defeat the virus. Behavior modification is the other part of the grand equation: wearing masks when going out, social distancing, avoiding super spreader events (9/26/2020 Rose Garden debacle!), and self quarantining when the data says you have it.

    But, who wants to be told what to do? Apparently over 200k dead isn't enough of a motivator to get people to behave responsibly and that we all have a role in the maintenance of public health. Why these MPB and MSB curves are so out of whack I do not know, except for the possibility that preferences are severely screwed up.

    We need to talk more about behavior and nudges. Testing is important, true, but so is how we behave as a society to face this existential threat. We'll keep hand wringing over fiscal and monetary bazookas to save the economy from ourselves. And, as Dr. Cochrane has expressed in other posts, the level of debt is getting worrisome. We are going to pay a huge price for being collectively irresponsible. Over 200k dead and millions of lives destroyed economically, and we're still not out of the woods.

    Best,
    M

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  11. Whatever happened to the idea of antibody testing and certificates of immunity? By now we must have millions of people who already had covid and for whom new testing would be a waste of money.

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    1. Because we have a few case of reinfection already, and antibodies testing has not guarantee actual immunity based on research so far.

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  12. Is false negative really 2%? I believe that's only the case after you're infected for 4~5 days, on earlier days the false negative rates can be significant when viral load is low. And I think that's the main issue with COVID vs. say SARS, it was easy to isolate because if someone has symptom you isolate that person, no need to worry about pre symptomatic case.

    In this case pre-symptomatic transmission is significant AND hard to detect, that's why doctor say if you're known to be close to someone who has COVID and you exhibit no symptom you should start quarantine right away and get a test only after 4~5 days has passed.

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  13. I agree with your perspective on at-home testing, FDA delays, etc. It's just that the specific BinaxNOW test is not the greatest example of these broader points.

    The purpose of BinaxNOW is that it can be rolled out by large pharmacy chains: it was never designed to be an "at home" test in the first place, and the marketing claims of "simple" must be understood in the context of "for a trained professional."

    And quite honestly, pharmacy use is enough if people are really willing to get tested. The only barrier the FDA has established here is that you need to spend an extra 15 minutes in the pharmacy where you'd have gone to buy an at home test in the first place. If your relatives want to get together for Thanksgiving the cost is 15 minutes in a pharmacy, no one is stopping you from doing it.

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  14. This is what the White House was doing----I believe that is what has been reported. They have had what appears to be a large number of cases (although there are 300 people who work as Staff for White House)--so maybe 10-12 cases is not that high given they are tested daily.

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