Vaccines at NR

I repackaged and rethought some of my earlier thoughts on vaccine allocation and markets vs. government for National Review here. Text here, without the lovely pop-up ads: 

Free Markets Beat Central Planning, Even for COVID-19 Tests and Vaccines January 12, 2021 

Surely, we can’t let there be a free market for COVID-19 tests and vaccines. Indeed, tests and vaccines encapsulate many of the “market failure” parables from introductory economics courses.

But the argument for free markets is not that they are perfect. The argument is that the known alternatives are much worse. And we have seen a catastrophic failure of government at all levels around the world to handle this pandemic, especially in delivering tests and vaccines.

The CDC delayed testing for about two months. While it dithered, it blocked private parties from testing. University labs, for example, were blocked from making and conducting their own tests. During those two months, someone could sell you a thermometer to detect a COVID-19 fever, but if someone tried to sell you anything more effective, the FDA would stop them. Once it finally approved paper-strip tests in November, the FDA insisted that $5 paper-strip tests require a prescription and be bundled with an app, driving the cost to $50. Rapid testing that lets people who are sick isolate, and lets businesses ensure that employees are healthy, is only just becoming widely available, held back for six months by the FDA.

Let’s imagine that the government had not prohibited free-market activities. This is not anarchy, just a lightly regulated sensible market on top of whatever the government wants to do.

Private companies would have developed tests quickly and would have worked to make them faster, better, and cheaper. Why? To make money! Lots of people, businesses, schools, and universities are willing to pay for good, fast testing. Medical companies, knowing they could make a lot of money so long as they beat the competition, would have raced to develop and sell tests. We would have had $5 or less at-home paper-strip tests by late spring. And that would have enabled much of the economy to reopen.

FDA vs. Astra-Zeneca; bureaucracy vs. evolution and exponential growth

 From Alex Tabarrok at Marginal Revolution, quoting Marty Makary, M.D., a professor of surgery and health policy at the Johns Hopkins University School of Medicine:

... the FDA needs to stop playing games and authorize the Oxford-AstraZeneca vaccine.  It’s safe, cheap ($2-$3 a dose), and is the easiest vaccine to distribute. It does not require freezing and is already approved and being administered in the United Kingdom.

Sadly, the FDA is months away from authorizing this vaccine because FDA career staff members insisted on another clinical trial to be completed and are punishing the company for inadvertently giving a half-dose of the vaccine to some people in the trial.

It’s like the FDA is holding out, pontificating existing excellent data and being vindictive against a company for making a mistake while thousands of Americans die each day...

My emphasis. Alex:

See also my post The AstraZeneca Factory in Baltimore. Thousands of people are dying every day. We have a vaccine factory ready to go. The FDA should lifts its ban on the AstraZeneca vaccine.

Alex understates the case. It is not just that "thousands of people are dying every day." It is that we are in the phase of exponential growth, and a new more infectious variant has just arrived bumping up the growth rate further. Every hour of delay means tens of thousands more will die.  

We are in a fight of bureaucracy vs. exponential growth and evolution. Exponential growth and evolution are winning. Just how many thousands have to be on the left side of the trolley switch before the FDA stops allowing Astra-Zeneca to pull it? What's the risk aversion coefficient that justifies months of delay and another clinical trial?  

More deeply, can the FDA ever figure out that the point here is to stop a pandemic? The mentality is traditional: we must provide a perfect vaccine to protect individuals, taking the disease as given, and people who die while we do more studies are worth the cost. That is simply not what's going on right now. The point of the vaccine is to stop a pandemic. The disease is growing exponentially, and mutating and evolving. The externality is everything. I know, it's awfully hard for bureaucracies to innovate and change mindset. Well, sometimes you have to.  

For years the FDA was focused on, don't repeat thalidomide. Drugs must be safe. AIDS forced a hard reckoning. The people who are dying while you wait matter. But this is a third, even harder conceptual change. Stopping the spread of the disease matters. And the FDA does not have the years it took to make the AIDS change of mindset. 

Nothing matters but reproduction rate R

The new strain and the need for speed by Alex Tabarrok on Marginal Revolution makes an excellent point. The new strain is more transmissible. That means the reproduction rate R is higher. For given behavior, the exponential growth is faster. If or where R was a bit below one and the virus contracting, now the virus is spreading exponentially again. 

 "a more transmissible variant is in some ways much more dangerous than a more severe variant. That’s because higher transmissibility subjects us to a more contagious virus spreading with exponential growth, whereas the risk from increased severity would have increased in a linear manner, affecting only those infected."

The recurring failure of our government response to this pandemic has been to get behind exponential growth. Here we go again. Wasted months when the vaccines were known to be safe. Wasted weeks to have thanksgiving dinner rather than  approve vaccine. Snafu after snafu in vaccine distribution. And CDC rationing that is designed to just about nothing to stop the spread. 

Free Market Vaccines

Part 1: Who should get the vaccine first? Sell to the highest bidder. The disease and recession go away faster. 

 Part 2: The cost of perfection. The vaccine was invented in a weekend, available in February. In free market land, we would not have had a pandemic, or a recession. 284 thousand people would be alive today. That is the cost of FDA "protection." 

Part 1: Who should get the vaccine first? 

Absolutely nobody* has mentioned in public the free market answer: Sell to the highest bidder. 

(Or just allow some sales to the highest bidder. Don't put people in jail for selling some to the highest bidder,) 

It's not as dumb as it sounds. Sure, there is an externality. A good vaccine policy might be to give it to those most likely to spread it to others, with the goal of swiftly reducing the prevalence of the disease. That argues for giving the vaccine in bars. 

That is not our public policy. The entire discussion centers around who should be protected first, from a disease whose prevalence is taken as given. Old people, nursing homes, health care workers, essential workers -- the argument is not the externality. The argument is entirely who should get the individual benefit of protection from the vaccine.  Just why "to the highest bidder" is wrong is then much less clear. 

The case is stronger than usual, for there is a second way to avoid infection: Stay home. Social distance. Wear protective gear. So the question is not, really, "Who should be protected from the virus?" The question is, really, "Who should get a treatment that allows them to be out and about, risking contact with the virus, rather than protect themselves by traditional means?" It is really mainly an economic benefit, avoidance of the cost of other measures to stay healthy. There is an economic answer: people should be out and about first who generate the most economic benefit from being out. And, therefore, are willing to pay the most to get the vaccine. 

Vaccines and externalities

 A lovely point from the always creative Tyler Cowen

Say, for the purposes of argument, that you had 20,000 vaccine doses to distribute. There are about 20,000 cities and towns in America. Would you send one dose to each location? That might sound fair, but such a distribution would limit the overall effect. Many of those 20,000 recipients would be safer, but your plan would not meaningfully reduce community transmission in any of those places, nor would it allow any public events to restart or schools to reopen.

Alternatively, say you chose one town or well-defined area and distributed all 20,000 doses there. Not only would you protect 20,000 people with the vaccine, but the surrounding area would be much safer, too. Children could go to school, for instance, knowing that most of the other people in the building had been vaccinated. Shopping and dining would boom as well.

All along our authorities have had trouble distinguishing public health from the treatment of individual patients. That's why testing has been such an unfulfilled promise.  "Who gets it first" is treated like who should the government send money to. The point of vaccine is not mainly to protect individuals, it is to stop the spread of a disease.  

Stanford Condemns Atlas

On Friday Nov. 20, as reported in the official Stanford News, the Stanford Faculty Senate formally condemned Scott Atlas, Hoover Senior Fellow and a special adviser to the reviled President Trump.  The full resolution is posted here (but only available with a Stanford id).

"Rise up"

The resolution lists a single documented fact.

in a post to his Twitter account,  Atlas called on the people of Michigan  to ‘rise up’  against their Governor in response to new public health measures...

They acknowledge his later correction 

Although he subsequently claimed that his call to rise up had  been misunderstood, we believe that this latest communication is a dangerous provocation

The President of the University himself piled on, 

President Marc Tessier-Lavigne said he was “deeply troubled by the views by Dr. Atlas, including his call to ‘rise up’ in Michigan.” Tessier-Lavigne noted that Atlas later clarified his statements, but he said that the tweet “was widely interpreted as an undermining of local health authorities, and even a call to violence.”

Now, indeed this was a dumb tweet, and I do not defend it. My view of scientific advisers is that they should advise and serve the President and shut up. Most presidents want them to do that, and not become an independent part of political messaging. But this administration is, er, different, and President Trump has not objected to Scott's tweeting habits. None of us know even if tweeting is expected or not in Scott's job. 

I do not here defend any of Scott's opinions, merely his freedom to state them, advise the President as he sees fit, and not be the first person formally condemned by the university for that speech. 

But let us be clear: It may have been dumb, but Atlas did not call for violence. Period. You can call it "interpreted," you can call it "dog whistle," you can put all the words into Scott's mouth you want, but those words are not there. Condemnation for speech is bad enough, condemnation because someone might misinterpret speech is unimaginable. 

You can also interpret it as I did, a call for people whose livelihoods and health are being imperiled by nitwit proclamations to exercise their rights and duties as citizens of this great country to, well, rise up, to protest to their elected officials, to complain in regular and social media, peaceably to assemble (with masks) and to petition the Government for a redress of grievances. 

So, is a tweet calling for the people of Michigan to 'rise up' against a set of widely panned, economically devastating, ineffectual public health measures, at least in Scott's view (more later), an act meriting this unprecedented and unique condemnation? 

Budish Covid-19 update

Eric Budish has an update to his excellent Covid-19 paper. Eric has a few deep central insights about pandemic management, which necessarily joins economics and epidemiology. 

Keep your eyes on R<1. 

The reproduction rate R -- how many people the average person who gets the disease passes it on to -- is really the only thing that matters. When R>1 the disease grows, initially exponentially, then only tailing off when a large (half or more) of the population is either immune or dead. When R<1, the disease tails off. The costs of the disease grow enormously when R>1. Once R<1, further reductions in R don't really do much good. 

From a public health perspective, you don't have to stop all transmission. Just get R less than one.  

Thus, The goal of pandemic policy must be to maximize the economy (maximize utility, if you're an economies) while keeping R<1. 

The costs of changing R are so smooth, and the benefits so nonlinear, we might as well treat R<1 as a constraint. 

..the formulation provides economics language for a policy middle ground between society-wide lockdown and ignore-the-virus, and a new infectious threat response paradigm alongside “eradicate” and “minimize”.

Important simple insights: 

the R ≤ 1 constraint imposes a disease- transmission budget on society. Society should optimally spend this budget on the activities with the highest ratio of utility to disease-transmission risk, dropping activities with too low a ratio of utility to risk. 

Contra most epidemiologists, you don't shut down everything. You accept risk, and even some transmission, where it is important. From my priorities, keeping business and school open is more important than bars nightclubs and parties, but gustibus do matter here. Market value is a good test however.    

Second, masks, tests, and other simple interventions increase activities’ utility-to-risk ratios, and hence expand how much activity society can engage in and utility society can achieve while staying within the R ≤ 1 budget. 

This is a deeply important point, which I really had not grasped: 

Do not evaluate the value of mask-wearing by how much it can reduce the spread of disease. Evaluate the value of mask-wearing by the vale of activities we can open up, while keeping the disease spread constant.  

Virus over? Not quite

The news of a vaccine seems to be sparking an its-all-over sigh of relief. Not so fast.  Interesting and challenging corona virus policy remains on the front burner. 

Holman Jenkins makes a few good points in WSJ. The media and many governments (mine) are focused on new case counts, now 100,000 per day. But 

Brown University’s Dr. Ashish Jha estimated while we are identifying 100,000 new cases a day, “we’re probably missing 70%, 80% of all the cases out there.”

He mentions other guesses that say 90%. 

Why does this matter? Well, 100,000 cases per day x (say) 2 weeks of infectiousness means that 1.4 million people are infectious, or 0.5% of the population. Not bad odds for a dinner party, maybe not a rave. But if we really have 500,000 or 1,000,000 cases per day, that means 2.5% to 5% of the people you are going to run in to may be infectious. Yikes.  

If Americans knew they were being laughably misled, that the virus is far more widespread and their chances of encountering it are much greater than the confirmed case count (currently 10 million) implies, their behavior might be different. Especially we might get more mask-wearing by unwitting carriers to curb unwitting spread.

And a lot less partying. 

More intriguing, 

Covid cycles

Theory: (From An SIR model with behavior)

Fact: (from Scott Gottlieb via Marginal Revolution)

I do not mean to toot my horn, as many other graphs from the model did not look like that. This particular graph did, and really offers a sad interpretation of what's going on. In the model that produced the graph, people and policymakers react to the current death rate in deciding how much risk to take by going out. 

It is entirely individually rational for people to go out and party when very few around them are infected. Sadly, that means the disease collectively ramps up. Then it is individually rational for people to cut back, and the disease slows down. Cycles can result.  

Public policy is supposed to get on top of these cycles, by stamping out disease when it is low, the same way you keep taking antibiotics even when you feel better. It is the policy that has failed rational expectations here, not people. (No, that does not mean lockdown business and print money so we all can stay home and order stuff that comes by magic from Amazon. Ambitious testing would have done the trick. Or at least containing the summer's wave of super spreading parties.) 

Sherwin Rosen, Kevin Murphy and José Scheinkman have a beautiful JPE paper Cattle Cycles describing a related phenomenon. But our governments are supposed to be smarter than cows. 

OECD talk -- rebuilding institutions in the wake of Covid-19

Friday morning I had the pleasure of participating in a session at the OECD, as part of their program on Confronting Planetary Emergencies - Solving Human Problems. I had the tough job of following brilliant remarks by Acting CEA chair Tyler Goodspeed and Ken Rogoff, and discussing great questions all starting at 5 AM. 

FYI here is the text of my prepared remarks. My focus is how to rebuild the competence of our institutions, which failed dismally in this crisis. 

(Update: Video of the event including Tyler Goodspeed's amazing critique,  plus Ken Rogoff's insightful talk. Thanks to Fahim M. from the comment below. Unknown says the audio is available on the main page, but I couldn't find it. )  

Covid and Beyond

John H. Cochrane

Remarks at the OECD, October 9, 2020

I very much appreciate the opportunity to speak today. Looking at some of the background documents, and listening to Tyler, I recognize that our panel is decidedly contrarian to the main views the OECD is pursuing, and those of the stars that you invited for previous panels. It says good things about the OECD that you want to listen to and understand heretical views.

I will try to answer to your question — what lessons should we take from the Covid experience? Many people say that “Covid changes everything.” I do not think the lesson is so radical. But the Covid  experience does, I think, bring to the fore and make urgent underlying problems that we need to address sooner rather than later. My “we” is global, and international institutions such as the OECD have a key role to play in this institutional regeneration. 

My theme is that we witnessed an outcome of grand institutional failure. We must reform our institutions, restore their basic competence, and thereby trust in that competence. We must de-politicize our institutions and insist that they return to the narrow focus of their competence. Trust must be earned. 

This erosion of our institutions has been going on for a long time now. in my view, the populist eruption, as well perhaps as much of the left-wing authoritarian woke eruption, stems from the view that elites don’t know why they are doing. That was laid bare in financial crisis, in many foreign policy misadventures, and laid bare by covid once again.

We are in a "planetary emergency." It is an emergency coming from the decay, or decadence if you will, of our governing institutions. They need to restore basic competence, not to embark on grand new adventures.  

The disease will pass, likely sooner rather than later due to the extraordinary inventiveness of our pharmaceutical and scientific institutions. The heroic efforts of doctors, and the speed with which they have learned to treat covid is remarkable. Diseases always have passed. And economies and societies returned to normal.

Covid -19 is, however, a fire drill, a wakeup call, a warning sign. It is almost perfectly designed to that purpose. It is just serious enough to get our attention, in a way that H1N1, SARS, and Ebola, were not.  But compared to plague, smallpox, typhus, cholera, 1918 influenza, the death rate is tiny.  

There is a virus out there, natural or engineered, that spreads like this one and kills 20% or more of the population. It will come sooner than we think. And we are wildly unprepared.  Ken Rogoff rightly points to a range of other tail events that we are wildly unprepared for. Antibiotic resistant bacteria.   Massive computer failure. Even a small nuclear war. 

Let us look somewhat chronologically at the list of failures in the last year.

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."

Belgian Doctors' open letter on covid-19

A correspondent sent me a link to the Belgian Doctors' open letter on covid-19. I found it original, documented, and worth reading and thinking about. It is at least an important contribution to a debate -- and one of its big points, we should be having a debate. Science is still quite uncertain about much regarding this disease, and science never did know much about economic and public policy. I'm not totally convinced, but it has several interesting ideas that I had not considered before. 

The headline

We ask for an open debate, where all experts are represented without any form of censorship. After the initial panic surrounding covid-19, the objective facts now show a completely different picture – there is no medical justification for any emergency policy anymore.

The current crisis management has become totally disproportionate and causes more damage than it does any good.

We call for an end to all measures and ask for an immediate restoration of our normal democratic governance and legal structures and of all our civil liberties.

A history 

Romer on testing

As part of an email conversation about testing, Paul Romer sent the following message. He so beautifully encapsulated the case for testing, I asked for permission to post his email. Here it is. 

Here is a short summary of the case for testing.

1. A program of "test and isolate" will reduce the effective reproduction number, R.

2. A combined policy of (i) more "test and isolate" which reduces R and (ii) more social interaction and more economic activity which increases R can be designed so that the net effect on R is zero.

3. The ratio of the cost of the additional testing to the additional economic activity that this combined policy will allow offers one way to estimate of the "rate or return" to spending on tests. My rough estimate is that this rate of return lies in the range of 10x to 100x so there is no doubt that test and isolate would be cost effective. To reach the higher end of the range, the cost of the test would have to be relatively low, say  $10.

4. The combined plan under #2 will lead to more total cases. If the main measure of policy success or failure were deaths, an increase in the number of cases would not matter. Under the current circumstances, an increase in the number of cases is likely to be interpreted as a sign of a policy failure. This increases the political cost to the administration of increasing the number of tests. A second-best solution that avoids this cost might be to use at home tests and encourage people to self-isolate. This way, the results from the tests need not generate any new confirmed cases.

[JC Comment: one reluctance that the president or governors may have is that more testing naturally produces more measured cases, and the media don't seem all that good about recognizing this fact.] 

Details on Targeting, Timing, and Compliance:

- Under the program in #3, the benefit created when more infectious people are isolated is received by unknown others who are free to resume normal activities. This is a classic case of an external effect. As a result, it makes sense for the government to pay for the tests and perhaps even to pay for "supported isolation" to increase the compliance rate. Because the fraction of the population that is infected is relatively small and because the required period of isolation is short, it would be relatively inexpensive to pay the few people who are in isolation, for example by making up any lost wages. Because transmission in the household is likely, it would make sense to offer a choice of isolation in a hotel or isolating the entire family at home. However, implementing this would require some way to confirm that someone is infectious, which precludes its use in the at-home approach noted under #4 above.

- For purposes of calculating the rate of return in the combined program described in #3, it is useful to consider a thought experiment of testing people at random. But in any practical program, the efficient way to use more tests is to start by targeting populations that have high ex ante probability of being infected. This could be done by concentrating the tests in high prevalence geographical regions, in high exposure populations, or on people identified by contact tracing. I am skeptical that contact tracing is the cost effective way to identify a large number of people who have a higher ex ante probability of being infected.

- For reducing R, what matters is the average number of infectious-person-days in isolation per test. This depends on (a) the number of true positives that are isolated and (b) when in the course of their infection they are isolated. The way to increase (a) is to target populations with a high ex ante probability of infection. The way to increase (b) is to use tests with a shorter time from sample to result.

- The choice between centralized lab testing and POC tests depends in part on an easily quantified tradeoff between a reduction in the sample-to-result time of most POC tests and a reduction in their sensitivity. But in the early months of any program for expanding the number of tests, the most important differentiator is likely to be the supply response. Many people are convinced that there is a large amount of lab capacity on university campuses that could rapidly be mobilized so that this path probably offers the lowest-cost path of expansion until manufacturing capacity increases for the POC or at home tests.

- There is a synergy between the frequency of testing in a population and the use of pooling to increase lab capacity. As the frequency increases, the frequency of positives will go down so that pooling becomes more cost effective.

-  A large fraction of the total cost of a test comes from the discomfort experienced by the person who gives the sample and the time it takes for a healthcare professional to collect the sample. On both grounds, saliva samples will almost surely have the lowest cost.

- To reduce the cost from isolating false positives, any initial positives could be retested. Because the number of positive results will be a small fraction of the number of tests, retesting adds only a small amount to the cost of the program.

- As long as any true positives are isolated, the net effect of the combined program described in #2 will be to increase the total amount of social interaction by people who are not infectious, even if there are some false positives.

I hope this is helpful. 

Paul. 

 

Jacobin pandemic

Casey Mulligan tweeted an interesting report on the coronavirus from Jacobin online magazine as "makes the most sense." Given that the Jacobins were 

"the most radical and ruthless of the political groups formed in the wake of the French Revolution, and in association with Robespierre they instituted the Terror of 1793–4."

(google dictionary) the link attracted my eye. (Do these people know history? Or is this intentional? And they're all upset about Trump and "authoritarianism?")  

Indeed, after the predictable throat-clearing editorializing about "disparate impact" and inequality, and despite idiotic question preambles like this one

"Under capitalism, we have become a species that increasingly exploits other creatures and their habitats, and moves in large numbers and with great speed around the globe, making us ripe for a pandemic like this one."

(China is.. capitalist? The plague, cholera, yellow fever, smallpox were... what?) Jacobin editorial board member Nicole Aschoff spurs Harvard professors Katherine Yih  and Martin Kulldorff to interesting, sensible and useful answers. The extreme source of this commonsense gives me some hope. However, read though or skip to my critical comments, as it's not as totally wise as Casey suggests. 

KY: ... I don’t think it’s wise or warranted to keep society locked down until vaccines become available. ..Instead of a medically oriented approach that focuses on the individual patient and seeks (unrealistically) to prevent new infections across the board, we need a public health–oriented approach that focuses on the population  and seeks to use patterns, or epidemiologic features, of the disease to minimize the number of cases of severe disease and death over the long run, as herd immunity builds up.

NA: Like Dr Yih, I am very concerned about the collateral damage of lockdowns. In public health policy, we cannot just consider the present consequences of one single disease. We must think more broadly, considering all short- and long-term health outcomes.

...Another example is school closings. Good education is not only important for academic achievement and financial well-being; it is also critical for the mental and physical health of children and into their subsequent adulthood. Kids have minimal risk from this virus, and it is sad that we are sacrificing our children instead of properly protecting the elderly and other high-risk groups.

(I hate to break it to modern-day Jacobins, but the Trump Administration is basically following this approach. And the disparate impact is precisely brought on by economic lockdown.  ) 

Read on for much common sense. 

However, I don't think this is totally right, and "damn the torpedoes, protect the old folks and let's sail on to herd immunity" is not, I think the right or at least complete answer.  

1) Herd immunity, on its own, is a meaningless concept.  Most people think herd immunity happens when everyone has gotten it, which is false.  A virus stops spreading when the reproduction rate is below one. The reproduction rate combines frequency of contact and fraction of immune in the population. Only that combination matters.

If each infected person meets 3 people and 67% of the population has immunity, the virus stops.  If each infected person meets two people and 51% the population has immunity, the virus stops. If each infected person meets 0.99 people and nobody is immune, the virus stops.  The fraction with immunity on its own is meaningless.

So we need to work on both parts of the equation -- reduce the contact rate and minimum economic and social cost, as well as wait for greater numbers to become immune. 

2) Long term consequences.  The article acknowledges these and moves on. This strikes me as a great unknown. The view that it’s like the flu, just let people get it until immunity rises, while keeping old and sick people safe, is predicated on the idea that there are few long term consequences other than death. 

 If 20% are getting long term important debilitation, that skews the treadeoff to less contact.  If this were the plague or cholera, with 50% death, we would not be talking about herd immunity.

3) Testing. The article is missing the one great opportunity we have to reduce the spread and reduce the social and economic cost of the disease, until a vaccine becomes available. "Test" only appears in the article in the section on protecting the elderly and nursing homes. This is the great unexploited opportunity. We can cheaply reduce the contact rate with next to no business or social cost.

Why in the world are we not embarking on widespread public-health testing? Why is the FDA still regulating tests, saying they may only be performed in a medical setting?  By what possible right or common sense can the FDA tell me that I cannot send samples of my body to a lab, and the lab cannot tell me what’s in them? Read Alex Tabarrok "our antigens, ourselves" to get really grumpy about this. You have to be astoundingly paternalistic about the stupid deplorable to believe that people need to be protected from simple information about what is in their body. There is zero medical danger from a saliva test. 

This thing could be over in  weeks if the FDA allowed cheap, fast, relatively inaccurate, cash-and-carry, completely unregulated tests. Go to CVS, get the test kit, find out if you have it. No referral, no doctor visit, no prescription, no insurance, no faxed paperwork. Let private decisions figure out what to do with the results. Businesses, restaurants, schools could all demand it. With a cheap test, the contact rate can go below one and we need no immunity. Of course, the government has every interest in paying for and subsidizing tests too. 

Frankly I do not understand this Administration. If President Trump simply tweeted, "FDA: Free the tests!" and "CDC: tell people to get tested" this thing could be over in weeks. We could reach herd immunity with a low contact rate alone, and reastaurants, schools, universities, airlines, could require test results and reopen quickly. Trump could go into the election with the number of cases and deaths crashing. He could campaign in empty hospitals. 

Atlas agonistes

A group of Stanford faculty recently circulated, and then posted, an open letter objecting to my Hoover colleague Scott Atlas, who serves as a senior adviser to the Administration on health policy. 

Read the letter. Then come back for a little reading comprehension test.

****

Q1: What specific "falsehoods and misrepresentations" do they accuse Scott of making?

Q2: Which of the following do they claim Scott is publicly denying, contrary to scientific evidence? 

1. Face masks, social distancing, handwashing and hygiene can help to reduce the spread of Covid-19. 
2. Crowded indoor spaces are dangerous. 
3. Asymptomatic people can spread covid-19
4. Testing asymptomatic people can help to slow the spread. 
5. Children can get Covid-19
6. Pandemics can end via herd immunity. Vaccines work, by conferring herd immunity.
7. Letting people get sick is better than a vaccine. 
8. All of the above  

Q3: What specific documented evidence of statements that contravene contemporary scientific consensus do the signatories provide? 

Q4: What role in the Administration do they cite that Scott has, and misuses? 

(Note present tense. Scott is an adviser. We all get to change our minds -- even Dr. Fauci once said face masks were not worth the bother, but the signatories don't seem to feel an "ethical obligation" to play gotcha on that one. What matters is, what is Scott currently advocating in the Administration?) 

*******

Abbott Labs to the rescue? Free the tests!

Context: Cheap, fast, tests can stop this pandemic quickly, even if they are not very accurate.

Last week, Abbott Labs announced (more info here) that (finally)

the U.S. Food and Drug Administration (FDA) has issued Emergency Use Authorization (EUA) for its BinaxNOW™ COVID-19 Ag Card rapid test for detection of COVID-19 infection. Abbott will sell this test for $5. It is highly portable (about the size of a credit card), affordable and provides results in 15 minutes. BinaxNOW uses proven Abbott lateral flow technology, making it a reliable and familiar format for frequent mass testing through their healthcare provider. With no equipment required, the device will be an important tool to manage risk by quickly identifying infectious people so they don't spread the disease to others.  

Note the last sentence. Abbott gets it -- the point of this test is not to diagnose sick people, it is to keep most sick people from spreading the disease.  If every American got this test once a week for a month ($5 x $350 million = $7 billion = one drop in bucket of the fiscal and economic cost of this pandemic) it would be over in a month.

Abbott will also launch a complementary mobile app for iPhone and Android devices named NAVICA™. This first-of-its-kind app, available at no charge, will allow people who test negative to display a temporary digital health pass that is renewed each time a person is tested through their healthcare provider together with the date of the test result. Organizations will be able to view and verify the information on a mobile device to facilitate entry into facilities along with hand-washing, social distancing, enhanced cleaning and mask-wearing.

"We intentionally designed the BinaxNOW test and NAVICA app so we could offer a comprehensive testing solution to help Americans feel more confident about their health and lives," said Robert B. Ford, president and chief executive officer...

Even better. (It does not say who the app reports data to, which could make it better yet. For example, it could automatically notify your employer.)

"With lab-based tests, you get excellent sensitivity but might have to wait days or longer to get the results. With a rapid antigen test, you get a result right away, getting infectious people off the streets and into quarantine so they don't spread the virus."

Again, Abbott gets it.

But, what's this business about "through their healthcare provider?"

Under FDA EUA, the BinaxNOW COVID-19 Ag Card is for use by healthcare professionals and can be used in point-of-care settings that are qualified to have the test performed and are operating under a CLIA (Clinical Laboratory Improvement Amendments) Certificate of Waiver, Certificate of Compliance, or Certificate of Accreditation. Within these settings, the test can be performed by doctors, nurses, school nurses, medical assistants and technicians, pharmacists, employer occupational health specialists, and more with minimal training and a patient prescription.   

What is wrong with these people? (FDA) If most of us call our health care providers, you get  non-urgent appointment in about 3 weeks, insurance gets billed about $400, we pay $150, to get the necessary referral, and prescription (!) and on for more delays and costs to get the test.

What possible reason is there for all these restrictions? How can anybody be hurt by taking this test, and how will all these layers of bureaucracy help that anyway? Yes, a huge employer like Stanford can probably obtain a CLIA CoW, CoC, etc. and hire a "occupational health specialist" to administer tests, but how is a restaurant going to do it?

There is a pandemic on, folks. Regulators gotta regulate, I guess, to justify their existence. But not now.

Free the tests!

More on tests

 Robert Zubrin puts the point well in a National Review essay (thanks to a commenter on my last post). 

There are now a variety of fast coronavirus tests that could be readily administered by businesses and schools and provide results within 20 minutes. These tests require only saliva samples, not deep upper nose swabs, and can be readily administered by practically anyone with very modest training. The FDA just approved “emergency use” of one of them by the NBA. The problem is that they won’t let the rest of us use them. Recently I was offered highly effective and economical rapid tests developed by an extremely well-qualified biotech firm. But FDA rules precluded transporting their tests across state lines. Upon appeal it now appears that the FDA might be willing to authorize such shipments on an “emergency basis,” but only for use in already overbooked clinics certified by yet another bureaucracy.

This won’t do. We need to be able to use the tests ourselves.

No clinics. No prescription. No doctor visit. No faxing forms to insurance companies. 

If we were allowed to use these tests, schools and businesses could test their students and workers at the start of each week and send all virus carriers home by 9 a.m. Monday. We could end the pandemic within four weeks, without needing to shut down any schools or companies. 

Testing every American every two weeks means about 30 million tests a day. 

The authorities can’t possibly administer 30 million tests per day. But we — the people — can do it easily, provided we are allowed to do so. 

We are currently forbidden from doing so. The financial cost is trivial compared to the $5 trillion the government is spending on covid relief.  

Test = vaccine

"Cheap, frequent COVID tests could be ‘akin to vaccine,’ professor says" from the Harvard Gazette HT Miles Kimball 

Yes, I'm repeating myself, but maybe if we just try over and over again we'll get through. We could stop this disease now with tests. Vaccines are just a tool to stop disease transmission. Widespread, cheap frequent tests are just as effective a tool to stop disease transmission. So I'll keep quoting anyone who wants to say this! 

A Harvard epidemiologist and expert in disease testing is calling for a shift in strategy toward a cheap, daily, do-it-yourself test that he says can be as effective as a vaccine at interrupting coronavirus transmission — and is currently the only viable option for a quick return to an approximation of normal life.

“These are our hope,” said Michal Mina, assistant professor of epidemiology at Harvard T.H. Chan School of Public Health and Brigham and Women’s Hospital. “We don’t have anything tomorrow, other than shutting down the economy and keeping schools closed.”

....the paper-strip tests have already been developed and their shotgun approach to testing — cheap and widespread — provides a way back to the workplace, classroom, and other venues.

The tests, which can be produced for less than a dollar, can be performed by consumers each day or every other day. Though not as accurate as current diagnostic tests, they are nonetheless effective at detecting virus when a person is most infectious, Mina said. If everyone who tests positive stays home, he said, the widespread effect would be similar to that of a vaccine, breaking transmission chains across the country.

... What I would like to see happen is to start using testing [as] a true public health tool to break transmission chains in the same way that we know we can use masks to decrease transmission,” Mina said. “I want these tests to tell people they’re transmitting [the virus to others] at the time they’re transmitting, and [when] people can act on it because they’re getting immediate results. And I want them to take it every single day, or every other day.”

Several companies have developed such tests, Mina said.

Why aren't we doing this, voluntarily even? 

The Food and Drug Administration,..  has held up approval because the tests aren’t as accurate as nasal-swab, lab-based tests. While that would matter if they were intended as an individual diagnostic tool, Mina said that from a public health viewpoint, they are accurate enough to provide critical initial screening on a large scale. ....

“Everyone says, ‘Why aren’t you doing this already?’ My answer is, ‘It is illegal to do this right now,’” Mina said. 

In other words, the FDA says:  "Yes, you can use a thermometer to screen people out and send them home. Yes, you can use a questionnaire to screen people out and send them home.  No, you may not use a far more accurate $1 paper test for exactly the same purpose. And if you try, we'll ruin your company and send you to jail." 

Alex Tabarrok puts it nicely: We're testing for contagiousness, not for infection. 

President Trump seems to have discovered President Obama's phone and pen. A suggestion: Tomorrow morning, 9 AM, executive order: The sale and use of these paper tests shall be legal. We could be done with Covid 19 in a month or two. 

Tests

America has essentially given up on containing the corona virus, and will just let it spread while we await a vaccine. Oh sure, our governors and other public officials flap around about wearing masks and social distancing. But there is no serious public health effort. (If you're in California, I encourage you to listen to NPR's faithful coverage of our Governor Gavin Newsom's noon daily press conference. Never has anyone so artfully said so little in so many words.) 

A vaccine is a technological device that, combined with an effective policy and public-health bureaucracy for its distribution,  allows us to stop the spread of a virus.  But we have such a thing already. Tests are a technological device that, combined with an effective policy and public-health bureaucracy for its distribution, allows us to stop the spread of a virus. 

For that public health purpose, tests do not need to be accurate. They need to be cheap, available, and fast. When the history of this virus is written, I suspect that the immense fubar, snafu, complete incompetence of the FDA, CDC, and health authorities in general at understanding and using available tests to stop the virus will be a central theme. (Well, forecasting historians is a dangerous game. Already "the virus increases inequality and social injustice" seems to be the narrative of the day.) 

Marginal revolution has three insightful posts on the issue. "Bill Gates is angry" starts with a  comment on the fact that currently, once you get a test, it can take days or even weeks to get the results.  

..that’s just stupidity. The majority of all US tests are completely garbage, wasted. 

If the point of the test is to find out who has it, and isolate them, then an answer that comes back after they've gone out to spread the virus to friends, family and co-workers is completely wasted. Gates has an econ-101 insight into why this is happening:

If you don’t care how late the date is and you reimburse at the same level, of course they’re going to take every customer...You have to have the reimbursement system pay a little bit extra for 24 hours, pay the normal fee for 48 hours, and pay nothing [if it isn’t done by then]. And they will fix it overnight.

I know a great such reimbursement system, but I'll hold that in suspense. (You can probably guess what it is.) 

A second great insight: 

Goodfellows and Garicano Interview

I did two videos last week that blog readers may enjoy.

I did an interview with Luis Garicano in his "capitalism after coronavirus" series



We covered many topics, but the aftermath of the huge government debt now being racked up is possibly the most interesting, at least to me.

Luis is currently a member of the European Parliament. Among many other things he was a PhD student and then professor of economics at the University of Chicago. He's a also a great interviewer. The interview is also available in Spanish, here.

In the latest Goodfellows, Niall, HR and I interview Victor Davis Hanson, about Trump, cancel culture, and the future of universities.



Podcast