influenza

Unending nightmares

pnrj current events, ethics, market failure, politics, public policy , , , , , , , , , , ,

Sep 19 JDN 2459477

We are living in a time of unending nightmares.

As I write this, we have just passed the 20th anniversary of 9/11. Yet only in the past month were US troops finally withdrawn from Afghanistan—and that withdrawal was immediately followed by a total collapse of the Afghan government and a reinstatement of the Taliban. The United States had been at war for nearly 20 years, spending trillions of dollars and causing thousands of deaths—and seems to have accomplished precisely nothing.

Some left-wing circles have been saying that the Taliban offered surrender all the way back in 2001; this is not accurate. Alternet even refers to it as an “unconditional surrender” which is utter nonsense. No one in their right mind—not even the most die-hard imperialist—would ever refuse an unconditional surrender, and the US most certainly did nothing of the sort.)

The Taliban did offer a peace deal in 2001, which would have involved giving the US control of Kandahar and turning Osama bin Laden over to a neutral country (not to the US or any US ally). It would also have granted amnesty to a number of high-level Taliban leaders, which was a major sticking point for the US. In hindsight, should they have taken the deal? Obviously. But I don’t think that was nearly so clear at the time—nor would it have been particularly palatable to most of the American public to leave Osama bin Laden under house arrest in some neutral country (which they never specified by the way; somewhere without US extradition, presumably?) and grant amnesty to the top leaders of the Taliban.

Thus, even after the 20-year nightmare of the war that refused to end, we are still back to the nightmare we were in before—Afghanistan ruled by fanatics who will oppress millions.

Yet somehow this isn’t even the worst unending nightmare, for after a year and a half we are still in the throes of a global pandemic which has now caused over 4.6 million deaths. We are still wearing masks wherever we go—at least, those of us who are complying with the rules. We have gotten vaccinated already, but likely will need booster shots—at least, those of us who believe in vaccines.

The most disturbing part of it all is how many people still aren’t willing to follow the most basic demands of public health agencies.

In case you thought this was just an American phenomenon: Just a few days ago I looked out the window of my apartment to see a protest in front of the Scottish Parliament complaining about vaccine and mask mandates, with signs declaring it all a hoax. (Yes, my current temporary apartment overlooks the Scottish Parliament.)

Some of those signs displayed a perplexing innumeracy. One sign claimed that the vaccines must be stopped because they had killed 1,400 people in the UK. This is not actually true; while there have been 1,400 people in the UK who died after receiving a vaccine, 48 million people in the UK have gotten the vaccine, and many of them were old and/or sick, so, purely by statistics, we’d expect some of them to die shortly afterward. Less than 100 of these deaths are in any way attributable to the vaccine. But suppose for a moment that we took the figure at face value, and assumed, quite implausibly, that everyone who died shortly after getting the vaccine was in fact killed by the vaccine. This 1,400 figure needs to be compared against the 156,000 UK deaths attributable to COVID itself. Since 7 million people in the UK have tested positive for the virus, this is a fatality rate of over 2%. Even if we suppose that literally everyone in the UK who hasn’t been vaccinated in fact had the virus, that would still only be 20 million (the UK population of 68 million – the 48 million vaccinated) people, so the death rate for COVID itself would still be at least 0.8%—a staggeringly high fatality rate for a pandemic airborne virus. Meanwhile, even on this ridiculous overestimate of the deaths caused by the vaccine, the fatality rate for vaccination would be at most 0.003%. Thus, even by the anti-vaxers’ own claims, the vaccine is nearly 300 times safer than catching the virus. If we use the official estimates of a 1.9% COVID fatality rate and 100 deaths caused by the vaccines, the vaccines are in fact over 9000 times safer.

Yet it does seem to be worse in the United States, as while 22% of Americans described themselves as opposed to vaccination in general, only about 2% of Britons said the same.

But this did not translate to such a large difference in actual vaccination: While 70% of people in the UK have received the vaccine, 64% of people in the US have. Both of these figures are tantalizingly close to, yet clearly below, the at least 84% necessary to achieve herd immunity. (Actually some early estimates thought 60-70% might be enough—but epidemiologists no longer believe this, and some think that even 90% wouldn’t be enough.)

Indeed, the predominant tone I get from trying to keep up on the current news in epidemiology is fatalism: It’s too late, we’ve already failed to contain the virus, we won’t reach herd immunity, we won’t ever eradicate it. At this point they now all seem to think that COVID is going to become the new influenza, always with us, a major cause of death that somehow recedes into the background and seems normal to us—but COVID, unlike influenza, may stick around all year long. The one glimmer of hope is that influenza itself was severely hampered by the anti-pandemic procedures, and influenza cases and deaths are indeed down in both the US and UK (though not zero, nor as drastically reduced as many have reported).

The contrast between terrorism and pandemics is a sobering one, as pandemics kill far more people, yet somehow don’t provoke anywhere near as committed a response.

9/11 was a massive outlier in terrorism, at 3,000 deaths on a single day; otherwise the average annual death rate by terrorism is about 20,000 worldwide, mostly committed by Islamist groups. Yet the threat is not actually to Americans in particular; annual deaths due to terrorism in the US are less than 100—and most of these by right-wing domestic terrorists, not international Islamists.

Meanwhile, in an ordinary year, influenza would kill 50,000 Americans and somewhere between 300,000 and 700,000 people worldwide. COVID in the past year and a half has killed over 650,000 Americans and 4.6 million people worldwide—annualize that and it would be 400,000 per year in the US and 3 million per year worldwide.

Yet in response to terrorism we as a country were prepared to spend $2.3 trillion dollars, lose nearly 4,000 US and allied troops, and kill nearly 50,000 civilians—not even counting the over 60,000 enemy soldiers killed. It’s not even clear that this accomplished anything as far as reducing terrorism—by some estimates it actually made it worse.

Were we prepared to respond so aggressively to pandemics? Certainly not to influenza; we somehow treat all those deaths are normal or inevitable. In response to COVID we did spend a great deal of money, even more than the wars in fact—a total of nearly $6 trillion. This was a very pleasant surprise to me (it’s the first time in my lifetime I’ve witnessed a serious, not watered-down Keynesian fiscal stimulus in the United States). And we imposed lockdowns—but these were all-too quickly removed, despite the pleading of public health officials. It seems to be that our governments tried to impose an aggressive response, but then too many of the citizens pushed back against it, unwilling to give up their “freedom” (read: convenience) in the name of public safety.

For the wars, all most of us had to do was pay some taxes and sit back and watch; but for the pandemic we were actually expected to stay home, wear masks, and get shots? Forget it.

Politics was clearly a very big factor here: In the US, the COVID death rate map and the 2020 election map look almost equivalent: By and large, people who voted for Biden have been wearing masks and getting vaccinated, while people who voted for Trump have not.

But pandemic response is precisely the sort of thing you can’t do halfway. If one area is containing a virus and another isn’t, the virus will still remain uncontained. (As some have remarked, it’s rather like having a “peeing section” of a swimming pool. Much worse, actually, as urine contains relatively few bacteria—but not zero—and is quickly diluted by the huge quantities of water in a swimming pool.)

Indeed, that seems to be what has happened, and why we can’t seem to return to normal life despite months of isolation. Since enough people are refusing to make any effort to contain the virus, the virus remains uncontained, and the only way to protect ourselves from it is to continue keeping restrictions in place indefinitely.

Had we simply kept the original lockdowns in place awhile longer and then made sure everyone got the vaccine—preferably by paying them for doing it, rather than punishing them for not—we might have been able to actually contain the virus and then bring things back to normal.

But as it is, this is what I think is going to happen: At some point, we’re just going to give up. We’ll see that the virus isn’t getting any more contained than it ever was, and we’ll be so tired of living in isolation that we’ll finally just give up on doing it anymore and take our chances. Some of us will continue to get our annual vaccines, but some won’t. Some of us will continue to wear masks, but most won’t. The virus will become a part of our lives, just as influenza did, and we’ll convince ourselves that millions of deaths is no big deal.

And then the nightmare will truly never end.

We still don’t know the fatality rate of COVID-19

pnrj current events, public policy , , , , ,

May 10 JDN2458978

You’d think after being in this pandemic for several weeks we would now have a clear idea of the fatality rate of the virus. Unfortunately, this is not the case.

The problem is that what we can track really doesn’t tell us what we need to know.

What we can track is how many people have tested positive versus how many people have died. As of this writing, 247,000 people have died and 3,504,000 have tested positive. If this were the true fatality rate, it would be horrifying: A death rate of 7% is clearly in excess of even the 1918 influenza pandemic.

Fortunately, this is almost certainly an overestimate. But it’s actually possible for it to be an underestimate, and here’s why: A lot of those people who currently have the virus could still die.

We really shouldn’t be dividing (total deaths)/(total confirmed infections). We should be dividing (total deaths)/(total deaths + total recoveries). If people haven’t recovered yet, it’s too soon to say whether they will live.

On that basis, this begins to look more like an ancient plague: The number of recoveries is only about four times the number of deaths, which would be a staggering fatality rate of 20%.

But as I said, it’s far more likely that this is an overestimate, because we don’t actually know how many people have been infected. We only know how many people have been infected and gotten tested. A large proportion have never been tested; many of these were simply asymptomatic.
We know this because of the few cases we have of rigorous testing of a whole population, such as the passengers on this cruise liner bound for Antarctica. On that cruise liner, 6 were hospitalized, but 128 tested positive for the virus. This means that the number of asymptomatic infections was twenty times that of the number of symptomatic infections.

There have been several studies attempting to determine what proportion of infections are asymptomatic, because this knowledge is so vital. Unfortunately the results are wildly inconsistent. They seem to range from 5% asymptomatic and 95% symptomatic to 95% asymptomatic and 5% symptomatic. The figure I find most plausible is about 80%: This means that the number of asymptomatic infected is about four times that of the number of symptomatic infected.

This means that the true calculation we should be doing actually looks like this: (total deaths)/(total deaths + total recoveries + total asymptomatic).

The number of deaths seems to be about one fourth the number of recoveries. But when you add the fact that four times as many who get infected are asymptomatic, things don’t look quite so bad. This yields an overall fatality rate of about 4%. This is still very high, and absolutely comparable to the 1918 influenza pandemic.

But the truth is, we just don’t know. South Korea’s fatality rate was only 0.7%, which would be a really bad flu season but nothing catastrophic. (A typical flu has a fatality rate of about 0.1%.) On the (deaths)/(deaths + recoveries) basis, it looks almost as bad as the Black Death.

With so much uncertainty, there’s really only one option: Prepare for the worst-case scenario. Assume that the real death rate is massive, and implement lockdown measures until you can confirm that it isn’t.

Ancient plagues, modern pandemics

pnrj current events, public policy , , , , , , , ,

Mar 1 JDN 2458917

The coronavirus epidemic continues; though it originated in Wuhan province, the virus has now been confirmed in places as far-flung as Italy, Brazil, and Mexico. So far, about 90,000 people have caught it, and about 3,000 have died, mostly in China.

There are legitimate reasons to be concerned about this epidemic: Like influenza, coronavirus spreads quickly, and can be carried without symptoms, yet unlike influenza, it has a very high rate of complications, causing hospitalization as often as 10% of the time and death as often as 2%. There’s a lot of uncertainty about these numbers, because it’s difficult to know exactly how many people are infected but either have no symptoms or have symptoms that can be confused with other diseases. But we do have reason to believe that coronavirus is much deadlier for those infected than influenza: Influenza spreads so widely that it kills about 300,000 people every year, but this is only 0.1% of the people infected.

And yet, despite our complex interwoven network of international trade that sends people and goods all around the world, our era is probably the safest in history in terms of the risk of infectious disease.

Partly this is technology: Especially for bacterial infections, we have highly effective treatments that our forebears lacked. But for most viral infections we actually don’t have very effective treatments—which means that technology per se is not the real hero here.

Vaccination is a major part of the answer: Vaccines have effectively eradicated polio and smallpox, and would probably be on track to eliminate measles and rubella if not for dangerous anti-vaccination ideology. But even with no vaccine against coronavirus (yet) and not very effective vaccines against influenza, still the death rates from these viruses are nowhere near those of ancient plagues.

The Black Death killed something like 40% of Europe’s entire population. The Plague of Justinian killed as many as 20% of the entire world’s population. This is a staggeringly large death rate compared to a modern pandemic, in which even a 2% death rate would be considered a total catastrophe.

Even the 1918 influenza pandemic, which killed more than all the battle deaths in World War I combined, wasn’t as terrible as an ancient plague; it killed about 2% of the infected population. And when a very similar influenza virus appeared in 2009, how many people did it kill? About 400,000 people, roughly 0.1% of those infected—slightly worse than the average flu season. That’s how much better our public health has gotten in the last century alone.

Remember SARS, a previous viral pandemic that also emerged in China? It only killed 774 people, in a year in which over 300,000 died of influenza.

Sanitation is probably the most important factor: Certainly sanitation was far worse in ancient times. Today almost everyone routinely showers and washes their hands, which makes a big difference—but it’s notable that widespread bathing didn’t save the Romans from the Plague of Justinian.

I think it’s underappreciated just how much better our communication and quarantine procedures are today than they once were. In ancient times, the only way you heard about a plague was a live messenger carrying the news—and that messenger might well be already carrying the virus. Today, an epidemic in China becomes immediate news around the world. This means that people prepare—they avoid travel, they stock up on food, they become more diligent about keeping clean. And perhaps even more important than the preparation by individual people is the preparation by institutions: Governments, hospitals, research labs. We can see the pandemic coming and be ready to respond weeks or even months before it hits us.

So yes, do wash your hands regularly. Wash for at least 20 seconds, which will definitely feel like a long time if you haven’t made it a habit—but it does make a difference. Try to avoid travel for awhile. Stock up on food and water in case you need to be quarantined. Follow whatever instructions public health officials give as the pandemic progresses. But you don’t need to panic: We’ve got this under control. That Horseman of the Apocalypse is dead; and fear not, Famine and War are next. I’m afraid Death himself will probably be awhile, though.

Influenza vaccination, herd immunity, and the Tragedy of the Commons

pnrj ethics, market failure, public policy , , , ,

Dec 24, JDN 2458112

Usually around this time of year I do a sort of “Christmas special” blog post, something about holidays or gifts. But this year I have a rather different seasonal idea in mind. It’s not just the holiday season; it’s also flu season.

Each year, influenza kills over 56,000 people in the US, and between 300,000 and 600,000 people worldwide, mostly in the winter months. And yet, in any given year, only about 40% of adults and 60% of children get the flu vaccine.

The reason for this should be obvious to any student of economics: It’s a Tragedy of the Commons. If enough people got vaccinated that we attained reliable herd immunity (which would take about 90%), then almost nobody would get influenza, and the death rate would plummet. But for any given individual, the vaccine is actually not all that effective. Your risk of getting the flu only drops by about half if you receive the vaccine. The effectiveness is particularly low among the elderly, who are also at the highest risk for serious complications due to influenza.

Thus, for any given individual, the incentive to get vaccinated isn’t all that strong, even though society as a whole would be much better off if we all got vaccinated. Your probability of suffering serious complications from influenza is quite low, and wouldn’t be reduced all that much if you got the vaccine; so even though flu vaccines aren’t that costly in terms of time, money, discomfort, and inconvenience, the cost is just high enough that a lot of us don’t bother to get the shot each year.

On an individual level, my advice is simple: Go get a flu shot. Don’t do it just for yourself; do it for everyone around you. You are protecting the most vulnerable people in our society.

But if we really want everyone to get vaccinated, we need a policy response. I can think of two policies that might work, which can be broadly called a “stick” and a “carrot”.

The “stick” approach would be to make vaccination mandatory, as it already is for many childhood vaccines. Some sort of penalty would have to be introduced, but that’s not the real challenge. The real challenge would be how to actually enforce that penalty: How do we tell who is vaccinated and who isn’t?

When schools make vaccination mandatory, they require vaccination records for admission. It would be simple enough to add annual flu vaccines to the list of required shots for high schools and colleges (though no doubt the anti-vax crowd would make a ruckus). But can you make vaccination mandatory for work? That seems like a much larger violation of civil liberties. Alternatively, we could require that people submit medical records with their tax returns to avoid a tax penalty—but the privacy violations there are quite substantial as well.

Hence, I would favor the “carrot” approach: Use government subsidies to provide a positive incentive for vaccination. Don’t simply make vaccination free; actually pay people to get vaccinated. Make the subsidy larger than the actual cost of the shots, and require that the doctors and pharmacies administering them remit the extra to the customers. Something like $20 per shot ought to do it; since the cost of the shots is also around $20, then vaccinating the full 300 million people of the United States every year would cost about $12 billion; this is less than the estimated economic cost of influenza, so it would essentially pay for itself.

$20 isn’t a lot of money for most people; but then, like I said, the time and inconvenience of a flu shot aren’t that large either. There have been moderately successful (but expensive) programs incentivizing doctors to perform vaccinations, but that’s stupid; frankly I’m amazed it worked at all. It’s patients who need incentivized. Doctors will give you a flu shot if you ask them. The problem is that most people don’t ask.

Do this, and we could potentially save tens of thousands of lives every year, for essentially zero net cost. And that sounds to me like a Christmas wish worth making.