Hospital beds

This is Joseph

This is a blog post from 2014 (so it was written long before the current era of covid-19). Note the shrinkage in hospital beds:

In 1990, according to OECD data, the OECD countries had on average 10% more beds per capita than Canada. By 2000, that had increased to 47% more beds.  By 2005, 71% more.  And by 2012, the OECD countries had 78% more hospital beds per capita than Canada.

The same thing is happening in the United States:

The fact is that between 1980 and today, 400,000 hospital beds have vanished from our system while Wall Street financed a bonanza of hospital mergers and acquisitions. Given population growth of 100 million over this period, this means that the number of hospital beds per 100,000 people in the US has fallen by more than half. In 1980 there was 595 hospital bed for every 100,000 people. Today there’s only 281 per 100,000.  

One of the tricky problems with covid-19 is the high level of hospitalization associated with it. The reduction in beds may well look like a short sighted way to decrease costs and increase profits in the scenario where there was any sort of infectious disease. In both Canada and the United States this episode should be a wake up call to do proper capacity planning for medical services.

How we got here repost

Thursday, May 30, 2013

The (ongoing) War on Data

I know we've been through this before, but from the New York Times (via ataxingmatter):

One bill, introduced in the House by Jeff Duncan of South Carolina, would effectively end all surveys by the bureau, except for the decennial census, and even that would be limited to counting noses — a silly interpretation of the census’s mandate. Banning the surveys would make it impossible to compile reliable data on employment, productivity, health, housing, poverty, crime and the environment, to name a few of the affected fields.

This bill would be too wacky to worry about, but its lunacy makes the other know-nothing bill look moderate. That bill, introduced in the House by Ted Poe of Texas and in the Senate by Rand Paul of Kentucky, targets the American Community Survey. Started in 2005 to replace the long-form census, the survey is the indispensable source of information on factors that define American life, including family configurations, education levels, work and living arrangements, income and insurance coverage. Credible information is the basis for a responsive government, an efficient economy and, by extension, a functional society. It also gives American policy makers and businesses a competitive edge, because it encourages decisions based on hard data as opposed to guesses or other faulty rationales that dominate in the absence of credible data.

About three million people receive the survey every year, and, as with the census, answering it is required by law. Mr. Poe and Mr. Rand want to make it voluntary, which would make the results less reliable, and potentially worthless, because fewer people would answer and those who did would not be a representative sample.

Canada recently replaced its mandatory long-form census with a voluntary survey — and now lives with the sorry results. To try to get an adequate level of response, the voluntary survey was sent to one in three Canadians instead of one in five, which increased costs. The response rate plunged anyway, from 94 percent to 68 percent. In a staggering one-fourth of Canadian communities, not enough people responded to make the data usable.

How we got here repost

Tuesday, January 20, 2015

The War on Data Continues

Andrew Gelman and I wrote a piece for the ASA a while back called "The War on Data." It discussed what appears to be a disturbing trend of powerful interest groups trying to discredit and/or defund major sources of important, high-quality data, ranging from the Census Bureau to the National Oceanic and Atmospheric Administration.

Now we can add the CBO to the list. Jonathan Chait spells out the ugly details. You should read the whole thing but here are a few key paragraphs.

The Congressional Budget Office is a 40-year-old institution that has acquired enormous clout within Washington by virtue of its reputation for ideological neutrality. It furnishes Congress and the public with budgetary estimates that, if necessarily imperfect (as all predictions must be), are arrived at fairly. It is also a perfect modern expression of an old Progressive Era–ideal: that policymakers should be informed by the work of impartial experts. That the conservative majority has set out to corrupt this institution as one of its first major acts is, therefore, perfectly fitting.

The old methods CBO used to measure legislation would account for changes in behavior that a new law might create. (Say, higher cigarette taxes would lead to less smoking.) They did not attempt to measure legislation’s impact on the economy as a whole. This is because the two parties disagree completely over what policies make the economy grow faster. Democrats, for instance, believe that tax rates on the rich have little effect on economic growth, but that investing in public infrastructure or education has a lot. Republicans believe the opposite. Congress voted yesterday to require the CBO’s measurement of the budgetary cost of legislation to incorporate assumptions about how it will affect economic growth. Specifically, the GOP's assumptions.
...
The whole reason the Republican Congress is instituting dynamic scoring comes as a response to its attempt to write a tax reform bill last year. The idea was to lower tax rates while eliminating loopholes and preferences. But Republicans discovered that, while lowering rates is easy, eliminating preferences is hard. After Representative Dave Camp produced a tax reform bill that failed to cut tax rates for high-income taxpayers enough for their liking, Republicans abandoned it en masse. Paul Ryan openly declared his plan to change the forecasting rules so that Republicans could cut tax rates without having to pay for every dollar by ending preferences. The first step was kicking out Douglas Elmendorf, the CBO director widely respected by both sides. The second step was yesterday’s vote.
...
The new, “dynamic” CBO will be systematically biased to make conservative proposals appear misleadingly cheap and liberal proposals misleadingly costly to the public fisc. This would be true even if the Republicans were soliciting a fair range of forecasting perspectives. By its design, the dynamic scoring rule allows the party in power to game its effects. It applies “dynamic scoring” only to legislation affecting 0.25 percent of Gross Domestic Product. As Chye-Ching Huang and Paul Van de Water point out, congressional leaders can manipulate this requirement easily: They can break up large pieces of legislation into smaller bills to avoid dynamic scoring, or combine smaller pieces into a major bill, if needed to make their agenda appear more affordable. Dynamic scoring is subject to abuse by its very design.

About to revisit this in a big way

Sunday, November 4, 2012

Strauss and the war on data

The most important aspect of Randianism as currently practiced is the lies its adherents tell themselves. "When you're successful, it's because other people are inferior to you." "When you fail, it's because inferior people persecute you (call it going Roark)." "One of these days you're going to run away and everyone who's been mean to you will be sorry."

The most important aspect of Straussianism as currently practiced is the lies its adherents tell others. Having started from the assumption that traditional democracy can't work because most people aren't smart enough to handle the role of voter, the Straussians conclude that superior minds must, for the good of society, lie to and manipulate the masses.

Joseph and I have an ongoing argument about which school is worse, a question greatly complicated by the compatibility of the two systems and the overlap of believers and their tactics and objectives. Joseph generally argues that Rand is worse (without, of course, defending Strauss) while I generally take the opposite position.

This week brought news that I think bolsters my case (though I suspect Joseph could easily turn it around to support his): one of the logical consequences of assuming typical voters can't evaluate information on their own is that data sources that are recognized as reliable are a threat to society. They can't be spun and they encourage people to make their own decisions.

To coin a phrase, if the masses can't handle the truth and need instead to be fed a version crafted by the elite to keep the people happy and doing what's best for them, the public's access to accurate, objective information has to be tightly controlled. With that in mind, consider the following from Jared Bernstein:

[D]ue to pressure from Republicans, the Congressional Research Service is withdrawing a report that showed the lack of correlation between high end tax cuts and economic growth.

The study, by economist Tom Hungerford, is of high quality, and is one I’ve cited here at OTE. Its findings are fairly common in the economics literature and the concerns raised by that noted econometrician Mitch McConnell are trumped up and bogus. He and his colleagues don’t like the findings because they strike at the supply-side arguments that they hold so dear.

And with Sandy still on everyone's mind, here's something from Menzie Chinn:

NOAA's programs are in function 300, Natural Resources and Environment, along with the U.S. Geological Survey (USGS) and a range of conservation and natural resources programs. In the near term, function 300 would be 14.6 percent lower in 2014 in the Ryan budget according to the Washington Post. It quotes David Kendall of The Third Way as warning about the potential impact on weather forecasting: "'Our weather forecasts would be only half as accurate for four to eight years until another polar satellite is launched,' estimates Kendall. 'For many people planning a weekend outdoors, they may have to wait until Thursday for a forecast as accurate as one they now get on Monday. … Perhaps most affected would be hurricane response. Governors and mayors would have to order evacuations for areas twice as large or wait twice as long for an accurate forecast.'"

There are also attempts from prominent conservatives to delegitimize objective data:

Apparently, Jack Welch, former chairman and CEO of General Electric, is accusing the Bureau of Labor Statistics of manipulating the jobs report to help President Obama. Others seem to be adding their voices to this slanderous lie. It is simply outrageous to make such a claim and echoes the worrying general distrust of facts that seems to have swept segments of our nation. The BLS employment report draws on two surveys, one (the establishment survey) of 141,000 businesses and government agencies and the other (the household survey) of 60,000 households. The household survey is done by the Census Bureau on behalf of BLS. It’s important to note that large single-month divergences between the employment numbers in these two surveys (like the divergence in September) are just not that rare. EPI’s Elise Gould has a great paper on the differences between these two surveys.

BLS is a highly professional agency with dozens of people involved in the tabulation and analysis of these data. The idea that the data are manipulated is just completely implausible. Moreover, the data trends reported are clearly in line with previous monthly reports and other economic indicators (such as GDP). The key result was the 114,000 increase in payroll employment from the establishment survey, which was right in line with what forecasters were expecting. This was a positive growth in jobs but roughly the amount to absorb a growing labor force and maintain a stable, not falling, unemployment rate. If someone wanted to help the president, they should have doubled the job growth the report showed. The household survey was much more positive, showing unemployment falling from 8.1 percent to 7.8 percent. These numbers are more volatile month to month and it wouldn’t be surprising to see unemployment rise a bit next month. Nevertheless, there’s nothing implausible about the reported data. The household survey has shown greater job growth in the recovery than the establishment survey throughout the recovery. The labor force participation rate (the share of adults who are working or unemployed) increased to 63.6 percent, which is an improvement from the prior month but still below the 63.7 percent reported for July. All in all, there was nothing particularly strange about this month’s jobs reports—and certainly nothing to spur accusations of outright fraud.

We can also put many of the attacks against Nate Silver in this category.

Going back a few months, we had this from Businessweek:

The House Committee on Appropriations recently proposed cutting the Census budget to $878 million, $10 million below its current budget and $91 million less than the bureau’s request for the next fiscal year. Included in the committee number is a $20 million cut in funding for this year’s Economic Census, considered the foundation of U.S. economic statistics.

And Bruce Bartlett had a whole set of examples involving Newt Gingrich:

On Nov. 21, Newt Gingrich, who is leading the race for the Republican presidential nomination in some polls, attacked the Congressional Budget Office. In a speech in New Hampshire, Mr. Gingrich said the C.B.O. "is a reactionary socialist institution which does not believe in economic growth, does not believe in innovation and does not believe in data that it has not internally generated."

Mr. Gingrich's charge is complete nonsense. The former C.B.O. director Douglas Holtz-Eakin, now a Republican policy adviser, labeled the description "ludicrous." Most policy analysts from both sides of the aisle would say the C.B.O. is one of the very few analytical institutions left in government that one can trust implicitly.

It's precisely its deep reservoir of respect that makes Mr. Gingrich hate the C.B.O., because it has long stood in the way of allowing Republicans to make up numbers to justify whatever they feel like doing.

...

Mr. Gingrich has long had special ire for the C.B.O. because it has consistently thrown cold water on his pet health schemes, from which he enriched himself after being forced out as speaker of the House in 1998. In 2005, he wrote an op-ed article in The Washington Times berating the C.B.O., then under the direction of Mr. Holtz-Eakin, saying it had improperly scored some Gingrich-backed proposals. At a debate on Nov. 5, Mr. Gingrich said, "If you are serious about real health reform, you must abolish the Congressional Budget Office because it lies."
...                                                                                                                                                                                                                                                                                                                                                            

Because Mr. Gingrich does know more than most politicians, the main obstacles to his grandiose schemes have always been Congress's professional staff members, many among the leading authorities anywhere in their areas of expertise.                                                                                                                                                                                                

To remove this obstacle, Mr. Gingrich did everything in his power to dismantle Congressional institutions that employed people with the knowledge, training and experience to know a harebrained idea when they saw it. When he became speaker in 1995, Mr. Gingrich moved quickly to slash the budgets and staff of the House committees, which employed thousands of professionals with long and deep institutional memories.

Of course, when party control in Congress changes, many of those employed by the previous majority party expect to lose their jobs. But the Democratic committee staff members that Mr. Gingrich fired in 1995 weren't replaced by Republicans. In essence, the positions were simply abolished, permanently crippling the committee system and depriving members of Congress of competent and informed advice on issues that they are responsible for overseeing.

Mr. Gingrich sold his committee-neutering as a money-saving measure. How could Congress cut the budgets of federal agencies if it wasn't willing to cut its own budget, he asked. In the heady days of the first Republican House since 1954, Mr. Gingrich pretty much got whatever he asked for.

In addition to decimating committee budgets, he also abolished two really useful Congressional agencies, the Office of Technology Assessment and the Advisory Commission on Intergovernmental Relations. The former brought high-level scientific expertise to bear on legislative issues and the latter gave state and local governments an important voice in Congressional deliberations.

The amount of money involved was trivial even in terms of Congress's budget. Mr. Gingrich's real purpose was to centralize power in the speaker's office, which was staffed with young right-wing zealots who followed his orders without question. Lacking the staff resources to challenge Mr. Gingrich, the committees could offer no resistance and his agenda was simply rubber-stamped.

Unfortunately, Gingrichism lives on. Republican Congressional leaders continually criticize every Congressional agency that stands in their way. In addition to the C.B.O., one often hears attacks on the Congressional Research Service, the Joint Committee on Taxation and the Government Accountability Office.

Lately, the G.A.O. has been the prime target. Appropriators are cutting its budget by $42 million, forcing furloughs and cutbacks in investigations that identify billions of dollars in savings yearly. So misguided is this effort that Senator Tom Coburn, Republican of Oklahoma and one of the most conservative members of Congress, came to the agency's defense.

In a report issued by his office on Nov. 16, Senator Coburn pointed out that the G.A.O.'s budget has been cut by 13 percent in real terms since 1992 and its work force reduced by 40 percent -- more than 2,000 people. By contrast, Congress's budget has risen at twice the rate of inflation and nearly doubled to $2.3 billion from $1.2 billion over the last decade.

Mr. Coburn's report is replete with examples of budget savings recommended by G.A.O. He estimated that cutting its budget would add $3.3 billion a year to government waste, fraud, abuse and inefficiency that will go unidentified.

For good measure, Mr. Coburn included a chapter in his report on how Congressional committees have fallen down in their responsibility to exercise oversight. The number of hearings has fallen sharply in both the House and Senate. Since the beginning of the Gingrich era, they have fallen almost in half, with the biggest decline coming in the 104th Congress (1995-96), his first as speaker.

In short, Mr. Gingrich's unprovoked attack on the C.B.O. is part of a pattern. He disdains the expertise of anyone other than himself and is willing to undercut any institution that stands in his way. Unfortunately, we are still living with the consequences of his foolish actions as speaker.

We could really use the Office of Technology Assessment at a time when Congress desperately needs scientific expertise on a variety of issues in involving health, energy, climate change, homeland security and many others. And given the enormous stress suffered by state and local governments as they are forced by Washington to do more with less, an organization like the Advisory Commission on Intergovernmental Relations would be invaluable.

You know all those films you've been pretending to have seen?

This might be a good time to check a few off of you list. If you have a library card (and everybody should have a library card), there's a good chance you have access to the online services Hoopla and/or Kanopy. All free.

The first is a pretty good online library. The second is just a streaming service, but for cinephiles it beats Netflix, Hulu and Amazon. While you're sheltering in place, why don't you cross off a few of the films you've been meaning to get around to since college.
































The greatest comedy, period.




I first saw this last one when I was ten or eleven. I was channel surfing and I came across an old movie on the educational TV channel. Had no idea what I was watching, but there was something about the story and particularly the lead actor that sucked me in. It wasn't till years later that I realized what I had seen.

Credit where credit is due (not to mention blame)

It is growing more and more obvious that the propaganda and disinformation from Fox and other conservative media outlets has done tremendous damages, perhaps to the point of legal liability.

"...I've been talking to Fox insiders over the last few days, there's a real concern inside the network that their early downplaying of the coronavirus actually exposes Fox News to potential legal action by viewers who maybe were misled. " —@gabrielsherman https://t.co/KOsSEQvILl

— Jay Rosen (@jayrosen_nyu) March 29, 2020

No one has done a better job reporting on this than Gabriel Sherman and it's important to recognize his work, but it's also important to remember how slow the rest of the mainstream media was to confront Fox and admit how toxic it had become.

Tuesday, May 16, 2017

How things got this bad -- part 4,675

I was digging through the archives researching an upcoming post and I came across a link from 2014. It led to a Talking Points Memo article that I had meant to write about at the time but had never gotten around to.

Since then, we have learned just how much the mainstream media was covering for Roger Ailes. Ideological differences proved trivial compared to social and professional ties and an often symbiotic relationship. We have also seen how unconcerned the mainstream press (and particularly the New York Times) can be a bout a genuinely chilling attack on journalism as long as that attack is directed at someone the establishment does not like.

It was a good read in 2014, but it has gained considerable resonance since then.

From Tom Kludt:

Janet Maslin didn’t much care for Gabriel Sherman’s critical biography of Roger Ailes. In her review of “The Loudest Voice in the Room” for the New York Times on Sunday, Maslin was sympathetic to Ailes and argued that Sherman’s tome was hollow. But what Maslin didn’t note is her decades-long friendship with an Ailes employee.

Gawker’s J.K. Trotter reported Wednesday on Maslin’s close bond with Peter Boyer, the former Newsweek reporter who joined Fox News as an editor in 2012. In a statement provided to Gawker, a Times spokeswoman dismissed the idea that the relationship posed a conflict of interest.

“Janet Maslin has been friends with Peter Boyer since the 1980’s when they worked together at The Times,” the spokeswoman said. “Her review of Gabe Sherman’s book was written independent of that fact.”

Don't make me invoke Liberty Ships again

Picking up (in a slightly less pissed-off mood) from Monday's rant.

Everyone by now knows that, we need to both flatten the curve and raise the line, to slow the spread while increasing the capacity of our healthcare system. We've gotten better about discussing the first, but it's more difficult to find sober, realistic discussions of the second.

Fortunately, we can count on Talking Points Memo.:

[Jeffrey Bialos is a partner at Eversheds-Sutherland, a global law firm. He previously served as Deputy Under Secretary of Defense for Industrial Affairs and as a member of Secure Virginia, the state’s homeland security advisory board.]


The simple fact is that the DPA, together with U.S. contracting capabilities and funding, can be utilized to methodically plan short, medium and long term solutions to health supply needs that can more quickly enable the country to return to some semblance of normalcy.

First, the President invoked some DPA powers – to prioritize and allocate production but said he only planned to use it in a “worst case” scenario. Yesterday, he authorized additional DPA powers – to incentivize businesses to expand capacity through loans and other measures and voluntary industrial agreements as needed. 

But, other than with respect to a single company, the President has steadfastly declined to use the authorities he’s invoked in any type of holistic way. All signs point to the refusal being driven perhaps in part by an ideological desire to rely on our private sector’s historic ability to step up and meet market needs without the government’s heavy hand. The President himself has raised the spectre that the DPA could result in the nationalization of industry – which has no basis in fact.

Indeed, the business community has lobbied against the use of the DPA, with the Chamber of Commerce raising the red herring that the United States would be in violation of its World Trade Organization requirements. This ignores the fact that the WTO has an “essential security” exception that surely can be invoked in this crisis situation. The Chamber’s assertion that the use of the DPA would somehow break up global supply chains also seems specious. The point here is to use the DPA to increase global volume and take the pressure off supply chains, and not disrupt them.

Volunteerism by industry is admirable and perhaps can help address the underlying health shortfalls at the margin. But, let’s be frank about it. The ad hoc reach-outs by White House advisors like Peter Navarro to underwear companies and other willing volunteers is no substitute for a serious industrial mobilization under the DPA. This type of ad hoc approach is at best likely to be only partially effective and at worst create false expectations and foster belief that the problem is being addressed when it’s not. And, worst of all, we run the risk of not knowing that the voluntary approach didn’t work until it’s too late.

In short, the answer here is clear. The administration needs to rapidly assemble an interagency team outside of the White House with the right experience, drawing on Health and Human Services for its health expertise, FEMA and the Department of Defense for their contracting expertise in exigencies (FEMA in natural disasters, DOD in setting up rapid equipping programs during the wars in Afghanistan and Iraq), and other relevant departments and agencies.

Tuesday Tweets -- Epitaph for a hack.

The reactions to Isaac Chotiner's interview Richard Epstein. This picks up our ongoing conversation about how conservative movement financing subsidizes and undermines the discourse (in this case through the Hoover Institution).

We'll start off with Hizoy's detailed take-down.

Richard Epstein, with the same genius for self-preservation that led him to publish his views on how we should respond to a pandemic despite his lack of expertise, has agreed to be interviewed by Isaac Chotiner.

The results are what you'd expect. https://t.co/uE005TLsk3

— hilzoy (@hilzoy) March 30, 2020

14/ Really. Biologists somehow overlooked the evolutionary component?

Sort of the way economic modelers so often overlook supply and demand? And geologists forget to take account of tectonic drift? Seriously?

— hilzoy (@hilzoy) March 30, 2020

What an incredible interview. https://t.co/CjKtOG0geW I'm not going to characterize it beyond that. Recommended. A lot.

— Jay Rosen (@jayrosen_nyu) March 30, 2020

https://twitter.com/junkcharts/status/1244667520931500035?s=20

One consequence of a fact-free presidency is that the entire evidence-based world lines up against it. That tempts learned people of a contrarian bent to conclude "must be wrong." The more resistance they get, the more certain they feel. Watch it play out. https://t.co/CjKtOG0geW

— Jay Rosen (@jayrosen_nyu) March 30, 2020

Always good when things take this turn: "You just don’t know anything about anything. You’re a journalist. Would you like to compare your résumé to mine?" https://t.co/j2Ufhbk2Rs via @NewYorker

— Chris Shea (@cshea4) March 30, 2020

“I’m happy to say” https://t.co/ZQ0rGheyIv

— John Harwood (@JohnJHarwood) March 30, 2020

"I’ve worked on evolutionary theory for forty years in its relationship to law." https://t.co/bBqV40ZUBt via @NewYorker

— Josh Marshall (@joshtpm) March 30, 2020

By any rational standard this should be the epitaph or perhaps the death warrant for a generation of law and economics types. (And yes, I know there are more subtle, intelligent version of it. But a lot of it is this.) pic.twitter.com/Bq28VNa5fR

— Josh Marshall (@joshtpm) March 30, 2020

We don't need another hero -- all those stories about 3d printing N95s and DIY masks are doing more harm than good

Blogger ate the post that was supposed to run this morning, so here's a quick rant so I can vent.

You know all of those stories about clever and inspiring workarounds to medical equipment shortages? Engineering team invents new ventilator, local resident uses 3d printer to help local hospital, grandparents volunteer to sew surgical masks. They are hopeful stories, they make you feel good and they need to stop.

We have, as a culture, become enamored of the trivial non-solution. Something interesting to talk about while giving us an excuse to put off what we need to do. In this case, we need to start producing tens of thousands of ventilators, millions of pieces of protective gear for health care workers and billions of cheaper surgical masks and gloves for the general public. We need to do it now. Any plan or suggestion that doesn't approach that scale is a dangerous and self-indulgent distraction.

This is the country that put out three Liberty Ships every two days. We are capable of filling warehouses with cheap plastic goods.

"1001 Albums You Must Hear Before You Die"

Since most of us are lock in to varying degrees, this seems like a good time to expand our musical horizons.

I've been chipping away at 1001 Albums You Must Hear Before You Die  over the years, focusing on albums I'd missed (or thought I'd missed -- turns out that I'd heard a lot of George Clinton in college).

Green Day - American Idiot is a little on the nose for this moment, so here's something a bit cooler for the weekend.

Check here for the complete list.

And a plot twist we should have seen coming

You may have noticed an uptick in the bullshit coming from the recent press briefing (a situation that's gotten so bad that there's a heated journalistic debate over the ethics of broadcasting them at all). It's a combination of medical pseudo-science, arrogance, and obliviousness. Where could something like that be coming from?

Let's ask Gabriel Sherman:

Sources say that Trump is leaning toward telling at least some Americans to return to work after the 15-day social-distancing period ends on March 31. This puts Trump on a potential collision course with Fauci that many fear will end with Fauci being fired or quitting. “Fauci is the best medical expert we have. We can’t lose him,” a former White House official said. Signs of tension between Trump and Fauci have been emerging. Over the weekend, Fauci gave a series of candid interviews. “I’ve been telling the president things he doesn’t want to hear,” Fauci told Maureen Dowd. “I have publicly had to say something different with what he states. It’s a risky business.” Fauci told Science magazine: “When you’re dealing with the White House, sometimes you have to say things one, two, three, four times, and then it happens. So, I’m going to keep pushing.”

Trump’s view that he can ignore Fauci’s opinion may be influenced by advice he’s getting from Jared Kushner, whose outside-the-box efforts have often rankled those in charge of managing the crisis. According to two sources, Kushner has told Trump about experimental treatments he’s heard about from executives in Silicon Valley. “Jared is bringing conspiracy theories to Trump about potential treatments,” a Republican briefed on the conversations told me. Another former West Wing official told me: “Trump is like an 11-year-old boy waiting for the fairy godmother to bring him a magic pill.” (The White House did not respond to a request for comment.)

What executives? Well, for starter, there's ...

Worth noting that Larry Ellison's previous medical research work — his foray into life-extension research, on which he spent hundreds of millions of dollars — is broadly seen as a scientific failure.

— Teddy Schleifer (@teddyschleifer) March 25, 2020

 
What Ellison's disruptive visionary attitude here appears to be popular among his fellow tech billionaires. Elon Musk suggested the virus would turn out to be no worse than a bad cold, but the funniest exchanges have been coming from another member of the PayPal Mafia, Keith Rabois.

randomized controls are horrible ideas. largest impediment to progress in health spans.

— Keith Rabois (@rabois) March 25, 2020

It's possible that Keith Rabois is the dumbest, most over-confident piece of shit VC in the US today.

This kind of stuff is dangerous and wrong.

This is basic stats. If you don't randomize, you can't be sure the intervention you're testing actually drives the outcome. https://t.co/NkDXEF2JaP

— Zach Weinberg (@zachweinberg) March 25, 2020

with very large numbers of n’s you don’t need randomization.

— Keith Rabois (@rabois) March 25, 2020

at some level of n, you avoid bias because of the real world. that is the whole point. in cardiology, there is a vigorous debate about whether statins induce memory loss even though no double blind study has confirmed it.

— Keith Rabois (@rabois) March 25, 2020

Rabois, of course, had a sharp comeback for his critics

that is utter nonsense. someone is obviously jelaous of my success.

— Keith Rabois (@rabois) March 25, 2020

Quick hit

This is Joseph

I can only hope that these sources are wildly incorrect:

Two sources close to the White House tell Sherman that Trump increasingly feels that “he can ignore Fauci’s opinion” because Kushner has been telling him about experimental coronavirus treatments he’s been hearing about from Silicon Valley entrepreneurs.

It is also a good time to recall why Jimmy Carter had to sell his peanut farm, as Josh Marshall notes:

 Yet here we are even having a discussion of “getting back to work” because the President is antsy after about a week of lockdowns in some parts of the country and is hearing from friends that the economic downturn could cost him reelection and (though we haven’t talked much about this) could drive him into personal bankruptcy. 

 But there is a real issue here with a president facing severe economic penalties and a lack of high quality advice. It is not that non-experts cannot be important voices. But would you want a car mechanic to debug software? Or a software engineer to repair a car? In a high stakes and high pressure situation?  Sure, it might occasionally work out, and the outsider might have important perspectives, but there is a lot of trial and error in jumping to a new field that maybe isn't ideal in a pandemic.

A way forward as the present becomes the future

This is Joseph

Mark and I have often talked about next steps in covid-19. It's an active area of correspondence between us. One area of frustration that I have is how the messaging is always focused on the current crisis and not the problems coming next.

For example, masks. Early on in the epidemic we were told masks did not help:

The simplicity of those recommendations is likely unsettling to people anxious to do more to protect themselves, so it’s no surprise that face masks are in short supply—despite the CDC specifically not recommending them for healthy people trying to protect against COVID-19. “It seems kind of intuitively obvious that if you put something—whether it’s a scarf or a mask—in front of your nose and mouth, that will filter out some of these viruses that are floating around out there,” says Dr. William Schaffner, professor of medicine in the division of infectious diseases at Vanderbilt University. The only problem: that’s not effective against respiratory illnesses like the flu and COVID-19. If it were, “the CDC would have recommended it years ago,” he says. “It doesn’t, because it makes science-based recommendations.”

Now the CDC says surgical masks can replace N95 masks under these dire conditions. Not only did the messaging backfire by reducing trust in government, it made it necessary to change messages.

The newest (correct) narrative is that we need to preserve masks for health cure workers in the current crisis. This is, unfortunately, completely correct. They bear extreme risk curves and this equipment is necessary to engage in patient treatment and to preserve the existing work force. The desperate circumstances in the hospitals is an ongoing emergency. Target even apologized for putting masks out for sale -- things are so desperate markets don't work.

But what comes next is what I want to talk about. Some studies suggest social distancing may last 18 months based on an Imperial College report. Countries like the US have invoked things like the defense production act.

But the real key will be the cost of distancing for the poor and disenfranchised. Right now there is a lot of goodwill. Rent is being forgiven or extended. Mortgages will be increased. But even if we halt evictions for the full 18 months, there are going to be some brutal social costs. In the US health insurance is linked to employment, and some small businesses will simply not be able to stay open for 18 months without revenue. People living in small apartments with 5 roommates will be in for a tough time. And most cities lack enough green space for half the population to be outside with appropriate social distancing.

So what else can we try?

Well, the goal of social distancing is to reduce the rate of transmission and flatten the curve. Do you know what else would do that? Compulsory mask wearing when outdoors. Preferably a properly fitted N95 mask.  With big fines for not being masked, training sessions on mask fitting, and free masks for all.

Could this be done?

Well, if it really is going to be 18 months we can make more. Current supplies are pitiful. But we are heading into a recession with a whole bunch of soon to be unemployed workers. What about making more? A lot more?

In the short run this will stop the tragic shortages at hospitals, which are getting worse before they get better. In the medium term this will let us ease some of the restrictions and permit a limited amount of public space use with lower transmission rates. Remember, they aren't magic and there will still be some transmission -- the goal is to lower R0 so that we can control the epidemic and eventually starve it of hosts.

And it is clear medical masks work. Here is a cluster randomized trial of cloth masks versus medical masks in Vietnam looking at respiratory infections.

The control group was wearing masks occasionally:

After providing informed consent, 1607 participants were randomised by ward to three arms: (1) medical masks at all times on their work shift; (2) cloth masks at all times on shift or (3) control arm (standard practice, which may or may not include mask use). Standard practice was used as control because the IRB deemed it unethical to ask participants to not wear a mask.

So consistent mask use seems to help with respiratory illness, relative to only using them for high risk. Now, to be clear, obviously in the face of a shortage they need to be rationed for health care providers. My question is: why don't we alleviate the shortage with increased production?

In the long run I am betting on the biomedical community succeeding with one or more of the multitude of vaccines under development (wikipeda tracks 30), with at least one in phase I trials. There are successful coronavirus vaccines in dogs and something in cats, although the research leaves questions I would want answered in a human trial.

There is more here, about tests and about mitigating long term impacts, but this post is long enough. Maybe a sequel?

Tuesday Tweets -- the plot twist we didn't see coming

Though, in our defense, it was one of those logic defying twists.




Over the weekend, we started hearing indications of a policy shift.

Every group of doomed idiots in countless horror movies had a better plan than this. https://t.co/mUXl5LGTh6

— Richard Roeper (@RichardERoeper) March 23, 2020

Trump supporters, who had only recently made the jump from hoax to Chinese plot, fell into line (you really have to listen to this).

What's extraordinary here is the framing. "We can't lose our whole country" https://t.co/R0e309JvcF

— Mark Palko (@MarkPalko1) March 24, 2020

Interestingly, in China people have expressed similar pride in the self-sacrifice they’ve undertaken during the coronavirus pandemic — but that sacrifice was to self-quarantine for weeks, not to return to business as usual.

— Felicia Sonmez (@feliciasonmez) March 24, 2020

Researchers pointed out the potential health care disaster.

In last 24 hrs there've been prominent US voices calling for a stop to social distancing, citing rationale that they're worse than impact of COVID itself. It’s worth looking very closely at that claim, where we are in US COVID epidemic and what happens if we stop. 1/x

— Tom Inglesby (@T_Inglesby) March 23, 2020

Even sane conservatives pointed out that less containment might cause even more damage to the economy.

The truly soul-shaking thing about it is nobody has the evidence they'd need to be justified in the belief that easing up on containment to keep the economy humming now won't just make the economy even worse later, amidst the mass death. But it's a gamble they're willing to take?

— Will Wilkinson 🌐 (@willwilkinson) March 24, 2020

There is no functioning economy unless we control the virus.

— Lindsey Graham (@LindseyGrahamSC) March 23, 2020

While others pointed out that easing the lock down wasn't really Trump's call.

I don’t really understand this discourse around Trump and reopening the economy ... the federal government didn’t order anything closed in the first place, it’s all state/local.

His contribution has been spreading misinformation and foot-dragging on boosting PPE production.

— Matthew Yglesias (@mattyglesias) March 23, 2020

 
Nor does this seem like a policy that will go over big with the base.

The median age of a prime-time viewer was 68 as of 2015.

Employment under covid-19

This is Joseph

While we are all quarantined, it may be time to start thinking about long term economic impacts as well. Look at this amazing chart:

This is a very atypical recession. There is no moral hazard involved as these people are losing their job to a pure external shock. But the risk that this will blossom into something worse is worth considering, especially if the epidemic lasts for a while. Schools and universities (and daycares!) are currently closed for months. This will impact hiring and employment. It is hard to job search while you are social distancing and economic activity is down. These numbers are unimaginable when compared to normal times:

Government of Canada has received 500,000 applications for Employment Insurance this week, PM Justin Trudeau says. That compares to 27,000 for the same week last year.

The time to be considering these consequences, and how to mitigate them, is now. We are so far outside the range of previous data that we should be thinking carefully about heroic measures and not hoping that normal measures will work.