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Happy Birthday, Matt!

(he posted it on Twitter)

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The article linked for Covid being leading cause of death in under 55 actually says “leading medical cause of death”, which is different. I was trying to reconcile it with the big NYT feature, which said amongst other things that more under 25s died of car accidents than Covid.

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Wow, an important clarification, thanks!

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I'm not sure that's an important clarification - see my comment below with some numbers. I'm thinking that "medical cause of death" means "cause of death as registered on a medical record".

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If so then you'd be right!

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May 18, 2022·edited May 18, 2022

I was also bothered by this and would love to see an edit to clarify the weasel word. They also play around with percentage increases between tiny numbers and huge numbers; if usually 30 people die and this year 40 died, that was a massive 33.3% increase, but if 300,000 people typically die and this year 378,000 died, that is ONLY a 26% increase.

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Car fatalities are probably about equal for people under 25 and people 25 to 55 (maybe slightly higher for the younger people, who both walk more and drive more recklessly when they drive). COVID fatalities are probably ten times as high for people 25 to 55 than people under 25, so it makes sense that it could be the leading cause of death for the entire age range, but not for the young end.

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I agree and so read the linked article and it doesn’t say leading cause of death for under 55, it says leading medical cause of death.

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The article isn't loading for me, but I'm not sure what "leading medical cause of death" means. I believe that somewhere between 30,000-50,000 Americans of all ages have died of car crashes each year for most of the last few decades.

I found covid deaths stratified by age here: https://data.cdc.gov/widgets/9bhg-hcku?mobile_redirect=true

It looks like 66,000 Americans age 45-54 died of covid over the past two years, so that age range alone probably contributes about as many covid deaths as *all* traffic fatalities during the past two years. There's another 27,000 covid deaths age 35-44 over the past two years, and another 11,000 age 25-34, and 2,600 age 15-24, and 474 age 0-14.

I found a site that claims to have traffic fatalities by year stratified by age: https://injuryfacts.nsc.org/motor-vehicle/historical-fatality-trends/deaths-by-age-group/

It looks like in 2020, there were 1300 deaths age 0-14, 6,900 age 15-24, 14,000 age 25-44, and 12,000 age 45-64. It does look like traffic fatalities dominate over covid deaths for ages under 35 (though for 25-34 the two seem pretty close), but covid fatalities dominate over traffic deaths for age 45-54 by a huge amount, and probably age 35-44 as well.

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Leading medical cause of death excludes accidents, homicides, suicides, overdoses. The article is focused on 2021 (post vaccine) and cites ~30,000 deaths in the 45-54 age group from Covid against ~26,000 from accidents, with the lower ages having more deaths from accidents than Covid.

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Thanks for that clarification! (I'm not sure why the link isn't working for me.)

I suspect this classification of "accidents" includes things like falls from roofs and ladders, accidental discharge of firearms, and many other things, while I'm used to seeing "traffic fatalities" as a separate category, which I guess makes me realize that it's really not clear how to count something like this as a "leading cause of death", since splitting and lumping can make such a big difference. (For 2019, it looks like "unintentional injuries" are the leading cause of death for each age range below 45, is third for age 45-64, and sixth for higher age ranges. But since traffic fatalities are less than a fifth of all unintentional injuries, they might barely make the top 5 for people below 25, top 10 for age 25-44, and not even be top 10 for older groups: https://www.cdc.gov/nchs/data/nvsr/nvsr70/nvsr70-09-508.pdf )

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Yup absolutely there’s a huge discretization problem.

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Dems gave all the money to state and local governments because they were fighting the last war. The continuous shedding of state and local jobs in the Great Recession was a huge drag on the economy. It's just they were very wrong about that happening this time and don't want to admit it.

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Correct, although I would expect Matt to have more sympathy here given how few people foresaw that this time would be different. I mean the private sector also expected a big recession - and scaled down production, leading to supply chain issues.

Plus there were reasons to think that the widely-expected COVID recession would be even *worse* for state and local governments than previous recessions. They faced a lot of additional public health expenses, and for those reliant on sales taxes everyone expected that lost restaurant and hotel revenue would be a disaster.

That was all reasonable to think at the time, and basically nobody was saying "actually it's going to be a rapid v shaped recovery with a huge spike in demand for goods and a housing price boom that floods local governments with property tax cash."

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This was definitely true in early 2020. It was arguably true when the aid was included in the HEROES act in October 2020.

But by early 2021 when ARP passed a lot of people were saying some version of your quote below. Local & State governments had already reported fiscal 2020 finances.

ARP suffered from the fact that it was just the HEROES act but not updated to account for changes in circumstance between 10/20 and 2/21

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I was trying to figure out whether localities had the same recovery that states did. The bill was always about state and local governments, but all the articles saying it was unnecessary were about state governments. Some localities are extremely dependent on sales taxes and I expected those to be under stress even as states recovered due to income taxes.

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I work primarily with Midwest local governments, so maybe there is regional variation that I'm not seeing in my work, but pretty much every local government I work with had basically no impact to revenue generators (property tax, sales tax, utility revenue, etc) and ended up with way more money than they typically would because of all the federal funds.

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That's good to know! I guess I saw the big sales tax hits in early 2020 and assumed they had continued in many places for the rest of the year, but I guess I didn't appreciate how much purchases of durable goods made up for reduced bar and restaurant revenues (and, I guess, it's possible that bar and restaurant revenues didn't actually decline much outside of big cities).

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And just to add: "let's deny likely desperately needed federal money to state and local governments because it might benefit our political opponents" would have been a pretty deplorable position at the time. So it's not right to apply that as the standard in retrospect.

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And to backfill some of the looming state and local pension crisis in places like New York and Illinois, where taxes have been going up and up and up and still don’t handle the burden.

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"It is true that if everyone had the same values, preferences, and worldviews as public health academics, public health outcomes would improve." But at wat economic cost?

We don't hire public health officials for their values, preferences and worldviews -- they are as entitled to them as anyone else -- we hire them to give individuals and policy makers information about the time and space varying trade-offs of the spread of infections and their consequences with different interventions -- NPI, vaccines, antivirals, etc.

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Academic Public Health is very much populated by people with the sort of upper class very left wing politics that get laughed at outside of academia. Because those departments can be such echo chambers they often aren’t even able to accurately assess trade-offs for policy.

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Probably so, but the kind of reporting I'd like to see would be more detailed about the specific decisions

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I guess the problem is that the policy makers didn't seem to be taking public health official's recommendations and then balancing them very well against public opinion.

Instead they effectively just said 'Believe in science' and pointed to the recommendations directly.

And strictly following the recommendations was never going to happen, due to the economic costs and, frankly, just the annoyance it would have entailed.

Which just led a substantial part of the country to just view the public health experts as out-of-touch eggheads, and become even more skeptical of their advice. Or to embrace ridiculous conspiracy theories.

I don't really blame public health officials for this, so much as the other govt officials/elected representatives that didn't do their job of balancing their recommendations against other public interests.

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May 18, 2022·edited May 18, 2022

If there is one thing you should really be upset with public health officials for, it was their call that everyone should still be cooped up in their homes in June 2020 unless you were protesting against police. Public health officials lost all credibility with the conservative side of the country at that point, and there was nothing they could do to get it back.

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Remember when outdoor protests agains lockdowns were supposed to be super spreader events?

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My memory is that this was about protests *inside* the Michigan capitol building, and that this was a main difference for the George Floyd protests, since they were mostly outdoors.

Then again, that first year had no shortage of news articles shaming beachgoers (though I don't know what actual public health people said about the beach at that time).

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I blame public health officials for not using their moral authority to champion what normal things people could still do. It seemed like they never actively promoted anything other than maximum precaution, even as it became apparent that certain things like outdoor restaurants or playgrounds were not that risky. They should have been promoting those things, and using their authority to put the covid hawks who trust them at ease about those things. They should have been promoting normalcy wherever they could. Their advice always went only one way. If it had gone both ways, I think they would have had more credibility with the covid dove half of the population.

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Entirely agreed.

I do wonder if this is just something that will be inherent to our more safety-focused bureaucracies though.

I've worked as a safety engineer, and noticed that all the structural incentives in that field are orientated towards a kind of CYA 'if in doubt, assume it is safety critical' posture.

The job/responsibility of arguing against safety (based on cost/benefit) is passed up the food chain, but no one there wants to accept responsibility for that either, so you just wind up with a system that maximizes risk avoidance to a frankly absurd degree.

I suspect that something similar is happening with these bigger federal bureaucracies.

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"Safety first" is a pithy statement that becomes a bottomless well of insane policy, procedure, and behavior if you accidentally take it literally.

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Similarly, they should have discouraged mitigation practices that had little to no benefit, like wearing masks while alone outside. They had the moral and scientific authority to do that and they didn’t. The result is that such behavior was “normalized” and is now harder to reverse. I speak as a frustrated resident of a blue area where people are still wearing masks everywhere inside and out, voluntarily. Putting on your mask when you leave your house, as a way of life, just seems perfectly normal to them. I get that people should be allowed to wear masks if they want to, but every time somebody wears a mask, they are sending a message to those around them “you should be doing this too”.

The public health authorities should have promoted mitigation up to the point of diminishing returns and discouraged it beyond that, for the sake of normalcy.

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The benefits of being outdoors was something that was scandalously underrated.

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The economic costs could be, and were, effectively offset for a period of time. I'll remain torn on the mechanisms involved, and we obviously overshot, but as an argument against lockdowns and social distancing there are definitely holes there. If it were important enough, in the future we know we can mostly wall off essential production and hold down the fort without everything imploding. We also know that folks will take things into their own hands when they feel unsafe, so the economic knock-on effects will happen in greater or lesser measure anyway.

What drives me up the wall is that a significant fraction of the COVID Warriors still will not admit the grave *human* costs of social distancing. Most especially in that they refused to hold a gun to the teachers' unions heads and say "do your damned job or starve on the street." like we did to all other essential workers.

And now we have vast upticks in violence across basically all age cohorts, demographic groups, and locales, hordes of depressed children and teenagers (not to mention adults), a year-long developmental gap in language and non-language communication in toddlers, even more yawning achievement gaps between the school-age children of the rich and poor, completely shattered trust in public schools, which are the key leveling institution in the nation...

The next time this comes around, unless the CFR for prime-age adults or children passes 3%, I'm going to laugh at the public health people, put my kid in an in-person private school, and go wherever and see whomever the fuck I want from day one.

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On a variety of issues, I find myself increasingly attracted to Singapore's "Pay public servants enough to entice the best of the private sector and *flog them in public when they fuck up*" model.

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Oh I see it to in schools. The masks though are coming off even the most diehard kids though. The ones wearing them now are not really afraid of Covid they just have kids' angst about how they look, and it is a conveinant way to deal with this.

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I do blame public health officials for lying about the efficacy of masks early on, in an attempt to prevent people from panic-buying the limited stock of masks.

And then doing an about-face a little later, which caused a lot of people to distrust them.

They had good intentions, but they did lie to the public and it came back and bit them.

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They weren’t so much lying about the efficacy, they were making the somewhat ridiculous argument that only a health professional understands how to wear a mask in hopes that would persuade people to let health professionals have the few effective masks available. The mass f*** up at the heart of it all was (a) not thinking to have a strategic stockpile of ppe in case of respiratory pandemic and (b) sending what we did have to China (where all our stuff was made!) in hopes it would go away like SARS-1 did. The cloths masks were an understandable seat-of-the-pants attempt to provide some protection while real, effective masks could be sourced, but unfortunately the free market and fashionistas made it a ubiquitous product that people kept using even when real, effective masks became easily available. For too long the CDC kept up the “N95s for health professionals only” when encouraging everyone to wear effective masks (even the 4-layer surgeons masks) could have eased the burden on health professionals.

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It wasn't so much a lie as I understand it, but the muddled message on boosters last fall was far worse in my book.

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It was a straight up lie. Besides, it would be worse if it wasn't. Imagine how insanely incompetent they would need to be to not understand something so simple.

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I do blame public health officials for not being clear on the relative benefits of various interventions. If there were an honest conversation about how much spread occurs in different circumstances, maybe some places would have closed bars but not schools.

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In a lot of places, jurisdiction over bars vs. schools were held by two different governments, which goes back to one of Matt's hobbyhorses of independent school districts being bad. Schools also tend to be far more unionized than bars, thus throwing another wrench into the gears.

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And because of this, let's be frank, outright dishonesty, next time we will close neither even if it is truly indicated.

We're all going to be falling back on "doing our own research". I just hope my own ability to parse data and heuristics for understanding it are the *right* ones come 2034 or whenever.

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As long as we're re-litigating the past, let's point a finger at the former president. When the country could have used a calm messenger highlighting flexibility, data collection, and decisive action, we got in many cases the exact opposite.

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A lot of people missed the presentation in the briefing about how quicky COVID was destroyed outdoors in sunny, breezy environments, because that was the briefing where the President suggested people drink disinfectant.

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Sure. I would not let politician off the hook, either. But PH officials should have been giving contingent information and emphasizing that it was contingent on ongoing research about the properties of the disease and the actual course of the disease by locality, percentage of people vaccinated, etc.

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"The great under-appreciated irony of 2020 is that progressives simultaneously took a sharp move to be much more skeptical of heavy-handed enforcement of rules while also wanting a bunch of new rules."

Under-appreciated in some quarters, maybe, but not here in Slowboringland!

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"...the need for public health academics to reconcile themselves to things like the existence of public opinion and electoral democracy."

Except that the source of the resistance to sound public health advice was not "public opinion" or "electoral democracy" in the abstract.

After all, there was plenty of both those things in America when we rolled out the campaigns to eliminate polio and small pox. There has always been plenty of public opinion and electoral democracy when kids lined up every year for their shots at school and new recruits got their shots at basic training.

What you are white-washing under the benign names of "public opinion" and "electoral democracy" is something very different: a coldblooded campaign of lying and deceit for the sake of partisan gain, undertaken with the knowledge that it would kill many extra thousands of people.

It did not have to play out this way: nothing about "the existence of public opinion and electoral democracy" mandated that grifters and monsters should rev up the QAnon machine and turn it into a campaign to kill Americans. That's on Fox News and the Republicans. Name them specifically, don't help their deceit by waving vaguely at "public opinion" and "electoral democracy".

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It seems the "my body, my choice" adherents cross party (and racial) lines, depending on the topic at hand.

Rather than the grifters and Fox, I suspect the vaccine resistant people are driven more by either a libertarian / anti-authoritarian streak or a deep-seated mistrust of government health programs. Looking at the data around vaccination status, the two groups who are less vaccinated are Black Americans and hard-core Trump supporters. I don't think this fits nicely into solely a partisan framework, though that clearly has had an influence.

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Pre-covid, I think there were four identifiable classes of anti-vaxxers:

--the religious right who feel it's against God's will

--the hippie left who think unnatural Big Pharma's exploiting us again

--the paranoid libertarians who think government's trying to control us

--the disadvantaged minorities who feel they're been used as guinea pigs again

All four of those have some sort of deep-seated distrust as you say, but also as you say these are four pretty ideologically divergent worldviews.

And then in all of this, that new group of partisanship got thrown into the mess.

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I think they’re actually driven by needle-phobia and pass it off as something else more socially acceptable, like conspiracy theories.

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The amazing/disturbing part of your comment is your (correct I think) understanding that conspiracy theories are more socially acceptable than needle-phobia.

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Has anyone been able to successfully study how much needlephobia has factored in? This is something I do agree is a factor but I haven't yet gotten a satisfactory answer as to how much.

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I really want someone to design a good study for this! It seems hard, because many people probably don't even admit to themself how relevant it is. I suspect it doesn't help that everyone with medical training spent many years desensitizing themself to this sort of thing, so they're just not used to interacting as peers with anyone who has any residual reaction.

I've been part of a longitudinal study about health during covid, and on three occasions they've sent me a kit of a spring-lancet to pierce my finger and a card that I needed to fill five spots with blood so they could test my antibodies. The first time it was extremely difficult to do this (and it didn't help that I have low blood flow so I failed to successfully produce enough blood even after sticking a couple fingers). But even by the third time it was no longer a challenge, and I bet it's hard for medical professionals to remember how tough a needle is for people who aren't used to it.

I thought this op-ed a year ago was helpful, though it's short on relevant statistics (for the reason that they are hard to come by): https://www.nytimes.com/2021/05/21/opinion/needle-fear-vaccine-covid.html

It definitely hasn't helped that for a year and a half, every TV segment about vaccines is illustrated with stock video of people being injected.

I think this is a vastly under-appreciated additional benefit for a nasal spray vaccine: https://www.nytimes.com/2022/05/16/opinion/covid-nasal-vaccine.html

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I would love to see a study on that! I suspect it would be hard because it’s kind of embarrassing to admit that you’re afraid of needles but it is worth it. There’s a reason many anti vaxxers have graphics of a tiny baby with a bunch of big needles pointed at it.

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And every stupid "get vaccinated!" ad that included a needle about to, or actively being plunged into someone's arm was a completely needless own-goal. So dumb.

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I would test this with an in-person study, ask them how they feel about vaccine and then check out how many tattoos they have.

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May 18, 2022·edited May 19, 2022

This is an intriguing idea. Did it come from Katja Grace or have multiple people converged on it independently?

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I don't know that I've read anything by her, but I have heard her name mentioned in connection with various covid theories (whose details I can't remember), so I can't confirm that I came to this idea fully independently from her.

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I was wrong, the idea is actually from Matthew Barnett responding to Katja: https://www.lesswrong.com/posts/cvNvfdibC3qa6PYBt/does-needle-anxiety-drive-vaccine-hesitancy

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But it's not only Republicans, right? I bet many Democrats continued wearing cloth masks even after better options became widely available, or went out for drinks in enclosed spaces.

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"I'm vaccinated and now I'm done with this shit" is a purple population that is so under-represented in the Twitter Discourse, etc. that it might as well not even exist.

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"I'm vaccinated and have enough of a science background to understand there are no more miracle pharmacological interventions waiting in the wings, so if I can't live somewhat normally now, I never will be able to."

Too specific a basket?

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There was never good messaging about better masks. Even though I abstractly knew that N95s were far better than cloth masks, I somehow didn’t end up wearing an N95 even once until omicron. At academic events I go to, about half of people are wearing surgical or N95 but half are still wearing cloth. Interestingly, when I went to Canada for a couple conferences in the past few months (one of which I got COVID at), I noticed that even people on the street were mostly wearing surgical or N95, and it was basically universal at academic events.

In the United States, the messaging was all about masks or no masks, with the differences among masks never being emphasized. As a result, people are shocked when I tell them that there’s good evidence that masks are about 10-20% effective in reducing spread - Americans seem to assume that it’s much higher effectiveness than that and also not realize that there could be studies.

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Messaging isn't the only problem here. To the best of my knowledge, places that mandated masks in the EU even after widespread vaccinations explicitly didn't allow cloth masks. I even flew to Europe a few months ago, and at the gate here in the US a flight attendant asked a passenger to remove his cloth mask and gave him a surgical (or maybe two?) mask to wear instead. After my arrival to Europe, I also saw cops handing out tickets for non-compliance with the mask mandate. (Of course, not all places I visited during my trip mandated masks.)

At the same time, here in the US there were places that were mandating masks AND accepting cloth masks under the mandate AND had no cops enforcing the mandate, which I found completely and utterly ridiculous.

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Just for an update on how things have changed, I flew to Europe last week on a US carrier. They only asked us to put masks on upon our initial descent. Once in the airport, I'd estimate around 50% were wearing masks (of all types) and no one said anything.

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Late to the discussion, but I'll just add that I was just at a scientific meeting in Germany, which has the strictest mask mandates in Europe as I understand it (N95/FFP2 everywhere). At the meeting, everyone was chided if they weren't wearing an N95-equivalent, but outside of that, it's around 50% most places (mask at all) and maybe 85% on public transportation. Even other Europeans who were there said it was hard to get used to putting a mask back on.

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After pointing out the difference between effective masks and cloth masks, you say “masks are about 10-20% effective” without any indication about what kind of masks you mean? Also whether masks are universal or voluntary, worn properly or not, seems it would make a big difference. Were these studies in the US?

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I'm basing the numbers on the Bangladesh mask study, which I think found something in the range of 10% for cloth masks and 20% for surgical masks, without studying N95 or equivalent. These numbers are imputed on the basis of numbers about a third of that for a change in observed mask wearing by about a third of the population. I've since heard additional criticisms of the study for using statistical techniques to try to extract more information than was actually present. I still think this is the closest thing we have to an actual study.

I think the hard thing to understand is that 10-20% effectiveness is both quite a bit lower than what most people expect, but also high enough to be worth actually doing in many contexts.

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What does 'effectiveness' mean in the study: protecting me from getting covid, or reducing the viral load I spread if I have covid? They aren't necessarily the same.

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The Bangladesh study was counting number of people in different communities with observed symptoms, and corroborating this with antibody tests at the end of the study period. They found that villages that got the free masks and widespread masking measures had 45% observed mask use compared to 15% in the control villages, and had 5-10% lower incidence of symptoms or antibodies, and I extrapolated from that that going from 0% to 100% mask use reduces risk of transmission by about 20 to 30%. There's all sorts of statistical questions people have raised about this, but this is one of very few studies of masks that rises to the level of being reasonable to raise statistical questions about.

Presumably the mask reduces viral load in the air by much more while you're wearing it, but as you note, what we care about is usually whether or not we get infected, and viral load of the air is only relevant insofar as it affects whether or not we get infected (and perhaps whether it makes a difference to how serious our infection is).

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I think I have heard of that study, though I don’t recall that particular finding. What I do recall was the finding that disposable surgical masks were pretty effective against COVID even when reused over and over for a long time.

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"To get out of this cycle, we’re going to need to develop a more general vaccine. Ideally, that means one that targets the shared properties of the entire coronavirus family and gets out of playing whack-a-mole with variants."

I don't disagree, but in fact we have NOT been playing whack a mole. My fourth booster had the the same mRNA in it as my first vaccine 18 months ago. I think we could have done better than that for not a lot of extra cost. And developing a system of rapidly "mutating" the vaccine (as we do and could do better with flu) will be useful for different families of viruses where a family vaccine is not so easy.

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May 18, 2022·edited May 18, 2022

As I understand it the issue wasn't a lack of funding, but rather gaps in scientists' understanding of how this stuff works, particularly around a phenomena they're calling Original Antigenic Sin.

https://www.science.org/content/blog-post/omicron-boosters-and-original-antigenic-sin#:~:text=But%20with%20either%20booster%2C%20antibodies,or%20less%20rousingly%2C%20antibody%20imprinting.

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Thanks for the information. I see the point. Some additional cost to changing the recipe and no addition benefit.

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May 18, 2022·edited May 18, 2022

I've been following some of this and the reality seems to be that absent mutations that swing much more widely of the original strain than we've seen to date, there doesn't seem to be much benefit. On the flip side, the initial vaccines were damned good, at least in the West, so if we're locked into that immune response regardless of vaccine tailoring, it could be worse.

What I'm wondering is if anyone will ever study the mortality statistics and parse out exactly how that effect plays out over the next decade between the places that initially vaccinated with Pfizer, Moderna, AZ, and Sinovac.

But I don't expect that to get funded because it would be embarrassing for many involved.

EDIT: Per Kenny below.

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Minor correction - alpha was not the original strain, but was the first globally noted variant, the was detected in England in late 2020. The vaccines are all tailored to the classic Wuhan strain, not alpha. (I forget if omicron is closer to classic or to alpha - but it’s not close to delta.)

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It's worth pointing out that BioNTech is just as much a small startup as Moderna and - similar to Moderna - received a large amount of money from an external source to develop their vaccine that they too could not afford to bring to mass production alone.

BioNTech's external funder was Pfizer, and it would make more sense here to compare Pfizer to BARDA rather than to Moderna.

That comparison makes BARDA look even better - Big Pharma like Pfizer have developed very little in the way of vaccines or treatments for any viral disease, which has almost always been either public sector or startup, and Big Pharma funding startups is really unusual - the Pfizer/BioNTech pair up is a really unusual example (far more often the Big Pharma buys the startup rather than partnering with it).

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"I keep hoping that at some point the really good reporters will stop publishing tell-all Trump books"

I want a "tell-all" about how and why the DFA and CDC made the decisions they did about test development, asymptomatic testing, not creating a surveillance system, not using human challenge trials, not doing the research to continually update the public and policy makers about the tradeoffs of NPIs and transmission, why the message that NPIS and vaccines are to protect other people, too, was never emphasized, etc. Most of these are now recognized as mistakes, but we have only a vague idea of why they made them.

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Scott Gottlieb’s book is pretty much exclusively about the inner workings of the CDC and FDA during the pandemic if you want to check something out like this.

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A very good book but beware: in his telling the CDC was almost totally incompetent, the FDA (he was ex-head) soldiered on bravely, and Trump almost always listened calmly to Gottlieb's wise counsel to him.

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That's the kind of thing, but even it was more a "who done it?" than a "why done it?"

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May 18, 2022·edited May 18, 2022

What amazes me is humanity’s awesome and awful ability to adapt to a new normal. Objectively, things have *somewhat* improved in the pandemic compared to its start: vaccinations and previous infection mitigate outcomes to an extent, and hospitals are better at treatment. HOWEVER, they’re not nearly as radically better as public attitude and official policy have shifted. I still remember the NYT front page “100,000 COVID deaths, an unimaginable loss” and it *was* horrifying and unimaginable *at the time*. And yet Eric Topple’s post (linked by MY) informs us of 175,000 more Americans dying from COVID just from the start of 2022! And none of us bat an eyelid! I’m not pointing this out to say that we were wrong to lockdown in 2020 or wrong to go back to normal now , but rather to suggest that we are on the verge of potentially normalizing hundreds of thousands, perhaps a million, excess deaths annually (!) , and who knows how many long term debilitating conditions. That’s kind of chilling.

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The 'baseline' yearly mortality rate in the US is approximately 3 million.

1 million people dying over the course of 2 years is only a ~16% increase of that baseline.

The sheer numbers are terrible. The % increase, assuming it isn't maintained for decades, isn't earth-shattering or society-shaking.

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I would think that a 15% increase in the death rate absolutely *is* earth-shattering! It’s as if we went from a world without cancer to a world with cancer.

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It's temporary, so I just kind of take reasonable precautions and shrug.

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founding

Yeah, I think that's the right response - treat covid like cancer, take basic precautions and look into ways that we as a society can do better at reducing the burden of disease people bear. It's really bad, and reduces lifespan by a noticeable amount, but only reasonable precautions are appropriate.

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May 18, 2022·edited May 18, 2022

Two points:

1. What's the alternative? Given the limitations on medical science, the other option is to normalize everyone acting like a shut-in forever, with the attendant vast upticks in all sorts of social and mental health ills, as far as I can see. Would that be better?

2. The "long-term debilitating conditions" angle has been so vastly overblown that it seems to have generated a critical mass of psychosomatic illnesses and become self-sustaining for a while. The less it's talked about, the more the problem seems to abate.

EDIT:

Actually a third as well:

3. Omicron's sheer contagiousness masked just how much better we've gotten at dealing with the virus, as well. To generate the 200,000 deaths we've seen since the beginning of 2022, Omicron infected perhaps a third of the country in the span of a month and a half.

We have gotten immensely better at this; if we hadn't, the Omicron surge would have killed an order of magnitude more people than it did.

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May 18, 2022·edited May 18, 2022

1. you don't seem to have read my comment carefully, or perhaps I didn't put it carefully, if you think I was advocating for a particular policy, or if you even think I suggested that our ability to adapt is, in and of itself, a bad thing. In fact, it is a good thing, and a necessary trait for human survival. It is the fact that we *need* to adapt to this that is very sad, however.

2. The mists haven't clear about this yet, nor are we anywhere near far enough in time and research to truly know the answer to that. I would point out however, that simply to assume that being pretty sick with "flu-like symptoms" to fight off infection, on average say 3 or 4 times a year, which may well be the experience of many people moving forward (natural COVID immunity now seems to wane with 2 months), is not something we know the long-term effects of and the cumulative toll on you body, over years.

3. That's somewhat besides the point. Sure, we got better but COVID got better too. At the end of the day people are dying in very high numbers. Numbers that two years ago seemed unimaginable, and now we don't bat an eyelid, and apparently present as a success? THAT is my entire point. The Change in our perception. I'm not saying this change is a bad thing, certainly not that it could be otherwise. I'm merely reflecting it's a sad state of affairs that this is the new normal.

Put another way - often we read about historical periods, the things people had to put up with on a daily basis, and asks our selves : how could they live like this? This is your answer, this is how it works. We adapt to the new normal for better or worse, we take the baseline conditions for granted, and in the past two years humanity's baseline health conditions have significantly deteriorated. Not to pre-modern medicine levels, thank god, but nevertheless quite significantly, with no sign of returning to the 2019 peak in the medium-term, at least.

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I was responding to you with a couple of thoughts, not arguing with you.

1. Was basically expressing the same fatalism as you had, lol, just framing it differently. We chose the least horrific path for a bunch of social animals to take. It'd be far more horrific if the COVID Apocalyptic Warrior faction won out on which norms we'd become accustomed to, IMO.

2. I don't really see any evidence for this take. The notion that we're all going to get severe COVID 3-4 times a year is just not supported by the evidence; if the "Russian Flu" theory of evolutionary biology holds true, and I think there's enough circumstantial evidence to say it's very likely correct, then human immune memory and long-term immunity are the primary drivers of endemicity, not viral virulence. COVID will continue to mutate, but between widespread vaccinations and convalescent immunity, those mutations will matter less and less each successive time. How often do we see or care about mutations in any of the two dozen viruses that we collectively refer to as the "common cold"? Yet they occur all the time.

3. Informed by the above, "COVID got better too" is just not the correct way to look at this at all. Endemicity along the lines of a common cold virus requires that we all be infected, likely repeatedly, over time. In that context, vaccinations and anti-viral treatments are a bridge which will allow us to reduce the death toll to a tenth of what it would have been in their absence while that progression takes place. 100,000,000 infections causing 200,000 deaths is an unabashed win compared to two years ago, when 5,000,000 infections caused 200,000 deaths. In a few more years, my informed guess is that the entire number of annual infections will cause 200,000 deaths.

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One million Americans dead from covid is not the same as one million excess American deaths. Both are bad, but they are different. Old people (and covid deaths are overwhelmingly old people) eventually die of something.

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I believe the excess deaths caused from COVID is actually higher than the 1 million figure. Most, but not all, are old. Everyone dies eventually, and I'd even agree that a plague killing mostly the elderly is not as bad as one killing other cohorts, BUT it is NOT the same as if it wasn't there! many of these people would have lived on for years longer!

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Great column—seems like a no-brainer to do this. The only thing I would add (slightly out of scope of your focus on clawback) is that getting the FDA to adopt a set of rules to enable more rapid adoption of multivalent/new variant vaccines also needs to happen. Additionally as you pointed out before, investing in more vaccine manufacturing capacity is critical since it just shouldn’t take 5-6 months to roll out a new vaccine variant. Seems strange that the Biden admin hasn’t really gone hard after this since it would allow them to lead on covid while also hitting on reshoring manufacturing capacity.

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Great post. I went to med school and did residency with Jay Varma -- smart guy. I've been frustrated that the Covid vaccines weren't allotted to individual medical offices. We tried to get the them in our office, but the red tape was a nightmare. There were a good number of skeptical people that I convinced to get vaccinated but then didn't b/c we didn't actually have the vaccine in office. And what I don't get is that Medicare, in general, is getting stingier about paying for vaccines in the doctor's office. For example Medicare won't pay for Shingrix (shingles vaccine) in office, sometimes won't pay for pneumococcal vaccine. The patient has to get at the pharmacy. Then it's a nightmare trying to keep track of vaccine records. Why are they being stingy about vaccines -- one of the best preventative medicine strategies we have in our arsenal?

Anyway, from my perspective, the pandemic is getting way better. Yes -- cases are again surging, but I haven't had to hospitalize anyone for 6 months. And Paxlovid works really well and (at least in LA) is widely available. I'm generally loathe to make predictions after having been burned in the past re: Covid, but I do think this we will get to an endemic state -- just another cold virus in a few years as we are vaccinated and exposed/recover several times.

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Regarding footnote #2, it exposed two things in my book. One is that there's a delusion among a sector of lefties that if they just make something a law, that alone will naturally induce people to follow it. That pretty clearly falls apart when you really need 100% compliance. The other is just how important highly visible forms of compliance are to these sectors, even if they're not the most effective.

This article (https://slate.com/news-and-politics/2022/05/abortion-activism-pro-choice-messaging-language-ireland-argentina.html) has nothing to do with this topic, but its last paragraph was just such a dead-on example of that type of mindset.

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“Operation Warp Speed” was terrible branding—the biggest reason I saw for vaccine hesitancy (among people who were not instinctively anti-vax) was “it was developed too quickly, I don’t know if it’s safe.” Trump had a hell of a time persuading people (other than his wealthy and elderly donors who didn’t need to be told) to take the vaccine.

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"The great under-appreciated irony of 2020 is that progressives simultaneously took a sharp move to be much more skeptical of heavy-handed enforcement of rules while also wanting a bunch of new rules."

I was just saying the other day that that's been one of the more crazy-making things over the past few years.

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Great article. I argued something similar in a policy memo for the Institute for Progress a few months ago.

https://progress.institute/creating-advanced-market-commitments-and-prizes-for-pandemic-preparedness/

Basically, use Advance Market Commitments and prize authority for vaccine development for next generation COVID-19 vaccines and/or neglected diseases in general.

Combining this with measures to reduce R&D costs, like human challenge trials, would be a nice addition as well.

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