I teach global and public health, so I can vouch for this being a good piece. My summer class just happens to be doing the failures of malaria policy this week, and I will probably assign this piece for extra credit today (I'm assuming this is unpaywalled, since it is linked on Twitter).
That said, I think one thing we should recognize is that the current failures of public health policy are, depressingly, not even a little bit new. We tend to have this idea that CDC, WHO, et al., used to be good and then lost their mojo, but the truth is that we have a few high-profile successes (besides smallpox eradication, the Obama-era ebola episode was a legit decent response to that crisis) and a lot of failures: AIDS, zika, malaria multiple times, every drug crisis so far, including opioid most recently--even, I would argue, the persistence of measles outbreaks in the US. And as that list of examples suggests, those failures go way beyond government. The much-touted malaria bed-net charities of the past twenty years are, with clockwork predictability, running into the problem that mosquitoes under selective pressure are shifting their feeding habits in places with high bed-net uptake.
All of which is just to reiterate and emphasize the point made in the article that these problems are very, very hard in ways that I have come to believe even the actors themselves underestimate. I think public health people genuinely underestimate the complexity of problems. We genuinely overestimate the efficacy of certain kinds of response (i.e. "if we just did the right messaging, X would happen," or "if people would just listen / could be forced / knew how to follow our advice, we could solve Y"). And we systematically commit certain kinds of cognitive errors, like misunderstandig how everyone else experiences and understands disease (for example, at the beginning of the pandemic, I told my students, "if this is the worst disease event of the last fifty years--if mortality is completely awful and we lose a million people next year--you might still not know anyone who died," and that held up, which helps to explain how you can have a disaster and also have the stupid debate we have over vaccination, because the two are not exclusive in human experience).
As a teacher, I try to help would-be public health professionals of the future to develop some tools against these problems. I try to help them see hubris and develop humility. We talk about the importance of not just telling the truth but telling it with precision and completeness. I'm a historian, so we do past episodes of failure and try to tease apart the complexities that get us places and the arguments and failures that recur (the unchanging nature of the vaccine debate, going all the way back to smallpox variolation, is simultaneously hilarious and depressing). And I think this all helps.
But as a historian I have come to the conclusion that the best we can hope for is to handle THIS episode and THAT episode correctly, because "public health" is, in some very real sense, too broad of a problem set for anyone to get their arms around. Like, how do you bind together a basket of issues that that includes needing to understand fentanyl production, monkeypox epidemiology, and maintenance of lifelong HIV antiviral drug production and delivery chains? It's a ridiculous claim on its face.
Of course, that raises a whole different set of policy questions, against which all the incentives of our system are set to produce non-optimal answers. So people yell about how bad the "official public health" response is, and they are right, and public health people yell back about how much they are misunderstood and under-resourced, and they are right, and everybody is right, and that sucks.
Thus concludes my professional public health downer rant.
There have been some major public health successes, around things like sewage systems and municipal water, iodized salt, and (maybe?) fluoridated water.
Totally agree, and also, this is a great example of the nature of the problem. So is public health an engineering problem? A nutrition problem that you can solve by formulating foods differently? A problem that you can solve with Big Brother type interventions where you just kind of impose a big change (i.e. fluoridation)? A vaccination problem? An epidemiology problem? A pest-control problem?
Obviously, the answer is, "yes," which means that to a first approximation, "public health" might be everything and nothing, which makes it really hard to get your arms around, as a policy matter. We're kind of trying to fit a set of responses into a mental umbrella of policy that is just really, really hard, so it frustrates your ability to fix it. Like, no one says, "We managed to reduce road fatalities by improving automobile safety, which is why I've put Becky, a road engineer, and Javier, and epidemiologist, in charge of our bicycle helmet program," because that would be a bizarre nonsense statement. And yet, if you actually look at public health...
This is also, hilariously, how you end up with the constant phenomenon in public health which is each new generation of economist superstars showing up and being like, "this stuff going on in public health is a bunch of nonsense, but we're going to fix it with econo-think!" that fails in ways that are both interestingly novel and depressingly similar to the previous generation of econo-think public health failures.
Everyone walks in thinking They Are Doing The New Thing to Fix the Failures of Those People Before Who Just Didn't Understand. It's like sitting down to the poker table and thinking, "everyone else here is a sucker because none of them has won the game yet." Yeah. That's not actually how that works.
Haha--I actually hadn't, because I was out for the evening, but apparently you and I are on the same wavelength to a hilarious degree. Maybe because we are both Philly people?
I doubt you and I actually disagree all that much. I think I would describe those exact same episodes as you and only slightly alter my explanation of what did and did not happen, and why, in ways that you would be like, "yeah, that makes sense." And I 1000% endorse the sentiment at the end of your comment. I basically just think that the barriers to fixing the problem are even deeper and worse than you might think, because they can sort of be described by "competence," and I hugely endorse pushing for maximum competence, but the meaning of that term and what it takes to achieve it is weirder and harder and requires more resources and different kinds of political judgements than expected.
Lol, it's a hell of a coincidence that your second paragraph reads as essentially a line-by-line response to mine from last night.
And I imagine we do agree on quite a bit regarding the past; success has many fathers, failure is an orphan. We remember the successes, forget the failures, and if we're lucky maybe the way the institution does things grows out of the experiences of both even though no one remembers why.
One element I think that could shed light on this "downer rant" (fantastic and informative comment, by the way) is: how does the US tend to stack up against other countries in this area? I'd guess "not that great" (especially if we adjust for wealth)—a recent coronavirus pandemic comes to mind—but I honestly don't know, and I'd be curious as to what other think, or is there a consensus?
Sort of. Explanation: the bed net comment originated in a conversation that I had with Michael Povelones, the mosquito guy at UPenn. We were discussing a conference he just got back from, which was mostly about the new-hotness genetically-altered-mosquito strategy. (This is actually not a public health connection; we're friends by random chance, because our wives happened to previously be professors together at a PSU branch campus near Philly. So we are the weirdos who talk mosquitoes over beer while the kids are playing.)
So I don't have the conference paper that was given a couple of weeks ago, for obvious reasons. But here is why I found it an unremarkable claim and consistent with other literature on the subject:
You can already easily dip your toe into the bed net debate if you Google "pyrethroid resistance" or "ITN resistance." Mosquito bed nets generally work in two potential ways: they present a physical barrier to the mosquitos, but they are also doped with an insecticide that, even if it does not kill the insects, causes them to physically leave the dwelling--they don't want to remain in proximity to it. The second part is important because the barrier part only protects you while you are physically in the confines of the netting (i.e., around your bed while sleeping). So if the mosquito can't get through the barrier but just waits around nearby, it can bite when you get up in the morning. A lot of mosquitoes are actually pretty lazy flyers; they don't like to move all that far.
The problem, as you can guess from my suggested search, is that some species can (and are) developing resistance to the insecticide, just as they developed resistance to DDT. And frankly, this is what you would expect. <Cue Jurassic Park clip.> There's a lot of hemming and hawing in the literature, which you will find if you read through it a bit. Doing real-world efficacy studies of this kind of thing is genuinely hard. But resistant mosquitos do, in fact, appear to change their behavior and continue hanging out in the homes. See, for example:
So why does insecticide resistance matter to my acceptance of the behavioral adaptation claim? Well, for one thing, because the behavioral claim is a knock-on effect--it's made more possible by resistance, if resistance allows the insects to hang out in the house (whereas before they left it). That's reason number one. This is precisely the follow-up you would expect from what we can prove is happening, which is the growing resistance.
But (reason 2) this also is a story that just fits very neatly into what we know about adaptation.
Mosquitoes don't drink blood to feed, precisely, in a nourishment kind of way. They need a blood meal specifically to reproduce; this is why only the females bite. Different varieties of mosquitoes have different preferences for where they get the blood; some strongly prefer humans, while others will bite lots of animals. The fussy human biters are the disproportionate problem. Bed nets work in part because mosquitoes are also fussy about WHEN they feed; they tend to prefer early morning and bedtime, but again, it varies across different kinds of mosquitoes.
In an ideal world, of course, you could imagine people who wear full-coverage clothing and repellant and only change clothes when they are in the area protected by the bed net. But over here, on Earth 1, that's not what actually happens, in part because it's a pain in the ass. But you can significantly reduce the biting by just having people inside the barrier protection (bed net) during those high-feeding periods.
Except that by putting in the bed net, you have now introduced a selection pressure. Females who refuse to feed except in the very narrow window covered by the net and the very narrow group of hosts (humans) are not going to get the blood meal they need to reproduce. Females who vary their biting habits are going to be more successful, in the reproduction / adaptation sense. Now, to be clear, that could include lots of adaptive strategies--if you said that over time you were seeing a greater willingness on the part of human-preferring biters to shift over to monkeys or dogs or something, I would also find that plausible. But "extend the feeding window" is just a really, really obvious one--more obvious than changing your preferred dietary target.
And it's already a behavioral adaptation they do. Like, if you walk into a room of females in need of a blood meal at noon, you are going to get bitten (I say as a person who grew up in the Houston area and spent a not inconsiderable amount of time as a child in swampy overgrown places.) The insecticide thing really tamps that problem down, because if the mosquitoes come looking for a meal while you are in the bed net zone and they die from the insecticide or at least get pushed out of the house, that partially solves the extended feeding hours thing. But once resistance increases, now you have a problem. The behavioral adaptation becomes a much smaller lift, and we are literally actively selecting for resistant, less time-fussy feeders. The fussy ones didn't reproduce.
And here is where I would point you to a piece in the Lancet:
This piece is agnostic on why reductions from ITN programs stalled in the late teens, and I want to be clear that I'm not pretending to be the final word on the matter. There are lots of ways things can break down, as the article itself discusses. But the timing is highly suggestive. Fears about insecticide resistance really got going earlier in the decade (look at the date stamps on the articles in your Google search for a sense of the timing).
If, as I described, it's a two-step process, and keeping in mind the severe limitations on the data quality in this area, then it's pretty reasonable to expect that we would now be seeing behavioral adaptation to the selection pressure that we created. Again, it would be inconsistent with our experience of biological systems generally and mosquitoes in particular if they DIDN'T adapt to the bed nets. It would be one thing if you could either achieve eradication or have a truly multi-pronged approach to the problem (for a completely different application of this same thought process, think about how we now use multi-drug cocktails for adaptive diseases like TB and HIV; at a certain point, adapting to 3-4 wildly different pressures simultaneously is just too hard for the target).
But bed nets were never going to be that. You would have needed to roll out a bunch of other measures, which are difficult and expensive, and the whole way that bed nets were sold was that they were supposed to be cheap and simple. And they were! Which is why you would expect their efficacy to drop over time.
So that's why I buy the claim. Obviously you could very reasonably say, "that's something you claim to have heard from some guy over the weekend; I call BS." But my claim here is that it's pretty consistent with the (limited) evidence at hand and historical experience.
Apologies if that was a longer walk than you wanted to take.
No worries; as a historian, I actually discuss these ideas extensively in my class, starting with the demographic / mortality transition. The ideas in Pinker's optimism work were mostly meta-analysis and extensions of ideas that long preceded Pinker in the history space. He's a great communicator (I read the Language Instinct as an undergrad and have been influenced by his thinking ever since, even when I'm not totally onboard), and I appreciate him bringing those ideas to the wider discourse--it was a genuinely valuable intervention--but the stuff he said was not especially novel. I will say that my one gripe with Pinker, et al., is that they systematically underestimate certain kinds of tail risk and structural causes because of the different nature of their training.
But honestly, my post above was a crie de couer specifically about "public health"--as a discipline, a political subject, a policy sphere, a profession / practice--rather than about "the health of the public," in the sense of overall life expectancy and basic metrics like nutrition status, if that makes sense. As a statistical matter, today is one of the best days to be a human, ever, even with Covid. It's just also the case that I would not suggest, as a way of investigating the dichotomoy, that you go to some Covid funerals or The First Thanksgiving without X this year and declare, "Did you know that public health is in a better place than ever in human history? It's an amazing time to be alive!" Because they will throw the gravy boat at you, and...fair.
Satire always introduces illegitimate elements to get the laugh, but I also think there's not much to the underlying complaint. 2020 involved a highly lethal, extremely contagious disease, and highly generalized behaviors that applied to a universal population. 2022 involves a very low lethality, low-contagion disease, and specific behaviors that at this point are largely relevant to a restricted, generally stigmatized population.
Comments along these lines (there was another one here I can't locate anymore which reference shutting down churches) seem to me to take the focus away from substantive failures, such as the ones Matt emphasizes, in order to trot out caricatures useful in dead-end culture-war battles.
OK, but counterpoint: the differences in contagiousness and the fact that this is (currently) restricted to a small, pretty identifiable population mean there was a chance to stop it in a way that there was never a chance to stop COVID. And we didn't know that immediately with COVID, but we certainly knew it (or should have known it) way past the point at which "stay home or you're killing grandma" was still a thing that people were saying.
I don't really understand what the "that" and "it" are in your second sentence, Emily, but I certainly get the point of your first sentence. Sure: all the things Matt writes about concerning our missed opportunity are true. But those don't include failing to issue mandates that would have prevented, for example, risky behavior during Pride--the legal hurdles for local government to target conduct involving gay men are insurmountable (justifiably). I certainly saw messaging that warned about transmission through sexual contact early on, and on the messaging front I don't know what more we should have asked for.
The big thing I think we could have asked for is local STD testing clinics to reach out to local gay bars and bathhouses where they have established relationships, and gotten them to put up informational flyers. I don't recall seeing any in early June, and I may not have been to any relevant venues recently, so it's possible they have.
I don't think there should have been mandates. But I agree with Dan Savage, who has called the national response "disorganized and unclear in its messaging." I think if you are here, you are probably more keyed in to content about monkeypox prevention than the average person.
I don't think that statement is likely correct, James, but if you have some basis for it I'm willing to change my mind.
The fatality rate for Covid cases in the US has been a little over 1%. Worldwide it has varied, by country, from below 0.5% up to over 5%. I presume the variance has to do with availability of treatment and comprehensiveness of case reporting, though since the two factors would tend to vary in parallel I'm not sure how the impact would manifest.
Today's (8/3 data) CDC count of US monkeypox cases stands at 6,600+ (https://www.cdc.gov/poxvirus/monkeypox/response/2022/us-map.html), but so far we have seen no fatalities, according to latest reports. Less certainly reliable online figures, a few days old, are for just over 16,000 cases worldwide, with nine fatalities.
US excess mortality over the period in question was about 114,000 higher than 1.06 million, so the # of reported COVID deaths can be taken as a reasonable estimate of the number of COVID deaths*, whereas it is known that the # of confirmed COVID cases is an underestimate of the # of COVID cases by some unknown but larger factor (2-4, probably, once re-infections are taken into account).
It's still too early in the monkeypox pandemic to get a good sense of the fatality of this particular strain because it emerged so recently. The best estimate we have for it is that the case fatality rate is 3.5% in Nigeria, based on the past 5 years of data:
"In May 2022, the Nigerian government released a report stating that between 2017 and 2022, 558 cases were confirmed across 32 states and the Federal Capital Territory. The Rivers State was the most affected by monkeypox followed by Bayelsa and Lagos. There were 8 deaths reported, making for a 3.5% Case Fatality Ratio."
Now, it's certainly possible that this particular virus will exhibit a large discrepancy in lethality where it's less lethal in first world hospitals settings and more lethal in poor countries, since that was the case for many other diseases. However, it's also possible that it will instead exhibit the same pattern as COVID and have a death rate that is overwhelmingly concentrated among the old and infirm, and its CFR is artificially low right now because the population of young gay men who go to a lot of parties are unusually young, thin, and fit compared to the general population.
*Note that excess mortality has been zero for the past month or two despite there still being ~400 covid deaths per day, indicating that people are dying *with* COVID rather than *of* COVID at this point
Thanks for replying with data, James. As James C. points out, the rate from Nigerian data is actually 1.4%. It seems to me that the best comparator to select in order to assess this data in comparison to Covid would be the Nigerian Covid case fatality rate, which was 1.2% (Johns Hopkins data). We do not know the likely undercount for either disease, but the variables are, at least, steady in terms the social, medical, and governmental contexts.
Some Covid deaths have always been "with" rather than "of," as is true, I suppose, of any infectious disease and its fatality rate. I'll second what James C. wrote about lags in complete death record tabulations.
Your question about the impact of a preexisting vaccine lowering fatality rates is valid. However, if the result would be an unknown number of cases where a fatality that would have occurred did not, because of weakened symptoms (artificially lowering the "natural" fatality rate), it could also include an unknown number of cases where symptoms never manifested because of vaccine effectiveness (artificially raising the natural worldwide fatality rate, and, potentially the US rate, if US fatalities occur).
See my note to John about complete death record tabulation.
If we use Nigerian numbers only for both monkeypox and COVID, then we'd both need to amend our initial statements. 1.4% is not 2x 1.2%, so my original claim would need to be changed, but 1.4% is greater than 1.2%, which means that rather than covid being "highly lethal" and monkeypox being "low lethality", monkeypox is "slightly more lethal than covid"
Also, at first glance, the 3.5% CFR seems to come out of no where. From the numbers given, 8/558 = 1.4%. When I followed the citation on wikipedia, it appears they got it because only 230 cases were confirmed, which is obviously a large undercount.
You're no doubt correct that differences in the populations infected are going to confound the CFR anyway, but I'm not sure that will change dramatically over time given their relative transmissibility.
If 1.4% was the true rate, it would still be a >2x higher CFR than COVID (~0.5%).
However, there's also no guarantee that 558 is the correct number of cases, so it's possible that monkeypox's CFR is lower, possibly quite a bit lower.
IIRC, excess mortality stats have a noticeable lag, so I don't think you can't trust them for the last month (it's been at least a year since I looked into this, so I can't remember where I came across that info). I wouldn't be surprised if some COVID deaths are *with* rather than *of* though.
Their last reported number is for June 7th, 2022, and excess mortality has been ~negligible for the period from March 8th to June 7th 2022 by their data.
Two months to collect the data for June sounds reasonable, and March is 5 months ago.
Secondary question -- of those infected in the US, how many were already vaccinated for smallpox, or were able to get vaccinated in the 4 day post-exposure window where getting vaccinated is expected to offer a substantial protective effect?
"CDC recommends that the vaccine be given within 4 days from the date of exposure for the best chance to prevent onset of the disease."
You would think, based on this characterization, that the people who complained about the Covid response in 2020 being too heavy-handed would be super-excited about how the public health establishment has responded to their concerns and corrected course in 2022.
And, of course, you would be totally wrong, because that's not really what it was about.
If I thought this was part of an actual correction and that, for instance, we were not still going to be fighting over school masking/closures in the fall and winter, I would find something to like in this. But this isn't "we heard you, prior behavior was a mistake, and going forward we have a new set of principles."
Also, I don't think anything should be shut down in response to this -- I think that's the right call. But I do think "stay home" was an appropriate thing to say to people in March of 2020 and there are contexts where it would be appropriate to say now.
I'm pretty unconvinced that the debate then or now being had in the public at-large is, fundamentally, a "public health" debate. Like, I think that is a category error. What we mostly have is a front in the larger culture / politics war with vague public health features. Weirdly, that is happening alongside and interwoven with a bunch of actual policy and technical debates, and those are also interwoven with political questions about funding, agency structure, etc., which is why I think the whole thing is totally f*cked.
But I am unpersuaded that a slightly different set of statements made by...who? precisely? is always a really interesting question...but I am unpersuaded that a different set of public statements made at the beginning of Pride would have appreciably altered this outbreak event. A big part of the whole problem with Covid is that everyone has way, way, way overestimated the power and significance of messaging to change outcomes in the real world. You have to do concrete stuff in the world, which we were pretty unprepared to do two months ago (and that is a real indictment of our society / politics / agencies / voters / all of us who can get sick, which is, you know, all of us).
I do think that if local STD testing sites that have strong relationships with the gay community had sent someone to each of the bars and bathhouses, with some sort of relatively neutral informational flyer to put up, that could have helped a bit. And it would also be helpful if Grindr sent out popup messages about it a bit more often (I've received two in the past few months - I forget if it's when I was traveling to bigger cities, which would be a nice sign of them targeting it to locations).
Totally agree. I would classify those kinds of interventions--targeted outreach--more in the way of "doing concrete stuff on the ground" than in the way of "messaging." I think of "messaging" as what you see on official social media feeds and in mass media outlets. But that's probably being hair-splitty, on my part.
I think of messaging as activities that are extremely low-cost, in the way that calling a reporter or holding a press conference is low cost. Good targeted outreach is often actually a lot of work, much of it done prior to the emergency (i.e. developing relationships with the relevant local communities--the gay community in this case, but I'm sure you can imagine ten others of interest for different situations).
I'd like a public health establishment that starts from the perspective that we should be honest with people about risk. Not "what should we tell people if want to produce a certain response?" or "what should we avoid telling people because we don't want to cause this other negative thing?" Just tell people the truth. It really undermines public faith in institutions when you don't do this, and it's not like the public health officials are such effective propagandists that they're even particularly likely to get the effect that they're trying to get.
This is my biggest problem with public health. Just tell people the truth. Even if it’s scary. I think this reluctance to tell the truth can be partly traced back to the belief among many well-educated Americans that a large segment of the general public is stupid/reckless/immoral and incapable of making good decisions. Therefore it’s okay and even necessary to deceive them. Of course, this is bad for society and feeds populism but then you just blame the public for being stupid.
True and I’m sympathetic with “hey you need to keep it super simple and get the message out,” too. Have a super simple rec. Also have an official explanation, a risk benefit analysis and options depending on risk appetite, sort of thing. Doesn’t have to be all or nothing. Don’t drink during pregnancy. But also one drink in nine months will not necessarily be super bad but also fetal alcohol effects are a spectrum and we don’t have a specific threshold below which is safe.
The messaging situation has been a total mess for a long, long time. I'm not even sure it's fixable, given the current information structure of our society.
Important to not separate the bad public health response with simply terrible political incentives - In 2009 in the face of swine flu the UK Health Secretary ordered £300 million worth of vaccines for it, and ended up being heavily criticised by the press as having been 'wasteful.' Sadly there's not much understanding about how sometimes you have to take financial risks in public health even if the worst of the downside does not materialise
The case that our public health experts are "just following the science", as opposed to the bad guys who act based on politics, is getting quite difficult to sustain.
Even worse - they are academics with no idea how to operate in the real world. At least politicians have voters to sort of be responsive to, even if they usually fail at it. There’s no Joe Manchin of public health, unfortunately
To both of your points, unfortunately, "Use science to make better-informed decisions!" wasn't pithy enough to catch on.
"We need to build a bridge over that there river. Follow the science!" Science can offer us the most basic, macroscale guidance like "gravity always points down" to the nitty-gritty microscale stuff like what different metals have different material properties like yield stress, stiffness, hardness, and corrosion resistance, and how we can alter those based on mixing different atoms together.
Science doesn't give you instructions on how to design a bridge. It doesn't really know what a bridge is, as a five-year-old would describe it. Science sure as hell doesn't give you instructions on how to build it, source cost-effective materials from reliable suppliers, manage the teams building the bridge, inspect and repair in service...
Regrettably, we now have a whole generation conditioned to think of science as offering direct instructions to fix our problems. Damn it all.
There was someone on here yesterday arguing that “the science” was telling us we’re on the verge of societal collapse due to climate change. That’s not at all what science does, or is for.
I'm a wordmonger, not a scientist, so I hold scientists in very high esteem (which my science-y husband says is dumb). But it's tragic that "use science to make better-informed decisions" isn't catching on. "Better-informed decisions" is probably the thing most desperately needed in the world today, but even in the face of massive failure, there seems to be little interest in figuring out why X failed and how to do better next time. Not just with respect to covid/public health, but across a range of dimensions. We just seem to lurch forward, hoping things work out.
There is an old saying that “public health is political but it shouldn’t be partisan”. Our public health establishment really needs to recommit to that. The vast majority of public health people are very liberal and they have a bad habit of dismissing people to the right of them as stupid and their beliefs should be dismissed. It’s hard to mount a response to a disease when you don’t have much respect for most of the public.
MattY, the botched response here is much much worse then how you present it. Public health officials repeatedly refused to ship to us vaccine doses already bought and even donated some to Europe , *after* the current outbreak was already happening . They also dropped the ball on the strategic stock pile, letting it deplete from 10s of millions of doses to nothing. And this is just *some* of the mistakes made. Everyone needs to read this thorough NYT reporting on the botched response, I thought I was a skeptic about us public health agencies already, but this is just unbelievable:
And the FDA took until last week to inspect the plant! You would think that health departments running out of vaccines within hours would give them a sense of urgency but nope.
Question #1: Do you know what the following acronyms stand for?
MRA
FDA
EMA
GMP
For the record, they are: Mutual Recognition Agreement, Food & Drug Administration, European Medicines Agency, and Good Manufacturing Practices.
Question #2: If you didn't recognize all four of these acronyms, did you nonetheless have a strong opinion about whether the United States should automatically accept European approvals of European pharmaceutical facilities instead of always requiring its own?
I didn't recognize these acronyms so accordingly I have no opinion on how well the FDA executed acquiring vaccine doses from Europe.
He makes a bad point. “You shouldn’t hold elected/appointed leadership accountable unless you are familiar with obscure acronyms. Also life or death emergency never justifies changing priorities or accelerating timelines..”
“Don’t know what OIS, EIS, CEW, ECW, AAR, or PIT mean? Stfu about police reform”
“Don’t know what HiMARS, MLRS, Nlaw stand for? Your opinions about Us giving aid to Ukraine are invalid and you have no right to hold them.”
Kevin Drum might be smart but he apparently isn’t wise.
His point is that while you may have a principled viewpoint -- "maximizing vaccine production and distribution should be a high priority" -- unless you know the mechanics of a situation, you are in a bad position to critique the process. Did the FDA drag its feet? Given the existing legal and regulatory environment, could they have done better? I don't know and you don't know.
It's easy to announce when an emergency hits that even though you hadn't given this a moment thought before, government should have done much better, even though you don't have the goods to know what that would mean in practice.
Do we then have to be experts in everything in order to have an opinion? No, but not being one should warrant a bit more humility.
Let's take, well, your last example, on giving aid to Ukraine when you don't know what HIMARS, MLRS, NLAW stand for. Yes, this is exactly a case for a bit more humility. Figuring out the best way to support weapon systems is what I spent my career doing so I think I have some standing for talking about the best way for the US (and others) to support Ukraine. And do I hear uninformed people offering unsupportable views on how we support Ukraine? Oh, you bet. We should be sending a hundred HIMARS to Ukraine! Oh no, we should not. They can't absorb them, they can't get trained quickly enough to use so many, they don't have the logistics structure to move the vast amount of munitions through the country to keep them supplied -- and we don't have that many to begin with.
The Ukrainians, through the supplies we are sending them, are trying to do something unprecedented in reinventing their entire military during an intense war. It's like flying a plane and at the same time totally rebuilding it in flight and managing to land it. One can support aiding the Ukrainians, and also believe the Ukrainians when they say they want more and faster support, but at the same time, one should have a bit more confidence that the people in our institutions know what they're doing, and not be so quick to think you know better.
That said, the fact that *we* don't know what the FDA could have done better is no reason for Congress to be waiting so long to create a commission to study what the FDA could have done better in any of the failures of the past couple years.
Update: read the two blog posts now. To my understanding they are rendered largely outdated in the meantime and address few to none of the problems raised in the NYT article. Still convinced us dropped the ball big time. The fact that us used to have a strategic stockpile of the new vaccines (that it allowed to go down the drain) and that it paid for their development makes the current state we’re in more of a screwup not less.
I'd agree that the NYT article is a fair knock on HHS. This looks like a straightforward case of dropping the ball on something that was well within their power to do.
I like the NYT article because they actually talked to experts and people knowledgeable about the events in question. That's good journalism. But it's a very specific and limited case. There's still too much tendency for folks to say, based on gut feeling and no knowledge, the [FDA/CDC/etc] are bunglers and here's one weird trick to make them work better.
But again, good NYT article. Thanks for pointing it out.
I think a thorough case has been made on how they dropped the ball repeatedly on COVID response too. I realize that responding to outbreaks of new diseases is just one part of their mandate, and does not reflect on how well they cope with so much more they're responsible for. Fair enough. But that's still one very very significant part of their mandate, and we seem to be getting pretty repeated and quite robust evidence at this point that they're just not doing well enough, especially considering how better resourced they're supposed to be compared to anywhere else in the world basically. We shouldn't simply accept the status quo. Stakes are too high.
I think the CDC did a fantastic job in their COVID response and every single criticism I've read of them has been dead wrong.
(I'll be here all week, folks. Be sure to tip your waiter.)
But seriously, even in a pretty damning case like this, you still have to watch out for trap doors. I think Scott Gottlieb is a very smart and well-informed guy and his book "Uncontrolled Spread" is a damning indictment of everything the CDC did wrong on COVID. I am in no position to say he's wrong. And yet . . . he was head of the FDA during the Trump administration and very strangely the FDA comes out looking good and innocent throughout the entire crisis (weirdly, he is very kind to Trump too). So I read him to say "CDC bad, my agency good" and that makes we wonder how much I can trust his expertise in analyzing our COVID response.
Which is a longwinded way of saying that sometimes it's really hard for us non-expert outsides to judge the evidence.
Briefly cause I have to go: testing dealys, botched mask guidance bordering on lying to the public and fostering long term distrust of masking, dealyed approval of the vaccines and later over-caution in approving them for more people (even more so the foolish delay with the approval of the boosters, probably a major reaons why the us is so dramatically behind peer countries on this).
These are just on the top of my head. the list of indictments honeslty goes on and on and on and on and on. And i'm relying e.g. on zeynep tufekci , not on partisan interest, but mostly i'm relying on comparing the cdc guidance and policies in real time with those of uk , eu, and other advanced nations. It was like living in the twilight zone. You just couldn't turst the us govenemnt, each and every time other countries mad e the right call and us was dropping the ball and getting in line after a precious daelay of a month or two. The outcomes were accordingly grimmer in the us. In other words, i'm not an expert myself, but I *can* compare varying policies of peer countires which all have experts, and the us was a bad outlier.
Thanks. I’ll read that. In return I’ll recommend reading the NYT piece of you haven’t done so. To my understanding the issue of European approvals is really not the main problem at all.
I’m at the point where “make the global south richer” is probably a more realistic response than hoping for useful NGO and government responses on these things. It’s going to take a long time, but at least it’s been proven that poor countries can become wealthier, and the free market basically works when there is financial incentive for pharma. And monkeypox doesn’t worry me and more than Zika or dengue or other diseases that we have already failed to contain. Making NGO and government public health responses useful on the other hand is unproven and highly theoretical.
We don’t have this time, and we’ve proven we *can* eradicate a disease globally with the global south being much poorer than it is today. So, yes, definitely let’s work to make the whole world richer, but this will take a long time. Action on disease needs to be taken asap.
Fair - I do think it's possible in theory, just not in the US right now (although it has only been proven with diseases at least as deadly as Ebola or smallpox, so I don't think it's fair to say we've proven we can tackle a disease *before* it mutates to become this bad). The basic problem is that one party doesn't believe in government, and the other doesn't care about competence. So it's essentially impossible to make a competent government agency in the US until our politics radically change.
Maybe philanthropists need to be working on some sort of market-based incentive to help pharmaceutical companies focus on diseases affecting the global south, so we don't have to wait for the entire region to develop stronger economies. Or just promote free trade as that's really the only way rich countries can help poor countries in general (it will take decades, but still probably faster than fixing the CDC). But I think public health is downstream of politics, so I'm very hopeless about improving US-specific public health responses without improving our politics in general.
Monkeypox is likely to become another syphilis or chlamydia, maybe a bit worse than either (with the awful potential side effect of making you infectious to your non-sexual friends). Zika somehow seems to have eliminated itself (or maybe it wasn’t actually associated with the microcephaly they had claimed it was?) and dengue seems to be currently remaining in tropical areas.
I found myself smugly brushing off the monkeypox threat, since I don't cheat on my wife, until I realized that my bi-weekly jiu jitsu class is essentially a worst case scenario if any of my dozens of training partners get it. I'd imagine similar risks exist in tons of martial arts and contact sports (as ringworm, staph, etc. always have). I'm frustrated that I am not vaccine eligible according to my county health dept. because I don't bang random dudes, when I do spend a few hours a week rolling around with them, sweatily trying to murder each other. Seems like another failure of imagination / blind spot from health authorities.
I think I will eventually, but I'm still under the impression that the vaccine is in genuinely short supply. We're in a liberal college town with a ton of gay kids, so I do want them to be first up before I take one of their spots. But that's what's frustrating - is there vaccine sitting on the shelves, where we can move to Risk Group #2? I don't know - the messaging isn't there. I'm seeing some friends in public health this weekend and plan to see what they know.
Respectfully, as of right now there is crazy scarcity of vaccines (which there shouldn’t be but that’s a different matter) and right now the disease hasn’t spread beyond the msm communities and has not yet reliably been shown to spread in non sexual ways despite it being theoretically possible. It could change of course but until it does someone in your situation getting the scarce vaccine doesn’t make sense for you and would make things worse for everyone because you’d effectively be preventing someone who needs it and is probably orders of magnitude more likely to get infected from getting protection.
Having said all that, I think this is all a good argument to consider opening up the acam2000 for which there isn’t scarcity for volunteers from the broader public. If you’re healthy but concerned you could opt for that. Your individual danger for side effects would be minuscule, you’d get peace of mind and you won’t be taking anyone else’s dose. It’s a shame they don’t give out that option.
One of the single biggest public health lessons from the early days of COVID was that you need a government backstop to spend money on this stuff, even if it means "wasting" it. No politician wants to have attack ads run against them for supporting a boondoggle, so their incentives are to be risk-averse.
Pharma had the knowledge to do research around coronaviruses (both vaccines and small molecule drugs) but wasn't going to invest in this without a potentially large market share. And now we're re-learning the lesson with monkeypox, with the added frustration that there already is a vaccine and the government simply didn't prepare. This is going to be true with new antibiotics as well; it's only a matter of time before we have a widespread bacterial infection that we can't treat. We (and by we, I mean society at large) may learn this lesson eventually, but I'm not optimistic.
Jerusalem Demsas keeps hitting it out of the park. You should have her as a guest blogger.
Also, in many of the discussions of ACAM2000, it’s been unclear to me just *how* unpleasant it is. Is it as bad as actually getting monkeypox? The descriptions seem compatible with that.
I had started noticing her byline a few days before she was a guest on Ezra Klein, and then a few days later I started noticing her byline at the Atlantic.
Is there a knowledgeable person who can tell what else the public health people are fucking up?
Like, there seem to be a bunch of ebola vaccines stuck in development hell—what’s up with that? Do they actually have a distribution plan for the smallpox vaccine stockpile in case of need? Are we behind the curve on MRSA, swine flu, bird flu, etc. the way we’ve been on every other virus to turn up in the past 3 years?
I’m not anywhere close to a public health person, but I would think that someone—CDC, WHO, HHS, whatever—should be tasked with formulating a top 20 list of biological threats, wargaming them out, and then plugging the gaps in our prepared response. I get that it might be a big task, but we’re putting a lot of money into the alphabet soup of public health and they’re falling down on preparedness.
Blame the voters. They routinely elect leaders who prioritize a few flashy things over meaningful investments. That said, when public health works….nobody notices.
The core problem is right there in your last line. We are not putting a lot of money into public health, vis-a-vis the difficulty of the problems, and I mean by something like a factor of ten or a hundred, which is why I think that reality is unlikely to change. But just to take one example, the thing James mentions about potemkin factory set ups is possible because inspectors for the FDA don't have anything like the necessary resources to conduct actual, hard-nosed inspections (i.e. snap surprise inspections, lots of inspections, minutely detailed accounting, etc.) because you would need an army of well-paid technical professionals to do that. Moreover you then need FDA to have considerably more enforcement tools / capacity to hand down penalties that actually change / dissuade bad behavior (rather than making the fine a simple cost-of-business expense) and the political clout to enforce those penalties.
Then, take that example, and multiply it across all the different agencies doing all the different things. It's a big problem that I am unconvinced there is any political will to solve, which is simultaneously insane--the costs of catastrophic public health failure relative to the costs of public health infrastructure would pencil out--and thus far accurate, because that's just not how humans think.
“The plant would prep heavily before audits,” the former supervisor said. “The plant basically turned into a movie set where only things the higher ups wanted the FDA to see were seen.”
I'm not a public health person either and I have no idea if they're doing anything like what you're proposing. Which means that perhaps they are. Unless we get a true expert to weigh in here -- i.e., someone who really knows these organizations inside and out -- all we're doing is guessing.
Oddly, the procedure is less horrifying than the needle. You can watch a brief video from the CDC, if you like, showing how it is used. (But, trigger warnings, obviously, if you don't like this sort of thing).
The bifurcated needle is not really injected under the skin, it just pokes the surface of the skin.
And it's bifurcated in order to hold the liquid between the prongs (a bit like ink in an old-fashioned pen nib). Neither prong is hollow (as I at first assumed).
Oh god the video looks way worse than a normal vaccine injection. RAPIDLY MAKE FIFTEEN JABS! I expect my needles to go in once and come out once, like the civilized objects they are. This looks like the doctor is trying to stab the patient to death.
Yeah, but they're so shallow and superficial that they are hardly jabs at all -- mere jablets. Jabules. Jabcitos. If they even had cannulae, they would be a cannellini.
I mean, the doc says that one sign of a successful vaccination is that there *may* be a little blood somewhere on the site. Most of those fifteen don't even draw blood!
But then, the difference in our reactions may just go to different flavors of needle-phobia. Would you rather get jabbed once by a horse-size needle, or jabbed fifteen times by duck-sized needles?
Yeah, definitely going with the one horse-sized needle. I can handle anything if it happens once and then it's over. I in fact found the line about the drop of blood horrifying, because "keep stabbing lightly but relentlessly until you see blood" sounds way worse to me than a single hard jab that's guaranteed to draw blood. Thank you, I have learned something about the subtleties of needle-phobia today!
"...I can handle anything if it happens once and then it's over."
That's exactly my philosophy of life. But I don't apply it to individual episodes in life, just life as a whole. It happens once, then it's over -- how bad can it be? I can totally handle it. Or die trying.
"The characteristic raised scar that BCG immunization leaves is often used as proof of prior immunization. This scar must be distinguished from that of smallpox vaccination, which it may resemble. "
How does the gay community feel about this? Gay men in San Francisco during the early 80s experienced higher death rates than the French Army during World War I. My understanding is the community adapted a lot, became somewhat less promiscuous, created strong social pressures to use condoms during casual sex and saved alot of lives through these lifestyle changes. There must be some old, gay men who remember their friends and lovers dying with seering regret and who would be very effective advocates for cost justified interventions. Are younger gay men aware of the holocaust their predecessors endured 40 years ago? Is bathhouse culture still a thing? I’m genuinely curious.
So to answer the actual question posed here, in my experience the initial reaction was split between people who were taking it seriously and people who were in denial and trying to argue "the Biden administration just wants to make gay men the scapegoat for this". (The latter tended to be younger folks in D+30 districts of major cities and their twitter followers; who still hate Biden with the fury of a thousand exploding suns for his crime of being more popular than Bernie and thus preventing them from getting the fully-automated luxury space communism they were certain Bernie would provide.)
That initial wave of backlash and denial has mostly died down now, thanks in part to a lot of gay media outlets doing a good job of responsibly reporting on the risks and letting people who have been infected share their harrowing stories. Now the common sentiment is much more about everyone trying their damnedest to actually get the vaccine, and expressing frustration at how difficult it is. (And seriously, trying to get a Monkeypox vaccine right now makes trying to get a COVID vaccine in December of 2020 look easy.)
On a more personal/anecdotal level, I was very much intending on having a very active social life in the latter half of the summer, after successfully completing a project that had consumed essentially all of my time. I'm currently delaying those plans until I can finally get the vaccine myself (and thus even more frustrated at how difficult it is to get vaccinated).
Younger gay men are aware on some level of what our older counterparts went through. And we’ve got a set of cultural practices as a result. If you’re promiscuous, you’re expected to get tested for gonorrhea, chlamydia, syphilis, and hiv at least once every few months, and to do contact tracing as needed. There is easy access to azithromycin for gonorrhea and chlamydia, penicillin for syphilis, and both a daily pill that prevents hiv and a treatment that makes it untransmissible and basically harmless. Bathhouses exist again, though more in Europe than the United States, and there’s still no bathhouse in San Francisco (though the Steamworks is in Berkeley and I think there are some all-genders sex clubs in SF proper). Grindr/Scruff and related apps are the bigger sources of sex for most people (though it’s less often big groups) but there’s also a range of closeted people that might not be as much in the culture of testing.
Quite possible! I've seen various articles that say San Francisco never re-legalized them after the 1980s, but I'm also not sure what legalization looks like (since in most cities they operate as private clubs, where you need to pay for membership to enter, and are thus outside the reach of some kinds of regulation, the way that I hear some bars operate in Utah). When I go to Yelp and search for "gay bathhouse" in San Francisco, it doesn't obviously find any (though it finds Steamworks in Berkeley, the Power Exchange and Eros that appear to be all genders sex venues, and Good Vibrations and other sex toy shops: https://www.yelp.com/search?find_desc=Gay+Bathhouse&find_loc=San+Francisco%2C+CA ).
They were sort of re-legalized in 2020, but in an ironic twist that's perfectly appropriate for this website, it turns out that the zoning ordinance no longer had a category that includes bathhouses as a permissible use, so they're still illegal, just for different reasons. The Board of Supervisors is apparently working on changing that (https://sfist.com/2022/03/17/two-pandemic-years-later-gay-batthhouse/), but presumably any attempt at actually opening one will get tied up in discretionary review for a few years, given that it's San Francisco.
I am misinformed then - Eros is the one by Whole Foods. Learn something every day! Also Ironworks is (used to be?) the goto climbing gym in Berkeley, I wonder if that ever confuses people.
They appear to be about a mile apart, so they might confuse people. I think the Vancouver location of Steamworks bathhouse is even closer to a brewpub named Steamworks, which likely causes more confusion.
The Holocaust was a deliberate genocide. Unless you are advocating a conspiracy theory about hiv I strongly suggest you change that wording. Victims of deliberate murder and their families don’t appreciate it being equated to an unthinking virus.
A totally awkward word choice that you’re explicitly told is offensive, but you decide to stand by it. Go for it. Hopefully your family members are never murdered so you won’t have to have fools compare that to a pandemic and realize what a jerk you’ve been.
I think technically, the WHO calls HIV a "global epidemic" rather than a "pandemic", though I was able to find some documents from the CDC that do use the word "pandemic" for it. I suppose the WHO is basing this on the idea that although in every part of the world, there are some demographics that are at risk of contracting it, in many parts of the world there are some demographics that are not at risk.
I happen to know the etymology of Holocaust (ὁλόκαυτος - I actually read greek). I’ve also lived in the states for a while and never heard anyone compare any disease to “holocaust” despite being in the states in the pandemic of the century. But do keep offending me. You’re making my day.
would it be offensive to describe the mass death of native Americans after Columbus as a holocaust? It killed a far greater proportion of the relevant population that the Nazis did in the 40s. The holocaust in the new world also occurred (mainly) through unthinking disease. Communities that had never seen a European were nearly wiped out.
"This mission was undermined by the election of relatively simple-minded authorities in the Reagan administration in the United States saying lesser government is better government, and one of the lesser [ideas] was to throw public health to the wind, and especially throwing public health to the wind if it dealt with diseases that they didn't want to deal with politically.
The combination of this anti-government approach that we have -- cut, cut, cut -- ... and [an attitude, which] I'm not sure whether it was malicious intent or just simple-mindedness, that if gay men get their disease and other people have sex and get their disease and junkies get their disease, Godspeed, this combination set a stage that was really horrific, that we feel the ramifications of today; that public health was undermined [from] doing its required effort to stop an epidemic, and that the leaders at the highest levels of government would not stand up and say, "Look, guys, I know that sex is unpleasant, needle injection is unpleasant, but we as a society have to take care of ourselves, and I will speak to you about that right now and go on talking about ways to interrupt the outbreak." The highest authorities in the United States really inhibited us at CDC and set the stage to really help the outbreak spread.
[...] As an example of what the higher authorities said, after we figured out the cause and I was running the laboratory at CDC there, was working with the Institute and others to determine the cause, then we had a lot of information. We had laboratory tests. We saw how far the virus had gone, how it was transmitted. It was all very clear by that time.
Then I shifted at the direction of the higher levels of CDC to make a plan of prevention. I think we called it Operation AIDS Control, and that plan was terribly expensive -- it was $30 [million], $40 million per year at the federal level and more at local levels, state and local. We would launch programs for testing and counseling and education for HIV/AIDS. That program was outlined in several pages by me, and several pages [of the] document went to the director of CDC. ... It went to Washington, and the word that we got back from Washington, as best as I can recall, was something like, "No, we're not going to fund it, and we want you to look pretty and do as little as you can."
There is no conspiracy theory, the Reagan Administration was - at best - ambivalent about AIDS and - at worst - not only actively withheld resources from the CDC to address it but told them to not do anything, stand by and let it go because it affected people they thought deserved it ("look pretty and do as little as possible"). That near an entire generation of gay men died from it and the government was fine with that sure seems to fit the bill for a holocaust label.
Edit: I got side-tracked arguing about the definition of "holocaust" when I initially meant to argue that the government's response to AIDS ("if gays get their disease, Godspeed" and "look pretty and do as little as possible") made it a deliberate genocide. Lost the thread a bit there.
Wow. You really really need to educate yourself if you think government inaction or withholding resources to fight a disease (a serious scandal by *american* 20th cent historical standards to be sure) “fits the label”. What utter ignorance. This is depressing .
This is some "it's not a holocaust unless it comes from the Nazi region of Germany" level of linguistic gymnastics.
A generation of gay men died from AIDS that could have been saved- the data was there, the tests had been done - if the government hadn't deliberately stood in the CDC's way. Listen to the press secretary laughing at the reporter asking if anything was being done about AIDS and implying that he had to be gay to care about it. Listen to the administration making jokes about it as the death count rose into the thousands.
Hmm no. It’s more like, it’s not a Holocaust if it’s not a whole nation state dedicating its resources to meticulously planning and executing a systematic genocide of millions in an industrialized manner, as its top priority, and as the ultimate fulfillment of its racist ideology.
That is The "capital-H" Holocaust. The "lower case-H" word "holocaust" is synonymous with genocide since it was the historical examination of The Holocaust that eventually led to the adoption of the term "genocide" to refer to acts of destruction carried out against a group. See it being used that way here:
Would you say that the government allowing a fatal disease to run rampant through an undesirable community when they could have prevented it was genocidal?
I'm not sure that the gay community is as intergenerational as you seem to imply by writing "some old, gay men who remember their friends and lovers dying with seering regret ... would be very effective advocates." Just from my personal experience, gays generally don't have gay friends of another generation, especially from a generation 40 years older. Speculatively, I think now that the gay political project is in many ways formally complete, we haven't had a need to organize cross-generationally.
This is an unfortunate problem for our community! As I entered my 40s, and became happier at seeing better childcare accommodations at conferences I go to, I started realizing that much of the modern American lifestyle is heavily segregated by age and parent status. In some ways this is just moderately frustrating, and preventing a certain natural expression of human sociality. But for people without children (and particularly gay people without children) I think this does pose a worry about what the last decade or two of our life will be like. People with children have an almost automatic support network (even if it's a small one, the way that children mainly grow up now with an automatic support network that only contains a small single digit number of adults) but it'll be more of a worry when nearly all my close friends are in our 80s or above. It would be good if the gay community were structured in ways that made it easier for us to have friends that are 20 years older or younger than us. (Not just for gays, but particularly for us.)
Eternal rest grant unto [old gays], O Lord, and let perpetual light shine upon them. May their souls and the souls of all the faithful departed, through the mercy of God, rest in peace. Amen.
It may be practically complete – assuming Obergefell is not overturned* – but it is not *formally* complete while discrimination in a bunch of areas is still legal, i.e. until the Equality Act is passed.
*although arguably the very fact that Obergefell can still be credibly threatened shows society still has some way to go regardless of the current legal landscape.
Niche complaint but the focus on male/male sexual encounters may also cause people to overlook other activities as risky. Martial arts are what I'm thinking of here - a jujitsu student can be in close contact with maybe 6 or 8 people a class, 2 or 3 classes a week... I don't know exactly how promiscuous promiscuous people are, but that has to be in the same ballpark, right?
Niche conspiracy theory: both recent pandemics were engineered by The Illuminati specifically to prevent me from getting back on the mats.
I guess one potential difference is how "open" or "closed" the network is. Do jujitsu students usually stay with the same class of people all week, or is it common for people to go to one venue on Tuesdays and another on Saturdays? If people travel for a work trip, how likely are they to go to a class in the other city? (It might not take that many individuals who do this sort of crossing to effectively make it one big network, the way the sexual network is.)
Fair point. I don't think travelers would typically take classes in other cities. Some people might train at more than one school, but the big cross contamination risk would be people who train more than one art. If you do BJJ on Saturdays and MMA on Thursdays, you could spread between schools.
Also, schools are big enough that you probably don't need many such links, as you say. One class is contact with 6-8 people, the next could be a whole different set. People do have regular training partners, but I think people also have regular sexual partners. Do promiscuous people tend to cluster into "pods" with relatively rare inter-pod encounters? Probably not to the same degree that martial artists do, but I don't really know.
I guess it's very understandable but people are very, very resistant to the fact that a new STD just exists now and probably isn't going back in the bottle anytime soon. Makes me wonder if there will ever be consensus again to allow another member into that class of diseases in the popular consciousness, because they're seen as stigmatizing and it could be seen as better to treat each new outbreak as sui generis.
Minor comment: JYNNEOS is preferred for its safety profile, and we should definitely procure it (see my main comment) but it’s worth noting that we actually know less about its effectiveness in smallpox* and it’s possibly less effective than the older vaccines (+needs two doses and currently we are giving only one). That’s why the world health organization recommends *against* it for its smallpox vaccine advice. ACAM2000 by contrast had robust clinical trials and does the job for sure with a single shot so we better keep 100s of millions in stock for now in case of smallpox outbreak and consider allowing use right now for monkeypox in some cases.
*neither vaccine was developed for monkeypox and although we *hope* they will work on it and have good reason to think so actual efficacy data from the current outbreak isn’t there yet.
P.S. there is a Japanese vaccine ( LC16m8 ) that’s supposed to be the best of both worlds. As safe as JYNNEOS but as robust as ACAM2000. It was used at the end of smallpox eradication and has the WHO seal of approval (unlike JYNNEOS). It’s curious nobody is talking about it.
Is it actually substantially less bad to get ACAM2000 than to get an uncontrolled exposure to monkeypox? Either way you get a painful sore and are potentially contagious.
People describe monkeypox as hellish pain (maybe because of the specific areas they get it ?) also I think it’s a rash that spreads ? And we don’t know the long term complications etc. vaccinia is totally harmless for most people, the one spot you get the “take” on isn’t supposed to be that painful (ever heard traumatic stories from your elders who got their smallpox vaccines?) . And the danger of contagion from the vaccine is very low if you’re not being a total idiot. Fact is with hundreds of millions being vaccinated for smallpox vaccinia never actually broke loose and became an endemic disease. Very different from the speeding pox viruses.
P.S. with ACAM2000 you get robust protection against smallpox which is nice to have. No idea what level of cross immunity you’d get from the monkeypox vaccine.
I teach global and public health, so I can vouch for this being a good piece. My summer class just happens to be doing the failures of malaria policy this week, and I will probably assign this piece for extra credit today (I'm assuming this is unpaywalled, since it is linked on Twitter).
That said, I think one thing we should recognize is that the current failures of public health policy are, depressingly, not even a little bit new. We tend to have this idea that CDC, WHO, et al., used to be good and then lost their mojo, but the truth is that we have a few high-profile successes (besides smallpox eradication, the Obama-era ebola episode was a legit decent response to that crisis) and a lot of failures: AIDS, zika, malaria multiple times, every drug crisis so far, including opioid most recently--even, I would argue, the persistence of measles outbreaks in the US. And as that list of examples suggests, those failures go way beyond government. The much-touted malaria bed-net charities of the past twenty years are, with clockwork predictability, running into the problem that mosquitoes under selective pressure are shifting their feeding habits in places with high bed-net uptake.
All of which is just to reiterate and emphasize the point made in the article that these problems are very, very hard in ways that I have come to believe even the actors themselves underestimate. I think public health people genuinely underestimate the complexity of problems. We genuinely overestimate the efficacy of certain kinds of response (i.e. "if we just did the right messaging, X would happen," or "if people would just listen / could be forced / knew how to follow our advice, we could solve Y"). And we systematically commit certain kinds of cognitive errors, like misunderstandig how everyone else experiences and understands disease (for example, at the beginning of the pandemic, I told my students, "if this is the worst disease event of the last fifty years--if mortality is completely awful and we lose a million people next year--you might still not know anyone who died," and that held up, which helps to explain how you can have a disaster and also have the stupid debate we have over vaccination, because the two are not exclusive in human experience).
As a teacher, I try to help would-be public health professionals of the future to develop some tools against these problems. I try to help them see hubris and develop humility. We talk about the importance of not just telling the truth but telling it with precision and completeness. I'm a historian, so we do past episodes of failure and try to tease apart the complexities that get us places and the arguments and failures that recur (the unchanging nature of the vaccine debate, going all the way back to smallpox variolation, is simultaneously hilarious and depressing). And I think this all helps.
But as a historian I have come to the conclusion that the best we can hope for is to handle THIS episode and THAT episode correctly, because "public health" is, in some very real sense, too broad of a problem set for anyone to get their arms around. Like, how do you bind together a basket of issues that that includes needing to understand fentanyl production, monkeypox epidemiology, and maintenance of lifelong HIV antiviral drug production and delivery chains? It's a ridiculous claim on its face.
Of course, that raises a whole different set of policy questions, against which all the incentives of our system are set to produce non-optimal answers. So people yell about how bad the "official public health" response is, and they are right, and public health people yell back about how much they are misunderstood and under-resourced, and they are right, and everybody is right, and that sucks.
Thus concludes my professional public health downer rant.
There have been some major public health successes, around things like sewage systems and municipal water, iodized salt, and (maybe?) fluoridated water.
Totally agree, and also, this is a great example of the nature of the problem. So is public health an engineering problem? A nutrition problem that you can solve by formulating foods differently? A problem that you can solve with Big Brother type interventions where you just kind of impose a big change (i.e. fluoridation)? A vaccination problem? An epidemiology problem? A pest-control problem?
Obviously, the answer is, "yes," which means that to a first approximation, "public health" might be everything and nothing, which makes it really hard to get your arms around, as a policy matter. We're kind of trying to fit a set of responses into a mental umbrella of policy that is just really, really hard, so it frustrates your ability to fix it. Like, no one says, "We managed to reduce road fatalities by improving automobile safety, which is why I've put Becky, a road engineer, and Javier, and epidemiologist, in charge of our bicycle helmet program," because that would be a bizarre nonsense statement. And yet, if you actually look at public health...
This is also, hilariously, how you end up with the constant phenomenon in public health which is each new generation of economist superstars showing up and being like, "this stuff going on in public health is a bunch of nonsense, but we're going to fix it with econo-think!" that fails in ways that are both interestingly novel and depressingly similar to the previous generation of econo-think public health failures.
Everyone walks in thinking They Are Doing The New Thing to Fix the Failures of Those People Before Who Just Didn't Understand. It's like sitting down to the poker table and thinking, "everyone else here is a sucker because none of them has won the game yet." Yeah. That's not actually how that works.
This XKCD comic is evergreen from the sounds of it:
https://xkcd.com/927/
YES.
I mean, pretty much always. About everything. Also, still my favorite: "Silent Hammer."
https://xkcd.com/666/
I see someone read my comment last night, lol.
I’m not sure I agree but I’m happy to discuss further over beer at a Philly SB Meetup.
Haha--I actually hadn't, because I was out for the evening, but apparently you and I are on the same wavelength to a hilarious degree. Maybe because we are both Philly people?
I doubt you and I actually disagree all that much. I think I would describe those exact same episodes as you and only slightly alter my explanation of what did and did not happen, and why, in ways that you would be like, "yeah, that makes sense." And I 1000% endorse the sentiment at the end of your comment. I basically just think that the barriers to fixing the problem are even deeper and worse than you might think, because they can sort of be described by "competence," and I hugely endorse pushing for maximum competence, but the meaning of that term and what it takes to achieve it is weirder and harder and requires more resources and different kinds of political judgements than expected.
Lol, it's a hell of a coincidence that your second paragraph reads as essentially a line-by-line response to mine from last night.
And I imagine we do agree on quite a bit regarding the past; success has many fathers, failure is an orphan. We remember the successes, forget the failures, and if we're lucky maybe the way the institution does things grows out of the experiences of both even though no one remembers why.
+1
One element I think that could shed light on this "downer rant" (fantastic and informative comment, by the way) is: how does the US tend to stack up against other countries in this area? I'd guess "not that great" (especially if we adjust for wealth)—a recent coronavirus pandemic comes to mind—but I honestly don't know, and I'd be curious as to what other think, or is there a consensus?
Could you link to the article on changing feeding habits in mosquitos? My Google fu isn’t strong enough for this one.
Sort of. Explanation: the bed net comment originated in a conversation that I had with Michael Povelones, the mosquito guy at UPenn. We were discussing a conference he just got back from, which was mostly about the new-hotness genetically-altered-mosquito strategy. (This is actually not a public health connection; we're friends by random chance, because our wives happened to previously be professors together at a PSU branch campus near Philly. So we are the weirdos who talk mosquitoes over beer while the kids are playing.)
So I don't have the conference paper that was given a couple of weeks ago, for obvious reasons. But here is why I found it an unremarkable claim and consistent with other literature on the subject:
You can already easily dip your toe into the bed net debate if you Google "pyrethroid resistance" or "ITN resistance." Mosquito bed nets generally work in two potential ways: they present a physical barrier to the mosquitos, but they are also doped with an insecticide that, even if it does not kill the insects, causes them to physically leave the dwelling--they don't want to remain in proximity to it. The second part is important because the barrier part only protects you while you are physically in the confines of the netting (i.e., around your bed while sleeping). So if the mosquito can't get through the barrier but just waits around nearby, it can bite when you get up in the morning. A lot of mosquitoes are actually pretty lazy flyers; they don't like to move all that far.
The problem, as you can guess from my suggested search, is that some species can (and are) developing resistance to the insecticide, just as they developed resistance to DDT. And frankly, this is what you would expect. <Cue Jurassic Park clip.> There's a lot of hemming and hawing in the literature, which you will find if you read through it a bit. Doing real-world efficacy studies of this kind of thing is genuinely hard. But resistant mosquitos do, in fact, appear to change their behavior and continue hanging out in the homes. See, for example:
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0266420
https://malariajournal.biomedcentral.com/articles/10.1186/s12936-020-03321-6
So why does insecticide resistance matter to my acceptance of the behavioral adaptation claim? Well, for one thing, because the behavioral claim is a knock-on effect--it's made more possible by resistance, if resistance allows the insects to hang out in the house (whereas before they left it). That's reason number one. This is precisely the follow-up you would expect from what we can prove is happening, which is the growing resistance.
But (reason 2) this also is a story that just fits very neatly into what we know about adaptation.
Mosquitoes don't drink blood to feed, precisely, in a nourishment kind of way. They need a blood meal specifically to reproduce; this is why only the females bite. Different varieties of mosquitoes have different preferences for where they get the blood; some strongly prefer humans, while others will bite lots of animals. The fussy human biters are the disproportionate problem. Bed nets work in part because mosquitoes are also fussy about WHEN they feed; they tend to prefer early morning and bedtime, but again, it varies across different kinds of mosquitoes.
In an ideal world, of course, you could imagine people who wear full-coverage clothing and repellant and only change clothes when they are in the area protected by the bed net. But over here, on Earth 1, that's not what actually happens, in part because it's a pain in the ass. But you can significantly reduce the biting by just having people inside the barrier protection (bed net) during those high-feeding periods.
Except that by putting in the bed net, you have now introduced a selection pressure. Females who refuse to feed except in the very narrow window covered by the net and the very narrow group of hosts (humans) are not going to get the blood meal they need to reproduce. Females who vary their biting habits are going to be more successful, in the reproduction / adaptation sense. Now, to be clear, that could include lots of adaptive strategies--if you said that over time you were seeing a greater willingness on the part of human-preferring biters to shift over to monkeys or dogs or something, I would also find that plausible. But "extend the feeding window" is just a really, really obvious one--more obvious than changing your preferred dietary target.
And it's already a behavioral adaptation they do. Like, if you walk into a room of females in need of a blood meal at noon, you are going to get bitten (I say as a person who grew up in the Houston area and spent a not inconsiderable amount of time as a child in swampy overgrown places.) The insecticide thing really tamps that problem down, because if the mosquitoes come looking for a meal while you are in the bed net zone and they die from the insecticide or at least get pushed out of the house, that partially solves the extended feeding hours thing. But once resistance increases, now you have a problem. The behavioral adaptation becomes a much smaller lift, and we are literally actively selecting for resistant, less time-fussy feeders. The fussy ones didn't reproduce.
And here is where I would point you to a piece in the Lancet:
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00216-3/fulltext
This piece is agnostic on why reductions from ITN programs stalled in the late teens, and I want to be clear that I'm not pretending to be the final word on the matter. There are lots of ways things can break down, as the article itself discusses. But the timing is highly suggestive. Fears about insecticide resistance really got going earlier in the decade (look at the date stamps on the articles in your Google search for a sense of the timing).
If, as I described, it's a two-step process, and keeping in mind the severe limitations on the data quality in this area, then it's pretty reasonable to expect that we would now be seeing behavioral adaptation to the selection pressure that we created. Again, it would be inconsistent with our experience of biological systems generally and mosquitoes in particular if they DIDN'T adapt to the bed nets. It would be one thing if you could either achieve eradication or have a truly multi-pronged approach to the problem (for a completely different application of this same thought process, think about how we now use multi-drug cocktails for adaptive diseases like TB and HIV; at a certain point, adapting to 3-4 wildly different pressures simultaneously is just too hard for the target).
But bed nets were never going to be that. You would have needed to roll out a bunch of other measures, which are difficult and expensive, and the whole way that bed nets were sold was that they were supposed to be cheap and simple. And they were! Which is why you would expect their efficacy to drop over time.
So that's why I buy the claim. Obviously you could very reasonably say, "that's something you claim to have heard from some guy over the weekend; I call BS." But my claim here is that it's pretty consistent with the (limited) evidence at hand and historical experience.
Apologies if that was a longer walk than you wanted to take.
Excellent comment. I think I would love to take one of your classes.
As for how to mange all the complexity I think having the CDC only focus on infectious disease would be a great start
No worries; as a historian, I actually discuss these ideas extensively in my class, starting with the demographic / mortality transition. The ideas in Pinker's optimism work were mostly meta-analysis and extensions of ideas that long preceded Pinker in the history space. He's a great communicator (I read the Language Instinct as an undergrad and have been influenced by his thinking ever since, even when I'm not totally onboard), and I appreciate him bringing those ideas to the wider discourse--it was a genuinely valuable intervention--but the stuff he said was not especially novel. I will say that my one gripe with Pinker, et al., is that they systematically underestimate certain kinds of tail risk and structural causes because of the different nature of their training.
But honestly, my post above was a crie de couer specifically about "public health"--as a discipline, a political subject, a policy sphere, a profession / practice--rather than about "the health of the public," in the sense of overall life expectancy and basic metrics like nutrition status, if that makes sense. As a statistical matter, today is one of the best days to be a human, ever, even with Covid. It's just also the case that I would not suggest, as a way of investigating the dichotomoy, that you go to some Covid funerals or The First Thanksgiving without X this year and declare, "Did you know that public health is in a better place than ever in human history? It's an amazing time to be alive!" Because they will throw the gravy boat at you, and...fair.
This is from Kat Rosenfield last week:
2020 public health: cover your disgusting face holes and stay the fuck home you bunch of selfish troglodytes
2022 public health: maybe just put a lil gauze on your monkeypox boils before your orgy, y’know, if you feel like it
If COVID response wasn’t the nail in the coffin for the whole idea of establishment expertise, this one probably is.
Satire always introduces illegitimate elements to get the laugh, but I also think there's not much to the underlying complaint. 2020 involved a highly lethal, extremely contagious disease, and highly generalized behaviors that applied to a universal population. 2022 involves a very low lethality, low-contagion disease, and specific behaviors that at this point are largely relevant to a restricted, generally stigmatized population.
Comments along these lines (there was another one here I can't locate anymore which reference shutting down churches) seem to me to take the focus away from substantive failures, such as the ones Matt emphasizes, in order to trot out caricatures useful in dead-end culture-war battles.
OK, but counterpoint: the differences in contagiousness and the fact that this is (currently) restricted to a small, pretty identifiable population mean there was a chance to stop it in a way that there was never a chance to stop COVID. And we didn't know that immediately with COVID, but we certainly knew it (or should have known it) way past the point at which "stay home or you're killing grandma" was still a thing that people were saying.
I don't really understand what the "that" and "it" are in your second sentence, Emily, but I certainly get the point of your first sentence. Sure: all the things Matt writes about concerning our missed opportunity are true. But those don't include failing to issue mandates that would have prevented, for example, risky behavior during Pride--the legal hurdles for local government to target conduct involving gay men are insurmountable (justifiably). I certainly saw messaging that warned about transmission through sexual contact early on, and on the messaging front I don't know what more we should have asked for.
The big thing I think we could have asked for is local STD testing clinics to reach out to local gay bars and bathhouses where they have established relationships, and gotten them to put up informational flyers. I don't recall seeing any in early June, and I may not have been to any relevant venues recently, so it's possible they have.
I don't think there should have been mandates. But I agree with Dan Savage, who has called the national response "disorganized and unclear in its messaging." I think if you are here, you are probably more keyed in to content about monkeypox prevention than the average person.
Monkeypox in its current iteration is probably more lethal than COVID-19 by a factor of 2-4.
I don't think that statement is likely correct, James, but if you have some basis for it I'm willing to change my mind.
The fatality rate for Covid cases in the US has been a little over 1%. Worldwide it has varied, by country, from below 0.5% up to over 5%. I presume the variance has to do with availability of treatment and comprehensiveness of case reporting, though since the two factors would tend to vary in parallel I'm not sure how the impact would manifest.
Today's (8/3 data) CDC count of US monkeypox cases stands at 6,600+ (https://www.cdc.gov/poxvirus/monkeypox/response/2022/us-map.html), but so far we have seen no fatalities, according to latest reports. Less certainly reliable online figures, a few days old, are for just over 16,000 cases worldwide, with nine fatalities.
According to https://www.worldometers.info/coronavirus/country/us/, the US has experienced 1,057,239 COVID deaths out of 93,593,214 confirmed cases.
US excess mortality over the period in question was about 114,000 higher than 1.06 million, so the # of reported COVID deaths can be taken as a reasonable estimate of the number of COVID deaths*, whereas it is known that the # of confirmed COVID cases is an underestimate of the # of COVID cases by some unknown but larger factor (2-4, probably, once re-infections are taken into account).
https://ourworldindata.org/grapher/excess-mortality-raw-death-count?country=~USA
So that gives a CFR of more like 0.5%
It's still too early in the monkeypox pandemic to get a good sense of the fatality of this particular strain because it emerged so recently. The best estimate we have for it is that the case fatality rate is 3.5% in Nigeria, based on the past 5 years of data:
"In May 2022, the Nigerian government released a report stating that between 2017 and 2022, 558 cases were confirmed across 32 states and the Federal Capital Territory. The Rivers State was the most affected by monkeypox followed by Bayelsa and Lagos. There were 8 deaths reported, making for a 3.5% Case Fatality Ratio."
https://en.wikipedia.org/wiki/Monkeypox#2022_outbreak
Now, it's certainly possible that this particular virus will exhibit a large discrepancy in lethality where it's less lethal in first world hospitals settings and more lethal in poor countries, since that was the case for many other diseases. However, it's also possible that it will instead exhibit the same pattern as COVID and have a death rate that is overwhelmingly concentrated among the old and infirm, and its CFR is artificially low right now because the population of young gay men who go to a lot of parties are unusually young, thin, and fit compared to the general population.
*Note that excess mortality has been zero for the past month or two despite there still being ~400 covid deaths per day, indicating that people are dying *with* COVID rather than *of* COVID at this point
Thanks for replying with data, James. As James C. points out, the rate from Nigerian data is actually 1.4%. It seems to me that the best comparator to select in order to assess this data in comparison to Covid would be the Nigerian Covid case fatality rate, which was 1.2% (Johns Hopkins data). We do not know the likely undercount for either disease, but the variables are, at least, steady in terms the social, medical, and governmental contexts.
Some Covid deaths have always been "with" rather than "of," as is true, I suppose, of any infectious disease and its fatality rate. I'll second what James C. wrote about lags in complete death record tabulations.
Your question about the impact of a preexisting vaccine lowering fatality rates is valid. However, if the result would be an unknown number of cases where a fatality that would have occurred did not, because of weakened symptoms (artificially lowering the "natural" fatality rate), it could also include an unknown number of cases where symptoms never manifested because of vaccine effectiveness (artificially raising the natural worldwide fatality rate, and, potentially the US rate, if US fatalities occur).
See my note to John about complete death record tabulation.
If we use Nigerian numbers only for both monkeypox and COVID, then we'd both need to amend our initial statements. 1.4% is not 2x 1.2%, so my original claim would need to be changed, but 1.4% is greater than 1.2%, which means that rather than covid being "highly lethal" and monkeypox being "low lethality", monkeypox is "slightly more lethal than covid"
Also, at first glance, the 3.5% CFR seems to come out of no where. From the numbers given, 8/558 = 1.4%. When I followed the citation on wikipedia, it appears they got it because only 230 cases were confirmed, which is obviously a large undercount.
https://www.premiumtimesng.com/news/top-news/528825-monkeypox-nigeria-records-558-cases-eight-deaths-in-five-years.html
You're no doubt correct that differences in the populations infected are going to confound the CFR anyway, but I'm not sure that will change dramatically over time given their relative transmissibility.
If 1.4% was the true rate, it would still be a >2x higher CFR than COVID (~0.5%).
However, there's also no guarantee that 558 is the correct number of cases, so it's possible that monkeypox's CFR is lower, possibly quite a bit lower.
IIRC, excess mortality stats have a noticeable lag, so I don't think you can't trust them for the last month (it's been at least a year since I looked into this, so I can't remember where I came across that info). I wouldn't be surprised if some COVID deaths are *with* rather than *of* though.
Their last reported number is for June 7th, 2022, and excess mortality has been ~negligible for the period from March 8th to June 7th 2022 by their data.
Two months to collect the data for June sounds reasonable, and March is 5 months ago.
https://ourworldindata.org/grapher/excess-mortality-raw-death-count?country=~USA
Secondary question -- of those infected in the US, how many were already vaccinated for smallpox, or were able to get vaccinated in the 4 day post-exposure window where getting vaccinated is expected to offer a substantial protective effect?
"CDC recommends that the vaccine be given within 4 days from the date of exposure for the best chance to prevent onset of the disease."
https://www.cdc.gov/poxvirus/monkeypox/considerations-for-monkeypox-vaccination.html
You would think, based on this characterization, that the people who complained about the Covid response in 2020 being too heavy-handed would be super-excited about how the public health establishment has responded to their concerns and corrected course in 2022.
And, of course, you would be totally wrong, because that's not really what it was about.
If I thought this was part of an actual correction and that, for instance, we were not still going to be fighting over school masking/closures in the fall and winter, I would find something to like in this. But this isn't "we heard you, prior behavior was a mistake, and going forward we have a new set of principles."
Also, I don't think anything should be shut down in response to this -- I think that's the right call. But I do think "stay home" was an appropriate thing to say to people in March of 2020 and there are contexts where it would be appropriate to say now.
I'm pretty unconvinced that the debate then or now being had in the public at-large is, fundamentally, a "public health" debate. Like, I think that is a category error. What we mostly have is a front in the larger culture / politics war with vague public health features. Weirdly, that is happening alongside and interwoven with a bunch of actual policy and technical debates, and those are also interwoven with political questions about funding, agency structure, etc., which is why I think the whole thing is totally f*cked.
But I am unpersuaded that a slightly different set of statements made by...who? precisely? is always a really interesting question...but I am unpersuaded that a different set of public statements made at the beginning of Pride would have appreciably altered this outbreak event. A big part of the whole problem with Covid is that everyone has way, way, way overestimated the power and significance of messaging to change outcomes in the real world. You have to do concrete stuff in the world, which we were pretty unprepared to do two months ago (and that is a real indictment of our society / politics / agencies / voters / all of us who can get sick, which is, you know, all of us).
I do think that if local STD testing sites that have strong relationships with the gay community had sent someone to each of the bars and bathhouses, with some sort of relatively neutral informational flyer to put up, that could have helped a bit. And it would also be helpful if Grindr sent out popup messages about it a bit more often (I've received two in the past few months - I forget if it's when I was traveling to bigger cities, which would be a nice sign of them targeting it to locations).
Totally agree. I would classify those kinds of interventions--targeted outreach--more in the way of "doing concrete stuff on the ground" than in the way of "messaging." I think of "messaging" as what you see on official social media feeds and in mass media outlets. But that's probably being hair-splitty, on my part.
I think of messaging as activities that are extremely low-cost, in the way that calling a reporter or holding a press conference is low cost. Good targeted outreach is often actually a lot of work, much of it done prior to the emergency (i.e. developing relationships with the relevant local communities--the gay community in this case, but I'm sure you can imagine ten others of interest for different situations).
incredibly selective right wing grievance mongering at work
I'd like a public health establishment that starts from the perspective that we should be honest with people about risk. Not "what should we tell people if want to produce a certain response?" or "what should we avoid telling people because we don't want to cause this other negative thing?" Just tell people the truth. It really undermines public faith in institutions when you don't do this, and it's not like the public health officials are such effective propagandists that they're even particularly likely to get the effect that they're trying to get.
This is my biggest problem with public health. Just tell people the truth. Even if it’s scary. I think this reluctance to tell the truth can be partly traced back to the belief among many well-educated Americans that a large segment of the general public is stupid/reckless/immoral and incapable of making good decisions. Therefore it’s okay and even necessary to deceive them. Of course, this is bad for society and feeds populism but then you just blame the public for being stupid.
“ a large segment of the general public is stupid/reckless/immoral and incapable of making good decisions”
Obviously. 40% of seniors rely exclusively on social security. These aren’t people who make good decisions.
Many things cause poverty--not only recklessness
True and I’m sympathetic with “hey you need to keep it super simple and get the message out,” too. Have a super simple rec. Also have an official explanation, a risk benefit analysis and options depending on risk appetite, sort of thing. Doesn’t have to be all or nothing. Don’t drink during pregnancy. But also one drink in nine months will not necessarily be super bad but also fetal alcohol effects are a spectrum and we don’t have a specific threshold below which is safe.
+1
The messaging situation has been a total mess for a long, long time. I'm not even sure it's fixable, given the current information structure of our society.
Important to not separate the bad public health response with simply terrible political incentives - In 2009 in the face of swine flu the UK Health Secretary ordered £300 million worth of vaccines for it, and ended up being heavily criticised by the press as having been 'wasteful.' Sadly there's not much understanding about how sometimes you have to take financial risks in public health even if the worst of the downside does not materialise
Would Matt have the clout to get an interview with those reporters and editors. Ask them if they’d publish the same story now?
I think that was the story basically everywhere in the EU back then.
Germany, for example: https://www.dw.com/en/germany-to-destroy-expensive-unwanted-swine-flu-vaccine/a-15324186
France: https://www.ft.com/content/b2b61aae-f962-11de-80dc-00144feab49a
I guess that may be part of the reason why the COVID vaccine rollout was so slow and terrible in the EU compared to the US.
edit: The FT article seems to be paywalled.
The case that our public health experts are "just following the science", as opposed to the bad guys who act based on politics, is getting quite difficult to sustain.
Even worse - they are academics with no idea how to operate in the real world. At least politicians have voters to sort of be responsive to, even if they usually fail at it. There’s no Joe Manchin of public health, unfortunately
To both of your points, unfortunately, "Use science to make better-informed decisions!" wasn't pithy enough to catch on.
"We need to build a bridge over that there river. Follow the science!" Science can offer us the most basic, macroscale guidance like "gravity always points down" to the nitty-gritty microscale stuff like what different metals have different material properties like yield stress, stiffness, hardness, and corrosion resistance, and how we can alter those based on mixing different atoms together.
Science doesn't give you instructions on how to design a bridge. It doesn't really know what a bridge is, as a five-year-old would describe it. Science sure as hell doesn't give you instructions on how to build it, source cost-effective materials from reliable suppliers, manage the teams building the bridge, inspect and repair in service...
Regrettably, we now have a whole generation conditioned to think of science as offering direct instructions to fix our problems. Damn it all.
There was someone on here yesterday arguing that “the science” was telling us we’re on the verge of societal collapse due to climate change. That’s not at all what science does, or is for.
I am now pinching the bridge of my nose hard enough to form diamonds.
Perhaps they were making an implicit claim that social sciences are sciences, too? /s
I'm a wordmonger, not a scientist, so I hold scientists in very high esteem (which my science-y husband says is dumb). But it's tragic that "use science to make better-informed decisions" isn't catching on. "Better-informed decisions" is probably the thing most desperately needed in the world today, but even in the face of massive failure, there seems to be little interest in figuring out why X failed and how to do better next time. Not just with respect to covid/public health, but across a range of dimensions. We just seem to lurch forward, hoping things work out.
As a scientist, your husband is correct
There is an old saying that “public health is political but it shouldn’t be partisan”. Our public health establishment really needs to recommit to that. The vast majority of public health people are very liberal and they have a bad habit of dismissing people to the right of them as stupid and their beliefs should be dismissed. It’s hard to mount a response to a disease when you don’t have much respect for most of the public.
Exactly.
MattY, the botched response here is much much worse then how you present it. Public health officials repeatedly refused to ship to us vaccine doses already bought and even donated some to Europe , *after* the current outbreak was already happening . They also dropped the ball on the strategic stock pile, letting it deplete from 10s of millions of doses to nothing. And this is just *some* of the mistakes made. Everyone needs to read this thorough NYT reporting on the botched response, I thought I was a skeptic about us public health agencies already, but this is just unbelievable:
https://www.nytimes.com/2022/08/03/us/politics/monkeypox-vaccine-doses-us.html
And the FDA took until last week to inspect the plant! You would think that health departments running out of vaccines within hours would give them a sense of urgency but nope.
It’s pretty clear at this point that these people/organizations don’t do urgency. That’s a huge problem.
My goto source for almost all wisdom is Kevin Drum and he is on point here: https://jabberwocking.com/why-doesnt-the-fda-have-an-mra-with-the-ema-for-gmp-on-pharmaceuticals/
In which he says:
Question #1: Do you know what the following acronyms stand for?
MRA
FDA
EMA
GMP
For the record, they are: Mutual Recognition Agreement, Food & Drug Administration, European Medicines Agency, and Good Manufacturing Practices.
Question #2: If you didn't recognize all four of these acronyms, did you nonetheless have a strong opinion about whether the United States should automatically accept European approvals of European pharmaceutical facilities instead of always requiring its own?
I didn't recognize these acronyms so accordingly I have no opinion on how well the FDA executed acquiring vaccine doses from Europe.
Also, interesting from Kevin on this topic: https://jabberwocking.com/how-big-a-disaster-is-the-fdas-monkeypox-approval-delay/
He makes a bad point. “You shouldn’t hold elected/appointed leadership accountable unless you are familiar with obscure acronyms. Also life or death emergency never justifies changing priorities or accelerating timelines..”
“Don’t know what OIS, EIS, CEW, ECW, AAR, or PIT mean? Stfu about police reform”
“Don’t know what HiMARS, MLRS, Nlaw stand for? Your opinions about Us giving aid to Ukraine are invalid and you have no right to hold them.”
Kevin Drum might be smart but he apparently isn’t wise.
His point is that while you may have a principled viewpoint -- "maximizing vaccine production and distribution should be a high priority" -- unless you know the mechanics of a situation, you are in a bad position to critique the process. Did the FDA drag its feet? Given the existing legal and regulatory environment, could they have done better? I don't know and you don't know.
It's easy to announce when an emergency hits that even though you hadn't given this a moment thought before, government should have done much better, even though you don't have the goods to know what that would mean in practice.
Do we then have to be experts in everything in order to have an opinion? No, but not being one should warrant a bit more humility.
Let's take, well, your last example, on giving aid to Ukraine when you don't know what HIMARS, MLRS, NLAW stand for. Yes, this is exactly a case for a bit more humility. Figuring out the best way to support weapon systems is what I spent my career doing so I think I have some standing for talking about the best way for the US (and others) to support Ukraine. And do I hear uninformed people offering unsupportable views on how we support Ukraine? Oh, you bet. We should be sending a hundred HIMARS to Ukraine! Oh no, we should not. They can't absorb them, they can't get trained quickly enough to use so many, they don't have the logistics structure to move the vast amount of munitions through the country to keep them supplied -- and we don't have that many to begin with.
The Ukrainians, through the supplies we are sending them, are trying to do something unprecedented in reinventing their entire military during an intense war. It's like flying a plane and at the same time totally rebuilding it in flight and managing to land it. One can support aiding the Ukrainians, and also believe the Ukrainians when they say they want more and faster support, but at the same time, one should have a bit more confidence that the people in our institutions know what they're doing, and not be so quick to think you know better.
That said, the fact that *we* don't know what the FDA could have done better is no reason for Congress to be waiting so long to create a commission to study what the FDA could have done better in any of the failures of the past couple years.
Absolutely!!
There’s another good reason for the US not to give NLAWs to Ukraine: It’s not an American weapon.
Update: read the two blog posts now. To my understanding they are rendered largely outdated in the meantime and address few to none of the problems raised in the NYT article. Still convinced us dropped the ball big time. The fact that us used to have a strategic stockpile of the new vaccines (that it allowed to go down the drain) and that it paid for their development makes the current state we’re in more of a screwup not less.
I'd agree that the NYT article is a fair knock on HHS. This looks like a straightforward case of dropping the ball on something that was well within their power to do.
I like the NYT article because they actually talked to experts and people knowledgeable about the events in question. That's good journalism. But it's a very specific and limited case. There's still too much tendency for folks to say, based on gut feeling and no knowledge, the [FDA/CDC/etc] are bunglers and here's one weird trick to make them work better.
But again, good NYT article. Thanks for pointing it out.
I think a thorough case has been made on how they dropped the ball repeatedly on COVID response too. I realize that responding to outbreaks of new diseases is just one part of their mandate, and does not reflect on how well they cope with so much more they're responsible for. Fair enough. But that's still one very very significant part of their mandate, and we seem to be getting pretty repeated and quite robust evidence at this point that they're just not doing well enough, especially considering how better resourced they're supposed to be compared to anywhere else in the world basically. We shouldn't simply accept the status quo. Stakes are too high.
I think the CDC did a fantastic job in their COVID response and every single criticism I've read of them has been dead wrong.
(I'll be here all week, folks. Be sure to tip your waiter.)
But seriously, even in a pretty damning case like this, you still have to watch out for trap doors. I think Scott Gottlieb is a very smart and well-informed guy and his book "Uncontrolled Spread" is a damning indictment of everything the CDC did wrong on COVID. I am in no position to say he's wrong. And yet . . . he was head of the FDA during the Trump administration and very strangely the FDA comes out looking good and innocent throughout the entire crisis (weirdly, he is very kind to Trump too). So I read him to say "CDC bad, my agency good" and that makes we wonder how much I can trust his expertise in analyzing our COVID response.
Which is a longwinded way of saying that sometimes it's really hard for us non-expert outsides to judge the evidence.
Briefly cause I have to go: testing dealys, botched mask guidance bordering on lying to the public and fostering long term distrust of masking, dealyed approval of the vaccines and later over-caution in approving them for more people (even more so the foolish delay with the approval of the boosters, probably a major reaons why the us is so dramatically behind peer countries on this).
These are just on the top of my head. the list of indictments honeslty goes on and on and on and on and on. And i'm relying e.g. on zeynep tufekci , not on partisan interest, but mostly i'm relying on comparing the cdc guidance and policies in real time with those of uk , eu, and other advanced nations. It was like living in the twilight zone. You just couldn't turst the us govenemnt, each and every time other countries mad e the right call and us was dropping the ball and getting in line after a precious daelay of a month or two. The outcomes were accordingly grimmer in the us. In other words, i'm not an expert myself, but I *can* compare varying policies of peer countires which all have experts, and the us was a bad outlier.
Interesting to find a Kevin Drum stan here of all places because his housing takes are just awful.
Thanks. I’ll read that. In return I’ll recommend reading the NYT piece of you haven’t done so. To my understanding the issue of European approvals is really not the main problem at all.
maybe public health agencies are staffed by the MDs that urgent care places pass over
I’m at the point where “make the global south richer” is probably a more realistic response than hoping for useful NGO and government responses on these things. It’s going to take a long time, but at least it’s been proven that poor countries can become wealthier, and the free market basically works when there is financial incentive for pharma. And monkeypox doesn’t worry me and more than Zika or dengue or other diseases that we have already failed to contain. Making NGO and government public health responses useful on the other hand is unproven and highly theoretical.
We don’t have this time, and we’ve proven we *can* eradicate a disease globally with the global south being much poorer than it is today. So, yes, definitely let’s work to make the whole world richer, but this will take a long time. Action on disease needs to be taken asap.
Fair - I do think it's possible in theory, just not in the US right now (although it has only been proven with diseases at least as deadly as Ebola or smallpox, so I don't think it's fair to say we've proven we can tackle a disease *before* it mutates to become this bad). The basic problem is that one party doesn't believe in government, and the other doesn't care about competence. So it's essentially impossible to make a competent government agency in the US until our politics radically change.
Maybe philanthropists need to be working on some sort of market-based incentive to help pharmaceutical companies focus on diseases affecting the global south, so we don't have to wait for the entire region to develop stronger economies. Or just promote free trade as that's really the only way rich countries can help poor countries in general (it will take decades, but still probably faster than fixing the CDC). But I think public health is downstream of politics, so I'm very hopeless about improving US-specific public health responses without improving our politics in general.
Monkeypox is likely to become another syphilis or chlamydia, maybe a bit worse than either (with the awful potential side effect of making you infectious to your non-sexual friends). Zika somehow seems to have eliminated itself (or maybe it wasn’t actually associated with the microcephaly they had claimed it was?) and dengue seems to be currently remaining in tropical areas.
I think the fact that you can't pass dengue person-person directly (AFAIK) is a big factor (like Zika but unlike Monkeypox)
I will say dengue is no fun... had to go to the hospital for IV fluids when I caught it in PR.
I found myself smugly brushing off the monkeypox threat, since I don't cheat on my wife, until I realized that my bi-weekly jiu jitsu class is essentially a worst case scenario if any of my dozens of training partners get it. I'd imagine similar risks exist in tons of martial arts and contact sports (as ringworm, staph, etc. always have). I'm frustrated that I am not vaccine eligible according to my county health dept. because I don't bang random dudes, when I do spend a few hours a week rolling around with them, sweatily trying to murder each other. Seems like another failure of imagination / blind spot from health authorities.
I wouldn't have said this a few years ago, but why not just lie about it?
I think I will eventually, but I'm still under the impression that the vaccine is in genuinely short supply. We're in a liberal college town with a ton of gay kids, so I do want them to be first up before I take one of their spots. But that's what's frustrating - is there vaccine sitting on the shelves, where we can move to Risk Group #2? I don't know - the messaging isn't there. I'm seeing some friends in public health this weekend and plan to see what they know.
Respectfully, as of right now there is crazy scarcity of vaccines (which there shouldn’t be but that’s a different matter) and right now the disease hasn’t spread beyond the msm communities and has not yet reliably been shown to spread in non sexual ways despite it being theoretically possible. It could change of course but until it does someone in your situation getting the scarce vaccine doesn’t make sense for you and would make things worse for everyone because you’d effectively be preventing someone who needs it and is probably orders of magnitude more likely to get infected from getting protection.
Having said all that, I think this is all a good argument to consider opening up the acam2000 for which there isn’t scarcity for volunteers from the broader public. If you’re healthy but concerned you could opt for that. Your individual danger for side effects would be minuscule, you’d get peace of mind and you won’t be taking anyone else’s dose. It’s a shame they don’t give out that option.
One of the single biggest public health lessons from the early days of COVID was that you need a government backstop to spend money on this stuff, even if it means "wasting" it. No politician wants to have attack ads run against them for supporting a boondoggle, so their incentives are to be risk-averse.
Pharma had the knowledge to do research around coronaviruses (both vaccines and small molecule drugs) but wasn't going to invest in this without a potentially large market share. And now we're re-learning the lesson with monkeypox, with the added frustration that there already is a vaccine and the government simply didn't prepare. This is going to be true with new antibiotics as well; it's only a matter of time before we have a widespread bacterial infection that we can't treat. We (and by we, I mean society at large) may learn this lesson eventually, but I'm not optimistic.
Jerusalem Demsas keeps hitting it out of the park. You should have her as a guest blogger.
Also, in many of the discussions of ACAM2000, it’s been unclear to me just *how* unpleasant it is. Is it as bad as actually getting monkeypox? The descriptions seem compatible with that.
I had just written "If I were Vox I'd really make sure she doesn't leave too" but https://www.theatlantic.com/press-releases/archive/2022/02/jerusalem-demsas-joins-atlantic-staff-writer/622093/
I had started noticing her byline a few days before she was a guest on Ezra Klein, and then a few days later I started noticing her byline at the Atlantic.
Is there a knowledgeable person who can tell what else the public health people are fucking up?
Like, there seem to be a bunch of ebola vaccines stuck in development hell—what’s up with that? Do they actually have a distribution plan for the smallpox vaccine stockpile in case of need? Are we behind the curve on MRSA, swine flu, bird flu, etc. the way we’ve been on every other virus to turn up in the past 3 years?
I’m not anywhere close to a public health person, but I would think that someone—CDC, WHO, HHS, whatever—should be tasked with formulating a top 20 list of biological threats, wargaming them out, and then plugging the gaps in our prepared response. I get that it might be a big task, but we’re putting a lot of money into the alphabet soup of public health and they’re falling down on preparedness.
Blame the voters. They routinely elect leaders who prioritize a few flashy things over meaningful investments. That said, when public health works….nobody notices.
Yes. Good public health people in government are like good referees in sports. The best ones are the ones whose names you've never heard of.
The core problem is right there in your last line. We are not putting a lot of money into public health, vis-a-vis the difficulty of the problems, and I mean by something like a factor of ten or a hundred, which is why I think that reality is unlikely to change. But just to take one example, the thing James mentions about potemkin factory set ups is possible because inspectors for the FDA don't have anything like the necessary resources to conduct actual, hard-nosed inspections (i.e. snap surprise inspections, lots of inspections, minutely detailed accounting, etc.) because you would need an army of well-paid technical professionals to do that. Moreover you then need FDA to have considerably more enforcement tools / capacity to hand down penalties that actually change / dissuade bad behavior (rather than making the fine a simple cost-of-business expense) and the political clout to enforce those penalties.
Then, take that example, and multiply it across all the different agencies doing all the different things. It's a big problem that I am unconvinced there is any political will to solve, which is simultaneously insane--the costs of catastrophic public health failure relative to the costs of public health infrastructure would pencil out--and thus far accurate, because that's just not how humans think.
Related:
Potemkin factories for the FDA
“The plant would prep heavily before audits,” the former supervisor said. “The plant basically turned into a movie set where only things the higher ups wanted the FDA to see were seen.”
https://www.politico.com/news/2022/08/04/baby-formula-plant-flaws-hidden-00049721?cid=apn
I'm not a public health person either and I have no idea if they're doing anything like what you're proposing. Which means that perhaps they are. Unless we get a true expert to weigh in here -- i.e., someone who really knows these organizations inside and out -- all we're doing is guessing.
We're just going to not talk about that two-pronged needle thing?
https://en.wikipedia.org/wiki/ACAM2000#/media/File:Smallpox_vaccination_needle.jpg
Yeah, let's just not talk about it.
You young'uns are getting soft. I had that thing when I was five, and I didn't even cry.
It was the price of being allowed to go to school, and I really wanted to start school.
Yeah, my dad still has the scar on his arm but he says it was not a big deal.
I do not like that at all.
Oddly, the procedure is less horrifying than the needle. You can watch a brief video from the CDC, if you like, showing how it is used. (But, trigger warnings, obviously, if you don't like this sort of thing).
https://www.youtube.com/watch?v=ZAqnsFa3VQ0
The bifurcated needle is not really injected under the skin, it just pokes the surface of the skin.
And it's bifurcated in order to hold the liquid between the prongs (a bit like ink in an old-fashioned pen nib). Neither prong is hollow (as I at first assumed).
Oh god the video looks way worse than a normal vaccine injection. RAPIDLY MAKE FIFTEEN JABS! I expect my needles to go in once and come out once, like the civilized objects they are. This looks like the doctor is trying to stab the patient to death.
"...FIFTEEN JABS!"
Yeah, but they're so shallow and superficial that they are hardly jabs at all -- mere jablets. Jabules. Jabcitos. If they even had cannulae, they would be a cannellini.
I mean, the doc says that one sign of a successful vaccination is that there *may* be a little blood somewhere on the site. Most of those fifteen don't even draw blood!
But then, the difference in our reactions may just go to different flavors of needle-phobia. Would you rather get jabbed once by a horse-size needle, or jabbed fifteen times by duck-sized needles?
Yeah, definitely going with the one horse-sized needle. I can handle anything if it happens once and then it's over. I in fact found the line about the drop of blood horrifying, because "keep stabbing lightly but relentlessly until you see blood" sounds way worse to me than a single hard jab that's guaranteed to draw blood. Thank you, I have learned something about the subtleties of needle-phobia today!
"...I can handle anything if it happens once and then it's over."
That's exactly my philosophy of life. But I don't apply it to individual episodes in life, just life as a whole. It happens once, then it's over -- how bad can it be? I can totally handle it. Or die trying.
If you think that's bad, take a look at how the BCG tuberculosis vaccine is administered:
https://en.wikipedia.org/wiki/BCG_vaccine#/media/File:BCG_apparatus_ja2.jpg
Nine short needles once, or one short needle 15 times? More choices to face!
Sounds like both leave a mark:
"The characteristic raised scar that BCG immunization leaves is often used as proof of prior immunization. This scar must be distinguished from that of smallpox vaccination, which it may resemble. "
How does the gay community feel about this? Gay men in San Francisco during the early 80s experienced higher death rates than the French Army during World War I. My understanding is the community adapted a lot, became somewhat less promiscuous, created strong social pressures to use condoms during casual sex and saved alot of lives through these lifestyle changes. There must be some old, gay men who remember their friends and lovers dying with seering regret and who would be very effective advocates for cost justified interventions. Are younger gay men aware of the holocaust their predecessors endured 40 years ago? Is bathhouse culture still a thing? I’m genuinely curious.
So to answer the actual question posed here, in my experience the initial reaction was split between people who were taking it seriously and people who were in denial and trying to argue "the Biden administration just wants to make gay men the scapegoat for this". (The latter tended to be younger folks in D+30 districts of major cities and their twitter followers; who still hate Biden with the fury of a thousand exploding suns for his crime of being more popular than Bernie and thus preventing them from getting the fully-automated luxury space communism they were certain Bernie would provide.)
That initial wave of backlash and denial has mostly died down now, thanks in part to a lot of gay media outlets doing a good job of responsibly reporting on the risks and letting people who have been infected share their harrowing stories. Now the common sentiment is much more about everyone trying their damnedest to actually get the vaccine, and expressing frustration at how difficult it is. (And seriously, trying to get a Monkeypox vaccine right now makes trying to get a COVID vaccine in December of 2020 look easy.)
On a more personal/anecdotal level, I was very much intending on having a very active social life in the latter half of the summer, after successfully completing a project that had consumed essentially all of my time. I'm currently delaying those plans until I can finally get the vaccine myself (and thus even more frustrated at how difficult it is to get vaccinated).
Good comment even if you had stopped at “fully-automated luxury space communism.”
Great phrase!
The full version is "fully-automated luxury gay space communism", even: https://knowyourmeme.com/memes/cultures/fully-automated-luxury-gay-space-communism
Younger gay men are aware on some level of what our older counterparts went through. And we’ve got a set of cultural practices as a result. If you’re promiscuous, you’re expected to get tested for gonorrhea, chlamydia, syphilis, and hiv at least once every few months, and to do contact tracing as needed. There is easy access to azithromycin for gonorrhea and chlamydia, penicillin for syphilis, and both a daily pill that prevents hiv and a treatment that makes it untransmissible and basically harmless. Bathhouses exist again, though more in Europe than the United States, and there’s still no bathhouse in San Francisco (though the Steamworks is in Berkeley and I think there are some all-genders sex clubs in SF proper). Grindr/Scruff and related apps are the bigger sources of sex for most people (though it’s less often big groups) but there’s also a range of closeted people that might not be as much in the culture of testing.
Pretty sure there is one by the Castro Whole Foods based on the signage when walking by, but not really my area of expertise.
Quite possible! I've seen various articles that say San Francisco never re-legalized them after the 1980s, but I'm also not sure what legalization looks like (since in most cities they operate as private clubs, where you need to pay for membership to enter, and are thus outside the reach of some kinds of regulation, the way that I hear some bars operate in Utah). When I go to Yelp and search for "gay bathhouse" in San Francisco, it doesn't obviously find any (though it finds Steamworks in Berkeley, the Power Exchange and Eros that appear to be all genders sex venues, and Good Vibrations and other sex toy shops: https://www.yelp.com/search?find_desc=Gay+Bathhouse&find_loc=San+Francisco%2C+CA ).
But regardless of legal status, gay bathhouses no longer have the cultural cachet to launch the careers of people like Bette Midler: https://en.wikipedia.org/wiki/Continental_Baths
They were sort of re-legalized in 2020, but in an ironic twist that's perfectly appropriate for this website, it turns out that the zoning ordinance no longer had a category that includes bathhouses as a permissible use, so they're still illegal, just for different reasons. The Board of Supervisors is apparently working on changing that (https://sfist.com/2022/03/17/two-pandemic-years-later-gay-batthhouse/), but presumably any attempt at actually opening one will get tied up in discretionary review for a few years, given that it's San Francisco.
I am misinformed then - Eros is the one by Whole Foods. Learn something every day! Also Ironworks is (used to be?) the goto climbing gym in Berkeley, I wonder if that ever confuses people.
They appear to be about a mile apart, so they might confuse people. I think the Vancouver location of Steamworks bathhouse is even closer to a brewpub named Steamworks, which likely causes more confusion.
The Holocaust was a deliberate genocide. Unless you are advocating a conspiracy theory about hiv I strongly suggest you change that wording. Victims of deliberate murder and their families don’t appreciate it being equated to an unthinking virus.
I just looked up “holocaust” and the first definition was “destruction or slaughter on a mass scale.”. I stand by my word choice
i find it offensive that you would tell me how to phrase myself
A totally awkward word choice that you’re explicitly told is offensive, but you decide to stand by it. Go for it. Hopefully your family members are never murdered so you won’t have to have fools compare that to a pandemic and realize what a jerk you’ve been.
HIV was never a pandemic. Your knowledge of English is shaky. You don’t even know what holocaust means
HIV was a pandemic and is actually still considered to be one.
I think technically, the WHO calls HIV a "global epidemic" rather than a "pandemic", though I was able to find some documents from the CDC that do use the word "pandemic" for it. I suppose the WHO is basing this on the idea that although in every part of the world, there are some demographics that are at risk of contracting it, in many parts of the world there are some demographics that are not at risk.
I happen to know the etymology of Holocaust (ὁλόκαυτος - I actually read greek). I’ve also lived in the states for a while and never heard anyone compare any disease to “holocaust” despite being in the states in the pandemic of the century. But do keep offending me. You’re making my day.
you don’t seem very good at distinguishing between proper and common nouns. I didn’t capitalize holocaust. You’d have a point if I did.
would it be offensive to describe the mass death of native Americans after Columbus as a holocaust? It killed a far greater proportion of the relevant population that the Nazis did in the 40s. The holocaust in the new world also occurred (mainly) through unthinking disease. Communities that had never seen a European were nearly wiped out.
General use of lower-h holocaust:
https://en.wikipedia.org/wiki/Nuclear_holocaust
https://www.dictionary.com/browse/holocaust
Specific use of 'holocaust' for disease:
https://www.masslive.com/entertainment/2018/01/influenza_1918_greatest_medica.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5139605/
https://www.history.com/news/1918-pandemic-spanish-flu-censorship
https://us.macmillan.com/books/9781250139436
https://www.merriam-webster.com/dictionary/pandemic
HIV definitely was a pandemic, unless you need to infect more than 9% of adults over most of a continent to count as a pandemic:
https://www.prb.org/resources/the-status-of-the-hiv-aids-epidemic-in-sub-saharan-africa/
"occurring over a wide geographic area (such as multiple countries or continents) and typically affecting a significant proportion of the population"
Multiple countries -> check
Significant proportion -> 9% is significant
"This mission was undermined by the election of relatively simple-minded authorities in the Reagan administration in the United States saying lesser government is better government, and one of the lesser [ideas] was to throw public health to the wind, and especially throwing public health to the wind if it dealt with diseases that they didn't want to deal with politically.
The combination of this anti-government approach that we have -- cut, cut, cut -- ... and [an attitude, which] I'm not sure whether it was malicious intent or just simple-mindedness, that if gay men get their disease and other people have sex and get their disease and junkies get their disease, Godspeed, this combination set a stage that was really horrific, that we feel the ramifications of today; that public health was undermined [from] doing its required effort to stop an epidemic, and that the leaders at the highest levels of government would not stand up and say, "Look, guys, I know that sex is unpleasant, needle injection is unpleasant, but we as a society have to take care of ourselves, and I will speak to you about that right now and go on talking about ways to interrupt the outbreak." The highest authorities in the United States really inhibited us at CDC and set the stage to really help the outbreak spread.
[...] As an example of what the higher authorities said, after we figured out the cause and I was running the laboratory at CDC there, was working with the Institute and others to determine the cause, then we had a lot of information. We had laboratory tests. We saw how far the virus had gone, how it was transmitted. It was all very clear by that time.
Then I shifted at the direction of the higher levels of CDC to make a plan of prevention. I think we called it Operation AIDS Control, and that plan was terribly expensive -- it was $30 [million], $40 million per year at the federal level and more at local levels, state and local. We would launch programs for testing and counseling and education for HIV/AIDS. That program was outlined in several pages by me, and several pages [of the] document went to the director of CDC. ... It went to Washington, and the word that we got back from Washington, as best as I can recall, was something like, "No, we're not going to fund it, and we want you to look pretty and do as little as you can."
https://www.pbs.org/wgbh/pages/frontline/aids/interviews/francis.html
https://youtu.be/yAzDn7tE1lU
There is no conspiracy theory, the Reagan Administration was - at best - ambivalent about AIDS and - at worst - not only actively withheld resources from the CDC to address it but told them to not do anything, stand by and let it go because it affected people they thought deserved it ("look pretty and do as little as possible"). That near an entire generation of gay men died from it and the government was fine with that sure seems to fit the bill for a holocaust label.
Edit: I got side-tracked arguing about the definition of "holocaust" when I initially meant to argue that the government's response to AIDS ("if gays get their disease, Godspeed" and "look pretty and do as little as possible") made it a deliberate genocide. Lost the thread a bit there.
Wow. You really really need to educate yourself if you think government inaction or withholding resources to fight a disease (a serious scandal by *american* 20th cent historical standards to be sure) “fits the label”. What utter ignorance. This is depressing .
This is some "it's not a holocaust unless it comes from the Nazi region of Germany" level of linguistic gymnastics.
A generation of gay men died from AIDS that could have been saved- the data was there, the tests had been done - if the government hadn't deliberately stood in the CDC's way. Listen to the press secretary laughing at the reporter asking if anything was being done about AIDS and implying that he had to be gay to care about it. Listen to the administration making jokes about it as the death count rose into the thousands.
Hmm no. It’s more like, it’s not a Holocaust if it’s not a whole nation state dedicating its resources to meticulously planning and executing a systematic genocide of millions in an industrialized manner, as its top priority, and as the ultimate fulfillment of its racist ideology.
That is The "capital-H" Holocaust. The "lower case-H" word "holocaust" is synonymous with genocide since it was the historical examination of The Holocaust that eventually led to the adoption of the term "genocide" to refer to acts of destruction carried out against a group. See it being used that way here:
https://www.newstimes.com/news/article/Many-holocausts-recorded-in-history-87345.php
Would you say that the government allowing a fatal disease to run rampant through an undesirable community when they could have prevented it was genocidal?
I'm not sure that the gay community is as intergenerational as you seem to imply by writing "some old, gay men who remember their friends and lovers dying with seering regret ... would be very effective advocates." Just from my personal experience, gays generally don't have gay friends of another generation, especially from a generation 40 years older. Speculatively, I think now that the gay political project is in many ways formally complete, we haven't had a need to organize cross-generationally.
This is an unfortunate problem for our community! As I entered my 40s, and became happier at seeing better childcare accommodations at conferences I go to, I started realizing that much of the modern American lifestyle is heavily segregated by age and parent status. In some ways this is just moderately frustrating, and preventing a certain natural expression of human sociality. But for people without children (and particularly gay people without children) I think this does pose a worry about what the last decade or two of our life will be like. People with children have an almost automatic support network (even if it's a small one, the way that children mainly grow up now with an automatic support network that only contains a small single digit number of adults) but it'll be more of a worry when nearly all my close friends are in our 80s or above. It would be good if the gay community were structured in ways that made it easier for us to have friends that are 20 years older or younger than us. (Not just for gays, but particularly for us.)
Something of a joke, but gay death happens at 30.
Eternal rest grant unto [old gays], O Lord, and let perpetual light shine upon them. May their souls and the souls of all the faithful departed, through the mercy of God, rest in peace. Amen.
It may be practically complete – assuming Obergefell is not overturned* – but it is not *formally* complete while discrimination in a bunch of areas is still legal, i.e. until the Equality Act is passed.
https://en.wikipedia.org/wiki/Equality_Act_(United_States)
*although arguably the very fact that Obergefell can still be credibly threatened shows society still has some way to go regardless of the current legal landscape.
Bathhouses are kinda dead, because grindr’s just better + less adverse selection.
Niche complaint but the focus on male/male sexual encounters may also cause people to overlook other activities as risky. Martial arts are what I'm thinking of here - a jujitsu student can be in close contact with maybe 6 or 8 people a class, 2 or 3 classes a week... I don't know exactly how promiscuous promiscuous people are, but that has to be in the same ballpark, right?
Niche conspiracy theory: both recent pandemics were engineered by The Illuminati specifically to prevent me from getting back on the mats.
I guess one potential difference is how "open" or "closed" the network is. Do jujitsu students usually stay with the same class of people all week, or is it common for people to go to one venue on Tuesdays and another on Saturdays? If people travel for a work trip, how likely are they to go to a class in the other city? (It might not take that many individuals who do this sort of crossing to effectively make it one big network, the way the sexual network is.)
Fair point. I don't think travelers would typically take classes in other cities. Some people might train at more than one school, but the big cross contamination risk would be people who train more than one art. If you do BJJ on Saturdays and MMA on Thursdays, you could spread between schools.
Also, schools are big enough that you probably don't need many such links, as you say. One class is contact with 6-8 people, the next could be a whole different set. People do have regular training partners, but I think people also have regular sexual partners. Do promiscuous people tend to cluster into "pods" with relatively rare inter-pod encounters? Probably not to the same degree that martial artists do, but I don't really know.
I guess it's very understandable but people are very, very resistant to the fact that a new STD just exists now and probably isn't going back in the bottle anytime soon. Makes me wonder if there will ever be consensus again to allow another member into that class of diseases in the popular consciousness, because they're seen as stigmatizing and it could be seen as better to treat each new outbreak as sui generis.
Minor comment: JYNNEOS is preferred for its safety profile, and we should definitely procure it (see my main comment) but it’s worth noting that we actually know less about its effectiveness in smallpox* and it’s possibly less effective than the older vaccines (+needs two doses and currently we are giving only one). That’s why the world health organization recommends *against* it for its smallpox vaccine advice. ACAM2000 by contrast had robust clinical trials and does the job for sure with a single shot so we better keep 100s of millions in stock for now in case of smallpox outbreak and consider allowing use right now for monkeypox in some cases.
*neither vaccine was developed for monkeypox and although we *hope* they will work on it and have good reason to think so actual efficacy data from the current outbreak isn’t there yet.
P.S. there is a Japanese vaccine ( LC16m8 ) that’s supposed to be the best of both worlds. As safe as JYNNEOS but as robust as ACAM2000. It was used at the end of smallpox eradication and has the WHO seal of approval (unlike JYNNEOS). It’s curious nobody is talking about it.
Is it actually substantially less bad to get ACAM2000 than to get an uncontrolled exposure to monkeypox? Either way you get a painful sore and are potentially contagious.
People describe monkeypox as hellish pain (maybe because of the specific areas they get it ?) also I think it’s a rash that spreads ? And we don’t know the long term complications etc. vaccinia is totally harmless for most people, the one spot you get the “take” on isn’t supposed to be that painful (ever heard traumatic stories from your elders who got their smallpox vaccines?) . And the danger of contagion from the vaccine is very low if you’re not being a total idiot. Fact is with hundreds of millions being vaccinated for smallpox vaccinia never actually broke loose and became an endemic disease. Very different from the speeding pox viruses.
P.S. with ACAM2000 you get robust protection against smallpox which is nice to have. No idea what level of cross immunity you’d get from the monkeypox vaccine.