So, two weeks ago we had desperate people fleeing the exultant entry of misogynistic religious extremists into Kabul:
This week we had desperate people fleeing another group of misogynistic religious extremists in Dallas:
Salesforce CEO Mark Beinoff said the company will help employees move out of Texas if they so choose after the state’s Republican governor signed a strict ban on abortions. “Ohana if you want to move we’ll help you exit TX,” Beinoff tweeted Friday, sharing a link to a CNBC article about the company’s decision.
Obviously, the suffering of Afghan women under the Taliban is vastly more than that of Texan women under the Republicans. But I hear the US Air Force has some C-17s that are currently between missions…
The US federal government has ordered that all nursing home personnel need to be vaccinated against Covid, which seems like an absolute least-you-could-do sort of measure, given the extraordinary risk of outbreaks among the frail elderly. But there’s a problem.
The American Health Care Association, a nursing home lobby, said it appreciated the order but that the mandate should apply to other healthcare providers as well so that workers who refuse vaccination won’t have a reason to change jobs within the industry.
Surely there can’t be that many openings for medical staff who aren’t willing to take minimal steps to protect their patients? Well…
David Grabowski, a professor of healthcare policy at Harvard Medical School, said that, because many nursing home aides are paid only the minimum wage or slightly higher, they would be more likely to seek out work at retail establishments. “The risk isn’t that they go to the hospital down the street—the risk is they go to Starbucks or Target,” he said in an interview. “It’s great if you want to mandate the vaccine, but you also want to make sure these workers are making a living wage.”
Hmm… if Starbucks is hiring unvaccinated care-home nurses to sling lattes for the same salary, there must be some vaccinated baristas who want to transfer in the other direction. What’s that you say? You can’t just hire any bored 20-year-old to care for the elderly? You need training and experience to do the nursing job, and it’s a far more gruelling job!
Then why are they earning the same salary? Low salaries are not immutable constants of nature, however much employers would like to suggest they are. Like
Jon Green, CEO of Pinewood Manor Nursing and Rehabilitation in rural Hawkinsville, Georgia, said the “vaccines are necessary for control of the virus,” but “if we would have mandated it ourselves, it would have caused [many workers] to leave.’’
The UK government is holding fast to its plan to drop all pandemic restrictions as of 19 July, even in the face of rapidly increasing infection rates, hospitalisation rates, and Covid deaths — all up by 25-40% over last week. And numerous medical experts are being quoted in the press supporting the decision. What’s going on?
To begin with, Johnson has boxed himself in. He promised “Freedom Day” to coincide with the summer solstice, and then was forced to climb down, just as he was from his initial “infect everyone, God will recognise his own” plan last March, on realising that his policies would yield an unsustainable level of disruption. The prime minister has, by now, no reputation for consistency or decisiveness left to protect, but even so he probably feels at the very least that a further delay would undermine his self-image as the nation’s Fun Dad. At the same time, the the new opening has been hollowed out, transformed from the original “Go back to living your lives like in pre-pandemic days” message to “Resume taxable leisure activities, with the onus on individuals and private businesses to enforce infection-minimisation procedures.” Thus we have, just today, the Transport Secretary announcing that he expected rail and bus companies to insist on masking, even while the government was removing the legal requirement.
But what are they hoping to accomplish, other than a slight reduction in the budget deficit? The only formal justification offered is that of Health Secretary Sajid Javid, who said on Monday
that infection rates were likely to get worse before they got better – potentially hitting 100,000 a day – but said the vaccination programme had severely weakened the link between infections, hospitalisations and deaths. Javid acknowledged the risks of reopening further, but said his message to those calling for delay was: “if not now, then when?”.
“Weakened the link” is an odd way of putting a situation where cases, hospitalisations, and Covid deaths are all growing exponentially at the same rate. What has changed is the gearing, the chain and all of its links is as strong as ever. In light of that exponential growth, what should we make Javid’s awkward channeling of Hillel the Elder?
I’ll talk about “masking” as synecdoche for all measures to reduce the likelihood of a person being infected or transmitting Covid. We need to consider separately the questions of when masking makes sense from an individual perspective, and from a public perspective. The individual perspective is straightforward:
On the societal level it’s more complicated, but I do find the argument of England’s Chief Medical Officer Chris Whitty… baffling:
“The slower we take it, the fewer people will have Covid, the smaller the peak will be, and the smaller the number of people who go into hospital and die,” he said. By moving slowly, he said modelling suggested the pressure on the NHS would not be “unsustainable”. Prof Whitty said there was less agreement on the “ideal date” to lift restrictions as there is “no such thing as an ideal date” . However, he said a further delay would mean opening up when schools return in autumn, or in winter, when the virus has an advantage and hospitals are under more pressure.
We may argue about how much effect government regulations have on the rate of the virus spreading, but I have never before heard anyone argue that the rate of change of government regulation is relevant. Of course, too rapid gyrations in public policy may confuse or anger the public. But how the rapidity of changing the rules relates to the size of the peak seems exceptionally obscure. To the extent that you are able to have any effect with the regulations, that effect should be seen directly in R0, and so in the weekly growth or contraction of Covid cases. If masking can push down the growth rate its effect is essentially equivalent at any time in terms of the final infection rate, but masking early gives fewer total cases.
To see this, consider a very simple model: With masking cases grow 25%/week, without masking they shrink 20%/week. So if we have 1000 cases/day now, then after some weeks of masking and the same number of weeks without masking, we’ll be back to 1000 cases/day at the end. But the total number of cases will be very different. Suppose there are 10 weeks of each policy, and we have four possibilities: masking first, unmasking first, alternating (MUMU…), alternating (UMUM…). The total number of cases will be:
Of course, the growth rate will not remain constant. The longer we delay, the more people are immune. In the last week close to 2 million vaccine doses have been administered in the UK. That means that a 4-week delay means about 4 million extra people who are effectively immune. If we mask first, the higher growth rate will come later, thus the growth rate will be lower, and more of the cases will be mild.
The only thing I can suppose is that someone did an economic cost-benefit analysis, and decided that the value of increased economic activity was greater than the cost of lives lost and destroyed. Better to let the younger people — who have patiently waited their turn to be vaccinated — be infected, and obtain their immunity that way, than to incur the costs of another slight delay while waiting for them to have their shot at the vaccine.
The young were always at the lowest risk in this pandemic. They were asked to make a huge sacrifice to protect the elderly. Now that the older people have been protected, there is no willingness to sacrifice even another month to protect the lives and health of the young.
Contentious advice will be removed from the government website, a spokesperson confirmed on Tuesday evening. It had advised against all but essential travel to and from eight areas of England where the Covid variant identified in India has been spreading. Instead, people will be advised to “minimise travel”.
This gets to something that I observed last spring when I (like many people) decided to immerse myself in the literature of epidemics — The Last Man, La Peste, Journal of the Plague Year, Pale Horse Pale Rider: In an epidemic, people can’t help but think of contagion as a moral failing, and so, thinking of themselves as blameless, underestimate the possibility that they could unwittingly infect someone else. This makes it socially uncomfortable to insist that others practice necessary hygiene, because it sounds like you’re accusing them of secret turpitude. Strangers should wear masks, but “we’re friends”, or even — much too casually — “you’re in my bubble”.
Thus two Bolton residents, whose hotel reservations on the Isle of Wight had been cancelled purely from abhorrence of their municipal origins, complained to the press: “Bolton people are being treated like lepers”.
On a literal level we have here people who are feared to be at high risk of carrying an explosively contagious infection that produces an acute disease with no very good treatment, that is often rapidly fatal; complaining that they are being unjustly shunned as though they might be carrying a different, mildly contagious infection, that produces a chronic disease that can be completely cured with medication.
But, of course, what they really mean is, we’re being treated like morally culpable potential disease carriers. This is a status that has traditionally been conferred on carriers of leprosy, something we do not question, but that only highlights our moral — hence also virological — purity.
The BBC is being scourged for having been — 25 years ago — once insufficiently open and honest with its rightful liege lords (in this case, the then Princess of Wales). Apparently they tried to trick her into giving an interview, though the BBC says it has a handwritten note from her saying she didn’t mind, and she would have done the interview anyway.
In the course of discussing this Diana’s brother is quoted saying “he ‘draws a line’ between the [BBC] interview and her death two years later.” It’s an interesting phrase, of a rare sort that I call auto-antonyms. The same words might mean two diametrically opposite things. I think he means to say that the two events are causally connected — as though by a straight line. But he could also mean that even though one event followed the other, he considers them to be completely separate — to emphasise which he would draw a (dividing) line between them.
Thirty years ago there were some who envisioned a new united Germany combining the best of east and west: A vibrant market economy with an expanded commitment to economic justice, a confident democratic federal government balanced by a greater variety of states, and a commitment to individual liberty reinforced by the recent experience of dictatorship. A bridge between the solid democracy in America and the rising democracy in Russia.
Instead, Covid has revealed the modern Federal Republic as the combined worst of both systems: A timid central government in thrall to private business interests, unable to take decisive action to protect public health because of a lack of confidence that their authority would be seen as sufficiently legitimate. A resurgent right wing inspired by American and Russian ethnonationalists to express their individual liberty by rejecting even elementary public health measures. And now, a public vaccination campaign dominated by the financial and status needs of private physicians, and prioritising those people with high levels of what the East Germans called Vitamin B — “B” for “Beziehungen“, connections, the way scarce resources were distributed under socialism.
When the vaccination program started it was concentrated in large vaccination centres (Impfzentren). These were highly efficient, providing rapid throughput and simple logistics, and the official priorities of the Permanent Vaccination Commission (Ständige Impfkomission, or STIKO) — covering people over 60 years old, those with serious medical conditions putting them at elevated risk of Covid complications (including pregnant women and their companions), police, teachers, and government officials — could be securely monitored.
There were two major problems with this system: First, the physicians in private practice, for whom vaccinations were traditionally a great money spinner, felt that they were losing money and influence; Second, there was no unobtrusive path to providing priority immunisation to people who were important, influential, or just rich, threatening to lead to the sort of blatant corruption that just embarrasses everyone. This led the government* to bring the GPs into the vaccination program, paying them upwards of €50 per vaccine. The GPs, unsurprisingly, rushed to vaccinate their friends and favourite patients — particularly those patients with private insurance, who they are generally keen to hold on to, as the private insurance covers all manner of treatments that the public insurance won’t pay for, and the payment levels are generally significantly higher.
How should one respond to this? The Ethics commission is very concerned… that people who haven’t been clever enough to work the system might be jealous of the superior people who have. Here is a comment from a recent podcast interview with commission chair Alena Buyx:
AB: We shouldn’t confuse the people who have gone the extra mile and somehow managed to get it organised, or had a stroke of luck, with those who have cheated.
Spiegel: … It could be that someone who isn’t so resourceful… for various reasons, it could be social background, it could be language, it could be some lack of access to information –and I can understand that they might feel he or she feels like you’re taking something away from them.
AB: These are things that one couldn’t have imagined earlier. We have vaccine envy and also vaccine guilty conscience. But all I can say is: Good People, every vaccination is a good vaccination… Those who have been lucky, or who have profited from this “flexibility” — if they haven’t cheated anyone — they should enjoy their good fortune.
In my social circle — definitely well off — is just about everyone vaccinated, and always the whole family, including the university-age children. None of them in the vaccination centre, always in the GP practice or through doctors they know personally. In other words, since the GPs have been doing vaccinations the prioritisation has fallen away de facto, at least for the “higher” levels of the population. This is not pretty, but as long as they’re managing to vaccinate up to a million people a day in Germany, I find it acceptable. One shouldn’t make a fuss about the people who try to cut ahead at the vaccination centres; Germany has much bigger problems than someone getting vaccinated a few days early. And, by the way, this is how it’s always been, that those who make the most noise prevail, and presumably that’s why Homo sapiens has managed to survive.***
* Just to be clear, this is not the official justification. This is a purely speculative exercise on my part. It’s hard to think of any other justification, though. It’s not as though the GPs were otherwise unoccupied, with huge amounts of spare capacity for taking on vaccination duty.
One might despair at how hopelessly behind Europe in general, and Germany in particular, is with its vaccination campaign. According to the data below from the Robert Koch Institute, they recovered last week from the collapse of the week before due to the brief rejection of the AstraZeneca vaccine, and resumed their very modest acceleration, but that seems to have stopped, and they’re now back to the rate of the previous week of about 1.5 million vaccines per week, a rate that would get them through the entire adult population in around… 2 years.
But not to worry! says Der Spiegel. They quote an expert — Sebastien Dullien, scientific director of the Institute for Macroeconomics and Economic Research (Institut für Makroökonomie und Konjunkturforschung (IMK) der Hans-Böckler-Stiftung), for which I’ll have to take their word that he’s somehow an expert on vaccines and public health, because his job (and his Wikipedia page) make it seem that he’s an expert on finance and economics — who claims that the vaccination of the entire German adult population will be complete before the middle of the summer. “Es ist realistisch, alle impfbereiten erwachsenen Deutschen bis Ende Juli durchgeimpft zu haben.” [It is realistic, that we can have all willing adult Germans vaccinated by the end of July.) Sounds good! He goes on to say “Dafür müssen nur zwei Bedingungen erfüllt werden.” [This depends on just two conditions being fulfilled.] Okay, two conditions. I hope the conditions are fulfilled… What are they?
Der Impfstoff muss kommen, und er muss verimpft werden. [We have to get the vaccine, and then we have to vaccinate people with it.]
It’s this kind of reduction of complex problems into manageable sub-problems that only the truly great minds can deliver. This goes on my list of “How-to-do-it” solutions to complex problems. (Previous entries here, here, and here.)
Actually, this is amazingly close to the Monty Python original, where the kiddie show How to Do It explained “how to rid the world of all known diseases”. Their method was more elaborate, though, involving five steps:
First of all, become a doctor, and discover a marvelous cure for something. And then, when the medical profession starts to take notice of you, you can jolly well tell them what to do and make sure they get everything right, so there will never be any diseases ever again.
Multiple European countries have now suspended use of the Oxford/AstraZeneca vaccine, because of scattered reports of rare clotting disorders following vaccination. In all the talk of “precautionary” approaches the urgency of the situation seems to be suddenly ignored. Every vaccine triggers serious side effects in some small number of individuals, occasionally fatal, and we recognise that in special systems for compensating the victims. It seems worth considering, when looking at the possibility of several-in-a-million complications, how many lives may be lost because of delayed vaccinations.
I start with the case fatality rate (CFR) from this metaanalysis, and multiply them by the current overall weekly case rate, which is 1.78 cases/thousand population in the EU (according to data from the ECDC). This ignores the differences between countries, and differences between age groups in infection rate, and certainly underestimates the infection rate for obvious reasons of selective testing.
CFR (per thousand)
Expected fatalities per week per million population
Number of days delay to match VFR
Let’s assume now that all of the blood clotting problems that have occurred in the EEA — 30 in total, according to this report — among the 5 million receiving the AZ vaccine were actually caused by the vaccine, and suppose (incorrectly) that all of those people had died.* That would produce a vaccine fatality rate (VFR) of 6 per million. We can double that to account for possible additional unreported cases, or other kinds of complications that have not yet been recognised. We can then calculate how many days of delay would cause as many extra deaths as the vaccine itself might cause.
The result is fairly clear: even the most extreme concerns raised about the AZ vaccine could not justify even a one-week delay in vaccination, at least among the population 55 years old and over. (I am also ignoring here the compounding effect of onward transmission prevented by vaccination, which makes the delay even more costly.) As is so often the case, “abundance of caution” turns out to be the opposite of cautious.
* I’m using only European data here, to account for the contention that there may be a specific problem with European production of the vaccine. The UK has used much more of the AZ vaccine, with even fewer problems.
I’ve been thinking for a long time that for all their merits as individual institutions, and all the advantages they offer to their faculty (like myself), students, and alumni (like myself), the hierarchical structure of tertiary education that defines their role, from which they benefit, and which they nurture, is fundamentally destructive.
I wrote an essay on this theme, and it has now appeared in the political magazine Current Affairs.