“Like lepers”

From yesterday’s Guardian:

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.

Auto-antonyms: Drawing a line

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.

Does a shot of vitamin B protect against Covid?

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.

From there to full social Darwinism is just a small step, and that step was taken by one Christoph S. in the comments section of the national newspaper Die Welt:

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.

Continue reading “Does a shot of vitamin B protect against Covid?”

How to vaccinate all the Germans in two easy steps

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.

RKI Vaccine statistics 1/4/2021

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.

Absence of caution: The European vaccine suspension fiasco

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.

Age group0-3435-4445-5455-6465-7475-8485+
CFR (per thousand)0.040.682.37.52585283
Expected fatalities per week per million population0.071.24.11345151504
Number of days delay to match VFR120070206.41.80.60.2

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.

Oxbridge Delenda Est

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.

The poisoned roots of German anti-vax sentiment

I’ve long thought it odd that Germany, where the politics is generally fairly rational, and science education in particular is generally quite good, has such broad acceptance of homeopathy and a variety of other forms of quackery, and a special word — Schulmedizin — “academic medicine” — to express a dismissive attitude toward what elsewhere would be called just “medicine”, or perhaps “evidence-based medicine”. I was recently looking into the history of this, and found that attacks on Schulmedizin — or “verjudete Schulmedizin” (jewified academic medicine) — were as much a part of the Nazi state science policy as “German mathematics” and “Arian physics”.

Medicine in the Third Reich remained a weird mixture of modern virology and pseudo-scientific “racial hygiene”. The celebrated physician Erwin Liek wrote

Es ist mein Glaube, dass das deutsche Volk berufen ist, nach und nach eine ganz neue, rein deutsche Heilkunst zu entwickeln.
(It is my belief, that the German people has a calling, gradually to develop a pure German art of healing.)

Liek was appealing for a synthesis of Schulmedizin with traditional German treatment. As with Arian physics*, and the Nazi state was careful not to push the healthy German understanding so far as to undermine important technology and industry. But the appeal to average people’s intuitive discomfort with modern science was a powerful propaganda tool that they couldn’t resist using, as in this 1933 cartoon “The vaccination” from Der Stürmer that shows an innocent blond arian mother uncomfortably watching her baby being vaccinated by a fiendish Jewish doctor. The caption reads “This puts me in a strange mood/Poison and Jews never do good.”

1933 Cartoon from Der Stürmer: Blond German mother looking concerned as a beastly Jewish doctor vaccinates her baby. Caption: "This puts me in a strange mood/Poison and Jews are seldom good."
1933 Der Stürmer cartoon “The vaccination”.

Today’s anti-vaxers fulminating against Schulmedizin and the Giftspritze (poison shot) are not necessarily being consciously anti-Semitic, but the vocabulary and the paranoid conspiracy thinking are surely not unconnected.

* Heisenberg was famously proud of having protected “Jewish physics” from being banned at his university, considering himself a hero for continuing to teach relativity theory, even while not objecting to the expulsion of the Jewish physicists, and agreeing not to attach their names to their work. Once when I was browsing in the science section of a Berlin bookstore in the early 1990s a man started chatting with me, telling me that he had worked for decades as a radio engineer in the GDR, and then going on to a long monologue apropos of nothing about how wonderful Heisenberg was, and how he had courageously defended German science during the Third Reich.

Can’t look away

Many years ago I read to my daughter a children’s book in which a little girl learning to ride a bicycle keeps running into objects like trees and lampposts. A bicycle instructor explains to her that when you become too fixated on an obstacle it exerts a strong psychological pull, so that the very exigency of evading it leads to a crash.

I used to wonder whether this was a real phenomenon. I don’t anymore…

Actually, I’ve long thought the second Iraq War was an example of the same phenomenon. There was no possibility that there wouldn’t be a war, because once they’d started to consider it Bush and Blair couldn’t bare not to see how it would turn out.

The first principle of statistical inference

When I first started teaching basic statistics, I thought about how to explain the importance of statistical hypothesis testing. I focused on a textbook example (specifically, Freedman, Pisani, Purves Statistics, 3rd ed., sec 28.2) of a data set that seems to show more women being right-handed than men. I pointed out that we could think of many possible explanations: Girls are pressured more to conform, women are more rational — hence left-brain-centred. But before we invest too much time and credibility in abstruse theories to explain the phenomenon, we should first make sure that the phenomenon is real, that it’s not just the kind of fluctuation that could happen by accident. (It turns out that the phenomenon is real. I don’t know if either of my explanations is valid, or if anyone has a more plausible theory.)

I thought if this when I heard about the strange Oxford-AstraZeneca vaccine serendipity that was announced this week. The third vaccine success announced in as many weeks, the researchers announced that they had found about a 70% efficacy, which is good, but not nearly as impressive as the 95% efficacy of the mRNA vaccines announced earlier in the month. But the strange thing was, they found that a subset of the test subjects who received only a half dose at the first injection, and a full dose later, showed a 90% efficacy. Experts have been all over the news media trying to explain how some weird idiosyncrasies of the human immune system and the chimpanzee adenovirus vector could make a smaller dose more effective. Here’s a summary from Science:

Researchers especially want to know why the half-dose prime would lead to a better outcome. The leading hypothesis is that people develop immune responses against adenoviruses, and the higher first dose could have spurred such a strong attack that it compromised the adenovirus’ ability to deliver the spike gene to the body with the booster shot. “I would bet on that being a contributor but not the whole story,” says Adrian Hill, director of Oxford’s Jenner Institute, which designed the vaccine…

Some evidence also suggests that slowly escalating the dose of a vaccine more closely mimics a natural viral infection, leading to a more robust immune response. “It’s not really mechanistically pinned down exactly how it works,” Hill says.

Because the different dosing schemes likely led to different immune responses, Hill says researchers have a chance to suss out the mechanism by comparing vaccinated participants’ antibody and T cell levels. The 62% efficacy, he says, “is a blessing in disguise.”

Others have pointed out that the populations receiving the full dose and the half dose were substantially different: The half dose was given by accident to a couple of thousand subjects at the start of the British arm of the study. These were exclusively younger, healthier individuals, something that could also explain the higher efficacy, in a less benedictory fashion.

But before we start arguing over these very interesting explanations, much less trying to use them to “suss out the mechanisms” the question they should be asking is, is the effect real? The Science article quotes immunologist John Moore asking “Was that a real, statistically robust 90%?” To ask that question is to answer it resoundingly: No.

They haven’t provided much data, but the AstraZeneca press release does give enough clues:

One dosing regimen (n=2,741) showed vaccine efficacy of 90% when AZD1222 was given as a half dose, followed by a full dose at least one month apart, and another dosing regimen (n=8,895) showed 62% efficacy when given as two full doses at least one month apart. The combined analysis from both dosing regimens (n=11,636) resulted in an average efficacy of 70%. All results were statistically significant (p<=0.0001)

Note two tricks they play here. First of all, they give those (n=big number) which makes it seem reassuringly like they have an impressively big study. But these are the numbers of people vaccinated, which is completely irrelevant for judging the uncertainty in the estimate of efficacy. The reason you need such huge numbers of subjects is so that you can get moderately large numbers where it counts: the number of subjects who become infected. Further, while it is surely true that the “results” were highly statistically significant — that is, the efficacy in each individual group was not zero — this tells us nothing about whether we can be confident that the efficacy is actually higher than what has been considered the minimum acceptable level of 50%, or — and this is crucial for the point at issue here — whether the two groups were different from each other.

They report a total of 131 cases. They don’t say how many cases were in each group, but if we assume that there were equal numbers of subjects getting the vaccine and the treatment in all groups then we can back-calculate the rest. We end up with 98 cases in the full-dose group (of which 27 received the vaccine) and 33 cases in the half-dose group, of which 3 received the vaccine. Just 33! Using the Clopper-Pearson exact method, we obtain 90% confidence intervals of (.781,.975) for the efficacy of the half dose and (.641, .798) for the efficacy of the full dose. Clearly some overlap there, and not much to justify drawing substantive conclusions from the difference between the two groups — which may actually be zero, or close to 0.