Again: Never reason from a fatality change

The future isn’t written yet

Last week Richard Epstein predicted around 500 fatalities in the United States (I originally misread his estimate to be 50,000 for the US, not the whole world). His estimate was tragically falsified within days and he has now revised his estimate to 5,000. I still think that’s optimistic but I am hopeful for less than 50,000 deaths in the United States given the social distancing measures currently in place.

Today, several US peers have become excited about a Daily Wire article on comments by a British epidemiologist, Neil Ferguson. He has lowered his UK projections from 500,000 to 20,000 Coronavirus fatalities. The article omits the context of the change. The original New Scientist article (from which the Daily Wire is derivative with little original reporting) explains that the new fatality rate is partly due to a shift in our understanding of existing infections, but also a result of the social distancing measures introduced.

The simple point is:

Policy interventions will change infection rates, alter future stresses on the health system, and (when they work) lower future projections of fatalities. When projections are lower, it is not necessarily because the Coranavirus is intrinsically less deadly than believed but because appropriate responses have made it less deadly.

Life

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No matter how old, frail or vulnerable it may be, a life isn’t something to take or risk at another’s discretion. Nor does it undermine culpability when someone dies as a result of negligence. The common law ‘eggshell skull’ rule reflects this moral principle.

During the Coronavirus pandemic, some erstwhile defenders of the famous Non-Aggression Principle (NAP) appear to have forgotten that natural rights are conceived to protect life as well as liberty and property. They seem to think that the liberties we ordinarily enjoy have priority over the right to life of others. The environment has changed and, for the time being, many activities that we previously knew to be safe for others are not. They are not part of our set of liberties until a reformed set of rules, norms and habits establishes a sufficiently hygienic public environment. To say that bans on public gatherings violate natural rights a priori is as untenable as G.A. Cohen’s claim that a prohibition on walking onto a train without a valid ticket is a violation of one’s freedom.

The clue for anarcho-capitalist state-sceptics that this is a genuine shift in social priorities is that even organized criminal gangs are willing to enforce social distancing. You do not have to believe that the state itself is legitimate to see that the need for social distancing is sufficiently morally compelling that it can be enforced absent free agreement, just as one does not need free agreement to exercise a right to self-defense.

Not every restriction is going to be justified, although erring on the restrictive side makes sense while uncertainty about the spread of infection persists. Ultimately, restrictions have to balance genuine costs with plausible benefits. But rejecting restrictions on a priori grounds does not cohere with libertarian principles. Right now, our absolute liberties extend to the right to be alone. Everything else must be negotiated under uncertainty. Someone else’s life, even two-weeks or so in the future, is a valid side-constraint on liberty. People can rightfully be made to stay at home if they are fortunate enough to have one. When people have to travel out of necessity, they can be temporarily exempted, compensated or offered an alternative reasonable means of satisfying their immediate needs.

Nightcap

  1. The role of the libertarian in non-libertarian societies Fabio Rojas, Bleeding Heart Libertarians
  2. Did I have the coronavirus? Ross Douthat, New York Times
  3. Hospital bed access across Canada Frances Woolley, Worthwhile Canadian Initiative
  4. The future of public employee unions Daniel DiSalvo, National Affairs

Pandemic responses are beyond Evidence-based Medicine

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John Ioannidis, a professor of medicine at Stanford University, fears that the draconian measures to enforce social distancing across Europe and United States could end up causing more harm than the pandemic itself. He believes that governments are acting on exaggerated claims and incomplete data and that a priority must be getting a more representative sample of populations currently suffering corona infections. I agree additional data would be enormously valuable but, following Saloni Dattani, I think we have more warrant for strong measures than Ioannidis implies.

Like Ioannidis’ Stanford colleague Richard Epstein, I agree that estimates of a relatively small overall fatality rate are plausible projections for most of the developed world and especially the United States. Unlike Epstein, I think those estimates are conditional on the radical social distancing (and self-isolation) measures that are currently being pushed rather than something that can be assumed. I am not in a position to challenge Ioannidis’ understanding of epidemiology. Others have used his piece as an opportunity to test and defend the assumptions of the worst-case scenarios.

Nevertheless, I can highlight the epistemic assumptions underlying Ioannidis’ pessimism about social distancing interventions. Ioannidis is a famous proponent (occasionally critic) of Evidence-based Medicine (EBM). Although open to refinement, at its core EBM argues that strict experimental methods (especially randomized controlled trials) and systematic reviews of published experimental studies with sound protocols are required to provide firm evidence for the success of a medical intervention.

The EBM movement was born out of a deep concern of its founder, Archie Cochrane, that clinicians wasted scarce resources on treatments that were often actively harmful for patients. Cochrane was particularly concerned that doctors could be dazzled or manipulated into using a treatment based on some theorized mechanism that had not been subject to rigorous testing. Only randomized controlled trials supposedly prove that an intervention works because only they minimize the possibility of a biased result (where characteristics of a patient or treatment path other than the intervention itself have influenced the result).

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So when Ioannidis looks for evidence that social distancing interventions work, he reaches for a Cochrane Review that emphasizes experimental studies over other research designs. As is often the case for a Cochrane review, many of the results point to uncertainty or relatively small effects from the existing literature. But is this because social distancing doesn’t work, or because RCTs are bad at measuring their effectiveness under pandemic circumstances (the circumstances where they might actually count)? The classic rejoinder to EBM proponents is that we know that parachutes can save lives but we can never subject them to RCT. Effective pandemic interventions could suffer similar problems.

Nancy Cartwright and I have argued that there are flaws in the methodology underlying EBM. A positive result for treatment against control in a randomized controlled trial shows you that an intervention worked in one place, at one time for one set of patients but not why and whether to expect it to work again in a different context. EBM proponents try to solve this problem by synthesizing the results of RCTs from many different contexts, often to derive some average effect size that makes a treatment expected to work overall or typically. The problem is that, without background knowledge of what determined the effect of an intervention, there is little warrant to be confident that this average effect will apply in new circumstances. Without understanding the mechanism of action, or what we call a theory of change, such inferences rely purely on induction.

The opposite problem is also present. An intervention that works for some specific people or in some specific circumstances might look unpromising when it is tested in a variety of cases where it does not work. It might not work ‘on average’. But that does not mean it is ineffective when the mechanism is fit to solve a particular problem such as a pandemic situation. Insistence on a narrow notion of evidence will mean missing these interventions in favor of ones that work marginally in a broad range of cases where the answer is not as important or relevant.

Thus even high-quality experimental evidence needs to be combined with strong background scientific and social scientific knowledge established using a variety of research approaches. Sometimes an RCT is useful to clinch the case for a particular intervention. But sometimes, other sources of information (especially when time is of the essence), can make the case more strongly than a putative RCT can.

In the case of pandemics, there are several reasons to hold back from making RCTs (and study designs that try to imitate them) decisive or required for testing social policy:

  1. There is no clear boundary between treatment and control groups since, by definition, an infectious disease can spread between and influence groups unless they are artificially segregated (rendering the experiment less useful for making broader inferences).
  2. The outcome of interest is not for an individual patient but the communal spread of a disease that is fatal to some. The worst-case outcome is not one death, but potentially very many deaths caused by the chain of infection. A marginal intervention at the individual level might be dramatically effective in terms of community outcomes.
  3. At least some people will behave differently, and be more willing to alter their conduct, during a widely publicized pandemic compared to hygienic interventions during ordinary times. Although this principle might be testable in different circumstances, the actual intervention won’t be known until it is tried in the reality of pandemic.

This means that rather than narrowly focusing on evidence from EBM and behavioral psychologists (or ‘nudge’), policymakers responding to pandemics must look to insights from political economy and social psychology, especially how to shift norms towards greater hygiene and social distancing. Without any bright ideas, traditional public health methods of clear guidance and occasionally enforced sanctions are having some effect.

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What evidence do we have at the moment? Right now, there is an increasing body of defeasible knowledge of the mechanisms with which the Coronavirus spreads. Our knowledge of existing viruses with comparable characteristics indicates that effectively implemented social distancing is expected to slow its spread and that things like face masks might slow the spread when physical distancing isn’t possible.

We also have some country and city-level policy studies. We saw an exponential growth of cases in China before extreme measures brought the virus under control. We saw immediate quarantine and contact tracing of cases in Singapore and South Korea that was effective without further draconian measures but required excellent public health infrastructure.

We have now also seen what looks like exponential growth in Italy, followed by a lockdown that appears to have slowed the growth of cases though not yet deaths. Some commentators do not believe that Italy is a relevant case for forecasting other countries. Was exponential growth a normal feature of the virus, or something specific to Italy and its aging population that might not be repeated in other parts of Europe? This seems like an odd claim at this stage given China’s similar experience. The nature of case studies is that we do not know with certainty what all the factors are while they are in progress. We are about to learn more as some countries have chosen a more relaxed policy.

Is there an ‘evidence-based’ approach to fighting the Coronavirus? As it is so new: no. This means policymakers must rely on epistemic practices that are more defeasible than the scientific evidence that we are used to hearing. But that does not mean a default to light-touch intervention is prudent during a pandemic response. Instead, the approaches that use models with reasonable assumptions based on evidence from unfolding case-studies are the best we can do. Right now, they suggest we should err on the side of caution, physical distancing, and isolation while medical treatments are tested.

Nightcap

  1. Why didn’t we see this coming? Scott Sumner, MoneyIllusion
  2. Against ageism Irfan Khawaja, Policy of Truth
  3. Expose the young Robin Hanson, Overcoming Bias
  4. Humility, not certainty Victor Davis Hanson, City Journal

I stopped French kissing. (Coronavirus alert!)

About 40 US deaths so far. The French have double that with 1/5 the population. My skeptical fiber is on full. Still I am washing my hands. When I run out of rubbing alcohol, I will use cheap brandy – of which I have plenty, of course. Oh, I almost forgot: I have decided to stop French kissing completely if the occasion arises! Extraordinary times require extraordinary measures! Count on me. I am wondering what the libertarian response should be to this public crises (plural).

My best to all.

A Small Reason Why I Don’t Want Big Government

Santa Cruz, California is really Silicon Valley Beach. It’s the closest; the next one is quite far. That’s in addition to drawing visitors from deep into the Central Valley of California, and a surprising number of European visitors.

One attractive beach close to its municipal wharf has only two (2) toilets. On Labor Day weekend Sunday, one of the two toilets was out of order. I estimate there were between 500 and a thousand people on that particular beach.

The day before, Labor Day weekend Saturday, the same toilet was already out of order. It was still out of order on Monday, Labor Day itself.

It was only a few months ago that the City of Santa Cruz joined a class action suit by a number of government entities against major oil companies for causing climate change. The first judge to look at the suit send the plaintiffs packing, of course.

So, this city of 60,000 wants to stop global warming but it does not have the ability to place two working toilets at the disposal of hundred of visitors who leave thousands of dollars in its coffers. The city cannot afford to hire a competent plumber on an emergency basis to fix the problem immediately. It does not have the timeX2 that would be required. Make it timeX3 on the outside. The total would come to $500 tops. Make it $1,000. It does not change anything.

The same happened last year or the year before. Surprise!

This is pathetic. We are governed by morons. Their gross incompetence is not natural, I am guessing. It’s learned stupidity. Our fault. We vote them in – with big help from UC Santa Cruz undergraduates who don’t care one way or the other, just want to feel good by electing “progressives.”

No one told our City Manager that Labor Day weekend, and its crowds, were coming. How was he supposed to know?