Tradeoffs

Since I think it has some bearing on discussions we’ve been having here, I’m going to reproduce this Wall Street Journal op-ed from Joseph A. Ladapo of UCLA’s medical school in its entirety:

A hallmark of Covid-19 pandemic policy has been the failure of political leaders and health officials to anticipate the unintended consequences of their actions. This tendency has haunted many decisions, from lockdowns that triggered enormous unemployment and increased alcohol and drug abuse, to school closures that are widening educational disparities between rich and poor families. Mask mandates may also have unintended consequences that outweigh the benefits.

First, consider how the debate has evolved and the underlying scientific evidence. Several randomized trials of community or household masking have been completed. Most have shown that wearing a mask has little or no effect on respiratory virus transmission, according to a review published earlier this year in Emerging Infectious Diseases, the Centers for Disease Control and Prevention’s journal. In March, when Anthony Fauci said, “wearing a mask might make people feel a little bit better” but “it’s not providing the perfect protection that people think it is,” his statement reflected scientific consensus, and was consistent with the World Health Organization’s guidance.

Almost overnight, the recommendations flipped. The reason? The risk of asymptomatic transmission. Health officials said mask mandates were now not only reasonable but critical. This is a weak rationale, given that presymptomatic spread of respiratory viruses isn’t a novel phenomenon in public health. Asymptomatic cases of influenza occur in up to a third of patients, according to a 2016 report in Emerging Infectious Diseases, and even more patients had mild cases that are never diagnosed. Asymptomatic or mild cases appear to contribute more to Covid-19 transmission, but this happens in flu cases, too, though no one has called for mask mandates during flu season.

The public assumes that research performed since the beginning of the pandemic supports mask mandates. Policy makers and the media point to low-quality evidence, such as a study of Covid-19 positive hairstylists in Missouri or a Georgia summer camp with an outbreak. These anecdotes, while valuable, tell us nothing about the experience of other hairdressers or other summer camps that adopted similar or different masking practices. Also low-quality evidence: Videos of droplets spreading through air as people talk, a well-intended line of research that has stoked fears about regular human interactions.

Rather, the highest-quality evidence so far is studies like the one published in June in Health Affairs, which found that U.S. states instituting mask mandates had a 2% reduction in growth rates of Covid-19 compared with states without these mandates. Because respiratory virus spread is exponential, modest reductions can translate into large differences over time. But these shifts in trajectory are distinct from the notion that mandating masks will bring the pandemic to an end. Based on evidence around the world, it should be clear that mask mandates won’t extinguish the virus.

The most reasonable conclusion from the available scientific evidence is that community mask mandates have—at most—a small effect on the course of the pandemic. But you wouldn’t know that from watching cable news or sitting next to a mother being forced off an airplane because her small children aren’t able to keep a mask on.

While mask-wearing has often been invoked in explanations for rising or falling Covid-19 case counts, the reality is that these trends reflect a basic human need to interact with one another. Claims that low mask compliance is responsible for rising case counts are also not supported by Gallup data, which show that the percentage of Americans reporting wearing masks has been high and relatively stable since June. Health officials and political leaders have assigned mask mandates a gravity unsupported by empirical research.

On even shakier scientific ground is the promotion of mask use outdoors. One contact-tracing study identified only a single incident of outdoor transmission among 318 outbreaks. Even the Rose Garden nomination ceremony for Justice Amy Coney Barrett, which the media giddily labeled a “superspreader” event, likely wasn’t; transmission more likely occurred during indoor gatherings associated with the ceremony.

By paying outsize and scientifically unjustified attention to masking, mask mandates have the unintended consequence of delaying public acceptance of the unavoidable truth. In countries with active community transmission and no herd immunity, nothing short of inhumane lockdowns can stop the spread of Covid-19, so the most sensible and sustainable path forward is to learn to live with the virus.

Shifting focus away from mask mandates and toward the reality of respiratory viral spread will free up time and resources to protect the most vulnerable Americans. There is strong evidence that treating patients early in outpatient settings can be effective, as outlined in a recent American Journal of Medicine paper, but these treatments are underused. Identifying effective treatments for hospitalized patients with Covid-19 is essential, but preventing severe illness before hospitalization will save more lives.

Until the reality of viral spread in the U.S.—with or without mask mandates—is accepted, political leaders will continue to feel justified in keeping schools and businesses closed, robbing young people of the opportunity to invest in their futures, and restricting activities that make life worthwhile. Policy makers ought to move forward with more wisdom and sensibility to mitigate avoidable costs to human life and well-being.

In the perfect, Aristotelian theoretical world measures that provide fractional improvements should always be put in place whether they produce 2% improvements or 25% improvements because, well, those are improvements but in the the messy, complex practical world it is different and there are many more factors that must be taken into consideration. Does the downside risk of the moral hazard introduced by the measures outweigh the gains? An example of the moral hazard to which I refer would be, in the case of mask-wearing, when people engage in more risky behaviors when they’re wearing masks in the mistaken belief that they are more protective than they really are but it also includes the risks introduced by the erosion of the rule of law produced by unenforced mandates or even laws. Both qualitative and quantitative results need to be taken into account. My take, for example, on the outbreak of cases of COVID-19 among White House staff is that it was caused by mistaken over-reliance on testing as a strategy for avoiding the disease.

There is also cost-benefit to be taken into account. The only known way to avoid contracting the virus completely is total isolation. If only benefit were considered, we should all lock ourselves into our homes and not venture out until the virus had vanished. But the costs of that are simply too high—not only would the economy collapse but we would all die of starvation.

I don’t think all of this makes me a “naysayer”; I wear a mask when I’m in stores or in the common areas of the office and on many other occasions simply to set a good example. I invariably wear my masks properly and launder them after use. I also maintain a three meter social distance to the greatest degree possible and avoid social contacts other than with my wife with whom I share my residence to the greatest degree possible. But I recognize that many people are not as coldly rational or completely disciplined as I and act and propose courses of action accordingly.

15 comments… add one
  • steve Link

    First, let me note that this track record is not very good. Back in March he said that whatever we did at the time our hospitals would all be overwhelmed. They were not. Going further, there is a lot to criticize here, but let’s go to a major problem right away. He lied, or close enough that there is no difference. His link claiming there is strong evidence does not provide evidence that outpatient treatments can or will help. He goes through a laundry list of meds that were heavily used early (so when he says they were underused he lies again) and have mostly been abandoned or are still used knowing that if they contribute their effects are very small. We have cut mortality in the inpatient setting by quite a bit, yet he leaves out a lot of that in favor of regimens with a poor track record. If they worked so well then mortality rates early should have been better than they are now. Instead it is the reverse.

    OK, just for fun lets look at some other parts.

    “though no one has called for mask mandates during flu season.”

    Duh, we have vaccines. You think he doesnt know that?

    “Rather, the highest-quality evidence so far is studies like the one published in June in Health Affairs, which found that U.S. states instituting mask mandates had a 2% reduction in growth rates of Covid-19 compared with states without these mandates.”

    Nope, no control or analysis of the other factors. Besides, what we really want to know is mask usage not if there was a mandate.

    ” it should be clear that mask mandates won’t extinguish the virus.”

    No one knowledgeable about the disease has made that claim.

    “In countries with active community transmission and no herd immunity, nothing short of inhumane lockdowns can stop the spread of Covid-19,”

    Where is his evidence for this claim? It was stopped in many countries without extensive lockdowns.

    I do agree with this, and have all along said that I think the risk of outdoor spread is probably low.

    “On even shakier scientific ground is the promotion of mask use outdoors.”

    ” Policy makers ought to move forward with more wisdom and sensibility to mitigate avoidable costs to human life and well-being.”

    Captain Obvious! The lockdowns were a good idea given what we saw happening in Italy and we didn’t know much about the virus. Now, it looks like distancing, masks and avoiding large gatherings can work pretty well. Save lockdowns for true emergencies.

    Steve

  • Drew Link

    Sigh.

  • Larry Link

    NPR this morning
    https://www.mainepublic.org/post/internal-documents-reveal-covid-19-hospitalization-data-government-keeps-hidden

    Internal Documents Reveal COVID-19 Hospitalization Data The Government Keeps Hidden

    As coronavirus cases rise swiftly around the country, surpassing both the spring and summer surges, health officials brace for a coming wave of hospitalization and deaths. Knowing which hospitals in which communities are reaching capacity could be key to an effective response to the growing crisis. That information is gathered by the federal government — but not shared openly with the public.

    NPR has obtained documents that give a snapshot of data the U.S. Department of Health and Human Services collects and analyzes daily. The documents — reports sent to agency staffers — highlight trends in hospitalizations and pinpoint cities nearing full hospital capacity and facilities under stress. They paint a granular picture of the strain on hospitals across the country that could help local citizens decide when to take extra precautions against COVID-19.

    Withholding this information from the public and the research community is a missed opportunity to help prevent outbreaks and even save lives, say public health and data experts who reviewed the documents for NPR.

    How to you fix this?

  • Jan Link

    There is no proven science regarding the efficacy of masks or even social distancing. There is no public health policy even supporting such mandated guidelines. Mainly we have alternating medical opinions dealing with masks, followed by politically inclined politicians to create punitive ways to enforce these mandates.

    Furthermore, these narrow minded ways of enforcement – closing down the economy, schools, isolating not only the sick but the healthy – gives little thought to the humongous damage to the mental/emotional/non-COVID physical/financial health of society, let alone the collateral damage imposed on the underclass or 3rd world countries, where it is estimated a hundred million will suffer food shortages.

  • There is reasonable scientific evidence that wearing a mask in situations of fairly intimate contact such as a health care setting, in the home, or other prolonged contact in an enclosed unventilated space can result in a fractional reduction in transmission. Links to studies have been published here many times—just search through the comments sections of old posts. There is fairly good reason to believe that “social distancing”, the greater the better, may also result in a fractional reduction in transmission. As long as they are accompanied by clear statements of their limitations I have no opposition to the encouragement of their use. I don’t believe in unenforced mandates of any kind since I believe they tend to undermine the rule of law. I also think that unenforced voluntary isolation is probably worse than useless and that mandatory enforced isolation is politically impossible in the U. S.

    Basically, wearing masks and social distancing are not much but they’re the best we can do to retard the spread of the virus. Other than that metaphysical certainty is not the province of science.

  • TarsTarkas Link

    ‘How to you fix this?’

    Stop mass testing. Fewer tests, fewer asymptomatic cases reported for the Guaranteed Agonizing Death Virus running count, less fear-mongering. As Steve knows and as pointed out we know now who’s at risk now and to what degree. We should concentrate scarce resources towards keeping the most vulnerable safe, frequently tested and treated when necessary, ditto for their caregivers. Locking down the healthy and unlikely to get very ill is no more sensible than banning cars because people die in car accidents. It’s lowest common denominator lunacy. Something which Potemkin and Calamity would subject us to indefinitely if they manage to steal the election, because you never know when the next bad bug might come along it might even be here now and we might even have to require hazmat suits for everybody in the country to ensure everybody’s safety!

    ‘As coronavirus cases rise swiftly around the country, surpassing both the spring and summer surges,’

    Surpassing the spring surge? Really? When there was no mass testing going on detecting asymptomatic cases? Apples and Oranges measurement.

    ‘A hallmark of Covid-19 pandemic policy has been the failure of political leaders and health officials to anticipate the unintended consequences of their actions.’

    No s**t, Sherlock. You choke the economy, and then are surprised when it starts sputtering? Stop treating Kung Flu as if it is the only danger extant and that nothing you do to ‘fight’ it will have the slightest effect on anything else. There ain’t no such thing as perfect safety.

    ‘Duh, we have vaccines.’

    Which don’t work very well for flu. And now we have governors and other politicians vowing not to use any FDA approved vaccines COVID-19 because they were created while OMB was in office and thus CANNOT be safe or effective because the FDA are approving thm just to suck up to the man, while at the same time wanting to make flu vaccines mandatory.

  • jan Link

    Dave, most of the studies I’ve run across have been inconclusive, at best. Masks, in general, should be worn with a meaningful purpose (a sick person or someone in a hospital setting) and regularly changed, rather than just as obligatory symbolism showing one is following a government mandate. Most masks, though, have become a fashion statement, made of smartly designed clothe (which has little protection), and reused over and over again.

    As for staying away from coughing/sneezing people (aka before social distancing became part of our daily language), staying home when sick, washing hands etc., these used to be considered common sense behavior. Now we are motivated to do these protective measures because of fear -fear of being contaminated by a disease or the reprisals of others.

    Finally, the metrics we were guided by initially were to flatten the curve and not overload hospitals. Now, going on 8 months later, it’s all hinges on the number of “positive test,”. not allowing any differentiation between symptomatic or asymptomatic – the latter being the most abundant in cases, even though many medical experts say that asymptomatic people usually don’t have enough viral load to be infectious. And, as Tars discussed, mass testing has led to mass hysteria. Testing those with symptoms, or the most vulnerable should be underscored. Remember, during the swine flu event, Obama stopped testing after 3 months.

  • Larry Link

    CDC estimates that the burden of illness during the 2018–2019 season included an estimated 35.5 million people getting sick with influenza, 16.5 million people going to a health care provider for their illness, 490,600 hospitalizations, and 34,200 deaths from influenza (Table 1).Jan 8, 2020

    CDC Covid Data

    TOTAL CASES
    8,834,393 +81,599 New Cases

    CASES IN LAST 7 DAYS 521,726

    TOTAL DEATHS 227,045 +1,060 New Deaths

    I’ll wear a mask, keep my distance and wash my hands even as I know that it is not 100% protection, I’ll take the 30% to keep my family as safe as I can. I’ll wait it out. Businesses can be rebuilt, a life cannot. I have an amazing grandchild some amazing kids who love him so much, he cannot be replaced or rebuilt. I’ll take my 30% protection and more when it becomes available.

    If you don’t wish to wear a mask, or keep your distance, or wash your hands, fine, but please respect my wishes to be as safe as I can.

    The flu last year infected 35.5 million – Covid infected 8,834,393 million in 10 months
    34,200 deaths from the flu last year – 227,045 deaths from covid in 10 months

    This is not the flu!

  • What is happening right now varies considerably depending on where in the world or where in the country you’re talking about. In most European countries the number of new cases is higher than they were during the spring but the number of new fatalities is considerably lower. Countries that escaped the worst outbreaks in the spring are seeing more new cases and new death now than then.

    In the U. S. most states are seeing a bump in new cases and a much smaller bump in new deaths but nothing nearly as bad as in the spring. Some states like Wisconsin are seeing outbreaks and new deaths considerably worse than in the the spring.

    Businesses can be rebuilt, a life cannot.

    That’s a nice slogan but it’s not as clear cut as that. The collapse of businesses will permanently blight lives as will the lack of in person schooling.

  • CuriousOnlooker Link

    “unenforced voluntary isolation is probably worse than useless and mandatory enforced isolation is politically impossible in the U. S”.

    The problem is no one has even tried to improve isolation in the US.

    If a State or City said anyone with coronavirus can go to a hospital or special setting (at no cost) where they can get 24/7 medical attention and that such attention can reduce the risk of dying from coronavirus (there are studies that show that); and oh as an inducement, the government pays 600 a week at the end of your stay; I think you can get 80/90/95% of people to voluntarily do it.

    People do react to incentives…. I think it is worth a shot, even now.

  • jan Link

    Most of the studies I’ve run across have been inconclusive, at best. Masks, in general, should be worn with a meaningful purpose (a sick person or someone in a hospital setting) and regularly changed, rather than just as obligatory symbolism showing one is following a government mandate. Most masks, though, have become a fashion statement, made of smartly designed clothe (which has little protection), and reused over and over again.

    As for staying away from coughing/sneezing people (aka before social distancing became part of our daily language), staying home when sick, washing hands etc., these used to be considered common sense behavior. Now we are motivated to do these protective measures because of fear -fear of being contaminated by a disease or the reprisals of others.

    Finally, the metrics we were guided by initially were to flatten the curve and not overload hospitals. Now, going on 8 months later, it all hinges on the number of “positive tests,”. not allowing any differentiation between symptomatic or asymptomatic – the latter being the most abundant in cases, even though many medical experts say that asymptomatic people usually don’t have enough viral load to be infectious. And, as Tars discussed, mass testing has led to mass hysteria. Testing those with symptoms, or the most vulnerable, should be underscored. Remember, during the swine flu event, Obama stopped testing after 3 months.

  • steve Link

    jan- You have linked to any of your studies. I have linked to quite a few here. I have been reading mask studies for quite a few years, since a bit before the H1N1 scare. Since I lectured on biological warfare agents while in the Air Force I had a bit of knowledge about the gear we used then, so this is a long term interest. I also have been working with Covid and looking at the stats for our network, which has seen quite a bit of Covid. So please link to these studies that show masks dont work.

    As i have said all along, masks clearly work. In lab studies they are pretty effective. In animal studies they are pretty effective. We know that in our network, no one has contracted Covid from a pt if they were wearing a mask, any kind of mask and the pt was also wearing a mask. We might have one case wear the pt was not and the provider was wearing a mask. The issue has always been the human element. Will people wear them properly and when they should. I must concede that your leader has done a lot to make sure that the human element might fail, however we have lots of indirect evidence he has not completely ruined things. We just arent seeing flu in the expected numbers yet.

    “even though many medical experts say that asymptomatic people usually don’t have enough viral load to be infectious. ”

    Again, please provide links to this. I read this stuff for a living and I have not seen anyone make that claim. Of course I read medical literature. It is felt by some that asympotmatic people might be less infectious. However, there is also literature which seem to suggest that people are most infectious while still asymptiomatic but right before they become symptomatic. Pretty sure I linked to that one here.

    “Most masks, though, have become a fashion statement,”

    This is bizarre right wing nut thinking. I wear a surgical mask. I am tired of it. It is not a fashion statement. I have an obligation to the pts for whim I care to be safe for them. I have an obligation to my family. I know the literature well. I know that I may be a bit more influenced, like a lot of us, by my experience and that of my workplace.

    Steve

  • Larry Link

    Dave, It’s interesting that so much attention is focused just on the death aspect of this virus, from some things that I have read just getting ill with covid can be a life changing event. In 1998 Maine had a really bad ice storm, lots of damage to property, no power for thousands for days and for weeks for some. When the weather forecasters announce a possible bad storm, people do the most amazing thing, they prepare just in case it happens again. Stores are flooded with folks stock piling all they can, batteries, TP, etc…This pandemic, this virus is not just about death, its effects can be devastating.

    “In the U. S. most states are seeing a bump in new cases and a much smaller bump in new deaths but nothing nearly as bad as in the spring. Some states like Wisconsin are seeing outbreaks and new deaths considerably worse than in the the spring”

    Businesses can be rebuilt, a life cannot.

    That’s a nice slogan but it’s not as clear cut as that. The collapse of businesses will permanently blight lives as will the lack of in person schooling.”

    Well, as we all know historically the U.S. has had many a natural disasters, fires, hurricanes, tornadoes, floods, etc…we worry about saving lives, communities rebuild, businesses rebuild, our economy does not collapse when we have natural disasters. This is a natural disaster, listen, that tornado is roaring across the field heading for your town, you take shelter you don’t stand out there taking photos with your cell phone. You pick up the pieces after. If we can give corporations 1.5 trillion in tax breaks, we can afford to take care of our fellow citizens until things end, until things become safe.

  • Grey Shambler Link

    just getting ill with covid can be a life changing event.

    We’ve all heard the same thing, lung damage, mental impairment, hair loss, on and on. Makes you think of the claims about agent orange, too numerous and diffuse to nail down.
    Until there are double blind studies done, these anecdotal stories are just that.
    Sounds cruel, but people can misinterpret their symptoms and correlation to causes very easily.
    What are the symptoms of panic attack? Too many to count and that’s how it is diagnosed.

  • Greyshambler Link

    Larry,
    Do you wear a mask when you’re with your grandchild?
    I expect that’s how we will catch it.
    They get sick, we get sick.

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