Soho Forum Debate on the Great Barrington Declaration

 I wrote a post a couple of months ago outlining a path toward herd immunity. Two days later, the Great Barrington Declaration (GBD) was released, authored by three epidemiologists (from Harvard, Oxford, and Stanford, so presumably they have some credibility). It outlines basically the same argument that I made: young, healthy people are relatively robust to the virus and should be living their lives freely (there is something like a factor of 1000 difference in mortality for the youngest versus oldest Covid patients), while the older and more vulnerable among us should be sheltering. The freely mixing population will get a lot of cases of Covid and develop some kind of herd immunity, at which point the virus will dissipate and the elderly can eventually get back to normal lives. 

My feeling is that the opponents of the Great Barrington Declaration don't really have a case. As in, it's not even close. This recent Soho Forum debate between Martin Kulldorff and Andrew Noymer increased my confidence. Watch the entire thing. I was slightly surprised that that the debate was a tie. The exact proposition was:

Coronavirus lockdowns should be lifted and replaced with a targeted strategy that protects the old and other high-risk groups.

Kulldorff, one of the authors of the GBD, is in favor and Noymer against. Kulldorff was not as articulate as I'd have liked. His performance is slightly choppy, which might have something to do with his accent. But the substance of his argument is right on. Noymer's arguments were terribly disappointing. I was hoping Noymer would at least articulate a clear reason for all-inclusive lockdowns that include the non-vulnerable. Some kind of cost-benefit analysis or something. In previous posts I've laid out the three main reasons why I could be wrong. 1) The risk to young people, while statistically quite small, should worry us. Or 2) There is no reliable way to keep this  teeming mass of young people separate from the vulnerable. Or 3) There are long-term consequences of a Covid infection that aren't revealed in the death figures. I was hoping to get a more thorough treatment of these possible arguments. Maybe a philosophical defense of 1), which I regard to be innumerate or irrational. Perhaps a formal treatment of 2), which I also find unreasonable. (How many elderly people would even say, "Yes, I want my adult children and grandchildren to go to such lengths for my sake." Would you, if you were a vulnerable person in your waning years?) Maybe a thorough fleshing out of 3), based on known hangover effects of prior infection. (As I've said before, appeals to "unknown" long-term after-effects, which aren't strict extrapolations from known after-effects, are a form of Pascal's Mugging.) 

None of this was on offer. Noymer suggests replacing the term "lockdown" with "public health orders." So that's his solution: replace an ugly term for an ugly policy with a revolting euphemism. I'm always a fan of more precise language, but this seemed like a cynical deflection to me. Noymer also repeatedly cited a statistic from his home community (Orange County, California I believe) that attempted to quantify the risk to young people, implying that it's larger than the GBD people presume. Maybe I missed his point, but I was left wondering "Why not use nationwide or international figures?" Was he cherry-picking an example of a community with an especially high death rate for young people? 

Perhaps most bizarre, Noymer repeatedly emphasizes that you don't know for certain whether you're in the low-risk group or not. Which suggests he doesn't know how to think seriously about risk. What you don't do is note that there is a non-zero risk and then catastrophize that you could be a casualty. What you should do is quantify the risk as best you can for your demographic, and treat such a risk as you would any numerically similar risk. (As in, Is it a numerically large enough risk for me to worry about it at all? Are particular efforts to mitigate the risk worth it in a cost-benefit sense? Am I using a cost-benefit calculus that is calibrated similarly to other hazards I face in my life?) Of course there could be some unseen variable working against you. Some genetic predisposition that magnifies your risk tenfold, the sheer bad luck of getting a very high viral load, a weakened immune system due to stress (possibly due to severe social isolation). You don't throw up your hands and say, "Gee, I don't actually know if I'm in the 'probability of death = 1' group or the 'probability of death = 0' group, so I'd better assume the former." You treat unknowns using the concept of probabilities, with lower probabilities warranting less concern. Hazards with probabilities below some threshold should be totally ignored, and the same goes for probabilities that are beyond your ability to control. Someone who is so terribly confused about basic concepts relevant to public health (or so confusing that he leaves listeners baffled about his point) should have no influence on important public policy decisions. Their commentary should be ignored.

I apologize for being such a broken record on this issue. In fairness to myself, I've been posting much less frequently than I used to. These thoughts occur to me about ten thousand times as frequently as I write about them. I admit it's making me rather grumpy. I feel like I do a decent job of understanding contrary viewpoints. There are three main reasons for failing to do so. One is that you fail to seek out such viewpoints. The second is that you observe such viewpoints but the topics and arguments are too subtle for you to understand. The third reason is that the viewpoint is hopelessly confused or poorly defined. I don't think the first or second apply. I am positively swimming in the standard "everyone must treat this as a deadly catastrophe" narrative. Having listened to Noymer's blather for about 45 minutes, I can safely say it's not the second. What I am seeing is a refusal to think seriously about how to quantify and respond to risk. I think I am seeing bad arguments being back-fit to foregone conclusions, and it comes out looking like a confused string of non sequiturs. This is a deadly serious disease, which threatens some people very close to me who qualify as "vulnerable." It needs to be treated with clear-headed thinking. 

Inconsistency/Hypocrisy In Health Policy?

Our friends on the Progressive left often tell us what a dire catastrophe it is that so many people lack health insurance. Healthcare is expensive. So, the thinking goes, those without health insurance will not seek care when necessary, either because they flat out can't afford it or they are unwilling to pay steep prices out of pocket. Supposedly all this foregone health care leads to bad health outcomes and higher overall mortality. 

I have serious doubts about this story. Like I've said many times, the Rand health insurance experiment and the Oregon Medicaid experiment both failed to find any substantial health impact for the "treatment" group. (The treatment group being the group that got into a Medicaid plan in the Oregon experiment and the one that got essentially a zero deductible in the Rand experiment.) And this result is consistent with a lot of observational/regression studies showing the same thing. Put that aside and let's say it's a plausible story that "lack of insurance" -> "less consumption of healthcare" -> "worse health outcomes". (The first causal link is real, but the second is not, assuming the obvious interpretation of the Rand and Oregon experiments is the correct one.)

My question is: Where have these commentators been all year? Consumption of health care is way down, and it's not just nonessential stuff. People aren't just skimping on their annual check-ups. Some people are so afraid of Covid that they're declining to seek treatment for a possible heart attack (which, given enough examples, means some people are not getting treatment for an actual heart attack). There has been a disruption of cancer treatments. People with known cancers haven't been getting their treatments on time, and cancer screenings are way down, which presumably means fewer cancers are getting caught in time to treat them. People are more prone to dither instead of seeking treatment at the first sign of a stroke, which can be deadly. Rapid treatment can spell the difference between life and death for a stroke victim. Patients aren't making it in to see their physicians for prescription renewals that require an office visit. The reduced consumption of medicine is due both to the patients' fear of contracting Covid and initial lockdown orders that put a temporary halt to "discretionary" health services. (Jeff Singer has a useful discussion of the issue here.)

Mental health has taken a serious hit. This is likely more due to the lockdowns themselves than it is a function of disrupted health care, but both effects are in play. Oddly enough, the only "statistically significant" effect of the Oregon Medicaid experiment was the improvement in mental health for the control group, and this was touted as a kind of success. In the Oregon experiment, most of the improvements in mental health happened before there was time for any appreciable amount of health services to be consumed, which probably means the mental health improvements were mainly due to peace of mind about the ability to obtain health care. If that's the case, a lot of people have been living without that peace of mind for much of the past ten months. 

My own view is that Progressive commentators on health insurance are wrong about the health consequences of being uninsured. But I also think that the sudden, extreme lack of availability of health services this year has caused real health consequences. You can go to the ER with a heart attack and will receive treatment, insurance or no insurance. But if people are simply declining to go because they've been unduly frightened of Covid (or appropriately frightened, but at the cost of ignoring other hazards to their health), I would expect that to show up in aggregate mortality figures. Much attention has been paid to the excess deaths in 2020, which some are attributing entirely to Covid-19. I think the story will be a little more complicated as this unravels. I would guess that the excess deaths in April and May are primarily due to Covid, but disruption of health services may have become a more important causal factor later in the year. We will know more at the end of 2021, because the CDC publishes its aggregate "cause of death" data at the end of the next year (the Wonder database and the detailed mortality file that I have been analyzing for the past five years). But if your priors are "going without healthcare leads to bad health outcomes", you should be very upset about disruption of services in 2020. 

Where is the outrage? I'm sure there has been some commentary on this, and a motivated reader could flood the comments of this blog post with links to news stories. But I've been sampling from the standard news streams. This story should be a major scandal, but it's a barely audible whisper in the cacophony. Nobody wants to say anything that sounds like "We exaggerated the risks of Covid." Suppose we try to deliver a slightly subtle message to the public, such as, "Covid is indeed dangerous, but not enough so that you should ignore the early signs of stroke or heart attack, or forego routine checkups and screenings." I think the narrative crafters, our public health professionals and media folks, are paranoid that this will be heard as "Covid isn't really a big deal," by a news-consuming public that doesn't have any appetite for nuance. They also don't want to put a single arrow into the quivers of conspiracy theorists or malcontents who think that lockdowns are harmful. I think these policy makers and commentators need to contend more seriously with the ways they've been hurting people (even supposing that lockdowns and extreme caution are on net beneficial). To the extent that these are the same people who were telling us how deadly it is to be uninsured, they need to confront an inconsistency in their own thinking.