Covid 11/11: Winter and Effective Treatments Are Coming

I was considering splitting off my analysis of the effectiveness of Pfizer’s Paxlovid, a new Covid-19 treatment pill, but it’s so straightforward there’s no reason to do that. It works, with our best guess being it is 89% effective at preventing hospitalization and death, and that’s that. Trial was halted because medical ‘ethics’ is crazy and decided we couldn’t study the pill because it was too effective. Paxlovid still needs to be approved and production needs to be scaled up, but both of these seem like near certainties. 

In the meantime, it looks like cases are heading back upwards again. There was high uncertainty (I said I’d be more surprised by no change than by some change, but it wasn’t obvious which direction was more likely) so this was definitely in the possibility space, but it’s near the top end and rather disheartening. 

There’s the usual kinds of developments on other fronts, but none of it should come as a meaningful surprise.

Executive Summary

1. Pfizer’s new Covid-19 treatment pill Paxlovid is ~89% effective at preventing hospitalization and death, but it will take several months to ramp up production and gain official approvals before it is widely available. Effective treatment is coming.
2. Cases are starting to increase again outside of the South. Winter is coming.
3. Everything else about as you’d expect.

Let’s run the numbers.

The Numbers

Predictions

Prediction from last week: 442k cases (no change) and 7500 deaths (-11%)

Results: 470k cases (+7%) and 8092 deaths (-4%).

Prediction for next week (EDIT 11/15): No prediction was made this week, which was an oversight. I didn’t notice until Monday morning. If you see me forget to do this again, please point it out. I don’t look at numbers during the week and not much happened, so I’m going to put my best guess here as to what my prediction would have been, which is 507k cases (+8%) and 7,690 deaths (-5%), but given the delay this one likely shouldn’t count for scoring purposes, no matter the result.

The miss on deaths is due to a large increase in the West. On reflection I likely should have baked some of that in, -11% was a lousy prediction and -7% or so would have been a better prediction. I do think that this is still a disappointing number despite that. For cases the miss is the same size, but this seems more like uncertainty rather than mostly being a mistake in prediction. Cases rising this much this quickly was definitely surprising, and a large update on what’s likely to happen this winter.

Deaths

The jump in the West is not centered on one particular state, with several reporting the highest levels in a while. I’d like to say it is a systematic reporting pattern somehow, and I presume that some deaths from last week out West got shifted into this week. I don’t have any gears for that explanation and given it’s not focused in one state I don’t feel great about not having any gears to explain it. Still, it seems a lot more likely than this being a real decline followed by a real increase. 

Cases

The increase looks fully real. The question is not whether cases will continue increasing, but rather whether the increase will accelerate and by how much. Child vaccinations will help a bit once they come online, but that will take a while and the total size is likely small, so we are probably looking at another winter wave. 

Vaccinations 

Skipping the graphs this week.

Vaccine Effectiveness

Half doses of Pfizer produce strong immune response (MR), presumably with fewer short term side effects, and conserving supply. We could have vaccinated far more people far quicker, here and around the world, with smaller doses. Oh well. At least kids are already going to get lower doses. This will almost certainly have exactly zero impact on the doses given out in the United States, and at this point it’s too late for most of the gains from this anyway. 

Did you know the vaccines are super effective against all-cause mortality? I mean, no, that’s crazy and any such finding is super duper suspicious and presumed hopelessly confounded but it would be remiss not to holy **** check out this chart from this video:

The effect is even stronger for Moderna than Pfizer which is stronger than J&J, and second doses are stronger than the first dose alone, and it survives segmentation by age, with the control group being people who got the flu vaccine within the last two years (but not the Covid-19 vaccines). Sample size is 11 million.

Can you imagine what people would say if these statistics were reversed with even 10% of this magnitude? With 1% of this magnitude? If people were somehow dropping dead far more after being vaccinated than those who didn’t get vaccinated? The vaccines most definitely would not remain legal, and no amount of figuring out and correcting for the confounders would make any difference. That would be the end.

I want to be super clear that I don’t buy this as a ‘real’ reduction. This has to be some sort of confounder effect somewhere, or an outright error, and the more interesting question is what that is all about. Maybe the control groups here are super weird somehow. I don’t have an explanation, and assume I’m missing something. Yet this is part of a very clear unmistakable pattern that no, the Covid-19 vaccinations aren’t causing major other problems in quantity. 

Vaccine Mandates

I’ve repeatedly noted that when vaccine mandates come into effect the number of people who actually quit rather than get vaccinated isn’t always zero, but it is always quite low. Would that change if the job is more fungible, more replicable and less appealing? For example, a truck driver?

This is a rather terrible place to put a mandate, since truck drivers mostly spend their time alone driving trucks and we can’t afford to lose them at the moment. That doesn’t automatically mean this calls for a carve-out, since rules need to be simple and once the exceptions start things escalate quickly. It does introduce a potential serious issue, since trucking is a potential bottleneck on much of the economy.

By default I don’t expect much impact here, for several reasons, yet there are still reasons to worry. First, here’s the case for not worrying, as I see it.

1. I don’t expect the rules to be enforced here in a meaningful way. Carve outs don’t need to be official to work, and I’m skeptical we’ll see much enforcement at all outside of the especially juicy targets.
2. The baseline that almost no one actually cares enough to lose a job over vaccination. We might see somewhat more but it’s still not that many.
3. If someone does quit, they have the option to walk over to a smaller truck company and get a job with them instead. Truck driving is mostly small businesses that are constantly forming and changing (source: listening to the Odd Lots podcast), with lots of turnover and highly fungible tasks. If someone needs to get in under the mandate’s employee limit to keep working, they’ll do that, and who does what job driving which truck is presumably mostly fungible in the end. That definitely works out on the road. What’s less clear to me is whether there’s the same flexibility at the ports to transfer staff to sufficiently small companies, if those jobs are sufficiently distinct, which in some ways they might be.
4. This has echoes of a few years ago, when everyone thought truckers would quit over monitoring devices, and basically none of them did. We actually ended up with a capacity overhang because everyone was ready for a bunch of drivers to quit and then they didn’t quit.
5. Thus there’s an either/or dynamic to this. If This Time Is Different it’s largely because it won’t much impact the supply chain, and if it would impact the chain, it won’t be different.

I’ve seen two counterarguments to all this that give me pause.

The first is that when someone leaves a particular trucking job, they often exit the trucking industry entirely. This is weird to me given that trucking jobs seem mostly fungible and there’s high demand for truckers, but it seems there’s other good options and the labor markets in those other options are very hot, so given the impetus of job switching some people will leave entirely. Which in turn implies that their cost of leaving the job is low, and it’s more realistic that they might quit a job over the vaccine issue.

The second is that while the effect will be small, this is a market where marginal throughput and capacity changes can have oversize effects. So if only let’s say 2% of truckers change jobs, even if that would long term return to equilibrium, that could have a very large impact on freight costs or cause bottlenecks. And for various reasons, especially stickiness in the future, it’s hard to quickly adjust wages sufficiently to compensate, so there might be considerable short term additional friction where we can least afford it.

In other mandate news, as a friend asked in a locked account, what exactly is the word “responsible” doing in this sentence?

This also seems to implicitly echo multiple other fallacies, which I know Scott knows better than. There is no ‘level we need to get to,’ there are only benefits to marginal improvements, and the existence of other ways to raise levels that we aren’t doing doesn’t change the question of the OSHA rule unless we can choose those options, nor does ‘divisiveness’ represent the obviously primary cost of policy. 

Meanwhile in Singapore, they’re done paying for Covid-19 treatment for the ‘voluntarily unvaccinated.’

But the Singaporean government said Monday that it will no longer cover the medical costs of people “unvaccinated by choice,” who make up the bulk of remaining new coronavirus cases and covid-19 hospitalizations in the city-state.

…

The government now foots the bill for any Singaporean citizen, permanent resident and holder of a long-term work pass who is sick with covid-19, unless they tested positive shortly after returning from overseas.

“This was to avoid financial considerations adding to public uncertainty and concern when covid-19 was an emergent and unfamiliar disease,” the Health Ministry said in its statement.

Then there’s Greece, where there’s fun being had with low social trust.

It turns out that giving out the real vaccine protects the doctors from getting in trouble for taking bribes to not administer the vaccine, but that doesn’t mean not taking the bribe, that would be crazy talk, who turns down perfectly good bribe money. 

In terms of humor value and schadenfreude value, I can’t argue with Agnus’s evaluation. 

But maybe this is actually… not the best? And we shouldn’t be happy about people getting vaccinated while the doctor tells them they’re getting water, regardless of the bribery and the attempted fraud, because the one does not make the other okay? 

It’s Over

Last week’s title was The After Times, and I made much more explicit my position that for all practical purposes that involve actual meaningful health risks, the pandemic for most people reading these posts is over now that booster shots are available and kids can get the vaccine as young as five. 

So basically this, except without the surprise.

That doesn’t mean we’re done with NPIs. There will be masks and tests and distancing and other such precautions and you and especially your children will be caught up in all that, perhaps for quite a while and perhaps at great cost. So it wasn’t fully over.

In any case, perhaps I should have waited a week, because Pfizer’s anti-Covid pill Paxlovid has interim results, and modulo the time it takes to ramp up production they can be summarized this way:

Washington Post write-up is here Here’s the AP rounding up to make it sound better, also they have a quote saying it’s ‘100% effective against death’ which is not the correct conclusion from 7 vs. 0 deaths. Here’s the Pfizer announcement. 

The trial was stopped due to ‘ethical considerations’ for being too effective. You see, we live in a world in which:

1. It is illegal to give this drug to any patients, because it hasn’t been proven safe and effective.
2. It is illegal to continue a trial to study the drug, because it has been proven so safe and effective that it isn’t ethical to not give the drug to half the patients.
3. Who, if they weren’t in the study, couldn’t get the drug at all, because it is illegal due to not being proven safe and effective yet. 
4. So now no one gets added to the trial so those who would have been definitely don’t get Paxlovid, and are several times more likely to die.
5. But our treatment of them is now ‘ethical.’
6. For the rest of time we will now hear about how it was only seven deaths and we can’t be sure Paxlovid works or how well it works, and I expect to spend hours arguing over exactly how much it works.
7. For the rest of time people will argue the study wasn’t big enough so we don’t know the Paxlovid is safe.
8. Those arguments will then be used both by people arguing to not take Paxlovid, and people who want to require other interventions because of these concerns.
9. FDA Delenda Est.

I propose the Law of Efficacy, which states that the requirement to halt a trial due to a drug being ‘too effective’ is that the drug has been approved for public use by the regulatory authorities. 

If it’s so damn obvious that the drug is safe and effective that we don’t need more data, then the authorities can make that determination. Until then, no halting trials.  

You can tell me that there’s one set of ‘ethics’ for people intertwined with randomness or who are in front of your face, and another for those who aren’t, and I will note that such arguments are obvious nonsense. I reject the Copenhagen Interpretation of Ethics. 

Merck’s pill was much less effective than Pfizer’s, and it was still a huge deal. Pfizer’s pill, by all rights, should change the whole game. An additional 89% reduction in hospitalization and death, on top of the gains from vaccination including booster shots, in vulnerable populations.

There is still far too much uncertainty in how effective Paxlovid is, due to the trial being halted early – the idea that we know what we need to know here already is absurd. But we do know enough that this should become the standard treatment, and it should mostly replace prevention efforts other than vaccination. 

Once Pfizer’s pill is widely available, and most who catch Covid-19 can get the treatment, on top of widely available safe, free and effective vaccines and booster shots, I can’t see any reasonable case for prevention measures that meaningfully interfere with the living of life. The cost-benefit on that does not make any sense, any more than we already interrupt our lives for the flu or any other disease. Stay home when you’re sick, get tested if you might have it and treated if you do, and all that, but that’s it. It’s a marginal concern, but that’s all it is, a marginal concern.  

Note that this means that the case for medium-term caution if a winter wave does hit is much stronger this week than it was last week. If you wait, you do get meaningfully more protected, and there’s greater plausibility that life could mostly return to the old normal within a reasonable time frame. Similarly, there’s a less stupid policy case for doing more to contain the spread and stop the wave, since stopping the wave now buys time for a meaningful change. 

I do not agree with those cases for those who have had booster shots, I think they still fall far short, but it is important to note that the arguments in favor did get substantially better. It’s a sign of how overdetermined things were before that I’m not close to changing my mind on this. 

Think of the Children

Big Bird got vaccinated for Covid-19 this week. Here’s a clip of him getting vaccinated back in 1972, so none of this is new. Yet somehow when he Tweeted (yes, Tweeted, which for a Big Bird does seem rather appropriate) about his vaccine shot, this was a big news item for a bit this week, as according to various sources such as Ted Cruz this was government propaganda being used to push the Covid-19 vaccine on children.

A lot of the responses to this from the anti-vaccine crowd are dark. Also dark humor, which only benefits from the author quite likely taking themselves seriously.

I mean the framing on that, the attention to detail. Chef’s kiss.

Ted Cruz’s offering is much less refined, but the concept is even better, so I say it still wins. I mean, that’s great stuff, only I don’t think it sends the message he has in mind.

Is this whole operation government propaganda? No, absolutely not, HBO and Sesame Workshop did this on their own. Is it propaganda? I mean, yeah, sure, I guess, if you want to call it that, is there a problem? 

Yes, there’s a problem. This horrible photographer thought a picture to remember forever justified spending a minute outside without a mask, and I’m glad I taught my daughter better than that, says proud area mother.

Once again, that photo, I mean look at her eyes, chef’s kiss. Future meme. Let this moment be remembered for exactly what it is. She has no mouth, and she must scream.

Therefore, Emily asks the tough questions about masks.

A number of pieces have also been written about the evidence of the protective value of masks in schools. Not everyone agrees on that topic. But today I want to look at what we know about the other side of the coin, which is actually the question I get most frequently from parents: Are  there any downsides to mask wearing for kids in school or child care?

I mean. Open mouth. Close mouth. Boggle. I mean, sure, measure the magnitude of the downside, but asking whether there are any downsides at all? I mean, seriously, have you met a child? Have you even met a human being? What in the world?

When people discuss possible concerns with masks for kids, there are a few key issues that are raised:

Interference with breathing/respiratory health

Interference with social development (ability to read emotions and interact with friends)

Interference with intellectual development (learning to speak, learning to read, learning in general)

Concerns about students with disabilities

Yes, yes, all of that is good, that is an excellent list of some of the downsides one should measure. It reminds me of nothing so much as an Effective Altruist trying to measure the advantages of an intervention to find things they can measure and put into a report. Yes, they will say, here is a thing called ‘development’ so it counts as something that can be put into the utility function and we can attach a number, excellent, very good. Then we can pretend that this is a full measure of how things actually work, and still imply that anyone who doesn’t give enough money is sort of kind of like Mega-Hitler, especially given all these matching funds. 

If you think you need to talk about Charles Darwin and the role of facial expressions in emotional development to understand that it’s not a free action to have to wear a mask all day, I’m sorry, I don’t think you have met a human being, I notice I am confused, what is even going on. No, that’s wrong. You’ve met a human, and you think that human hasn’t met any humans, or is willing to act as if they have not met any humans, and you’re reacting accordingly. And then, in this case, you’re forced to conclude that you can’t prove anything in terms of magnitude, so maybe masks are fine and don’t matter?

Burden of proof is a hell of a drug. So are demands for this kind of “scientific” rigor. 
 

Ministry of Truth

In potential blog movement news, as my previous post noted, I’m considering moving to Substack, and I’m now also considering Ghost. If you have thoughts on that, please comment on the linked post rather than here. This includes if anyone has a good source for making the block editor or comment section on WordPress not terrible, or a recommended comment solution for Ghost since it requires you to pick one. 

One of my considerations is potential future censorship, as this blog’s statements would doubtless have been suppressed and probably outright censored on major social networks and distribution channels such as Facebook or YouTube.  Wordpress and Ghost allow self-hosting and are effectively immune. Substack so far has taken a strong anti-censorship position, but history tells us we should worry how long that will last. 

Usually when I mention these concerns people will respond that no, that’s ridiculous, such actions aren’t taken in such cases, they have much bigger things to worry about. Except, well, no:

This is Cochrane. They are the gold standard on reviews of the medical literature. I’ve had my disagreements with them over the years, but it’s not like there’s anyone out there doing it better, unless there’s something I don’t know, in which case definitely let me know. Here is their Instagram, which has been declared dangerous and unmentionable due to ‘repeated posting of false information.’ 

So yeah. I’m going to continue worrying about such things.

In Other News

This story talks about trouble in the CDC, and I can’t figure out what it thinks went wrong beyond ‘political missteps’ and some sort of failure to get the White House to kowtow further to the CDC? It says there’s a ‘credibility problem’ and points to a few places where they outright proved not credible (e.g. said that which was not, and then couldn’t pretend they hadn’t done that) but didn’t seem to get into the systematic actual problems. 

Twitter thread from Kelsey Piper about how much one can poison the well on an intervention by suggesting people actually use it, repeatedly and loudly, simply because it probably works. Also she points out that the guidelines for using Fluvoxamine still haven’t been updated.