Covid 11/18: Paxlovid Remains Illegal

I had already written most of this week’s post, and also spun out a way-too-long way-too-deep dive on what happened with a retracted FLCCC paper that that I was planning to publish today but I can’t yet because the rabbit hole is still getting deeper, when Scott Alexander posted Ivermectin: Much More Than You Wanted To Know.

My reaction to that was a deep sense of gratitude, as I was worried I’d have to write something because someone had to and no one else would. Then Scott Alexander wrote it. So now I didn’t have to. I don’t agree with every decision he made, I definitely ‘have thoughts’ and I’ll probably end up writing about that, but it can wait for another week.

There’s a variety of other stuff going on as well, including a rise in cases that is unlikely to be going away any time soon, none of it terribly surprising. Paxlovid remains illegal and somehow this may not be easy, various mandates were imposed, children noticed it was nice not to wear masks, and those against vaccination have their latest crazy nonsense where they think they can ‘detox’ and undo the vaccination shot. What a time to be alive.

Executive Summary

1. Ivermectin: Much More Than You Wanted To Know.
2. Rise in cases is accelerating. Winter is coming.
3. Paxlovid remains illegal.

Let’s run the numbers.

The Numbers

Predictions

Prediction from last week (accidentally made on Monday 11/15, so it doesn’t count for prediction scoring purposes, but I didn’t get meaningful new data before then and it still attempts to represent my expectations at the time): 507k cases (+8%) and 7,690 deaths (-5%)

Results: 554k cases (+18%) and 7,427 deaths (-8%).

Prediction for next week: 654k cases (+18%) and 7,500 deaths (+1%).

Prediction for two weeks from now: We’ll see less deaths than normal due to the Thanksgiving holiday messing up reporting, and the counterfactual Zvi that didn’t put in this note likely would have forgotten to adjust for it.

Winter is coming. Boosters and child vaccinations will help a nonzero amount but they’re not sufficiently powerful to put a stop to this, and there’s very little appetite or tolerance for trying to shut things down again. There is no reason to think cases are going to stop rising any time soon, and having seen the acceleration this past week there’s a chance that the rise will be even larger in percentage terms over the next month. That means cases are likely to more than double before we peak again and it would be unsurprising if our case numbers peaked similarly to where they peaked a year ago.

Deaths

Deaths continued to decline because they lag cases. With cases rising again, this trend should reverse shortly, and death counts will begin rising again within two weeks. The only question is when, as there’s no reason to think the IFR/CFR will change much until they approve Paxlovid or (to a lesser and less certain but still probably noticeable extent) if we got more widespread use of Fluvoxamine than we currently have.

Cases

When something similar happened last year I was terrified. This year, I notice almost all of my worry is about the reaction to the coming wave. I don’t want there to be several times as much Covid-19 running around, I’m sad that more people are going to die, I’m sad about those who for medical reasons can’t get boosters, and I’m mildly worried about hospital overloads, but mostly I am worried about all the Covid-19 prevention that will result from this because almost everyone has the opportunity to get booster shots, with a booster protection is robust, and during the worst part of the wave we should have Paxlovid available, although we might still be short on supply.

It is an interesting time, in terms of intertemporal substitution. In the short term, risk is going to rise quite a bit in at least the Midwest and Northeast and probably at least the West as well, so if you have something you’d like to do a few weeks from now, it’s better to do it now while you still can and can do it safer. However, after that, Paxlovid is coming, which will make things dramatically safer again, so as long as that goes smoothly Christmas should be fine, and I’m not worried about the vacation I have planned for January.

Vaccinations 

The statistical implications of vaccine counts have gotten rather muddled. There’s booster shots which help but have less impact than new vaccinations, and there’s children getting vaccinated which helps but less than vaccinating adults helps. The rise we’re seeing is more difficult to put in context.

It has been two weeks since children became eligible, but it has been a very long time since parents knew this was coming, so in some ways it feels strange (even though it isn’t actually strange) that child vaccinations are moving so slowly – not that so few kids have been vaccinated so much as there are so many kids who will be vaccinated but whose parents haven’t gotten around to it yet. Some of that is logistical problems, some of that is the action becoming normal. The important question is how much low hanging fruit is available here before we exhaust the parents who actively want to protect their kids, and get into the parents that don’t want to.

This piece by Chris Arnade, called Among the Unvaccinated is a lot of where we are at. Consider reading the whole thing. The core takeaway is that being unvaccinated is core to these people’s identities, and they actively distrust both elites and all the markers of authority and credibility that the elites think give you authority and credibility, so if you’re going to convince them rather than coerce them into getting vaccinated, it’s going to have to come from people like them and it sure as hell isn’t going to be easy. Sufficiently strong coercion still does seem to mostly work.

They’re holding on to this so tightly that a new trend (as always, how widespread it actually is isn’t clear) seems to be ‘detox’ to ‘undo’ one’s vaccination. People are getting the shot because they have to, and then rushing back home to do various things that it is claimed will remove the vaccine’s effects, while often also making TikTok videos. Needless to say, this is not a physical thing one can do, and nothing they are trying does anything to interfere with the vaccine. But if one’s identity is wrapped up in not being vaccinated, it makes sense to do whatever it takes to continue to tell that story. And if you are running an anti-vaxx effort, it makes sense to be able to save face with such nonsense.

If you want details of what they’re up to, you can follow the links, nasty chemicals are involved so these are definitely not ‘free actions’ and it seemed prudent not to list it directly.

Here’s where we are more broadly:

Booster shots for some, somewhat higher risk of Covid-19 and social media rants for others. Previously I’ve noted that if you wanted to be in the first category, all you had to do was check a box saying you were high risk.

The dam on even that is starting to break, and states are noticing they can they can change the eligibility rules to everyone who is 18+ years old and there isn’t anything that can stop them.

Also worth reminding people that even if you’re not in those states, and you’re not all right checking the box unless it’s technically correct, it’s probably technically correct.

Meanwhile, it’s good to persuade others to get vaccinated, and I’m not against applying a non-zero amount of pressure on them, but even when it has positive mood affiliation and makes us smile and no it isn’t a crime and the bad legal take in the other image is indeed a very bad legal take but seriously, can we please do it without committing fraud and applauding those who do? Thanks.

Vaccine Mandates

So I don’t fully agree with this, but I do think it’s an unusually clear and honest statement that is pointing to important things that need to be understood:

I do not think this is a major imposition compared to what we already put up with, and that is a crux for me and for many commenters from past weeks who opposed the vaccine mandate, although not one I’m looking to re-litigate. I do think I might possibly have rights, and much prefer the worlds where I have more rather than less rights, while also recognizing that there’s very little support for people having rights in the sense that I care about them having rights.

I also continue to feel strongly that if you’re going to do a mandate, it’s better to go the legitimate route and actually mandate what you want, rather than approaching the problem as if your authority is illegitimate and you have to use workarounds. And wherever you think that line is, it seems Upper Austria is well over it:

Here’s Guardian’s coverage, as well. If you’re going to tell people they need to be vaccinated in order to leave their house, it seems to me like that’s strictly worse than outright mandating vaccinations. Do, or do not.

On the plus side, if you drop by Vienna after vaccination there’s a brothel that will give you a 30 euro voucher. It sounds good at first, but that’s squarely in the range of amounts that tempt you, but where the services you’d want you can’t afford, and the services you could afford you don’t want. It’s a great publicity stunt either way and every little incentive helps, but if you weren’t already going, how often should a 30 euro discount change your mind? I also can’t help but notice that this means a bunch of still effectively unvaccinated customers are the ones newly showing up to the brothel, which doesn’t sound ideal for the workers there.

Latvia has banned unvaccinated lawmakers from voting. Given the precedent this sets, this seems like it sets the stage for much future trouble. Again, do or do not. Congressional voting from remote locations has been an ongoing strangely difficult problem this pandemic for reasons I still don’t fully understand, with congress risking outbreaks repeatedly back in 2020 rather than do what most of the country did and work remotely.

Paxlovid Remains Illegal

The great amazing news on Paxlovid is that Pfizer has signed agreements allowing others to manufacture the drug. This opens the door for much more rapid scaling up of supply, maybe even enough to treat the whole world.

Meanwhile, it remains illegal, with my explanation from last week making the rounds including at Marginal Revolution. It seems to continue to be the official position that:

1. Paxlovid is safe and effective.
2. Paxlovid has proven this sufficiently that it isn’t ‘ethical’ to continue running a clinical trial on it.
3. Paxlovid will be approved by the FDA in December.
4. Until then, Paxlovid must remain illegal.

We aren’t 100% sure Paxlovid is getting approved, but the consensus seems to be that unless there is (very unexpected) detection of outright fraud this is an open and shut case.

This seems to be a case that is sufficiently stark and obvious that a bunch of people have finally noticed the skulls and suggested maybe December should be November instead.

For example, here’s Matt Yglesias:

There’s the invisible graveyard caused by drugs that never got developed or approved, and then there’s the highly visible, obvious, in front of your face graveyard.

Washington Examiner points out the obvious, that the FDA is killing thousands of people by delaying Pfizer’s and Merck’s Covid treatments. It’s good to state simple things simply:

So, set Merck aside for now and consider Pfizer’s Paxlovid. In the past 30 days, more than 37,000 people died of COVID in the United States, according to the CDC . Over the next 35 days, Paxlovid could prevent tens of thousands of avoidable deaths. But instead, the FDA won’t immediately let Pfizer sell a drug it knows to be lifesaving.

This isn’t the behavior of a government set on maximizing public health. This is a bureaucracy religiously devoted to its own tedious rules to the point of defeating its own purpose for existence.

An obvious solution that is even more obviously not happening any time soon, if one cared about getting life saving medicine into the hands of patients more than other considerations, would be a prediction market for FDA approval. Thus, we could have a market on whether the FDA will approve Paxlovid within some period, let’s say 60 days, for emergency use authorization. Then, if it’s trading above let’s say 95% (p < 0.05!), we can treat that as an emergency use authorization until such time as it can be formalized.

I’ve asked Polymarket to create this market for us.

The only thing minimizing the number of lives lost, at least for now, to a lack of approval is the need to scale up supply. We don’t have enough supply to treat everyone yet, so to the extent that all doses we can create end up getting used for a while, excess people won’t die unless you count secondary effects that doubtless slowed down manufacturing.

Also, remember when I said that for all time people will question the effectiveness of Paxlovid because we didn’t run enough experiments and gather enough data? Here you go.

I’d be very surprised if the insurance companies actually tried to pull that stunt, and even more surprised if it did anything but blow up in their face, and when something is 90% effective you’ll know pretty fast whether or not it works.

And then there’s the article he links to, which asks the eight tough questions.

1. Which pill is more effective, I mean golly, who can say.

Which one works better?

At the headline level, Pfizer’s pill reduced the risk of hospitalization and death by 89%, while Merck showed a reduction of 50%. But neither firm has disclosed detailed data from its pivotal studies, and the trials were not identically designed.

So yes, let the endless debates about the thing that we already know begin.

2. Their second question is if the pills would work even better together then maybe we can use them together? And they say no, haha, of course not, that probably would work (as in save more lives) but will never be allowed.
3. Will the antiviral be available for vaccinated patients with breakthrough infections?

So regulators and public health officials will have to make a judgement on the risks and benefits of the Covid pills for people with breakthrough infections — without direct data in these populations.

Pfizer is running a clinical trial, with results due next year, that does include vaccinated patients, and the company’s executives have expressed confidence based on the results so far that the treatment should work. Both Merck and Pfizer are also running studies to show that the drugs can prevent people from developing symptoms if they take the antivirals after they are exposed to the virus.

So this goes even deeper than Gellad’s concern. We might be in a position where people who have Covid-19 need to tell the hospital they’re unvaccinated in order to get treatment.

The good news is that it seems the clinical trial that includes vaccinated patients was allowed to proceed. So it’s now ‘ethical’ to continue the trial for people who don’t need the drug enough for us to be certain it works on them, but not to give it to the people who we know it definitely works on. Sounds right.

4. Do the drugs work the same way? They say no, not really.
5. How do they compare to monoclonal antibodies? Easier to administer, including at home, and then there’s the price. Effectiveness, it seems, is similar enough it’s not important?
6. How easy will they be to get? It seems the actual question is ‘how easy will it be to get tested in time?’ which is somehow still a question.
7. Will it affect a patient’s DNA? Are we seriously doing this one again? Yeah, sorry, we’re going to be doing this again.
8. What will this mean for cancer patients? It seems the new drugs will interfere with many cancer treatments.

Some good information and good questions there, but it should be clear that no, absolutely not, we do not have enough information, because ‘enough information’ means ‘enough that people don’t demand more information before letting you do correct things.’ Anything less than that is not enough.

The other good news is that we can at least keep running our thought experiments, which everyone knows are better anyway.

NPIs Including Mask and Testing Mandates 

Taking an at-home test, or one where the logistics are well-handled, is cheap, and a reasonable thing to require if one requires reassurance for whatever reason.

Alas, many locales are both requiring a bunch of tests in marginal situations, and also many of those same locales are doing a rather poor job of making tests reasonably available to get. This gets rather expensive. For example here’s New York City.

On masks I’m pleased that the news seems to be about removing mandates rather than imposing new ones. Washington, DC is the latest example, lifting some of its mask requirements (WaPo).

Meanwhile, who wanted the clean glass?

I went to the bar to refill my wine glass with a second pouring of chardonnay. The bartender pulled out another, clean glass. “That’s okay,” I said, “you can refill this glass that I’ve been using.”

“No sir,” she replied. “Covid restrictions require that we always use new glasses.”

I smiled and thanked her as I took the freshly poured wine – and then said softly to myself, as I walked away from the bar needing that second glass a bit more than I did just a moment earlier, “Good thing the Covidocracy is protecting me from catching Covid from me.”

Again, the world is not right.

Think of the Children

When can vaccinated children, forced to attend schools, stop also being forced to wear masks? This NPR story asks a bunch of people that question, and gets widely varying answers. New York’s incoming mayor Eric Adams in particular says he “looks forward to it… if we can find a safe way to do it.” I believe I know a safe way to do it, and would be happy to consult with him at no charge.

Then there’s this story from WBUR, with lots of students in an ‘experiment’ allowing them to go maskless at school expressing how relieved they are to be able to hear each other properly, see each other’s faces and such. If you don’t laugh, you’ll cry. I found that story via this thread, which puts the point in stark relief.

And yet the thread condemns this whole unmasking event.

In this particular case I don’t think Emma is doing the thing where you can allow masks for all or masks for none but experimenting suddenly means what you’re doing is terrible and unethical. I think she’s merely shouting from the rooftops that it’s insane to think you need to experiment with this. I disagree, because I’ve seen time and again that there are people who don’t seem to have met their fellow human beings, and thus think that masks don’t matter, and if it takes an ‘experiment’ to show them they’re wrong, then it sure beats the alternatives.

As usual, such things also highlight how if you reversed the presumption of what is a default or what is action or what things count as risks to panic about, you see how nonsensical everyone’s actions mostly are.

Long Covid

It is always interesting when different studies live in completely different universes.

This French study claims that having self-reported symptoms associated with Long Covid is highly correlated with self-reported Covid-19 infection, but aside from lack of sense of smell, there wasn’t any association with laboratory-confirmed Covid-19 infection. Huge if true, as it would imply that Long Covid is mostly a phenomenon where people blame their long term health problems on Covid rather than a thing where Covid causes long term health problems, to the extent that they retroactively decide they likely had Covid, or perhaps also that those who think they had Covid but didn’t get confirmation often go looking for symptoms.

Then the CDC comes out and says that a full fifty percent of people get Long Covid, with symptoms that persist for at least six months. If that was actually true, we would know, because a large percentage of the population got Covid-19, so the population statistics would be screaming at us. There’s this great tidbit:

The median (IQR) proportion of COVID-19 survivors experiencing at least 1 PASC at 1 month was 54.0% (45.0%-69.0%; 13 studies); at 2-5 months, 55.0% (34.8%-65.5%; 38 studies); and at 6 or more months, 54.0% (31.0%- 67.0%; 9 studies).

So you’re telling me the percentage is the same at one month as it is at six months, and also two to five months? This has got to be some sort of fishing expedition for fishing expeditions.

My combined update from this week is to move closer to the French study’s position.

In Other News

Your periodic reminder that if we were serious about minimizing harm from Covid-19 we would be emphasizing general good health, and at a minimum we would be addressing obesity rather than pretending it’s not a thing.

The good news is that Biden finally nominated someone to head the FDA. Manchin, without whom nothing ever happens in Washington these days, responds by opposing him due to ‘ties with pharmaceutical companies.’

Some insight into the early days of the epidemic in New York, and how the state government was handling it. A good summary would be ‘not well.’ Collaborations between state and city were actively prevented.

Not Covid

Britney Spears is finally, actually free! I wish her all the best, and would like to see a gears-level evaluation of whether the Free Britney thing had an impact here, and if so how, and the dynamics involved. Like the question of the ports, this seems like a situation in which this was amplified somewhat because it presented well (e.g. it was Britney Spears and the superficial optics were terrible) and also because her whole situation was indeed objectively terrible.

Like the situation at the port, success in such an enterprise seems like it brings hope and momentum rather than causing people to be satisfied that everything is fine now. And like the situation at the port, it’s a small part of a much larger problem, in this case our rather dystopian and heavily abused legal guardian system. What we need is a way to not only free one person wrongfully imprisoned, but to change the underlying dynamics of the system.

As the thread points out, it’s also an example of earlier ‘safety’ culture gone mad, and places where rules that may or may not have made sense on a temporary basis becoming impossible to get rid of once they no longer make any sense.

Also new study suggests that psilocybin may be helpful in treating depression. I mean, yeah, could have told you that on priors, and also the results look short term enough that they don’t mean much, but hopefully these concrete particular things continue to help make various such things legal again.

Point of Order: Substack Ho?

This post was drafted using the Substack editor, as a test. My tentative conclusion is that it performed quite well aside from inability to paste from spreadsheets (I’ve emailed them to ask about that). I’ve put up a copy of the post there, so you can compare and contrast what it looks like over there. Use that comment section for any comparisons of the two versions, or to express thoughts on whether I should make the move.

Next week’s post the plan is to try out the Ghost editor.

The Lighter Side

At the movies: I was in the appropriate mood without enough time to actually go to the movies, so I saw Red Notice on Netflix. It’s living its worst life given the talents of the people involved, who make noble efforts as far as these things go. Man that was bad. No, it doesn’t make any sense on reflection. But I pretty much knew that coming in, so was it still fun? Yeah, it was still kind of fun, cause hey, why not.

At the theater: I got to see Iliza Shlesinger perform live at the Beacon Theater. She delivered the goods, exactly the way you would expect if you have seen her Netflix specials. All new material. A fine night.

Also these: