Letters to My Great Grandchildren, Part 1: Obesity and Bewilderment

Let me begin with the obvious. I do not actually expect you to actually read these. The dead, as Kipling observed, are only borne in mind for a little, little span. Digital preservation being what it is right now, I don't even really expect it to survive. And even if you do somehow read it, it is hard to know what will strike you as interesting about my time. Assuredly, the things that I find noteworthy about modernity may have nothing to do with what interests you. A lot of your questions will probably relate to things like "what was life like without [indispensable invention X]?". Alas, I cannot tell you - it seems pretty normal to me! One throws this note in a bottle into the digital sea - the modern version of the same impulse that made men once paint on cave walls.

One thing I can tell you, however. In certain respects, the early 21st century is a bewildering time to be alive. And this is especially so in a respect that I imagine will strike you as especially jarring when you look at photos from this time. Namely, why is everybody so enormously fat and unhealthy-looking? 

The immediate question you are probably wondering is how we didn't figure this out. Didn't they look around and notice there was a huge problem? How could you possibly fail to spot the obvious answer of [cause Y]? 

To take the obvious first - we definitely noticed. Human nature did not change so much that the obese failed to observe that they were obese. Nor did they fail to observe the health and lifestyle costs. Indeed, in the sexual marketplace, the fewer people who are thin and in shape, the higher the payoffs to those traits, making the perception even more acute. 

It is glaringly obvious that, at least in this respect, something has gone very wrong with modernity in the last 60 years or so. Obesity, testosterone, sperm counts, the list is long. But time series changes are incredibly difficult things to parse out. The problem is that dozens, if not hundreds, of things are changing all at once. The curse of knowledge is always a tough one to circumvent. When you know something, it will always seem like it ought to be obvious to people who don't know that thing. But it isn't. It turns out it is more difficult than you think to credibly put yourself in the shoes of someone who doesn't know, in this case, why everyone got so fat.

To begin with one aspect that makes the problem hard. Across different categories, there is a large difference in regulation about what can occur, and how much data collection and notification goes into it. To take one example, which may or may not be relevant to obesity (which is the most glaring and acute of the modern problems). There are a lot of requirements about labeling the ingredients in food. But there are almost none about labeling the chemicals used the packaging that the food comes in. There is some attention paid to the composition of trace chemicals in the water people drink, but it depends a lot on which chemical. There is little attention paid to the amount and type of radiation people are exposed to. Lack of regulation and lack of interest is strongly correlated with lack of data to test hypotheses well. The hardest of which is not "does this increase weight in controlled settings", but "does this quantitatively explain the world around us?" 

Are any of the examples above actually *important*? That, future reader, is the aspect I most want to discuss. The problem is not the lack of plausible theories, or possible contributing causes, or partial remedies. The problem is the complete surplus of them, and the difficulty of sifting between them. Smart, motivated, curious people live in a world of leaping from one lead to the next. They have a scarce budget of time and attention and effort, but great confusion as to where to allocate it to solve a problem that seems all pervasive. The obvious candidates are things associated with modernity, broadly defined. But which ones? Do you need to be reducing the amount of carbs you eat? Do you need to cut back on seed oils? Less salt? Do you need to limit the hours in a day when you eat? Or perhaps the problem is chemical in nature. Do we need to work to reduce our exposure to  polyfluoroalkyl substances? BPA? Microplastics? Lithium? Antibiotics? Glyphosate? Blue light? 5G radiation?

Or is the problem even thornier - that we were simply evolved for a world of calorie scarcity, and our hardwired instincts are now pathological in a world of permanent calorie excess, moths circling a flame of our own making, consisting of hamburgers and doritos? Because, as Eliezer Yudkowsky put it, we can do what we want, but we cannot want what we want? It is striking that the unusual period in history when we consume too many calories is the same period, and same places, that our houses now routinely accumulate junk possessions which occupy much time and effort getting rid of. Both problems would seem bizarre to people a hundred years ago. 

I have no doubt this list will seem comical and insane by the time you read it. But this is the point. To live in 2024, and spend any time pondering not just obesity, but the various other maladies that seem to afflicted us more than in the past, is to have a complicated and uneasy relationship with the modern world. There are many things that are probably in the category that the distribution of effect sizes starts at zero, and includes small negatives and considerable negatives. That is to say, not many people seem to think you should be *increasing* your consumption of microplastics. But is it a small problem, or a large one, or actually not really a big deal? That's the difficulty. You can try to play it safe, as it were. But the precautionary principle breaks down very fast when the space of possible things to avoid is sufficiently large. And many of them carry tradeoffs that only become obvious in hindsight, because some of the things are so prevalent. You might be worried about contaminants in your water, perhaps. So you buy a cheap water filter, except now all your water runs through a plastic container made of whatever as-bad-or-worse BPA substitute they're using these days. You take supplements to try to improve your health. But you buy the easy to swallow ones without thinking about it, and end up consuming a lot of whatever is included in the dubious term "gel caps". One ends up being pushed towards rejecting more and more of the modern world, where the end point is rejecting it wholesale, like the Unabomber, or the Amish, or Boko Haram. We don't want this, of course. We still want to be able to write our essays on the internet. 

You can guess at the outlines, of course. It has to be pervasive, hard to avoid entirely. Every area of every country seems to have gotten fatter. It has to be associated with modernity, probably the 1960s/70s onwards, but also increasing over that time. In the cross section, who is affected more seems to be largely genetic, from the twin studies. But since genes haven't changed much in 70 years, this means either genes are a big determinant of response to a time series change, or genes determine willpower, and the ability to use effort to overcome the force pushing you in the same direction. It doesn't seem to be from cross-sectional environmental exposure. Which is weird, since a large time series change sounds a lot like environment. 

You're probably thinking to yourself, that's it? Well, not exactly. There is lots more specific evidence, but this is much more murky and open to interpretation. If you want to know how to control obesity, you've got a larger set of options, with their own limited success. But, for instance, it seems very unlikely that the rise of obesity in the 1980s came from people abandoning their previous one-meal-a-day keto diet, even if you think that might be a decent remedy for the underlying cause. If people stick to it. The distinction between "this would work, if people actually do it", and "this is a thing that the average person could credibly do" is also surprising blurry in the way matters are discussed. 

The other aspect, which you might not guess, is what the response is to this confusion. You would probably guess at there being a frank acknowledgement of the lack of understanding. But there's not. There appears to be some strange aspect where in the face of intractible problems, people would rather believe vehemently in some theory or other, and that it just hasn't been tried hard enough. People would rather hear a wrong theory, vigorously and persuasively espoused, than to frankly admit that all their theories aren't working, and they're largely out of ideas until big pharma invents the right drug. There is a need for action, even partial or unsatisfactory or pointless or symbolic or improbable-to-be-successful action. And once this has occurred, cognitive dissonance takes care of a lot of the rest, changing beliefs to match the actions already taken. 

People believe passionately in their particular theory of weight loss and weight gain. Their passion is strangely out of all proportion with the actual level of confidence that you could attach to intent to treat estimates. That is, if you think the problem is seed oils, is this the same as making a concrete prediction that everyone who cuts seed oils from their diet by, say, 90%, and makes no other changes, will obtain and maintain a healthy BMI? I mean, it would probably help, at least a little. But that's not the same thing. Notably, they believe this much more passionately than for things where knowledge is straightforward. Nobody is passionate about vitamin C being a cure for scurvy. Hell, nobody is even especially passionate about whether Ozempic tends to produce weight loss, because it does. This is just boring, ordinary knowledge. But why everyone got fat in the first place? The honest assessment, that we just don't really know, is the one you are perhaps least likely to hear. 

So here we are. In these strange times, to admit to this plight, is to have some sympathy for the Carthaginians. Nature abhors a causality vacuum. It is more comforting to sacrifice some children to the gods to try to bring rain, than it is to sit there powerless, day after day, not doing anything, not able to even really know what you should be doing. 

For now, Ozempic has been a small light at the end of the tunnel. Once better drugs get invented, and it perhaps gets fully solved, it might eventually just be a subject of later academic or historical interest as to what it was all about in the first place, rather like what caused the decline of the Roman empire. In the shorter term, if we do find out the answer, the people so strongly clinging to this or that theory of diet will forget that they ever did so. Cognitive dissonance is strange like that.

In other words, your likely bewilderment looking at photos and videos of us is matched only by our own bewilderment in looking at ourselves. It is a strange time, but alas, we have no other. 

Anyway, I hope to write some more of these soon. Life is busy, not least from looking after your grandparent and great uncle or aunt. 

With all my love, 

[Shylock] 

The Covid19 death rate is higher than 2%

I understand why Moldbug wanted to write a post on the coronavirus. As usual, Moldbug was ahead of the curve. The reason is that he reads sources that other people don’t read. If you read the same as everyone else, you think the same as everyone else. This is the main (respectable) reason I’m on twitter, (other than the shitposting which is like terrible cheap carbs of reading material). 95% of it is garbage, but the remaining 5% is stuff you just don’t find anywhere else.

And what Moldbug, and MorlockP, and Loki Julianus and some others have figured out is that there’s a decent chance that this is the start of the shit hitting the fan, but nobody in the west seems much concerned yet. It’s a fascinating insight into how people respond to gradually unfolding disaster. We expect disaster to strike out of the blue. One day, the Soviets nuke us, or an asteroid strikes. Or, failing that, we expect to see a fairly rapid and linear growth of things getting worse, like in a disaster movie where the plot has to unfold in a predictable manner to all be wrapped up in 90 minutes.

What our instincts don’t work well for, however, is exponential growth. It just doesn’t fit people’s casual intuitions about what’s going to happen. The probably mythical story about the inventor of chess is that he asked to be paid as a reward by the king in a grain of rice for the first square, two grains for the second square, four for the third square, and so on. Of course, the point of the story is that the king was an idiot and by the end figured out he couldn’t possible pay. Ha ha ha. Nobody would be that dumb.

Well, here’s some grains of rice accumulating.

If you take the number of coronavirus cases reported, it’s close to an exponential curve. Not quite, however. If you plot things on a log scale, you can see the rate of increase in reported cases slowing down.

By eyeballing the log scale graph, you can see that things started to decline starting around Jan 30^th. If you run a regression of log number of cases on number of days since outbreak, from Jan 30^th until February 13^th, you get a coefficient on time of 0.126, or e^0.126= 13.4% growth per day. If you want to be conservative, and just use the February 5^th – 11^th data, excluding the big jump on February 12^th when they changed reporting standards, you still get an average growth of e^0.078, or 8.1% growth per day. The R2 of this regression is 0.98, by the way, so this is a shockingly good fit. If you use the whole period, you get a whopping e^0.199=22.0% average growth per day. And even with the slowdown, the R2 is still over 0.92.

Since these are only rough data, because God knows how many unreported cases there are, suppose the number of cases is growing about 10% per day. There’s a rule of thumb for turning growth rates into doubling times called the rule of 72. Divide 72 by the growth rate and you get a decent estimate of the doubling time. So in this case, 72/10 = 7.2. In other words, on current trends we expect the number of cases to double every week. Even at the low rate of 7.8%, the number of cases is expected to double in around 9 days. We won’t use this rule exactly, but it’s pretty good for thinking about intuition.

And this causes all sorts of weird mistakes. One, which I think is underappreciated by most people, is wildly distorted estimates of the death rate.

The number that keeps getting currently quoted in the press is a death rate of around 2%. As of February 13th, there have been 1,384 deaths out of 64,473 cases, according to worldometer. This gives a death rate of 2.15%. Which sounds pretty encouraging. It seems like you have to get very unlucky to actually die from it.

But the strange thing is, there’s another, smaller set of people talking about a death rate of 16%. What’s that? Well, it’s the ratio of deaths (1,384) to closed cases (8,566), or 16.16%.

Now, you might look at it be concerned about the definition of closed cases. Maybe they’re just very reluctant to declare someone cured, so there’s lowball numbers here (whereas they’re less reluctant to declare someone dead). Many of the diagnosed will eventually recover, but it takes ages to classify them as healthy again. So no big deal! 16% is too high, and the true number will be much lower.

Well, here’s a pretty strong reason to prefer the ratio using closed cases. From the descriptions you read about the progression of cases in places like Hong Kong, the disease generally takes 2-3 weeks from diagnosis to actually kill you.

Why is this a big deal?

Because the number of cases is growing at around 8-10% a day. And as long as that holds, the number of deaths will always be lagging the total number of cases in the growth phase. The death rate actually ought to be compared with the number of cases from 2-3 weeks earlier, because that’s the number of people who could have reasonably died by this point. It’s also the expectation of the fraction of currently alive new cases who will eventually die. Again, this may seem like pedantry. Except that the number of cases is growing 8% per day!

Let’s start with lower bounds. Assume that average growth in cases is conservatively 7.8%. Also, let’s assume the disease kills you quickly, on average in two weeks (which is optimistic for the purposes of our estimated death rate being on the low side). In this case, the number of cases in the denominator is too high by a factor of e^(14*0.078) = 2.98. So the true death rate will end up being 2.15*2.98 = 6.42%

If it takes 2.5 weeks on average to kill you, the death rate will end up being 2.15* e^(17.5*0.078) = 8.43%.

But we’re using a pretty conservative estimate of growth rates. Suppose you take dates since February 5^th, but include the increase in cases on Feb 12^th and 13^th. Then the average growth rate is 9.75%. Add a 2.5 week average time to death, and the death rate is actually 2.15*e^(17.5*0.0975) = 11.85%. If the disease takes three weeks on average to kill you, the true death rate is 16.67%. Which sounds very close to the death rate from closed cases. Add in growth rates from the earlier period, and the numbers get even higher.

Plug in your own assumptions or data fiddling, and the answers fall right out. There’s obviously big standard errors on this stuff. But one thing is pretty clear. There is more than enough evidence at this point, no matter how you cut it, that the overall death rate is going to be a lot higher than 2%. I’m betting on 5-10%. You ought to be making plans accordingly.

This doesn’t tell you about the rate of transmission, of course, either in China or the US. Maybe we’ll lucky, and it won’t turn into a pandemic outside China. Want to bet on that?

The good news from all this is that most people don’t care about China, haven’t read reports of any major outbreak in the US, and so aren’t really concerned. Which means that if you do think that there’s a non-trivial chance that the porridge may totally hit the propeller in a month or two, it’s still relatively easy to buy at least several months of storable food supplies. Amazon will still deliver them in a few days. Prices will be the same as normal. The guy delivering them has a very low chance of having the coronavirus. Maybe those things will still be true in three months. Maybe they won’t.

For the sake of a few hundred bucks, you’d be mad not to. You want to have a viable strategy in place to be able to not leave your house for an extended period of time. This is just basic finance. You want to hedge left tail outcomes, especially if the outcome is a catastrophe, and the cost of hedging it is very cheap. Surely everyone who understands finance is doing this, right?

Ha ha, no, of course they’re not. We’ve ignored the largest reason smart people don’t do this stuff. It’s unfashionable. It’s for loser, tin foil prepper types. Do you really want to be doing this stuff? Tell your friends you’ve started buying large quantities of canned food and you think they should too, and they’ll look at you like you’re a conspiracy theory loon. They’ll have a good laugh.

So did the King, when they were only up to the fourth chess square.

Lies, Damn Lies, and STD Risk Statistics, Part 2

Continued from Part 1.

If you've just joined us, we're giving a good fisking to the Mayo Clinic's worthless list of STD risk factors, namely:

Having unprotected sex. 
Having sexual contact with multiple partners. 
Abusing alcohol or using recreational drugs. 
Injecting drugs. 
Being an adolescent female 

The biggest proof that their advice is completely worthless comes from the full description of the first point, 'having unprotected sex'. At a very minimum, they don't make the most minimal distinction between vaginal, anal and oral intercourse. But even within that, the whole thing is basically a ridiculous scare campaign:

Vaginal or anal penetration by an infected partner who is not wearing a latex condom transmits some diseases with particular efficiency. Without a condom, a man who has gonorrhea has a 70 to 80 percent chance of infecting his female partner in a single act of vaginal intercourse. Improper or inconsistent use of condoms can also increase your risk. Oral sex is less risky but may still transmit infection without a latex condom or dental dam. Dental dams — thin, square pieces of rubber made with latex or silicone — prevent skin-to-skin contact.

This one I know is in the 'deliberately misleading to fool the public' category. You know why? Because they use the weasel words 'some diseases'. They then back it up with the gonorrhea example, where one-off unprotected vaginal transmission rates are high. But people don't generally stay up late at night freaking out about getting gonorrhea, do they? As a matter fact, you don't hear about it much, because it can be treated with antibiotics. What people actually worry about the most is HIV. Why not tell them about that instead?

So what are the chances of HIV transmission from unprotected vaginal intercourse with someone who is HIV positive? This is such a classic that I want to put the answer (and the rest of the post, which gets even more awesome by the way, though you may not believe it's possible) below the jump. Suppose a man and a woman have unprotected vaginal intercourse once. 

a) If the man is HIV positive, what is the chance the women contracts HIV?

b) If the woman is HIV positive, what is the chance the man contracts HIV?

Lies, Damn Lies, and STD Risk Statistics, Part 1

Every time I read anything about STD risks, I tend to get mightily annoyed at how difficult it is to get any useful information from the medical profession, at least in the popular press, about the actual magnitude of different types of risks. I remember talking about this problem in the case of cancer risks and smoking. Smoking causes cancer, living under power lines causes cancer, and eating burnt steak causes cancer, but they do not all cause cancer at anything like the same rate. Same thing with STDs. I sometimes find it hard to tell how much of this is because the people writing it are morons when it comes to causal inference, and how much is due to them knowing the right answer but spinning nonsense for public consumption, assuming that everyone is a child unable to make their own risk assessments. 

Let's hear from the Mayo Clinic, they're a famous hospital, surely they'll have top quality medical advice about what big ticket items to avoid. And their list of risk factors is ...(drumroll).... :

Having unprotected sex.
Having sexual contact with multiple partners.
Abusing alcohol or using recreational drugs.
Injecting drugs.
Being an adolescent female

Seriously. 

The first thing you know is that what people mostly want to know are estimated treatment effects of particular actions. If I do X, my chance of an infection go up by Y%. Instead, what you get are a mish-mash of treatment effects, correlations with prevalence, correlations with transmission rates, and absolutely nothing on relative magnitudes, all leading to answers that are just laughable.

'Abusing alcohol or using recreational drugs' is hilariously stupid, because it doesn't map to anything directly. It could be correlation, it could be treatment, it could be both, who knows. They explain it as if it's mostly a treatment effect - "Substance abuse can inhibit your judgment, making you more willing to participate in risky behaviors.". In other words, the whole of their advice is that once you're drunk, you might do other stupid stuff. So just list that stuff! Of course, there's a strong correlation between people who get drunk all the time and people who do other stupid things. At a minimum, any treatment effects are going to be wildly heterogeneous. I'm pretty sure if your Aunty Gladys has a few too many sneaky shandies, the increase in her STD risk is zero. If you're a normally sensible person and you get drunk once, the chance of you picking up an STD are similarly low, because I'm guessing that most people will be unlikely to rush out and have anal sex with strangers just because they got drunk, though obviously some will. Most of the effect that makes this a risk factor has to be straight correlation with omitted factors, namely a tendency for reckless and risky behaviour. This is marginally actionable, if it tells you to avoid sleeping with perpetual drunks, but that's about it.

'Being an adolescent female' is even more stupid. The actionable interpretation of the previous statement was that perhaps we were being given correlations with overall prevalence. But how the hell do you interpret this one then? Do you really think that 'adolescent females' have high STD rates? Of course not. They may have higher transmission rates of certain diseases relating to cervical cancer, but this is a very different proposition. In what sane ordering is this among the five biggest STD risks for the general population to worry about? What adolescent females do have is a high rate of unplanned pregnancies, and it would be greatly in their interest to start using condoms regularly. So just say that! Stop trying to sell us a bunch of bull$#!& about how they also have massively high STD risks.

Since this post is already turning into a monster, I'll be back with Part 2 in a few days.

The Benefits of Having Smoked

Back when I was in high school, it seemed important to do something cool to get rid of my nerd image. In the fertile logic of the teenage mind, the obvious answer was to take up smoking. My older sister smoked at the time, so clearly this was a good decision.

None of my friends were interested in joining, and lacking any social aspect it was never particularly enjoyable. This was especially so given that I never really liked it much - I enjoyed blowing smoke (The Couch: You still do, actually), especially smoke rings, but the actual inhalation part was never that pleasant. So the whole process went as follows:  *puff*...This is so stupid ...*drag*... *puff*... This is probably giving me cancer... etc.

As you can imagine, this phase lasted about 3 months before the absurdity finally became too much - I had to not smoke for a week on a chemistry trip (yes, really), and I never bothered restarting when I came back.

Let's take it as given that I'm deeply glad that I gave up when I did.

Yet strangely enough, I'm actually glad that I smoked a little bit. And the reason is that it left me with a vague appreciation for the smell of cigarette smoke. I find it somewhat pleasant. Not in every situation, of course, and definitely not when you smell it on your clothes after a night out at a smoking venue. But if I walk past someone who is smoking, it doesn't cause me any discomfort, and sometimes smells quite nice.

I never used to have this feeling before I smoked - I just had the classic non-smoker's reaction of instant revulsion. 3 months, however, is sufficient to give you an appreciation for it.

Which is nice, because in life you're going to come across people smoking, and it's a relief to not be bothered by it. Otherwise you might end up like one of those unbearable busybodies, noisily complaining every time someone nearby is smoking. "Can you please not smoke around my child?", you'll hear them ask. I always thought an appropriate response would be "Well, I was here first, lady. Can you please not disrupt my smoking break with your bratty child?"

If you want to see how much the anti-smoking brigade has descended into a joyless, liberal scolding parody of itself, look at the reaction to e-cigarettes. They're basically a cigarette that doesn't cause the vast majority of the nasty health side effects. So celebrate! Except the anti-smoking brigade doesn't. Because, you know, kids might start smoking e-cigarettes, and then decide that they really want cancer as well as nicotine and so now start on the real thing. Despite the fact that the vast majority of substitution is likely to be away from real smoking towards e-cigarettes, not away from nothing towards e-cigarettes (as Slate Star Codex pointed out ).

I find myself siding with the smokers most of the time. The world would be better off if fewer people smoked, but most of the anti-smoking movement is just status signalling against a dis-favored group.

The fastest way to irritate anti-smoking types is to tell them "I'm a big supporter of taxes on cigarettes, because they're a heavily regressive tax. Not only is it the same dollar amount per pack for rich and poor, but since poor people smoke more than rich people, we're clawing more money out of the poor. Which I like, because our tax system is far too progressive."

Let's Eliminate Salmonella. No, wait, let's not.

Over at Hacker News, there was a link to this great Forbes article talking about the differences in regulation in the treatment of eggs. Apparently in the US, eggs are forced to be washed, while in the EU eggs are forced to not be washed. This also relates to the fact that US eggs are stored in the fridge, while EU eggs tend to be left at room temperature.

The whole thing is presented as a kind of 'duelling regulations' thing - in the end, it looks like there's odd biological reasons why being washed or not can impact how you choose to store them, and the chances of disease.

And then, buried at the end of page three, comes this gem:

Since the late 1990’s British farmers have been vaccinating hens against salmonella following a crisis that sickened thousands of people who had consumed infected eggs. Amazingly, this measure has virtually wiped out the health threat in Britain. In 1997, there were 14,771 reported cases of salmonella poisoning there, by 2009 this had dropped to just 581 cases. About 90 percent of British eggs now come from vaccinated hens – it’s required for producers who want to belong to the Lion scheme. The remaining 10 percent come from very small farmers who don’t sell to major retailers.

In contrast, there is no such requirement for commercial hens in the US. Consequently, according to FDA data, there are about 142,000 illnesses every year caused by consuming eggs contaminated by the most common strain of salmonella. Only about one-third of farmers here choose to inoculate their flocks. Farmers cite cost as the main reason not to opt for vaccination –FDA estimates say it would cost about 14 cents a bird. The average hen produces about 260 eggs over the course of her lifetime.

Wait, what? You mean that for 0.05 cents per egg, you can virtually eliminate salmonella poisoning? And this isn't being done in the US, because US farmers have correctly estimated that ignorant consumers aren't savvy enough to insist on this purchase?

Talk about burying the lead.

Wow. That sounds pretty outrageous. I read this piece, and my instinct was the think that the British policy of vaccinating hens sounds like a no-brainer.

But then again, we wouldn't be economists if we didn't shut up and multiply.

Let's assume that the entire reduction in salmonella comes from this policy:  14,771 - 581 = 14,190 cases of salmonella avoided by vaccinating hens.

The cost per egg as we noted is 0.05 cents (14 cents per hen, divided by 260 eggs per hen).

So how many eggs are consumed in Britain each year?

According to this estimate, almost 11 billion. That sounds ridiculously large, until you realise that with a population of 63.182 million, this amounts to a consumption of 174 eggs per person per year, or roughly one egg every two days.

Let's go with that number.

So the total cost of the policy each year is thus roughly 11,000,000,000 *$0.14/260 = $592 million.

This implies a shadow cost of each case of Salmonella equal to ($592 million / 14,190), or $41,741.

Put that way, it seems like more of an arguable proposition. Maybe we should cancel the policy?

Not so fast! Do you know how much weight I should place on your hunch about the value of salmonella? Zero! Shut up and keep multiplying!

According to this PubMed article there were 1316 salmonella-related deaths between 1990 and 2006. The paper abstract reports the mortality per person-year, but what we want to know is the mortality per salmonella case. According to the original article, there are about 142,000 salmonella cases per year in the US. Assuming a constant number of infections over the years, this gives us a probability of death conditional on salmonella poisoning of 1316/(142,000*17) = 0.000545. Using a statistical value of human life of about $7 million, this gives an expected mortality cost per salmonella case of $3816.

Do you value the pain and suffering of a non-fatal case of salmonella at $37,925? I sure don't. If you paid me 38 grand and guaranteed it wouldn't kill me, I'd be pretty keen to sign up for a case of salmonella.

Put differently, the implied cost of human life in the salmonella reduction program is ($41,741 / 0.000545) = $76.57 million, ignoring any value placed on pain and suffering for non-lethal cases.

In other words, despite the intuitive appeal of getting rid of salmonella just by vaccinating chickens, as a society we'd probably be better off spending the money on road safety, medical research, or something else with a lower cost of saving each life.

The interesting thing is that when I started out writing this blog post, my initial reaction was that it was amazing that the US wasn't requiring chicken vaccinations, and the hard numbers changed my mind.

Sometimes the best treatment is to do nothing. Long live NPV!

How to find a primary care physician in America

Step 1. Go to websites like Healthgrades or RateMDs and check out the ratings of doctors in your area

Step 2. Read through the reviews, try to decipher which ones are bogus. Decide that the doctors that score well must at least be doing a good internet reputation management system, and hey, isn't that a sign that they care?

Step 3. Read through some of the profiles and figure out that the ratings are based on junk like 'he's a really nice guy' and 'he spends time with me', and if you're lucky maybe one review complaining about a specific misdiagnosis. This lets you identify some doctors that suck, leaving you with the 'all 5 star possibly bogus reviews' guys.

Step 4. Figure out that in fact the far more useful information is the quality of the medical school they went to and the quality of the hospital they interned at. There is, of course, no way to filter by this information.

Step 5. Settle on some guy that looks good based on your really half-assed search criteria of 'went to a medical school I've heard of' and 'well-rated on both websites'. Call up to make an appointment, get told he's not taking new patients.

Step 6-12. Go down the eligibility list repeating this procedure for successively less desirable doctors. Begin to realise that most of the best doctors are closed to new patients, and that the accuracy of the 'Accepting New Patients' checkbox on the website is no more than 50%. In a few lucky cases, you'll get a doctor who is accepting new patients, but the earliest appointment for a new patient is in 6 weeks time. This is less helpful if you happen to be in need of medical care, you know, now.

Step 13. Call up one of the reception desks at a place you'd previously been refused and ask when the earliest new patient appointment is if you don't care who the doctor is. Realise from the receptionist's reply that the vast number of places do not apparently have appointment management software that can actually answer that question easily, even for the doctors within their own practice.

Step 14. Using a repetition of the procedure in step 13, reach a receptionist who actually doesn't even bother to check the calendar but instead refers you to a doctor in another practice. A quick search reveals that the internet knows virtually nothing about this person or the quality of her care, except that the dates on her profile make it clear that she's only recently moved to this state, and hence doesn't have many patients.

Step 15. Make an appointment with Sally Random, MD, for two days time.

Step 16. Start thinking whether you want to make a 6 weeks time appointment with one of the better doctors for a general checkup or some junk just to get on the 'current patients' list. Decide to put it off until you find out just how bad Sally Random, MD, actually is.

Step 17. Finally figure out why everyone just goes to emergency rooms or urgent care places for medical treatment, or, in the case of my friend, only calls up specialists directly, since they actually have appointments available.

Update: Step 18. Double check on Sally Random, find out her medical degree is from some place in the Caribbean. Decide this is unacceptable, start going through the list of doctors in the medical group you're examining and just reference their medical school with lists of rankings of medical schools. Hate life.

The Obamacare Ruling, Part 1

So I'm about half way through the Obamacare ruling - so far, I've gotten through the Roberts opinion and the Ginsburg opinion. My thoughts on the relative merits of the cases may change when I read through the dissenters.

A couple of thoughts on what I've read so far.

First, there is a marked contrast in how much the different opinions seem to opine on the merits of the law. Here's Roberts take, at page 59 of the PDF:

The Framers created a Federal Government of limited powers, and assigned to this  Court the duty of enforcing those limits. The Court does so today. But the Court does not express any opinion on the wisdom of the Affordable Care Act.  Under the Constitution, that judgment is reserved to the people.

By contrast, Ginsburg's opinions have an irritating habit of inserting thinly disguised editorialising about her support of the laws in question as a matter of policy. From page 74 of the PDF:

To make its chosen approach work, however, Congress had to use some new tools, including a requirement that most individuals obtain private health insurance coverage. See 26 U. S. C. §5000A (2006 ed., Supp. IV) (the minimum coverage provision). As explained below, by employing these tools, Congress was able to achieve a practical, altogether reasonable, solution.

I guess she didn't get the Roberts memo about not expressing any opinions on the wisdom of the legislation.

Here's Ginsburg, dishonestly repeating one of the classic talking points of the left about healthcare, from page 70 of the PDF:

Not all U. S. residents, however, have health insurance. In 2009, approximately 50 million people were uninsured, either by choice or, more likely, because they could not afford private insurance and did not qualify for government aid.

The Census estimate was 46 million, but what's a few million between friends. And out of this number,  (by the Politifact estimate) at least 15% of those 'residents' don't have health insurance because they're illegal aliens who shouldn't be in the country in the first place. To describe their problem as being one of 'not qualifying for government aid' is deliberately disingenuous.

But what is most egregious about the Ginsburg opinion is the reliance it makes on the free-rider problem.This is an important part of her argument justifying the law under the Interstate Commerce Clause. The individual mandate is justified as being 'necessary and proper' for regulating interstate commerce. There's a long argument starting on page 70 of the pdf, which I won't reprint in full, but the gist of it is that you can't force insurers to cover people with pre-existing conditions at the same price as everyone else without the individual mandate. This is because guaranteeing that pre-existing conditions will be covered at no extra cost creates an incentive for people to wait until they get an expensive illness, and only buy insurance then. This causes huge cost-shifting in the insurance market, and threatens to make the whole thing collapse. It's a classic free-rider, or moral hazard, problem.

Ginsburg's description of this problem, as a matter of economics, is really quite good, and I don't have much to quibble about there.

But why is this a social issue? Can't the hospital just deny them treatment? That may be considered unfair, but it's a pretty damn effective solution to the free-rider problem. And here's where Ginsburg's argument comes in:

The large number of individuals without health insurance, Congress found, heavily burdens the national health-care market. See 42 U. S. C. §18091(2).  As just noted, the cost of emergency care or treatment for a serious illness generally exceeds what an individual can afford to pay on her own. Unlike markets for most products, however, the inability to pay for care does not mean that an uninsured individual will receive no care. Federal and state law, as well as professional obligations and embedded social norms, require hospitals and physicians to provide care when it is most needed, regardless of the patient’s ability to pay.

Let's reprint the key bits again, in case you missed them:

Federal and state law, as well as professional obligations and embedded social norms, require hospitals and physicians to provide care when it is most needed, regardless of the patient’s ability to pay.

Got that? Federal Law has created a free-rider problem in this market, and now it requires a solution.

Now, as a practical description of the problem, that's totally fine. It is, indeed, the root of a lot of the problems.

But as a constitutional justification for the law, this is insane.

The government wouldn't ordinarily be able to compel individuals to purchase something under the interstate commerce clause, as I read the Ginsburg opinion, unless this is 'necessary and proper' to some already constitutional purpose.

No problem! The government passes laws that create a free-rider problem. One solution (not the only solution, but who cares!) to the problem is to mandate a pool of customers to subsidise those that you've legislated to ride for free. And the existence the government-created free-rider problem is used as the constitutional basis for justifying the entire edifice.

Don't believe me? Listen to Ginsburg's description of why it would be absurd to suggest that the government might be able to create a mandate for eating broccoli:

Consider the chain of inferences the Court would have to accept to conclude that a vegetable-purchase mandate was likely to have a substantial effect on the health-care costs borne by lithe Americans. The Court would have to believe that individuals forced to buy vegetables would then eat them (instead of throwing or giving them away), would prepare the vegetables in a healthy way (steamed or raw, not deep-fried), would cut back on unhealthy foods, and would not allow other factors (such as lack of exercise or little sleep) to trump the improved diet.  Such “pil[ing of] inference upon inference” is just what the Court re­fused to do in Lopez and Morrison. 

I don't know whether this argument is presented as deliberately misleading bull#$%^, or just very sloppy thinking. This is what the government would have to do to justify a broccoli mandate under the guise of it reducing healthcare costs.

But suppose that a government wanted you to eat broccoli. Justice Ginsburg has created a far simpler method for them to justify it! Just pass a 'Broccoli Human Rights Act of 2014', requiring that no person shall be denied broccoli by any supermarket or store based on their inability to pay, provided that they can prove that they are sufficiently hungry. There's a real problem - some people go hungry. Broccoli is a good solution to that problem. Presto! Our starving poor now have access to broccoli.

But we've now created a terrible free-rider problem. Broccoli-sellers have started to lose tons of money. One might characterise the problem as being that 'Federal and State Law, as well as professional and social obligations to not let people starve to death, require stores to provide broccoli when it is most needed, regardless of the customer's ability to pay'. One solution to this is the Affordable Broccoli Food Act of 2020, with it's Broccoli Individual Mandate component.

And this is exactly the same logic that Ginsburg found so compelling above. She'd pass it here. She'd pass it there. She'd pass that legislation anywhere.

So what are the other limits on the likely existence of the Broccoli mandate under the Ginsburg reasoning?

Other provisions of the Constitution also check congressional overreaching. A mandate to purchase a particular product would be unconstitutional if, for example, the edict impermissibly abridged the freedom of speech, interfered with the free exercise of religion, or infringed on a liberty interest protected by the Due Process Clause. 

At last we've gotten an honest argument. Legislation justified under the interstate Commerce clause will be struck down if it's explicitly prohibited elsewhere.

You can tell me this is a good way of running a government. But don't tell me that this is still a Federal government of enumerated powers. Everything that is not prohibited is permitted.

Fortunately, this is not the current law of the land on the Interstate Commerce clause. (The law was upheld under the taxing authority, which I might get to in part 2). Unfortunately I fear that Justice Ginsburg will prove spot on in one assessment in particular, though:

THE CHIEF JUSTICE’s crabbed reading of the Commerce Clause harks back to the era in which the Court routinely thwarted Congress’ efforts to regulate the national economy in the interest of those who labor to sustain it.  See,  e.g., Railroad Retirement Bd. v.  Alton R. Co., 295 U. S. 330, 362, 368 (1935) (invalidating compulsory retirement and pension plan for employees of carriers subject to the Inter­state Commerce Act; Court found law related essentially “to the social welfare of the worker, and therefore remote from any regulation of commerce as such”).  It is a reading that should not have staying power. 

Absolutely.

For one reason, because the vast majority of interstate commerce clause decisions they've made in the past have gone in this direction. 'Regulating Interstate Commerce' includes banning marijuana that's grown in one state and sold within the state, regulating swimming pools (which are pretty darn hard to transport across state lines once they're in the ground), and stopping a farmer growing too much wheat on his own property for his own farm use.

The only rule I can glean from their precedents before now is 'If it affects a price of something, somewhere, somehow, it's interstate commerce.' Now the court has said that, in theory, it won't keep going in this direction, even though it didn't have the stones to overturn the law in the end.

But let's get back to the quote itself. The other half of the problem is that a good chunk of the Court thinks that it is appropriate to put in an important and widely-read opinion that it feels that New Deal legislation was 'efforts to regulate the national economy in the interest of those who labor to sustain it'.

Just under half the court think that this is what constitutes being non-partisan, and they usually manage to find a swing voter from among the rest, I suspect her assessment will prove entirely correct.

Crass consumerism wins again

An Oregon environmentalist decides to save the planet with reusable shopping bags instead of disposable plastic bags.

They instead end up giving seven girls on their daughter's soccer team the norovirus, which they got from eating cookies contaminated with said virus from the bag.

If the outbreak were limited to the parents who provided the bag, I could chug down a gallon of tasty schadenfreude without blinking, but unfortunately modish lefty causes tend to have negative externalities. (I know, right! Who could have seen that coming?)

The article is too polite to point out that the norovirus comes from 'fecal-oral contact'.

In other words, the bag was covered in someone's poo. Saving the environment one day, pooing on a cookie and offering it to your children the next!

What lesson can we learn from this?

"What this report does is it helps raise awareness of the complex and indirect way that norovirus can spread," said Aron Hall, an epidemiologist with the Division of Viral Diseases at the Centers for Disease Control and Prevention.

His agency says the best way to fend off the virus is thorough hand-washing and cleaning contaminated surfaces with a bleach-based solution.

Lame.

Or, you could learn that it's not sufficient to avoid reusable shopping bags, you also need to avoid the children of trendy parents who are too busy reusing shopping bags to wash their hands after going to the toilet.

Enjoy your norovirus, hippies!

54% of UK doctors are either pig-ignorant about statistics and/or meddling nanny-state fools

At some point, the incremental loss of liberty in Britain becomes such a constant depressing dripping that it's hard to maintain the incredulity. 

On the one hand, the police harassed a gallery that displayed a photograph of a sculpture that depicted a mythical scene from Greek antiquity, because they thought it might "promote bestiality". (No, really). Despite the fact that nobody had complained about the photo. That's a separate outrage post all of its own.

On the other hand, the Daily Mail cites a recent UK study where 54% of doctors agreed that the NHS should " be allowed to refuse non-emergency treatments to patients unless they lose weight or stop smoking".

Those god damn smug condescending prats.

If a doctor refused to treat the injuries of a drunk driver at a hospital and let him bleed out on the floor, we'd label him as a monster. And drunk driving has way, way bigger costs to other members of society than smoking does.

In the first place, the size of the true effect of smoking on health is hard to measure. The chances of you dying of lung cancer given you smoke seem to be only around 0.3%. More importantly, very few people seem to have any real sense of magnitudes when considering the question of exactly how harmful things like smoking are.

But let's give the doctors the benefit of the doubt, and assume they know the risks perfectly. 

What exactly is the principle at stake here? Is it:

a) You shouldn't get treatment if the actions were your fault.

b) You shouldn't get treatment if your actions cost the government too much money

c) You shouldn't get treatment if you're an unfavored group.

The first one is a ridiculous way to run a health care system. All of us take risks in things we do all the time. Driving 5 miles an hour over the limit? Increases your risk of death. Take part in an equestrian event? Increases your risk of death. Fail to eat only lentils and beans to minimize your chances of heart disease? Increases your risk of death. Go out drinking at a pub in Covent Garden on a Saturday night? Increases your risk of death, by stabbing or road accident if nothing else.

Where the hell does it end? The reality is that everyone is going to die at some point or other. Actions that you take might make it happen earlier or later, but there's no escaping it. Any test on this point is going to end up transforming into test c) - some risks are deemed politically acceptable, and others aren't.

The second test is actually a fair basis for running a healthcare system (assuming you buy the assumption that it's the government's business to be doing that in the first place, which I don't necessarily). But does it really apply here? It's pretty damn hard to tell, because it depends a lot on how much stuff you account for.

Suppose you die of heart disease that comes from smoking. Since heart disease kills a lot of non-smokers as well, it's not clear that the difference in treatment costs in nominal dollar terms are large, or even positive. It's not like this is a $10 million treatment for some rare disease - smokers die from heart disease and cancer, the same as everyone else, and treating these costs about the same as for everyone else. The cost does arrive sooner for smokers than non-smokers. This does mean that the present value of costs is higher, but it's not clear how large this difference is.

But what else happens? You don't claim the pension for thirty years, either. And based on a fair accounting for these two effects, it's not at all obvious that smokers on net cost the government more money. Absent healthcare costs, dropping dead right before the pension cheques are about to start is good news for the government budget.

So what's really going on here?

The answer is of course option c). Smokers and Fatties are today's out-of-favour social groups. Everyone loves shaming smokers, and nobody sticks up for their right to smoke, notwithstanding its bad effects on health.

Tax them! Make them stand out in the cold! Deny them medical care so they die quicker! When you see them huddled outside in the snow, tell them what a 'disgusting habit' it is, with as much condescension in your voice as you can muster! Feel smug and self-righteous about your own superior decisions!

*#$% THAT.

For some reason people's general sense of politeness in terms of not offering up gratuitous, unsolicited criticisms of people's personal choices that don't affect others seems to go out the window in the case of smoking. No level of hassling is too great. We'll badger them into health! Then when they get fat from giving up the smoking, we'll badger them into going jogging too.

Don't like smoking? Don't smoke. Otherwise, shut the hell up. They're adults. They know the risks. If they decide that they enjoy cigarettes enough that it justifies the reduction in life expectancy, that's their damn choice. 

Bathroom Floor Herd Immunity

I was in the gym with SMH and we'd adjourned to the locker rooms to shower.

SMH is American, and a fairly organised kind of fellow. As a result, he had his shower thongs (or flip flops, in the parlance of these lands).

I, on the other hand, manage to be chronically disorganised. It should thus come as no surprise to find out that despite meaning to do so for about 3 years, I still haven't bought a spare pair of thongs and put them in my gym bag.

Now, I lean towards the laissez faire attitude to hygiene. The human immune system is incredibly well suited towards things like touching bathroom door handles and toilet seats without collapsing in a quivering heap of bacterial infection. Most purported hygiene issues (outside a hospital or food handling setting) are largely just a feeling of ickiness masquerading as health concerns.

Boy howdy do Americans go crazy for bathroom hygiene. There is a shocking number of otherwise sensible people who literally will not touch a bathroom door handle, and will grab a paper towel to open the door because they're so paranoid. This even makes its way on to official instructions sometimes, like here. There doesn't seem to be much of a sense of historical perspective - back in the 60s, I'm pretty sure people weren't using paper towels to open doors (not least because paper towel wasn't that common). I'm also pretty sure they weren't dropping dead from bathroom-door-related infections either. Perhaps, just perhaps, all this craze for hand sanitisers and never touching any public surfaces is just modern man turning into a complete weenie.

Nonetheless, showers in gyms do run the risk of getting fungal infections. The floors tend to be always wet and slightly warm, and lots of feet are walking over them. So it probably is prudent to get a pair of thongs.

But despite 3 years of not wearing them and showering at this gym, I'd pretty much been fine.

And I finally figured out why.

Herd Immunity.

When enough people are vaccinated against a disease, it becomes hard for the disease to spread. As a result, people who don't get vaccinated get to free ride off the added group protection from those who do vaccinate.

And something similar happens with bathroom floors. In the US, the vast majority of people wear thongs to public showers. I'm quite sure this is due to the hygiene/gross-out combo, and not out of any sense of public-spiritedness. But the effect is the same - if there are very few people who aren't wearing thongs, there's very few people likely to be spreading around foot infections. And that means that it's actually pretty safe for free-riders like me to go without.

I'm like the Jenny McCarthy of the gym shower world, free to be recklessly stupid and indulgent thanks to everyone else's good decisions, meanwhile imposing a small negative externality on everyone else by my own actions.

It's just like Tom Petty sang:

And I'm Freeee
I'm Freeee Riiiiiddding.

Good times.