Back when Scott wrote at Slatestarcodex, enough people found the on-site commenting to be frustrating enough to set up a subreddit, and it became increasingly popular.
It was about as lacking in features as Substack comments, but at least the old comments could reach into the hundreds without struggling to load.
“ Regulatory Reciprocity: I will keep this one in here until somebody does something about it. It’s the idea that Americans should be allowed to buy medical products if they’ve been approved by some trusted ally, like the European Union, possibly in exchange for the EU giving FDA-approved products the same deal in Europe.”
Good luck with that. States don’t respect other states’ licenses of US trained physicians so do their own multi month process and health systems don’t trust state licensing as an indication of vetted training, requiring 3 months of their own vetting and confirmation process (credentialing). Have a hard time believing international regulation regimes have much of a shot.
I mean its a lot easier to be confident some drugs do what they say they do / aren't dangerous than to be confident that all medical professionals coming into your jurisdiction are up to your standards...
Why does it need to be reciprocal in the first place? We could just have way looser regulations and just automatically approve anything the EU approves. The EU doesn't need to approve our drugs in turn, because they absolutely shouldn't trust us anymore.
Because that would encourage biotech companies to focus entirely on the EU and ignore US regulations entirely. Likely physically relocating there and crippling the US medical research industry.
Make it "Americans should be allowed to buy medical products *with a prescription* if they’ve been approved by some trusted ally."
IMHO, while there are arguments that the FDA should have the power to deny people the right to have any drug they want, there are no good arguments why the FDA should have the power to prohibit doctors from prescribing drugs, even if the /aren't/ approved by some trusted ally. So this seems like a no-brainer to me.
>there are no good arguments why the FDA should have the power to prohibit doctors from prescribing drugs
Granting every individual expert the power of granting access to X is barely a safeguard. Before long word will get out which doctors will prescribe each drug and people will choose the doctors who will give them what they want. Also, this would incentivize doctors to relax their standards to get more paying patients
This is /already/ the situation we're in, for things much more hardcore than the median EU-but-not-US-approved antacid or whatever (what will be more nanny-state-unapproved than oxycodone, methamphetamine, ketamine, ...?), so it's hard to see the rationale for "one more drop in the bucket is toooo far!"
There is nothing I hate in all the world more than the fact that credentialism applies even to the decision as to what substances I am allowed to consume. What am I, a fucking toddler?
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(I know this is orthogonal to the thrust of your comment but to see it phrased so bluntly and blithely—as if /of course/ we'll need permission as to what we can eat, that goes without saying! ...and, unfortunately, it does—just scrapes at my soul)
I get it, there are quite a few cases where I'd like to be able to bypass doctors and think I could do a reasonably good job of it. But some drugs are very poisonous and some people are very stupid and as a society - not just doctors but everyone- we're totally unwilling to accept somewhere between hundreds and tens of thousands of people dying because they heard from a friend of a friend that Digoxin is really good for your skin tone or something. People just won't accept that- so the question is not whether we regulate, but how since regulation is a political inevitability.
Thalidomide is a case against it. 10,000-20,000 thalidomide babies were born according to Wikipedia. But we must weigh that against the number of people unable to buy drugs because they can't afford them, and the people unable to buy drugs because they were never made, because they couldn't be profitable.
Personally, I also weigh the fact that in my limited experience, the FDA approval process is worthless. I was studying the safety of long-term exposure to aspartame and saccharin in 2012 or so, and I read maybe 80 studies on aspartame done over a period of almost 50 years, about half of which said it was safe, & about half of which said it was terribly dangerous.
It was approved once in 1974, but this approval was revoked in 1975. It was approved again in 1981, just after Reagan was elected with the help of Searle CEO Donald Rumsfeld; there are suspicions this was political payback. In 1991 aspartame was linked to brain tumors, and it went thru another review process, and was finally approved in 1996.
I read the notes for the meeting at which it was approved. The committee had a large number of drugs to vote up or down in one meeting, and would have had about half an hour for each if they divided the time up equally. It was obvious that all they did was quote points from the conclusions of one review study of the safety data published shortly before that meeting. The study was so terrible and stupid--one of its arguments was that, sure, aspartame produces formaldehyde, but formaldehyde (they said) is not actually toxic to humans!--that I checked the biographies of the study's authors, and found that every one of them was employed by pharma companies with an interest in approving aspartame. The study did not mention this conflict of interest.
It makes me wonder how many of those babies would’ve been born. had that drug been approved for use in the United States. Still I take your point. I certainly won’t argue with you about it because I don’t have enough knowledge. I’ve heard some pretty crappy things about the FDA
It's very weird that 1) there are things that you CANNOT have access to, unless they are prescribed by a doctor; and 2) once a doctor has made it through any medical school and doctor process, they can prescribe whatever, with zero or no checking if it is necessary, more or less forever; and you can find such a doctor to prescribe you, say, a diabetes drug even though you don't have diabetes, for enough cash.
This was basically the process for my getting a prescription for regulated ADHD drugs: "Do you have ADHD?" "Um, well, I'm not a doctor, I guess I have trouble focusing sometimes..." "You have ADHD. Here's your prescription." Total conversation: 15 mins, total cost $350
I think the reason for having a lot of medications restricted to "must be prescribed by a doctor, any doctor, we aren't fussy" is to screen out hypochondriacs and people who a five-minute conversation will reveal do NOT actually have a need for the medication.
Every year, people die because of forgetting fairly basic stuff like "you really really shouldn't take Tylenol and drink alcohol at the same time." There are a lot of medications with side-effects much more complicated than this, or which need to be taken on very precise time schedules, or in conjunction with obscure secondary medications. We could abandon the requirement for prescriptions and just say "caveat emptor," but the guy saying "caveat emptor" probably isn't going to have to bury all the dead bodies.
Every year, millions of people blow thousands of dollars each on totally useless 'supplements' and random placebos like homeopathic medicines, because it's legal to talk people into spending a ton of money on pseudo-medicine that does nothing. If pharmaceutical companies, which in the US can already advertise direct to clients, could also SELL their products directly to clients without a prescription, then they'd be able to get into that market too, and a gullible person's money spent on medicine they absolutely don't need is going to spend just as well as the money of someone who does need the medicine.
Every year, tons of people mis-diagnose their own health complaints or decide they don't have problems they really do have. Every year people think "gee, I could get access to amphetamines if only I could convince someone I have a condition that makes it necessary." Every year people think "gee, some of these real medications would make great precursors for illegal drugs if only I could find them!"
The point isn't to make it super-duper-difficult to get medicine, it's that the combination of cost and risk that goes with a lot of medications is high enough that it would be very reckless for a society to just say "you can get literally any medicine you want and can pay for." If nothing else, health insurance companies would probably start shutting down their pharmacy plans immediately, to avoid being bankrupted by random superfluous spelling.
Licensing is not about distrusting the standards of other jurisdictions, though that's often the reason given; it's about people limiting their competition so they can reap the benefits of protection. It doesn't seem to me that reciprocity of drug approval would face the same hurdles, ie special interest groups wanting to maintain protective barriers against labor competition
This just strikes me as part of libertarianism. We should mostly just let the people involved (buying the drugs/ thing) decide what to do. But with some guard rails. Letting US residents buy get drugs from Canada or the EU, makes total sense to me.
NIH grants $48B/yr with no meaningful oversight of the quality and integrity of research data or the processes and systems labs use. We know how to do this - witness the Toyota Production System or the transformation in software quality due to Agile/DevOps. It’s time for a SciOps revolution. And it’s time to start auditing data and process quality in labs receiving public funds.
So the NIH is going to put boots on the ground in every wet lab across American's R1 universities? Come on, this is absurd. Within a rounding error, nobody at NIH even knows what "quality" research looks like in a particular subdiscipline: that's why they convene study sections.
"Everyone knows the solution - compensating organ donors"
Being a wet blanket again, the solution isn't totally without its own problems. America compensates blood donors and this provides plasma for commercial treatment into useful products, both at home and abroad.
That's lovely. Until the commercial products use contaminated blood from people who desperately need money and are reduced to selling body parts for quick cash, and those contaminated blood products infect vulnerable people overseas:
Ireland (we've actually had *two* contaminated blood scandals, this is the one involving imported products):
"The Lindsay tribunal set up in 2000 examined the contamination of Factor 8 products used by men with haemophilia which were contaminated with HIV and hepatitis C.
The tribunal heard how home-produced blood clotting agent caused infection in seven haemophiliacs despite earlier claims that it was safe.
Evidence to the tribunal revealed how clotting agents were manufactured in the US from blood donated by homeless people and drug addicts. It was also revealed no effort was made to trace people who could have become infected. More than 1,200 received contaminated blood product.
Another 220 men with haemophilia were infected with HIV and hepatitis C. Most were infected from imported clotting concentrates manufactured by commercial firms."
"Two main groups of NHS patients were affected by what has been called the biggest treatment disaster in the history of the NHS.
Firstly, haemophiliacs - and those with similar disorders - who have a rare genetic condition which means their blood does not clot properly.
People with haemophilia A have a shortage of a clotting agent called Factor VIII, while people with haemophilia B do not have enough Factor IX.
In the 1970s, a new treatment using donated human blood plasma was developed to replace these clotting agents.
But whole batches were contaminated with deadly viruses.
After being given the infected treatments, about 1,250 people in the UK with bleeding disorders developed both HIV and hepatitis C, including 380 children.
About two-thirds later died of Aids-related illnesses. Some unintentionally gave HIV to their partners.
Another 2,400 to 5,000 people developed hepatitis C on its own, which can cause cirrhosis and liver cancer.
...The report said:
- too little was done to stop importing blood products from abroad, which used blood from high-risk donors such as prisoners and drug addicts
- in the UK, blood donations were accepted from high-risk groups such as prisoners until 1986
- blood products were not heat-treated to eliminate HIV until the end of 1985, although the risks were known in 1982
- there was too little testing to reduce the risk of hepatitis, from the 1970s onwards"
'Compensation for donors' sounds great, but in reality who is going to sell a kidney? People in dire straits. What donors are likely to be in poor health/at risk of having drug addictions or infections that compromise their organs? People in dire straits. Maybe the donated kidneys will be rigorously screened to make sure they're absolutely healthy, but if it's a case of "John needs a new kidney now or he'll die in three weeks", the pressure of time and need may work against such lengthy processes.
Today does seem to be my day for going "Bah, humbug" but yeah;
"Representative Nicole Malliotakis has introduced a bipartisan bill to provide $50,000 in refundable tax credits for people who donate kidneys to strangers"
That is only an incentive to someone who needs/wants/earns enough for it to be worth having that much tax credits, and they're much less likely to be in dire enough straits that "selling my kidney is my only option here". I can see people in that tax bracket being willing to go "I'll donate a kidney to Uncle Bob *and* get a tax relief!" but not enough of them wanting to do it for a total stranger.
The people who will sell kidneys are those who need money fast and have no other way of getting it, and a tax credit when they're not earning enough to be liable for that much tax isn't much good to them. As the blood contamination scandals show, "let's increase donations by paying for them to incentivise people to donate, what could possibly go wrong?", well, the second part there often comes back to bite us.
"Refundable" tax credits are credits that you can get in full even if you do not owe offsetting tax. So if you are in a low tax bracket and only owe $1,000 in income tax, and you get a $50,000 *refundable* tax credit, that's $49,000 cash in your pocket.
Thank you for hte correction. So the benefits will be restricted to people who can provide proof of "I have income and a home address and am paying tax so you can set these credits against that", which will rule out the most desperate cases.
But will the people in those brackets step up enough to donate organs? Maybe there is a huge untapped pool of donors who will sell a kidney for $10,000-$40,000 (depending on tax bracket) but would otherwise not donate. It's possible. We'll have to see what happens if this is ever legalised.
And of course, because I'm cynical, I await the first heart-rending tale by a journo seeking a Pulitzer about "Lourdes-Maria, single mother of three, working two jobs, who was forced to sell a kidney to pay for her child's medical bills and is now on dialysis herself due to later health problems; if her remaining kidney fails, she could die and her kids will be left as orphans; why are we complacent about modern-day slavery????"
In all fairness, that sounds like a pretty bad thing to happen to Lourdes-Maria and it doesn't seem unreasonable for a society to try to make it impossible for that to happen to people.
Libertarian principles work best when there is a broad degree of rough equality in what people can and cannot be pressured into doing by the 'nonviolent' force. When everyone actually DOES have the ability to say "no, I won't sell myself into slavery because that would be a negation of my basic worth as a human being," as opposed to there being some people who get to have worth as a human being and some people who get to have massive debt as the cost of getting to live and then get to have debt collectors play Metallica at 90 dB outside their houses 24/7 until they stagger out in a daze and sign a self-enslavement contract just to make it stop.
If we're going to accept that we live in a society where some people get to own multiple personal palaces and private rocketships, while other people get to worry that their little girl's gonna literally die because they can't scrape up $20,000 to pay to Palace Man's company in a hurry, and oh hey, you can sell one of your kidneys or retinas for $20,000, you get, well...
You get cyberpunk.
Cyberpunk is basically "libertarianism, in a society whose underlying conditions take a lot of the things that make libertarianism palatable in theory, and then discards those things to create a society that is unpalatable in practice."
The proposal is in favour of donors "to strangers" only so uncle bob is unlikely to qualify (and cheating is anyway easy to prevent by stipulating the donor has no say as to the identity of the donee)
The other problem is, this is Murica. In the UK you would just send kidneys to the NHS waiting list, in America how does it work?
If I can get a tax write-off for donating to a stranger but not to Uncle Bob who is just as in need of a kidney, how is that fair and equal treatment?
It's America, law suits are the answer to everything. I'm confident that any attempts to make it that "you can't get the tax credit for doing a charitable deed for a family member" is going to be challenged in court.
>I'm confident that any attempts to make it that "you can't get the tax credit for doing a charitable deed for a family member" is going to be challenged in court.
Yeah, I'd be surprised if it goes unchallenged for long, if that is indeed how it's proposed to work. It's sort of like punishing family-feelin' (you know, like fellow-feeling; I just made it up, and—wait, is "fellow-feeling" even an idiom of some kind? did I make /that/ one up too? uh–)
This is an execution problem though? The blood could have been tested? Yes, if money changes hands, it's more likely. But also, a kidney donation is much bigger a unit, nothing like a mass blood/plasma donation process. So testing easier.
I agree with you that people more likely to donate would be, maybe not in dire straits but at least poor or in specific need. But this in itself isn't a problem. I'd consider donating my kidney for 50k (sterling, a bit more in dollars) because that amount would be life-changing in the sense of sorting out the biggest material hurdle to improving both my life practically and my mental state, tho I might be too old. There's NO WAY I'd consider doing this for free for anyone that's not my child. If only because how would cover the cost of living, household help, daily care and human company in the recovery period?
I think there are quite a few people like me. And you'd have much better chance of filtering out dodgy donors because each is a much bigger part of the project.
Comparison of "desperation profile" with blood donors is imperfect: what I mean is for example the fees for plasma in the US appear really low. Probably not worth the hassle for anyone not REALLY desperate. Many even poor people could earn comparable amounts in the time needed to donate. It's not life changing. But 50k for let's say even 2 months of "work"? That's significantly better than surrogacy, and yes, it reflects the loss of an organ that could be needed later in life but still, imo much more likely to tempt more "normal", safer profile people.
Btw I'd include a clause that donors would automatically be put at the top of list if they ever needed a donated kidney in the future.
I would sell my kidney if it was for 100k, I have been considering donating anyways since it seems to not be that dangerous. I think a lot of people who are on the edge of donating could be convinced by the right sum of money.
I agree the poor people problem seems difficult but maybe with having more donors available we could have very high health standards for the donors (to prevent them from suffering because of the donation) so that it wouldn't actually be a problem?
If the tax credits are capped at $50,000, you would need to be earning so little that your tax liabilities were minimal and to sell both kidneys to get that $100,000.
That, or arrange to sell to a billionaire who needs a new kidney *now* and doesn't want to wait around.
Or we could go the Chinese route and just cut up executed prisoners for spare parts. Waste not, want not!
"Some of the more than 1.5 million detainees in Chinese prison camps are being killed for their organs to serve a booming transplant trade that is worth some $1 billion a year, concluded the China Tribunal, an independent body tasked with investigating organ harvesting from prisoners of conscience in the authoritarian state."
Why not? If paying for organs doesn't result in enough donations, what's the next step?
*Refundable* tax credits. That means that if you pay less than $50,000 in income taxes, you can filen a tax return saying that you owe "negative money", and the government sends *you* a check (or a direct deposit) for the difference. If your income tax owed happens to be literally zero, then that check will be the full $50,000. You do still have to file a tax return to get the money, but that's all.
The proposal is a tax credit though, so it's not at all "selling body parts for quick cash". I think a tax credit would filter out most of the riff-raff, so-to-speak.
It would, but that's my sticking-point. People who are in good health and take care of themselves and are doing okay enough that the tax credit doesn't make that much of a difference to them are not going to be tempted by it. People who are likely to sell body parts (because that is what "compensate donors" comes down to) are people who need that money/tax credit, and so are less likely to be in prime condition.
You may indeed hit the sweet spot of "healthy enough *and* in need enough" that the tax credit is tempting them to donate to strangers, but will that be enough people to meet the need for donors? One way to find out is "try it and see" but you have to try and plan around any downsides, not simply hope that the optimistic "tons of people who would otherwise not donate now will donate" approach works.
It didn't work out in liberal denominations that went all-in on gay etc. rights, when the selling-point there by the progressives was "there are all these LGBT people who would *love* to be Christians, except for the regressive stance on modern sexuality". A lot of churches junked traditional theology and (for example in the case of TEC) ended up with splits, schisms, conservative parishes leaving, and none of the mooted flood of LGBT people and their allies into the pews to replace them happened, because it wasn't about "we'd love to be Christians except...", it was about "bake the cake, bigot".
"I totally would donate one of my kidneys to a stranger, except the tax credits aren't good enough" sounds like one of those hopeful strategies that don't pan out in reality.
My gut feeling is that even if you only got donations from the most unhealthy drug addicts that is still miles better than no donation at all. 10 people dying from "bad" organs make the headlines while a thousand people dying waiting in line is just another Tuesday.
If Uncle Bob's transplant fails because the kidney came from Denny the Druggie, the family are going to hit the roof over "this was supposed to be safe!"
Try explaining to them that hey, if Bill died due to a bad kidney, that was just the luck of the draw and at least he lived six months longer. You'll end up the next organ donor due to being torn apart by the Furies.
This failure case is something that happens every day in medicine. There must be some kind of protocol in terms of managing expectations. Just doing a quick look it seems like the 1 year survival rate is between 90 and 95%. So the current system already has 1 in 10 or 1 in 20 dying and I would assume that the nephrologists murder rate isn't shooting through the roof
I think this is true, but I suspect the general public wouldn’t agree, or at least wouldn’t ’viscerally agree’, and this will be a perennial PR problem. Given that the public attitude in general is that it’s better for a hundred people to die due to the illegality of a type of transaction than one person to die due to said transaction type, there would likely be a backlash the moment one person dies from a bad transplant. Keeping kidney selling legal in the face of that inevitable backlash may be much harder than getting it legalized in the first place.
>Given that the public attitude in general is that it’s better for a hundred people to die due to the illegality of a type of transaction than one person to die due to said transaction type
This frustrates me a lot.
It's not exactly the same, but something similar: I have, once in my life, been in utterly incomprehensible agony—such that I'd have kilt myself if I could have done more than crawl around on the floor trying to remember my own name and waiting for my then-wife to get home—and when I got to the ER, retching and weeping and with some ungodly heart rate & BP (IIRC it was in the low 200s per minute resting; I dunno what metrics they use, but I'd have thought I was /obviously/ in horrible pain), I waited /hours/ while they decided if they dared risk giving pain relief to someone who MIGHT POSSIBLY be an addict or something.
I was too hazy to even really feel anything else, but my wife was furious. But better a false negative than a false positive; better someone writhe in agony than someone get a morphine shot who just /wanted/ it, sinfully. Or something.
Never understood it, tbh. You can also observe this sort of effect by just rephrasing things for people: phrased in the "active" way, they'll be against it, and mutatis mutandis for the "passive" phrasing, if you know what I mean.
For what it's worth, I was told by a cardiologist (when discussing my own bouts of atrial fibrillation) that they generally do wait and see if the high heart rate will come down of its own accord before they intervene with drugs.
If it reverts by itself within six or however many hours, great! If it goes on for longer than twenty-four hours, okay, maybe they need to do something.
I can't speak about pain relief but they may have wanted to avoid masking any symptoms that would then turn out to be "uh-oh we need to intervene now".
But who else is desperate enough to sell their organs? We shouldn't be trusting people just because they're rich anyways. Plenty of drug-addled bourgeois around. Test all donators, sue the harvester if it's defective.
I think "the poor being coerced to sell body parts" is the central example of the ick we're talking about. Personally I'd rather just bite the bullet, allow life saving mutually beneficial transactions to occur rather than denying them because it forces us to confront the true reality of economic hardship
The underlying problem comes up if as a society we've effectively precommitted as to not actually tackling the reality of economic hardship and forcibly banishing it from reality, AND we keep embracing policies that potentially introduce new ways for economic hardship to be a hard reality.
Because then we're at risk of falling down the "Murder-Ghandi" slippery slope.
You've probably heard this one- Ghandi is very saintly, one reasons, so him taking a pill that would make him be only 99% as inclined to murder people would have effectively no effect, he'd still not be doing any murders. So if he could take such a pill for a million dollars, he should, since there's no downside.
But then he's confronted with the decision to take the same pill again, and with his new reduced scruples about murder, he sees no reason not to be only 99% as anti-murder as he was before, and again and again until he's a very rich serial killer. So the joke-example goes.
You can absolutely do the same thing with wealth inequality. Because adding "just one more" new way in which the condition of poverty is a harsh reality that makes people miserable in exchange for one more clearly good thing that seems net-beneficial isn't actually zero-downside. It makes the condition of poverty that little bit statistically worse and more prevalent and harder to escape. And if you keep making that decision a hundred times, going "the poor are always with us, their lot is hard, it's the nature of things" over and over... Well, you end up in a Dickensian nightmare world.
This has the flavor of moral panic to me- "dirty blood from homeless and drug users"! As well as obviously being, well, trivial compared to the issue of shortages. I mean a small risk of infection (accepting for the sake of argument that this policy would increase) is not even in the same ballpark as simply dying because you had no donor in the first place.
Additional to Deisach's important point, once you fundamentally internalize the idea that it's just "okay" that this thing happens, you lose a lot of the protection that KEEPS the risk of infection small.
Actually I mostly object to economic coercion being used to take organs from people, so a non-refundable tax credit capped at 50k is probably the best case scenario if this idea were enacted (I hope it is not). It would prevent the Musks and Zucks (or more realistically, Bryan Johnsons) of the world from using poor people as organ farms.
File this under "What Could Possibly Go Wrong?" Of course we can avoid the pay-for-organs problem if we simply revive our past enthusiasm for capital punishment. Larry Niven shows the way in his great story "The Jigsaw Man", in which the availability of life saving organs is dramatically increased by harvesting them from condemned criminals. One minor downside of this approach is that the public, seeing the benefits of organ transplants, demands that offenses such as shoplifting, reckless driving, etc. be reclassified as capital crimes.
I think a good starting point - which would likely be easier changes than paying kidney donors outright - would be to expand the scope of coverage for recipients. My understanding (although this may be flawed and I'd love for a medical professional to chime in), is that the medical costs for surgery and recovery are covered; however, there is still the opportunity cost of either hourly wage that is being lost, or otherwise needing to use sick days. Some kind of daily cost to cover living expenses, as well allowing time spent donating a kidney to not deduct from total sick leave would help to at least marginally make it easier for people may want to donate for altruistic reasons, but cannot due to the financial cost.
Additionally, my understanding is that countries that default organ donations to opt-out policy rather than the United States opt-in policy tend to have a significantly higher percentage of organ donors. I'd be curious to see if anyone has possibly run the numbers regarding to what extent increased organ donation would alleviate shortages of kidneys
If you saw a motorist with a flat, would you even think of stopping and offering them your spare?
If you really want to up kidney donations, guarantee preferential and free treatment to the donor should they later find they need a kidney themselves.
In the middle of a snowstorm on an interstate my spare was flat. A guy l did not know pulled over and gave me his spare. I later got it back to him. But that is not today's country.
This is already a thing, no? From reading ACX accounts of donations, it sounds like by doing an undirected donation, not only are you moved to the top of the list, you can designate a relative to be moved to the top of the list as well (as you might have been able to donate to them).
> If you really want to up kidney donations, guarantee preferential and free treatment to the donor should they later find they need a kidney themselves.
This is already the case. If you make an undirected kidney donation, you shoot to the top of the list if you need a kidney, and you can designate five people, the first of whom to need a kidney also gets shot to the top of the list. (Of course, the only way you're going to be allowed to make an undirected kidney donation is if your kidneys are really good, so people who have altruistically donated a kidney actually have a lower risk of kidney issues than the general population.)
Only one of those five gets a kidney though. That’s important. It’s the first one to need it not all five. And what are the odds you pick five people who need a kidney transplant?
> For example, you could set the goal of reducing airborne disease in military housing by 50% by the start of 2028. Because the government pays for military healthcare, this would save costs and also create the evidence needed for private industry (workplaces, nursing homes, cruise ships, etc.) to implement air quality interventions for themselves.
These all look reasonable to me, and it's a very good thing to be constructive, but I can't help feeling that Scott is simultaneously getting some second-order troll kicks out of this.
"Separating ARPA-H from the NIH will protect it it from this fate, help it deliver on its intended goals, and help NIH reducing the number of institutes and centers it oversees (granting more research dollars per center)."
Ah, didn't we just have a full entire post about "taking money from/shutting down one programme does not mean the clawed-back funding is going to go to the good things we want"?
Reorganization != shutting down. I don't think Scott would've made that post if they had simply shuffled PEPFAR from USAID to the NIH, so long as it didn't threaten its current or future operations.
It's the "granting more research dollars per centre" part; the objections Scott raises in his post apply here. The NIH now has more money that it's not spending on funding ARPA-H. That does not mean this extra funding can be kept by the NIH to give the excess to the centres it does oversee; the extra may well be clawed back into the main government budget and distributed elsewhere.
Claw-back does happen in government all the time; you aren't spending all the budget doesn't mean you get to keep it, it means "we notice you don't need as much money to run that service as you received, so we're taking back the excess left over *plus* we're reducing your funding next year because you don't need as much".
If the condition of the funding is "you will receive $X to fund the ARPA-H service" and then the ARPA-H is spun off into its own thing, then you lose that funding. You don't get to keep it to spend on other projects in that centre.
"AA CLG also received a grant of €1,000,000 from a local government authority. The conditions of the grant are that it must be spent on the building of a new community centre. Another condition of the grant is that the community centre must host the annual provincial youth boxing championships for each of the next 10 years. There is no certainty as to whether AA CLG will host this tournament as they must tender for it each year. If these terms are not complied with, the local government authority can clawback the grant, with the amount that can be clawed back equal to €100,000 for each year the condition is not met. AA CLG immediately spend the money on building the community centre.
In this instance, AA CLG should initially recognise the grant of €1,000,000 as a liability and then recognise €100,000 in income each year for the period of 10 years (when they meet the conditions each year). If AA failed to comply with the conditions of the grant then the balance repayable should be held as a liability until it is clawed back by the local government."
> It's the "granting more research dollars per centre" part; the objections Scott raises in his post apply here. The NIH now has more money that it's not spending on funding ARPA-H.
So you're kind of leaving off the first part of the phrase:
>help NIH reducing the number of institutes and centers it oversees (granting more research dollars per center).
I interpret that as NIH will save money on general overhead because it has less to oversee, not that ARPA-H funding is being given to NIH. Maybe I'm wrong but I don't see how you could spin off ARPA-H and not have it take it's allocated funding without Congressional approval
Sure, if we're talking "overhead costs come down because now we're not running three labs" or whatever out of the centre, I can see that point.
But I still don't think that converts into research funding; the money saved on electricity bills etc. will go into the general pot of funding to pay salaries and bills. Grants for research are generally earmarked as such and aren't fungible, as per Scott's own post:
"If you cancelled PEPFAR - the single best foreign aid program, which saves millions of foreign lives - the money wouldn’t automatically redirect itself to the single best domestic aid program which saves millions of American lives.
Instead, it would . . . well, technically it would sit unspent, because Congress earmarked it for PEPFAR, and the executive branch cannot re-earmark it. But probably something would happen, deals would be made, Congress would think about the extra money when deciding how much deficit spending to do, and eventually it would in some vague sense go back into the general pot of all other federal spending."
So they might have more money in the budget for overheads and general expenditure, but for 'more money for research' they'd need to seek out funding for that specifically.
>Increase funding for novel research: Bhattacharya co-authored a paper finding that projects which explore new ideas get less government funding than those confirming existing paradigms.
In light of the replication crisis and high-profile academic fraud issues we've seen, shouldn't we want the government to focus on confirming existing paradigms/studies more than exploring new ideas? Obviously NIH is big enough to do both, but it seems to me that we need someone to focus on the boring stuff like actually proving novel research will replicate and isn't fraudulent.
Hm, this depends on whether confirming studies can be trusted to avoid confirmation bias and actually disprove things that are wrong (I have no idea if they can; I do get the impression medical research has tightened up somewhat in recent years)
I mean if we can't trust confirming studies because of confirmation bias doesn't that sort of undermine the basis of scientific research in this field?
"the health establishment chose paternalism and the moral high of trying to save volunteers from themselves."
Also perhaps trying to save themselves from being sued by the families of the volunteers who die, because healthy volunteers do die during clinical trials?
"Over the past decade, an average of 177,798 clinical trial participants have died each year in the U.S. For deaths that could be expected because of the patient’s condition, drug developers report the event to the FDA and business continues as usual.
But sometimes, deaths are unexpected or are linked directly to the investigational therapy.
...Anthony Japour, CEO of biopharma company iTolerance, has served as a clinical investigator, a member of an institutional review board and a medical monitor for clinical research studies with a CRO. He told BioSpace about a clinical trial that occurred early on in his career.
“I’ll never forget this,” Japour said, “because a healthy volunteer almost died—literally, almost died.” The trial assessed the safety of a combined therapy in which one of the products was already marketed and widely used.
The event was caused by “a rare, idiosyncratic response to the drug,” Japour explained. “We terminated the study immediately.”
In that case, the participant was treated in hospital and survived. “We had to pay all the hospital bills. There was a major lawsuit, which we settled out of court, and that was that,” Japour said."
"A 24 year old previously healthy woman has died as a result of participating in a research project as an experimental subject.
Her death raises serious questions about the safety and ethics of human experimentation. The woman, Ellen Roche, worked as a laboratory technician at the Johns Hopkins Bayview Medical Center's Asthma and Allergy Center in Baltimore, Maryland.
She volunteered as a research subject in a baseline physiological test, which induced asthmatic reactions in people without asthma to determine how bronchiolar reflexes differ between the two populations. Specifically, the study was designed to test a controversial theory of asthma, which holds that people with asthma and those without both react similarly to inhaled irritants—experiencing bronchiolar vasoconstriction—but that people without asthma are able to overcome this reaction through deep inspiration."
"One person died, and five others were hospitalized, after a clinical trial of an experimental drug in France went tragically wrong.
...In recent years, there have been two major changes to French laws affecting the approval of drugs in clinical trials. France strengthened its medical-safety laws following the 2009 withdrawal of a diabetes drug that was suspected of causing hundreds of deaths: a 2011 law, in particular, tightened rules on conflicts of interest for people involved in the country’s drug-approval process, as well as giving authorities more power to demand safety tests of medications after they are approved. Then, in 2012, the government passed a separate law intended to streamline the rules for research involving humans, to speed up therapeutic progress and to make France a more attractive place for companies to carry out clinical trials."
"As Nature went to press, two previously healthy young men were in critical condition and another four seriously ill at Northwick Park Hospital in London. On 13 March, they received intravenous injections of TGN1412, an antibody made by Boehringer Ingelheim for TeGenero, a small, privately owned biotechnology firm in Würzburg, Germany. The drug was being developed to fight autoimmune diseases and leukaemia. Parexel International, a contract research organization based in Waltham, Massachusetts, that operates in 39 countries, was running the trial for TeGenero.
...Within one to two hours of being injected, the six volunteers suffered violent reactions that included headache, backache, nausea, a drop in blood pressure and, ultimately, multiple organ failure. The trial was the first test of the drug in humans; it was immediately suspended by the UK Medicines and Healthcare Products Regulatory Agency, which is now investigating."
Honest question: What are you saying we do about it?
We should fully expect healthy people to die during drug trials. There is no realistic way to get that number to 0. Many drugs have a low possibility of severe side effects, and yet are very useful to treat certain conditions. We have to test them on humans to determine their real efficacy, and that will always result in some number of life threatening illnesses/deaths in the healthy population.
Do you think there is some safety precautions we are not taking? Do you just want people to acknowledge that this is not a risk-free proposal?
I'm saying that the mass of people won't understand "yes, we expect healthy people to die but that's baked in and besides, the good of the many outweighs the good of the few".
"We had no idea bad outcome" is deemed less blameworthy than "we knew bad outcome was one possibility" in things like deaths.
We should shut down all fire and police departments. We know that sometimes fire fighters and police officers will die in the course of their jobs, and the mass of people won't let a cold utilitarian calculus tell us that this sacrifice is worth it because eliminating these jobs would cost more lives than it saves.
Good luck with that one, you might be able to have it done but most people will be "my healthy son/husband volunteered out of the goodness of his heart to help people, and he trusted this pharma company that it would be okay, but he died and they knew this might happen, so this must Not Be Permitted To Ever Happen Again".
What if we make them into heroes like soldiers, firefighters, and rescue workers? "Your son/husband is a hero who willingly risked his life and unfortunately lost it fighting to save the weak and the vulnerable." Family don't get to sue the military when their otherwise healthy family members die in battle. They don't sue the police or firefighters when people in those services die, except in extremely rare cases of negligence I think where procedures are not being followed. Give them the same legal protections so it can function, and social praise to try to keep the PR good.
Possibly, but you're asking for society to venerate martyrs once again, and I don't think that attitude has remained. We expect things like drug trials to be safe (at least not lethal) because we have expectations around "this is to help, not to harm".
Unforeseen side effects are one thing, but going in with "there's an X chance of death" will be another.
In the case of fireman, for example, there's the expectation that everything that can be done to avoid injury or death will be done, and if the fireman dies then that was a tragedy that could not have been prevented (and if the investigation shows it could have been prevented, then those held responsible are punished). If the job description was "we fully expect 10 out of every 300 firemen to kick the bucket and if you do die in the course of duty, we'll just go on as usual", I think you'd have much fewer people joining up.
How are those not the same? In challenge trials and dangerous service jobs both there is an expectation that everything that can be done (within reason) to avoid injury or death will be done. I say "within reason", because it's conditional on the job itself being done at all, and sometimes you need to take risks to do the job effectively and save lives, even if it puts the job-doer in more risk along the way. It's the exact same utilitarian calculation. And most importantly, it's voluntary and done knowingly. They know they're signing up for a risky job, on purpose, to help other people, and they're doing it willingly, not being forcibly drafted.
The difference between a hero and a martyr is that the martyr is being persecuted by someone and would no longer be in harm's way if that person simply stopped being evil. The hero is being harmed by reality: reality is set up that someone is going to suffer and the hero takes that suffering away from someone else and onto themselves and, ideally, in much less magnitude. If you get a 10% chance to die in exchange for saving 5 lives, that's better than simply having these 5 people die instead of those 5 people.
Again, I stress, it's voluntary, and people do volunteer. The problem is not that nobody wants to be a hero, it's that the government is making it illegal to be a hero and/or enabling family members to retroactively withdraw that consent from a dead family member and sue the people who enabled their heroic sacrifice.
Given just how much very, very angry sentiment got thrown around at the Biden administration for basing its public health policy on that observation, and on accusations that assorted extremely improbable but very nasty vaccine side effects were ignored, I question whether it's sustainable as a public policy matter to adopt this stance.
You're not wrong, but the kind of person who can say what you said and mean it isn't going to be able to get along with the anti-COVID-vaccine movement, and therefore has no chance of getting near the levers of power in the present administration's public health policy.
running a challenge trial and paying large settlements to anyone who dies seems clearly preferably to doing neither of those things in a situation such as COVID?
Yeah it’s funny. They are just going to defund all the programs because they are “waste”. They don’t care about health of poor people outside or inside of US.
Some individuals involved in the administration almost certainly do. That said, the people at the top of the executive branch are unlikely to aid or empower them.
Approve of what? To be clear, I'm saying that Trump and his immediate cabinet appointees are unlikely to help or empower people within their administration who care about health or poor people in this country or outside of it. I think it's entirely probable that some or all of the people Scott referenced in this article as potentially getting behind these policy proposals might genuinely want to do good for this country. But I don't think aiding them in doing so is a meaningful priority for Trump or his cabinet.
Of course he cares about poor whites, that's most of his own supporters! The challenge is in making sure the people getting screwed over are mostly people that didn't support him.
I don't think it's at all apparent that he cares about his support base, or is interested in enacting policies that benefit him, as long as he thinks he can maintain his own power. This may or may not involve trying to keep their approval depending on the degree to which he thinks he can rig the system in his favor, but either way he seems willing to lean quite heavily on simply lying to his supporters and trusting in their cognitive dissonance to justify whatever he does.
A dictatorship needs support, but it doesn't need majority support. It's enough if the appearance of institutional legitimacy, and influence over the flow of information, makes it much easier for its supporters than its opponents to effectively coordinate.
Of course, of course, but uneducated proles are a decently large portion of his base. He really can't afford to mindless cut stuff like welfare due to the potential backlash.
A man can be a very happy dictator with many presidential palaces and an endless supply of hot and cold running showgirls, with dungeons and secret police and armies to take on all comers, even when the state of public health is so bad that the average citizen dies at the age of sixty. From the US's point of view, being reduced to such a condition would be the most terrible act of war ever committed against it by any enemy, foreign or domestic, but it's a thing that CAN happen.
The job of actually lynching the opposition can be taken by indoctrinated fanatics in their twenties and thirties whose health hasn't collapsed yet and who don't care that their families' health has collapsed because they've been told to blame the opposition.
You're begging the question that a voting base responds positively to policies that help them and negatively to policies that harm them. With effective marketing, that's not necessarily the case.
...It's pretty hard to fake giving people money. I understand there are ways around that, such as distraction and scapegoating, but people are always going to get pissed if you take away their bread and circuses.
That seems very unlikely. Plenty of departments are going to remain, and will have Trump supporters at their head. They might be unqualified, disagreeably politically and personally, and have some explicit policies I think will inherently despicable, unfeasible or will backfire.
Nevertheless ... the wild variance of the situation means they will try some things that wouldn't happen under more even keeled leadership. Even if they try 9 terrible things for every 1 bad one (or worse ratios) we still have a good chance of trying some worthwhile initiatives.
I don't expect Trump to approve of anything pandemic-prevention-related. His handling of COVID was too embarrassing, and I think he would MUCH prefer the Chinese approach of sweeping it all under the rug:
Your trump derangement is near terminal; rfk is a very public figure, was a democrat, and will be in charge of something health related; you may think he's insane but why would he do nothing when he's willing to talk so much about the topic?
Because his position of power depends on not goring the oxen of anyone else with more influence in the administration, and probably on not asking anyone for more money unless he can explain how that money will be routed as a kickback to one of the new rising class of oligarchs.
It's not Trump, or rather, it's not just Trump. It's the literal dozen billionaires around him, and all the billionaires who are giving Trump money. All you have to do is follow the money; the underlying pattern of the second Trump administration is very simple. We are being set up to be ruled by a Russian-style economic oligarchy centered on a president who may be autonomous or may be a puppet of one or more of the oligarchs depending on how the future unfolds.
Insofar as RFK Jr is not angling to become an oligarch himself, he cannot tread on the oligarchs' toes.
"They were not only opinionative, peevish, covetous, morose, vain, talkative; but incapable of friendship, and dead to all natural affection, which never descended below their grandchildren. Envy, and impotent desires, are their prevailing passions. But those objects against which their envy seems principally directed, are the vices of the younger sort, and the deaths of the old."
Swift on struldbruggs. There's a lot of other stuff to sort out before we start taking longevity research seriously. We would not be where we are now if American males popped their clogs at three score years and ten as the Lord intended.
>There's a lot of other stuff to sort out before we start taking longevity research seriously.
No, there's not. Or, rather, one could make this argument about /anything/: there's a lot of other stuff to sort out before we start taking heart disease research seriously, cancer research seriously, poverty alleviation efforts seriously, ...
Just depends on what you value. I value longevity.
>We would not be where we are now if American males popped their clogs at three score years and ten as the Lord intended
Why stop at 70? Maybe we'd be even better off if we set the bar at 40!
Longevity with all the good stuff would be great. With chronic disease, dementia, unemployability and consequent funding requirements, it's net undesirable
I'm aware. I assumed the point was meant to be something about the social desirability of a "natural" lifespan (thus "but perhaps even less than that is even better!", y'see?), not that you were advocating a literal hard cut-off at 70.
>Longevity with all the good stuff would be great. With chronic disease, dementia, unemployability and consequent funding requirements, it's net undesirable
I don't think "longevity but aging continues apace at the same time" is on the table, in both the sense that no one is advocating for or aiming at it, and the sense that it's not likely to be possible. [edit: Not to any great extent, I mean; we've plucked most of that fruit. Most longevity research that I've seen proposed aims to increase healthy lifespan.]
Scott, I remember a few years ago, you wrote something like the following:
"Doctors give you crappy advice about how to lose weight like 'eat less and exercise more' because no one knows what's making you fat in the first place. It's like someone is slipping a drug into the water supply that causes everyone to gain weight, and the obvious thing to do in that situation is stop drinking the tainted water, but that option isn't available since we don't know what or where the taint is actually coming from, so instead we have to fall back on this vastly inferior advice of 'just eat less and exercise more.'"
Semaglutide is great and all, but someone still needs to find the thing that's making everybody fat. Seems like this would be about the biggest thing that RFK's "Make America Healthy Again" slogan could achieve (way bigger than air quality), and if he managed to make a real contribution in this regard, I'd be willing to overlook a polio pandemic or two that might result from his anti vaccine craziness.
Calories consumed per day has risen since the mid 20th century by 15-25% (finding competing numbers, don't know who to trust). That, combined with a more sedentary lifestyle, seems like it would inevitably lead to weight gain. I don't know there is any "secret" thing making people fat.
Well the question is really mainly why calorie intake has gone up. Plausible theories include things like "technology has made junk food more delicious" and "people have more money to spend on food" but those are not obviously sufficient. Many suspect there are also factors (possibly chemicals) disrupting the body's weight regulation system in some subtle way. Very roughly speaking, this might be kind of the opposite of what semaglutide does I guess?
As for energy expenditure, the population may be more sedentary overall now, but in 1950 obesity was pretty rare even among sedentary people, so I doubt it's a big part.
> Well the question is really mainly why calorie intake has gone up. Plausible theories include things like "technology has made junk food more delicious" and "people have more money to spend on food" but those are not obviously sufficient.
No, they're pretty sufficient by now.
KD Hall et al. Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake (2019)
Take 20 adults in their early thirties, 10 male, 10 female. Feed them unprocessed food for 2 weeks, then processed food for 2 weeks. For half of them flip it, and feed them the other one first. People ate ad libitum - ie whatever they chose and as much as they wanted.
When on the processed food portion, people ate ~500 more calories per day on average.
People gained ~0.9kg on the processed diet, and lost ~0.9kg on the unprocessed diet, regardless of order.
500 calories more per day is HUGE and can entirely account for average obesity trajectories. Also, you save money eating UPF. For these diets in the study, the "real food" diets cost $150 a week, and the UPF diets cost $100 a week.
There is some weak evidence that ultra-processed food causes "weight homeostat" imbalances in and of itself, too, due to the fat and sugar content and possibly due to the barely-regulated (in the US) additives and flavoring agents put into them:
Inflammation and hypothalamic impacts from high fat diets in humans:
That is like saying that alcoholics are alcoholics because they drink more than non-alcoholics. True, but trivial.
What is the difference between someone who is craving drinks and someone who is not?
What is the difference between someone who feels compelled to eat more than necessary vs. someone who isn't? Why has the former set of people grown in the last 50 years? People in 1970 weren't hunters and gatherers (certainly New Yorkers, Londoners etc. weren't), but any street video from back then will show you just how much thinner everyone was.
Are environmental factors in play?
These are absolutely non-trivial questions and we don't know the answers yet.
Being rich makes large-scale obesity possible in the first place, but it's clearly more complicated than richer=fatter. Real wages in Japan have been stagnant for 30 years, and their obesity rate has been slowly rising anyway.
Yeah. I suspect that "workaholism" is outright disproportionately a white-collar disease, because it's at white-collar jobs that you can sit at your desk obsessively collating your notes and aligning the cover sheets on your TSP reports for twelve hours a day without just collapsing from exhaustion. A guy who builds roofs for a living is going to have actual aches and pains at the end of the day; he WANTS to get off shift and drink a couple of beers to take his mind off it.
Many Thanks! Agreed re blue collar occupations. You paint white collar occupations in an unjustifiably negative way, "obsessively collating", but so be it.
What are the downsides of just staying on it for life? Putting aside any financial concerns or insufficient supply concerns, which seem easy enough to get around.
The bone lose drugs suck; you may as well be asking why nicotine isn't good enough.
Theres 100s of drugs that are known to cause weight lost; chemotherphy, coke+caffeine+steroids, they are usually poisonous or most dangerous to the people who are actually are risk for heart attacks. Its insane to blanket such a radical interventions that fight so hard with a fundamental instinct of evolution.
From what I've heard on the studies done on semaglutides, not only do they not appear to have surprise downsides, instead they have surprise upsides of improving other things they weren't intended to! Completely unlike those other drugs.
Evolution brought people to the point where they are dying from eating too much rather than too little. At current margins this appears to be a clear improvement.
Right, but your argument was "may as well ask why nicotine or chemotherapy isn't good enough", which are clearly (arguendo) risks of a different order.
I mentioned chemo to justify claiming 100's of drugs
I think nicotine patches are safer then the new fad with what must be a new way to make fraudulent studies(curing every illness) that rapidly has celebrities(a small subset of the population, i.e. not lottery winners) complaining about bone loss or extreme side effects
I think “need” and “good enough” are red herrings. It seems like it could well be better to figure out the root cause than to treat the problem, and that’s reason enough to put significant effort into research, whether we “need” it or not.
People have been working on how to deal with obesity for a long time. I don't think people are likely to find a better solution than this unusually effective one any time soon.
A “solution” means there is no problem any more. Very few significant problems admit of a solution in this sense.
Having a partial solution means that getting a better partial solution is less pressing than it used to be, but doesn’t automatically mean you should just give up.
"Doctors give you crappy advice about how to lose weight like 'eat less and exercise more' because no one knows what's making you fat in the first place."
That does not sound like something Scott would say.
Safety is quicker and easier to come by, meaning you'd have to prove efficacy directly to doctors to expand adoption. Likely this wouldn't be an approval scenario, but one where you convince early adopters first, then gradually expand market share as the efficacy evidence mounts.
To make a system like that feasible, you need a different payment paradigm, so insurance and Medicare know how to reimburse. Investors aren't going to get on board unless you can prove there's a path to insurance reimbursement. (Speaking from personal experience, here.)
I like the idea, but I don't think you can do it whole-hog. It's too much of a disruption to the current system, so you'll get huge institutional push back - especially from small pharma and investors.
However, I think there are a few innovative ideas I've seen that can't get funding under the current model (because there's no path to reimbursement), where safety isn't a concern, and where large efficacy studies or indication/clinical idiosyncracies make it difficult to seek approval under the current system. This scheme could really work for them.
I propose separation of the two approvals:
1. Safety approval
2. Efficacy approval
This wouldn't impact current processes, since everything in the current development pipeline would continue to seek safety and efficacy approval. But some indications might work better looking for safety first, then later working toward efficacy. Then you'd need to find ways to reimburse for safety-only approvals, but there are already some ways to get there under the current system. A physician can prescribe off label (everything would be off label for a safety only approval), with clinical justification from the literature. Early on, this will be few docs, focusing on patients for whom none of the efficacy-approved drugs work. Later, is might expand to the extent efficacy data suggests the drug works.
Normally, we talk about "Marketing Authorization". I think you'd still not be allowed to market something for an indication unless you have efficacy approval. Or perhaps you could combine with an idea from the OP and allow marketing authorization reciprocity, so long as you first get FDA safety approval.
"...you'd have to prove efficacy directly to doctors to expand adoption"
Or just invite the doctors to "conferences" in swankier resorts with comelier hostesses than the competition, to discuss how awesome your new drug is. Four or five Mai Tais and they won't be able to read the powerpoint slide where you show the actual data.
This isn't a good description of the conferences I've been to. They still play hide the data, but in a more sophisticated way. For example, they have departments called "medical affairs", where the hire teams of PhDs to visit doctors and persuade them to prescribe more of their drugs.
Very hard to causally-validate aging biomarkers. For one, it necessarily requires one to wait long enough to know if aging really has occurred. Two, it requires observation of the change in those biomarkers in response to things we know change aging (which we don’t know exist).
The science of longevity is far, far from being ready for such efforts - many, many higher EV areas to focus on.
Mammals seem to age in a roughly similar way, but at very different speeds.
For a biomarker of aging, I would propose to observe it in rats, squirrels, cats, dogs, horses, lemurs, smaller monkeys etc. If the observations are consistent, it is likely that the same thing works in humans as well.
Vague recollection: I thought that most mammals live for about a billion heartbeats, while we live for about three billion? And that evolution has therefore already significantly extended metabolism-scaled human lifetime as compared to other mammals? Which weakens the applicability of animal models of aging to humans, making this area even harder than most areas of biomedical science?
But that means there's something special about human biology that extends are lifespan, right? If we can figure out the mechanism behind that, we might be able to extend it even further. It'll probably require human testing, but... that should become easier under the new administration.
>But that means there's something special about human biology that extends are lifespan, right?
Yup! Many Thanks!
>If we can figure out the mechanism behind that, we might be able to extend it even further.
Or it might already be maxed out. :-(
>It'll probably require human testing, but... that should become easier under the new administration.
Yes, but the time scale problem doesn't go away. :-(
It comes back to the same validation problem that Brian Locke, MD MSc described in his comment. :-(
What would make the field much easier would be if there was a mammal that just lived a year, but with such a fast metabolism that it had four billion heartbeats in that year. Such an animal would have a good shot at being a model for aging biomarkers and interventions with a time scale of a year instead of 80 for the experiments. AFAIK, no such animal exists :-(
There's no known physical law that mandates mortality. Entropy exists, of course, but as long as we have access to energy, there's no reason that something HAS to die. Mortality will still be naturally selected for in most cases because stagnation is death, but manually optimizing lifeforms solves that issue.
An alternative solution would be to somehow "reset" the body and its cells like the immortal jellyfish does, though I am slightly doubtful that's a viable option for more complex animals... https://en.m.wikipedia.org/wiki/Turritopsis_dohrnii
>There's no known physical law that mandates mortality. Entropy exists, of course, but as long as we have access to energy, there's no reason that something HAS to die.
Agreed. Many Thanks!
>An alternative solution would be to somehow "reset" the body and its cells like the immortal jellyfish does
Yes, though one would need to also get regeneration to work for structures that are "build once, then never refurbish". As someone with lots of floaters in my eyes, I'm all too aware that e.g. the vitreous humor in our eyes is in this category...
If I could deploy unlimited resources on solving aging, I'd be inclined to bet on building Drexler/Merkle nanotechnology, aka atomically precise manufacturing, then use _that_ to build "known good" replacement cells, tissues, and organs, and do massively parallel microsurgery to put them in place.
It would be wonderful if there was some cocktail of small-molecule medications which turned out to do something like upregulate repair enough to make our bodies accurately fix themselves faster than aging damaged them, but there is no existence proof that any such set of medications can exist. :-(
If they are that obvious it seems like you might be able to list them without falling into a screed. It’s not even clear to me what you mean by “this”.
It's only a matter of time before a three-letter agency comes for Scott. Co-writer of the piece, Josh Morrison, is an anagram of Sir John's Room, which is famously used for dead-drops and private meetings in southwest England. Revealing this information as he did in an essay about health reforms is clearly a coded message regarding the next pandemic.
Fortunately, as I learned by googling, there are apparently Sir John’s Rooms all over the British touring industry, so perhaps there is enough plausible deniability to protect Scott for a little longer.
If this follows the usual pattern, the "many reasons" are "I'm mad and don't like this administration", which is a lot easier to make /sound/ like "many *good* reasons" if you don't actually list anything.
I look forward to a thoughtful review in a year that grades these cheerful predictions/wishes.
Improved transparency and access to data, resources put into protecting air quality, and increasing funding for scientific research are all explicitly the opposite of what's happened under the Trump administration in the first two weeks. I'm not sure what word to use to describe a wishlist - even framed as an optimistic one - that all those will reverse entirely. And as an effective altruist who cares about global health and poverty alleviation, I'd been hoping Scott use his platform (which he says has a direct audience to the administration!) to throw his support behind USAID and similar initiatives being hamfistedly gutted right now. Maybe I'll put my own overly optimistic hat on and hope that's coming soon, and not that, like many others, Scott's begin to warp his public writing with an eye to "must start fitting in to avoid the gestapo coming for me."
Y'know what, I just saw there was a post defending PEPFAR yesterday that I missed! Mea cupla on that front, glad to see that support. I still grade today's post as comically optimistic but here's a prayer that I may continue to be proven wrong.
I talked to Josh about this a bit, and the result is the sentence "For practical reasons, we focus on upside only".
I agree that there are many ways that the Trump administration could mess up health. But I think screaming at them and telling them they suck would briefly feel good but accomplish nothing, and politely saying some good things they could do might result in them doing some of those things (I personally wouldn't expect them to be moved by blog posts, but the competent lobbyists I co-wrote this post with think the chance is low but nonzero). I would feel stupid if I screamed at them (in a way that doesn't even help - I'm sure enough people are screaming at them that they've already maxxed out how bad they feel) and lost a chance to actually convince them of some important lifesaving thing.
Trump Administration Live Updates: Trump Directly Calls for U.S.A.I.D. to Be Shut Down
Citing unspecified fraud and corruption at U.S.A.I.D., the government’s main provider of humanitarian and development aid worldwide, President Trump called on Friday to “CLOSE IT DOWN” in a post on social media. Virtually all employees at the agency were already set to be put on indefinite administrative leave on Friday…
Gunflint, I've seen an awful lot of "Trump is shutting down programmes to heal the sick and feed starving kids" and so I wondered "well what exactly does USAID do or fund?"
And the answer seems to be "It's all about soft power" which sounds less to me about "we're doing this out of altruistic charity to help the needy" and more "we're doing this to make foreign countries come under our sphere of influence so they'll side with us".
"USAID is a foremost tool of U.S. soft power" - that's now how *I* would start off an article about how this is a vital humanitarian endeavour, but that's just me.
"... strengthened development efforts abroad that proponents say have underpinned U.S. national security and cultivated goodwill toward the United States." I do understand the political logic here, but it also shows that the whole topic is a lot more complex than the simple "Trump is killing sick people and kids!" messaging.
It seems it did not start off with charity as the prime end in mind:
"President John F. Kennedy created USAID via executive order at the height of the Cold War in 1961—based on authority provided in the 1961 Foreign Assistance Act—to counter Soviet influence abroad."
"The agency’s range of activities is broad and it aims to, among other duties:
“- provide assistance to strategically important countries and countries in conflict,
- lead U.S. efforts to alleviate poverty, disease, and humanitarian need, and
- assist U.S. commercial interests by supporting developing countries’ economic growth.”
I guess it's too bad if you're not strategically important and in need, you're down the list of targets to be helped? Okay, that's a little sarcastic, but the fact remains that politics and all kinds of other considerations are tangled up in this.
If Trump's administration strips away the superfluous and does reduce USAID to "relieve poverty and disease", maybe that would both fulfil the aims people think it currently meets and reduce waste. I can think of a lot of social media warriors for great justice who would be *very* unhappy with that part about "assist US commercial interests", for example, as just more colonialism and resource extraction from underdeveloped nations.
"In early February, the White House followed up with a list of projects overseen by USAID that it identified as “waste and abuse.” This includes millions of dollars given to the U.S.-based nongovernmental organization EcoHealth Alliance, which was allegedly involved in research at the laboratory in Wuhan, China, where the COVID-19 pandemic broke out."
I know we're still fighting over the lab leak hypothesis, but Fauci for one was involved in this research funding (one of the reasons I said in a reply above that in the future his gleam may be tarnished). One of the 'waste and abuse' items was described as "$70,000 for production of a “DEI musical” in Ireland":
This seems to be a concert that was put on by the US Ambassador, or hosted by them, in conjunction with Irish and other funding. I can't remember it because it's not something I would have been particularly interested in, but yeah - by the description, it sounds like somebody* got a nice little earner out of promoting a concert for an "equitable future" whatever that might be (the performers all seem to be white, so it's not exactly about minority voices):
I really don't see why a humanitarian aid organisation is part-funding a concert in Ireland which is already within the US sphere of influence. I would strip this out of the budget were it put before me as part of "tackling disease and poverty world-wide" for funding:
"The "DEI musical" was a public US/Irish live streamed cultural event co-sponsored by PwC & Coca Cola (they know that studies show that DEI policies improve corporate performance) hosted at the US Embassy in Ireland. Artists included the brilliant Grammy-winning duo Rhiannon Giddens & Francesco Turrisi"
Price Waterhouse Cooper, huh? Yeah, I can think of a *lot* of lefties who would not be one bit happy about the likes of that 😀
Take that seventy grand and put it towards a vaccination programme, I won't complain. A lot of conservatives won't complain. But funding a pleasant evening of schmoozing for the ambassador and guests? Where is that helping heal the sick and feed the hungry?
An Irish company is listed on filings published by the United States Government. The company is called Ceiliuradh, and has an address in Ventry, Co Kerry. It received a $70,000 payment in September 2022, the same month a live music event took place at the Irish Embassy, organised by a group called Other Voices. Other Voices Limited is registered at the same address, as is another company called South Wind Blows Limited.
The three companies in question are owned by a Mr P King, according to company filings. Ceiliuradh is described as a “minority owned business” and a non–profit. According to receipts from the US Department of State, it received the funding to “deliver a live musical event to promote the U.S. and Irish shared values of diversity, equity, inclusion and accessibility.”
The same month the payment was made to Ceiliuradh, an event took place at the Irish Embassy in Dublin called ‘Dignity 2022.’
A note on the event page said: “The Biden Administration is committed to principles of diversity, equity, inclusion, and access (DEIA). With this event we aim to highlight and celebrate the work that the Embassy, the Irish Government and our partners are doing to advance DEIA throughout Irish society. These ideals have long underpinned the strong relationship between both countries.” then-US Ambassador to Ireland Claire Cronin said ahead of the event.”
Other Voices also said: “Inspired by the shared cultural identity and history which bonds to the two places, these live performances will bookend a full day of events hosted by the U.S. Embassy and curated by Rethink Ireland celebrating DEIA in the civil society and business sectors.
“The event will bring together key stakeholders, leaders and social justice advocates with the aim of strengthening the equality landscape in Ireland, whilst also recognising ongoing inequalities in our society, current barriers to inclusion, and steps towards a more equitable Ireland.”
So yeah, USAID funds (funded?) a complicated mix of things, some of which you would sniff disapprovingly at, such as cultural festivals with a diversity committee to make the ethnic minorities feel welcome, and some of which you would hopefully not, such as HIV medication for babies born with the disease.
And yes, the ultimate goal of the agency is to maintain US standing and soft-power influence on the global stage, by giving lots of people all over the world various specific reasons to feel like Americans are helpful, friendly people, as opposed to a bunch of cruel domineering murderous jerks.
This is not actually a particularly sinister or unreasonable thing for a country to have a government agency for doing, when the country in question is a superpower that profits enormously from being in a position of economic and military pre-eminence at the head of a very large global alliance structure.
Having people in like 150 countries who think well of us because we did something good for them is a valuable asset, and cutting that money off abruptly and capriciously is going to undermine any attempt by the US to maintain its status as the hegemon in the coming decades as nations like China potentially step in to be the "nice, generous friendly people" that the US is resolved to no longer be.
Say what you want about Elon and DOGE hooking potentially-unsecured AI servers up to government health databases, it does in fact increase access to data.
It's not a "philosophy", it's a trademark for various scam products. He isn't against "big pharma" out of some "everyone eat organic, no processed chemicals" type of thing, he's against it because he wants people to buy his BS nutritional supplements instead.
>An impactful focus are for Makary could be addressing the practical and legal challenges that hinder
Grammar
>His contrarian COVID positions provoked censorship and harassment from Big Tech and the academic establishment; the experience seems to have low-key traumatized him
Maybe dont write this if you want to be nice to a righty.
I know it's a much smaller win but what about halting government from paying for subscriptions to these "exclusive" journals like Elsevier. And do something like "all government funded research will be available to the public for free" and create a very cheap online site that is fully searchable.
All government funded medical research must be published under a license that makes it open access after a year, I believe. They should extend that to all funded research, but they’ve got a good start already.
I didn't see any indication at the link that he lurks here. Rather, someone in the subreddit read his tweet (which doesn't mention ACX/SSC) and linked to it.
Yep. I saw JD mentioning Scott`s SSC post-title: "Gay rights are civil rites" in his interview with Joe Rogan - saying sth like: "See, it's a religion" - not sure, this is proof he read it (I would comment: "See it is a mainstream tradition now"), but I guess he did.
J. D. Vance strikes me as the kind of man who, given an intellectual work of philosophy to read, will selectively remember the bits that support whatever he wanted to believe anyway and then forget the rest. A man who was sincerely and deeply committed to objectivity, intellectual integrity, and prioritizing truth over feeling good about himself or what he was doing would probably not lead the life trajectory that he has.
Right. Scott's actually more influential on the right than he is on the left, despite being broadly on the left, because IMHO
1. He has this sort of 'neither left nor right' aura, so people read him for an extra viewpoint. Smart conservatives know they're 'on the outs' in the life of the mind to begin with, so they're more willing to read strange views.
2. He's discussed a lot of topics of interest to conservatives, and his blog has always been open to conservative commenters.
3. I think for whatever reason he vibes with conservatives more than liberals. In a lot of ways, like his pronatalism, appreciation for Chesterton's fence and old architecture, he's what a conservative born in a very liberal milieu might look like.
4. Most controversial: I think he's Jewish but not anti-white, so a lot of mildly racist people can read him without feeling like they're supporting the next Hitler.
Your suggestions seem to based on the idea that Scott is more influential on the right than the left because more people on the right read him. The best indication of readership would seem to be the ACX survey, and in the most recent ACX survey, about 2/3 of the respondents classify themselves in ways that I would consider on the left: liberal (35.7%), social democrat (29.0%), or marxist (1.64%). The remaining 1/3 classify themselves as conservative (10.1%), libertarian (19.7%), neoreactionary (1.99%), or alt-right (1.85%).
Excellent point and I was trying to figure out how to account for that. You've brought my enthymeme's assumption into the open.
I think despite his audience leaning majority left, he is more *influential* on the right, because he's known to have heterodox views no leftist can admit to (HBD, criticism of feminism and social-justice ideology). A left-winger can't admit to reading Scott, a right-winger can.
You could cite Richard Hanania on the right having a smaller bench of intellectuals, so that someone like Aaron Sibarium can be the most effective "rightwing" journalist even though he's a Obama-voter.
Well, I certainly have no qualms about admitting to reading Scott. I’m sure there are people on the left who are too close minded to read Scott, but less sure there’s a contingent who read him but won’t admit it.
In any case, I agree that readership doesn’t necessarily correspond to influence. Perhaps a better measure would be something like a citation index. If there are more links to Scott’s articles from conservative bloggers than from liberal bloggers, that would be a pretty good indication of influence.
Agreed, citation analysis would probably be the best way. I don't know if this sort of thing makes money for Substack, but the technology is there. I'm going to leave this out there in case one of the many techies reading this blog decides to write a script to answer the question. You'd probably search Substack's website, categorize bloggers as conservative or liberal through network analysis, and then see what network ACX is in. I'd bet it probably tracks with 'intellectual dark web' or whatever they're calling the leftmost end of the online right now.
It's not that more righties read him, but that the righties who do read him are more influential. Like JD Vance, for instance, but also the likes of Peter Thiel and (probably) Elon Musk.
It's very hard to imagine Kamala Harris or Tim Walz reading and quoting SSC. Influential Democrats don't read anything other than absolute doctrinaire left-wing stuff, which is part of the reason the Democrats are in such trouble.
That's not to say that there's not a bunch of smart left-of-centre people reading here, just that those people have absolutely no influence on the sort of people who actually get to make decisions on the left.
Those families of flu-viruses keep changing AND the new shot each year works just fine (I get mine each year, zero side effects), so why spent a lot of resources (brain, time, money) on something that may work worse - even the post sees the real value in keeping the staff busy while waiting for a more urgent task. But sure: nice to have. Likelihood it will be better than the ones we have: low, imho. Because the ones we have are actually working fine for those who do no fear a tiny needle.
>Because the ones we have are actually working fine for those who do no fear a tiny needle.
I thought it was closer to: fine _if_ the vaccine developers are successful at picking the right strain that winds up dominating this year's flu season else harmless but ineffective. My impression is that picking the right strain is pretty good (>50% ???) but not perfect.
If it works worse but a much larger portion of the population gets it (because they don't have to put any time or effort into getting the new shot every year), that may well be worth the tradeoff.
AIUI & IIRC, there's a particular site on every flu viral body – joining the variable H & N segments – that's conserved. A vaccine targeting that part could be effective against every flu.
Have we double-blinded putting air filters in schools and nursing homes and comparing outcomes? Even for places where we can't do an RCT, have the researchers, before looking at the data, come up with the theories they expect to see from it, ruling out other causes? (I am 0% surprised that poor areas have worse educational outcomes and more pollution, but that doesn't mean B caused A.) Can a group with access to all data except particulate count make as good predictions as a group with access to particulate count?
The issue with regulator reciprocity is that the moment it happens people venue shop for the lowest regulation barriers. This in turn tends to lead to regulatory harmonization to prevent that. Which in turn means you have international frameworks setting domestic regulation. In principle, this is fine... except that the EU wants to be protectionist, to favor domestic firms (and fine non-European firms a great deal), and have higher regulations than the US will agree to. And the US is not going to agree to let its rules be set in Europe. Nor will Europe let its rules be set by the US.
This is also why the EU and US don't have a free trade agreement. Europe is unwilling to accept American standards.
There's also the fact the US pays for, and produces, most medical research. Even most foreign medical products, like ozempic, is disproportionately funded by profits from sales in the United States. And the American medical industry (with some justification) thinks of Europeans as massive free riders. In fact they think most nations are free riders. And Europe is not going to concede the primary thing the US would want: to let drug prices rise there and fall in the US.
If you want to do this you need to either convince the EU to be a better partner or you need to go around it. And that's probably possible. The UK wants regulatory reciprocity. Canada and Australia can probably be convinced as well. Japan and South Korea also want a closer economic and research relationship. And those nations are about equal to the EU collectively without having its problems. You could maybe throw in Mexico if you want a cheap drug production base and to keep the USMCA intact.
For example, regulatory reciprocity could be introduced for certain classes of drugs only. Say, antibiotics or monoclonal antibodies. The low-hanging fruit is probably in drugs which save acutely threatened lives: patients with serious infections or active cancer.
That's the issue. There is no will on the European side because they want to continue a system that benefits them and won't make concessions the US wants.
> The issue with regulator reciprocity is that the moment it happens people venue shop for the lowest regulation barriers
> the EU wants to be protectionist, to favor domestic firms (and fine non-European firms a great deal), and have higher regulations than the US will agree to
Putting these two together, it sounds like you're saying that the US regulations will be the ones businesses would target. If so, then unilaterally allowing EU rules in the US seems like it wouldn't be worse than the status quo?
What we see in practice is that the FDA is way more conservative than EU medical regulators, with the result that new medical devices and products are often available in the EU for years, sometimes decades, before being offered in the US.
No, that's not how it'd work. If America opens up unilaterally then regardless of which one is lower they will use the European one. Because that means using American standards won't let you into Europe but using European standards will let you into America.
If you want to outsource American medical regulation to Europe you can make that case. But I don't think it'll be politically sustainable. Especially because it would cause jobs to leave for Europe and mean the US would have to constantly watch European standards and lose that bit of sovereignty in exchange for nothing.
But aren't drug manufacturers already using European standards? Most drugs available in the US are also available in the EU - see e.g. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2795755 - so it seems most manufacturers do the testing, paperwork, etc, to both US and EU standards.
This almost certainly involves wasteful duplication of effort, so there would be at least some benefit to reciprocity. Or even unilateral half-reciprocity, so long as the Europeans aren't approving horribly unsafe or ineffective drugs.
No, they're validating and often producing the drugs in both markets sometimes to subtly different standards. Eg, a lot (I think a majority) of the ozempic in the US is made in North Carolina. Which is itself a political economy issue if you want to open up the US to European factories but not vice versa.
The actual middle ground here would be to have a fast track where the standards aren't harmonized but you allow the other company to submit evidence from compliance in the other market. These are called MRAs or GMP certifications (at least in non-medicine). And you could have one of those unilaterally without much issue. I'm not sure if we do.
For example, if US standards are you need to have no mercury based preservatives and at least 1 part per million of saline (or whatever) then the approval from the EU that shows it has at least 1 part per million of saline would be accepted by the US as evidence of that fact. They would then just have to prove it meets the mercury requirement.
"$50,000 in refundable tax credits for people who donate kidneys to strangers."
Claude 3.5 says that among living donors, approximately 60-70% are biologically related family members of the recipient. The restriction that only strangers can be paid will discourage relatives from donating, in the expectation that a non-related donor will come forward. If every related donor is replaced by a non-related donor, that might cancel out all the gains of the new policy.
If compensating kidney donation is so effective that family members are confident someone will come forward to donate, then mission accomplished! At that point what you're proposing is a situation where almost everyone who needs a kidney get one, which is an improvement over the current situation.
We don't know how many people would sell their kidneys at any chosen price. If the number of people eager to sell a kidney for $50,000 turns out to be about the same as the number of relatives able and willing to donate a kidney, you might end up with the same number of patients getting kidneys, due to related donors backing out. Then people could point to the program and say it had no effect, even though it motivated a lot of people to donate kidneys who otherwise would not have. The problem isn't that less people would get kidneys; the problem is that the program might be stopped for not increasing the number of kidneys donated as much as expected.
Meanwhile, on the other hand, I can think of no good reason not to pay relatives to donate their kidneys. It seems unjust.
> If the number of people eager to sell a kidney for $50,000 turns out to be about the same as the number of relatives able and willing to donate a kidney, you might end up with the same number of patients getting kidneys
But not the *same* patients getting them. Some of the patients who would otherwise have received a kidney donation from a relative will get stranger kidneys, but others won't. For those who don't receive a stranger kidney we would expect a family member to donate. This would increase the total number of kidneys donated.
You are right that it would be most efficient to pay everyone, regardless of family status.
Here's a suggestion for another item: Consider combination therapy. During Covid, there were several drugs or herbs which were shown to be effective with over 80% but less than 95% confidence. Advertising any of these for treating covid was forbidden by the FDA and denounced by the CDC as misinformation, even though one could combine 2 or 3 of these therapies and say that combination therapy had a greater than 95% chance of being effective.
I don't know how to implement that. Maybe just enforce a policy at the CDC of not calling things "proven ineffective" when they were proven effective with less than 95% confidence. Maybe make it very easy (no studies) for the FDA to approve a combination therapy of multiple therapies each of which was proven safe by current standards, and which taken together, with an independence assumption, can be proven effective to current standards just by doing the math on the p-values of the studies for the effectiveness of each separately.
Which drugs or herbs had >80% confidence in being effective? Also you can’t just multiply confidences like that. You could do a study which compares a combination therapy to a placebo and see if that is effective.
There were a metric shit-ton (to use the technical term) of experiments done during the early days of the pandemic world-wide by everyone trying their favourite theory that "megadoses of vitamin D will cure it or at least help people recover!" and some of them, according to the bodies carrying them out, totes worked absolutely.
Except when digging deeper, as some meta-studies did, those studies weren't worth spit. Ivermectin was a popular one, alone or in combination with the kitchen sink thrown in. Scott also did a post way back on the meta-study comparing all those studies, and I did some digging through and a lot of them were very shaky, to say the least (e.g. "we started on this dose, half our subjects dropped out, halfway through we switched to this drug instead, and now we're saying that of our remaining subjects, not all of them died").
Some people are still convinced that "this one Brazilian hospital experiment proved that clover in combination with doing six hours of tap-dancing weekly shortened hospital stays and overall mortality rates".
That’s not how p values work. If you change your protocol so that you’ll allow approval on its own if it passes one threshold, and also allow approval as part of a combination if they all pass some second threshold, then there are two possibilities for error instead of just one. The p value is the probability of any error resulting from your protocol, so this new protocol creates higher p values for the same threshold. You’re not allowed to change the protocol after you’ve got the results.
This is great, more of this please! Identifying good policies that this administration might implement would be great. If we have to go through the next four years of trump we might as well get something out of it.
Can we please stop pretending effective altruists are any significant percentage of clinical trial volunteers? You guys didn’t invent clinical trials, you just discovered them a very few years ago. It feels insulting to all the other volunteers to see their work credited to a movement they likely never heard of.
I think this is literally true for human challenge trials? There aren't that many of them and it's pretty weird to get involved. Most of the news articles I've seen on human challenge trials mention the EA connection.
I mean...wanna bet? I think you're getting misled by what you hear from your acquaintances and EA-focused news sources, whereas the typical clinical trial volunteer is never likely to cross your radar.
I can tell you I've been in five clinical trials and never encountered any participants with known EA motivations, nor did researchers seem to expect EA motivations. I expect this is different for a few particularly trendy human challenge trials (like those that get advertised on major blogs), but overall I would expect participants in human challenge trials to be similar to the demographic of people in clinical trials more generally.
It IS weird to be in a challenge trial, but it's even more weird to be an EA, and getting paid is a very salient motivation that draws most of the volunteers—you can get roughly a few thousand dollars for non-full-time non-skilled work. Many clinical trial volunteers are "repeats" who have been doing this for years. EAs, on the other hand, only got interested in challenge trials within the last few years.
Were any of the clinical trials you were involved in, human challenge trials? Because it seems quite plausible that the demographics there would be substantially different than for more ordinary clinical trials.
Yeah, I disagree, because although challenge trials are legally different from other clinical trials, the experience of the volunteer is similar. The same people who are willing to take experimental drugs for money are willing to get infected for money. The main difference is that many challenge trials require you to be isolated for infection control purposes, but they also pay you more to make up for it.
To answer your question, I haven’t actually been in a challenge trial, but i’ve gotten close enough to understand how they work
I think human challenge studies for vaccines are a good idea and I appreciate 1daysooner championing them. But I find the focus on vaccines a little odd, given how much more useful challenge studies would seem for other research.
Here are some questions that are difficult to answer without challenge studies but easy to do with them:
- How much does the dose of a virus you're exposed to effect the likelihood and severity of illness?
- If I had close contact with a sick person already, how much does additional exposure to them increase my odds of catching their illness?
Does anyone know if we have good answers to these questions? Have we at least done the obvious experiments on animals?
This is what I was saying during the pandemic. A challenge trial on the vaccine alone wouldn’t tell you what you want to know, unless you had also done challenge trials prior to the vaccine. And these challenge trials could tell us more about the effectiveness of masks and spacing and outdoor activity as well.
The downside of regulatory reciprocity is that you probably wind up with all drug approvals being dumped on whichever country provides the friendliest process. So every gets considered by the National Agency for Medicines and Medical Devices of Romania or something, and all other countries just follow suit. Pretty soon, all other countries have shut down their drug approvals bureaucracy and forgotten how to do it, so we're all dependent on the vagaries of the Romanian agency and hoping it doesn't turn corrupt.
I suspect that what you really want is temporary reciprocity. If something has been approved in one country, then it is available in all other partners for two years, giving your agency time to catch up or shut things down.
"support 'Americans should be allowed to buy any and all medical products as they damn well please' "
Don't worry, Grim Trigger, I fully support your right to consume as much adulterated products as you desire to bring you to an early grave. Why should I step in to prevent you killing yourself?
Banned for this comment, but I mostly do support "Americans should be allowed to buy any and all medical products as they damn well please" - it's just not a realistic policy recommendation, even for this administration.
I think you’re making the same mistake here that you made in the USAID piece yesterday: facilitating a con against MAGA voters by making it seems as if doomed half-proposals certain to be largely stopped by the courts represent “getting something done.” They don’t. Nothing, least of all destruction of bureaucracy, has been accomplished here. It is a proposal, and so far one that is likely to fail in its core elements.
> Bhattacharya is a rare doctor and medical professor who also has a PhD in economics. His contrarian COVID positions provoked censorship and harassment from Big Tech and the academic establishment; the experience seems to have low-key traumatized him…
Scott: You do your readers a great disservice by trying to whitewash Bhattacharya’s behavior. Let’s do some fact-checking.
Re: his qualifications: Bhattacharya has an MD, but he never undertook nor completed a medical residency — nor has he a license to practice medicine. Rather than becoming a medical professional, he hopped over to get a PhD in economics. Since he never completed a residency in preventive medicine, he can’t really be called an expert in communicable diseases or epidemiology — nor does his PhD in economics equate to a research fellowship in infectious diseases or microbiology — and it doesn't qualify him to be an expert in public health. Yet he's being treated as such.
Re: his claims of harassment and censorship: It’s funny how rightwing talking heads get all upset when people push back on their opinions. This is the man who never passed up a chance to denigrate Dr. Anthony Fauci — calling him, among other things, "probably the number one anti-vaxxer" in America. (And Fauci, BTW, happens to have an MD and completed his residency, and he spent his career involved in basic and applied research to prevent, diagnose, and treat infectious diseases such as HIV/AIDS, respiratory infections, diarrheal diseases, tuberculosis, malaria, and Ebola.) Despite all the “censorship” directed at Bhattacharya, he was a regular on Faux News, and the Murdoch media empire gave him plenty of coverage in publications such as the Wall Street Journal.
Worst of all, he’s either intellectually dishonest or a crank. Despite being confronted with the evidence that he was wrong about so many things during the pandemic, he’s doubled down and claimed he’s been vindicated. Among his most egregious errors were stating that COVID was just the flu while mass burials were happening in NYC. He fabricated data about the rate of SARS2 asymptomicity. And he fought tooth and nail against non-pharmaceutical interventions such as masking and social distancing — even when confronted with the evidence that the SF Bay Area and Seattle area counties that imposed these policies early saw many fewer deaths than places like NYC that implemented NPIs late. That meme that COVID is just the flu is still echoing through the right-wing media.
Sadly, he’s whining about the trauma of being criticized and snubbed by his peers while ignoring the trauma his actions caused tens of thousands, perhaps hundreds of thousands, of people who lost family members because they didn’t take precaution or bother to get vaccinated because COVID was “just the flu.”
Everybody can remember what they got right about this brand new phenomenon and nobody can remember what they got wrong about the pandemic.
Dr. Bhattacharya's studies in the spring of 2020 did an excellent job debunking his own theory that so many people were infected that covid was approach herd immunity already. For example, from the Los Angeles Times:
"Fewer than 1% of MLB employees test positive for COVID-19 antibodies
"By BILL SHAIKIN STAFF WRITER
"MAY 10, 2020 3:26 PM
"The coronavirus outbreak largely has spared the baseball world, with data released Sunday to prove it.
"Of the 5,603 major league employees who submitted to what researchers called the largest national antibody study to date, only 60 tested positive, researchers said Sunday.
"... The researchers announced an estimated positive rate of 0.72% after adjusting the results for what they said were false positives and false negatives. ...
"Still, the minute percentage of positive tests provided a data point as scientists determine how wide the coronavirus has spread within the United States. Bhattacharya said he expected a larger positive rate.
"“The epidemic has not gotten very far,” he said. “We have quite a way to go.”"
Hmmm. Here's the timeline of the links I have in my notes.
In March of 2020, Bhattacharya co-authored a Wall Street Journal op-ed titled "Is the Coronavirus as Deadly as They Say?" In it, he questioned the estimated fatality rate of COVID-19, suggesting it might be closer to that of the seasonal flu. It was picked up by Faux News and re-echoed around rightwing media outlets. Note: There were yet no seroprevalence studies, but he was already claiming its IFR (the Infection Fatality Ratio) was no worse than the flu based on no data at all. So, Bhattacharya was just bullshitting at that point.
Late in April 2020, Bhattacharya et al. released the Santa Clara Seroprevalence Study. The study concluded that COVID-19 infections were 50–80x more common than reported cases. It put the COVID IFR between 0.12–0.2% — which is suspiciously close to the range of seasonal flu IFRs (0.01% – 0.1%) and conveniently less than the IFRs of 2009 H1N1 Swine Flu (IFR of 0.01% – 0.03%), the 1957–1958 H2N2 Pandemic (est IFR of 0.1% – 0.3%), the 1968 H3N2 Pandemic (est. IFR of 0.2% – 0.4%). Meanwhile, NYC was setting up temporary ICUs, refrigerated trucks were brought in to serve as temporary morgues, and 100+ COVID victims were being buried each day in mass graves on Hart Island.
The Santa Clara Seroprevalence Study never went through peer review. When the data was examined, other researchers raised serious questions about the study's methodology. Bhattacharya and his co-authors used Facebook ads to recruit participants. The study was criticized because of likely selection bias — i.e., people who had symptoms or believed they had been exposed might have been more likely to volunteer, leading to an overestimation of the actual seroprevalence. Also, the study used antibody tests for Premier Biotech — and it later came out that they gave an extremely high false positive rate. Some experts questioned whether the authors hadn't P-hacked their conclusions. Also, David Neeleman, co-founder of JetBlue Airways, who was fighting for fewer COVID restrictions, reportedly funded the study (conflict of interest, anyone?) At any rate, the samples were not representative of Santa Clara County’s demographics.
There were calls to retract the study, but Bhattacharya and his co-authors never did so. Instead, they circulated it to media to make their case that COVID was no worse than the flu.
Throughout 2020, Bhattacharya continued to argue that COVID-19's risk was highly stratified by age and that for most people and it posed a risk similar to the flu for younger age cohorts. For instance, in a December 2020 interview with the Ron Paul Liberty Report, he stated that for young and healthy individuals, COVID-19 was "less deadly than the flu." (Sorry, but the link I have for this interview gives me a 404.)
Meanwhile, a slew of studies had been done that showed the IFR and CFR for COVID was higher than the flu even for younger age cohorts. John Ioannidis (ironically, from Stanford University) published a meta-analysis early in 2021 that put the IFR for COVID for ages 25-34 at between 0.01%–0.02%. The IFR for ages 35-44 was 0.02% – 0.05%. and it increased progressively with age.
In flu seasons before 2020, young adults (20s-30s) had extremely low IFRs, close to 0.005% or lower, while those in their late 30s approached 0.01%.
In October of 2020, Bhattacharya was one of the lead authors of the Great Barring Declaration. The American Institute for Economic Research, a conservative free-market think tank located in Great Barrington, MA, commissioned the opinion piece. The AIER also funds studies that claim to refute anthropogenic climate change. The Great Barrington Declaration claimed that NPIs were more harmful than beneficial for most of the population, but it provided no evidence for this assertion.
Frankly, I think Bhattacharya's behavior over the course of the pandemic was despicable. Given his history with SARS2 and COVID-19, If an A(H5) pandemic revs up, I doubt if he'll be there to throw us a life preserver.
Why is it despicable to publish an important hypothesis and then quickly conduct and publish several studies -- such as Bhattacharya's study showing very low coronavirus infection rates among employees of 26 major league baseball teams around the country -- that debunk your own theory?
Is it because Bhattacharya's opponents tended to be too stupid to realize that his own studies proved them right?
I feel like very few people distinguished themselves intellectually during covid. I certainly didn't get that much right, but at least I could read Bhattacharya's studies and see that they falsified his own theory.
Shouting fire in a crowded theater (when there isn't one) is considered to be reckless endangerment—and if people die in the resulting panic, it's considered to be a felony with harsh prison terms. Wouldn't gaslighting people and telling them that there's no fire in the theater (when there is one), and that it's all smoke and mirrors, also be reckless endangerment?
Yes, there were all sorts of early studies and models put forth that turned out to be wrong. In fact, I'd say that with SARS-CoV-2 and COVID-19, never have so many experts been so wrong about so many things! I’d respect them if they said, "Oops, I was wrong." That means they’re learning from their mistakes. But Bhattacharya still denies that NPIs reduced the mortality rate among the general population. And he continues to claim that COVID-19 wasn't much worse than the flu among the general population. That he continues to insist on these things despite the evidence to contrary suggests he's either a fool or a con man. Well, our culture is full of fools and con men, but what I find despicable is that his foolishness or his con contributed to the death COVID-19 death toll by downplaying the seriousness of the pandemic.
> Shouting fire in a crowded theater (when there isn't one) is considered to be reckless endangerment—and if people die in the resulting panic, it's considered to be a felony with harsh prison terms.
That case was partially overturned though. The standards for punishing speech is extremely high nowadays.
> In that ruling, the Court wrote that the First Amendment prohibits state regulation of advocacy unless that advocacy "is directed to inciting or producing imminent lawless action and is likely to incite or produce such action." Inslee's press release omitted any mention of an imminence requirement. As First Amendment scholar and Volokh Conspiracy blogger Eugene Volokh told Reason, imminence is a high bar. An example of imminent lawless action, Volokh said, is "standing outside a police station and yelling 'burn it down.'" Claiming fraudulent election results, Volokh said, is not incitement.
I blogged about that Bhattacharya's Santa Clara study on April 17, 2020. My headline read:
"Infection Rate in Silicon Valley in Early April Was 1% to 6%, Suggesting Infection Fatality Rate Is Much Lower Than Case Fatality Rate, But That Herd Immunity Is Far Off"
"Today, Santa Clara County has 1,870 official cumulative cases, with a current doubling rate of every three weeks, one of the lower in the country. Today, it has 73 official deaths. So that’s a Case Fatality Rate of 3.9% (which I don’t think anybody believes anymore).
"On the other hand, that looks like a long way from herd immunity, which is usually assumed to be over 50%.
"There have been two popular arguments for optimism:
"Infection Fatality Rate has been much lower than the Case Fatality Rate
"We are practically to Herd Immunity already
"This new paper seems to support the first proposition, but not the second."
I can't get around the paywall to access that full article, but from the bits I can see, they're suggesting the infection fatality rate may be 10 or maybe 100 times smaller than the case fatality rate of 2-4%. My own best estimate is about 0.2-0.5% for people under the age of 75, so this seems about right. The whole thing is worded with the amount of uncertainty I'd expect of something published in spring 2020 and does reference the data available then, rather than just "bullshitting".
A 0.2% fatality rate across NYC's population would be about 16,000 deaths. Obviously not everyone in NYC got infected, but there's no contradiction between this number and mass graves.
It is not normal to retract a study over small inaccuracies such as you list, especially when they are hearsay. If other researchers had a problem with it, they should publish a rebuttal or perform their own study. This is a good example of attempted censorship.
> Bhattacharya continued to argue that COVID-19's risk was highly stratified by age
Oh no, he wrote an opinion piece for conservatives! Who think conservative things! But I see no evidence that "The Great Barrington Declaration claimed that NPIs were more harmful than beneficial for most of the population, but it provided no evidence for this assertion.", rather what I see in the piece is "Simple hygiene measures, such as hand washing and staying home when sick should be practiced by everyone" which sure sounds like recommending non-pharmaceutical interventions to me.
I think covid's in a really awkward spot for being able to communicate its severity accurately. Because before vaccines, it really was about 10x worse than the flu (excluding the elderly). And people round the flu to 0, so they round 10x that to 0 as well. But it's really not, so everyone makes sure to say extra hard that it's an awful pandemic so nobody gets confused. But then when I think awful pandemic I'm thinking smallpox or black death or at least measles or polio, which is even farther from being an accurate comparison. If I really have to shove it in one of those boxes, it better go in the flu one.
Edit: Now that I'm actually looking up the measles fatality rate, it's a good bit lower than I'd thought and actually not too far from covid. Today I learned.
Please don't do this. The rest of online activity is bad enough with everybody calling everybody else insulting names, I'd like if we could be better than that on here. I've never liked Murdoch nor his opportunistic media empire (which he directed to switch allegiances as to what political party to back, depending on how he thought it would grow his bottom line) but Fox News is as valid a news station as MSNBC and the rest of them (note, that does not mean it is not partisan nor that it is particularly excellent, but as a non-American I'm probably more used to media being openly partisan than Americans so this is something I both expect and know to discount).
As for Fauci, well I think he's not someone whose basket you should put all your eggs in. I think he'll end up like Avenatti one day - the skeletons will tumble out of the closet and all the enthusiasm for him as heroic fighter against orange man bad will come back to embarrass the enthusiasts.
I'm happy to read you laying out the facts about this Bhattacharya guy, but please try not to revert to Bluesky posting name-calling. We seem to already have Grim Trigger in a comment doing the good old "I'm going to call people I don't like names" with "Dempanic neurotics" and such like (presumably that would refer to Democrat supporters and that might include you, beowulf888?)
Point taken, but I guess the question is: should we be publicly respectful to fools and charlatans? I find the COVID hysterics to be just as obnoxious and annoying, but at least they didn't try to gaslight people into believing the pandemic wasn't serious.
I was considering putting together a list of what Fauci got wrong and what Fauci got right during the pandemic. It would also have to include how his words and his actions have been distorted by both the rightwing mouthpieces as well as some of the aforementioned COVID hysterics. I'll try to get that done for not the upcoming open thread but the following week's open thread.
Please consider the possibility that insulting him in a post intended to convince him to do things would have been a bad idea.
I admit writing a post intended to convince people to do things is dangerous because it creates incentives to say false things, but I tried my best to balance these considerations.
At the beginning of covid in the spring of 2020, Jay Bhattacharya put forward an important hypothesis: that the coronavirus wasn't much of a threat because a huge fraction of Americans had already had it so the public was getting close to herd immunity. He then quickly put out, if I recall correctly, three studies he'd done of this question, all of which showed he was wrong. My favorite was his study of how he'd gotten 26 of the 30 major league baseball teams to each have 200 of their employees tested for coronavirus antibodies. To Bhattacharya's surprise, the results for the 5000+ baseball franchise employees, players, coaches, and office workers, showed that infection rates were in the low single digit percentages.
All this strikes me as admirable. He put forward a theory that might have been true that he strongly wished was true, and then he disproved his own theory with good scientific studies.
Exactly. His assumptions about this turned out incorrect, he bravely admitted it but he was basically right about everything else.
The fact that this community is so much against him made me rethink and lose faith in rationalists. They even did many other things not based on evidence, like demanding Paxlovid for non-risk groups etc.
Covid restrictions were assault on my freedom, my rights and also an insult to science. Possibly these all was due to fear of death. Many rationalists speaks endlessly about immortality projects and their own plans to achieve it through cryopreservation etc. I consider it all unnecessary. Even if admirable in principle, we don't have such technologies yet, maybe will not have for several hundreds of years. Accept your mortality and spend your time in the best way.
The main function of the FDA proving efficacy of drugs is telling doctors what they should prescribe and insurance companies what they should cover. That function might be better served by a different agency or by a non-governmental organization. But it's clearly a job that needs at least some centralization, as we can't expect doctors to follow the entire literature.
Fair enough. My point is that “safe but useless” makes it no different, and no better, than placebos. Whatever agency that job falls upon, if the bar is “safe but useless”, you’d be getting placebos approved.
> There was a movement to have some of these during COVID - which would have sped up vaccines, shortened lockdowns, and saved tens of thousands of lives
I’m 100% in favor of vaccine challenge trials, for any disease out there. But specifically for Covid, is that actually true? Let’s say they got together a bunch of EAs and all 3 leading vaccines (Pfizer, Moderna, AstraZeneca) got approved. By how much would this have sped up the manufacturing capabilities in practice? My understanding is that a lot of the constrains were logistical and at least Pfizer operated under the assumption their stuff is going to work.
There were also plenty of restrictions *after* mass vaccination was complete. The U.S. didn’t lift the absurd Europe travel ban until November 2021, even though the ban didn’t make sense since Day 1 given that it exempted US citizens, as if Americans were magically more immune to the virus. Same deal with China that finished vaccinations and then… spent another year and a half in pointless restrictions.
This is pure fantasy on the part of the author. The changes to health policy advocated here depend on the vast apparatus of government health bureaucracy still being in place, like it or not. What we have going on here is the wholesale destruction of our bureaucratic apparatus, to be replaced by ideologically aligned loyalists.
You are not going to be able to get these magical policy improvements if the apparatus for funding, directing, regulating and implementing them has been destroyed.
This post might have been interesting to think about before the inauguration, but now that we see the current path of this deliberately broken executive branch, looking around to see which pet-causes might be favored is an act to be done only by the un-serious.
On kidney donation, it would be great if someone could build and most importantly enable a marketing/publicity machine support it, a system that let's people know about those in need about 2 steps removed.
I would know if my immediate or even extended family needed my kidney and would donate if I could. I already know that many fellow citizens would benefit ... but I am too selfish to donate. But what about someone in my kid's hockey league? I probably have seen them at games. They would be in my broader tribal circle. Or living in my neighborhood? Or fellow patron of a certain blog/substack.
The weak form of this (sympathetic recipient, much publicity) seems to happen regularly. Some cute little girl gets some local TV publicity and some local (maybe the assistant manager at the local grocery store) sees it and donates. Seems like targeted social media and better access to data could weaponize tribal sympathy.
this is a great idea. It seems like social networks mostly have the information needed to do this, i wonder what the best way to motivate them to do it would be
My suspicion is that the more we centralize these requests, the less effective each appeal will be, psychologically. Compare with medical expenses kickstarters: people often donate a small amount to acquaintances when the link is shared socially, but hardly anyone just goes to kickstarter.com and scrolls through the "medical" tag. Tribal sympathy is only triggered through the tribe's ordinary communication channels.
OMG, I love you! I'm subscribing here again, (After a hiatus.. giving my limited $ elsewhere.) The Trump train is a potential time of change, and you can just get on one of the cars. And still not support any of those other cars. (Though we are all cars on the same train, and there remains some connection... )
Personally I really like Bobby and Tulsi and Kash. A time of change I hope.
Oh an idea for an ambitious post. The exact amount of waste in all the federal departments is hard to know. But let's make a guess for each one. And how much we could potentially save. Defense contractors seem like a highly centralized part of spending. What if we took 1/3 of the defense budget and sent it out for bids by smaller companies? Or some other idea to make better guns (things) for cheaper. I guess the hard nut to crack is Social Security (SS). My next door neighbor is a few years younger than me. But his body is way more broken, because he was a bricklayer for much of his life.
The defense procurement budget mostly goes to things that can't realistically be made by smaller companies. You're not going to get anyone smaller than Huntington-Ingalls to build a fleet aircraft carrier. You could maybe imagine something midway between Lockheed-Martin ($71E9 gross revenue) and Saab AB ($5E9 gross revenue) that could develop our next-generation combat aircraft, but that wouldn't save all that much and it runs into the problem that no such company exists.
"...focus are for Makary..." ? "...focus Marty Makary..." would make more sense to me. But how does a focus have an impact? I can't really understand this sentence. Our host did better without coauthors.
I'd be surprised if the Trump administration acts on any of them, but if even one gets read by all the conservatives who secretly and not-so-secretly read your blog it will do some good. So, thanks.
These are great! I'm surprised there aren't far *more* suggestions!
Also I would love if you gave more direct political thoughts and ideas. Just a personal preference.
This was recently discussed on the sub, if you're interested: https://www.reddit.com/r/slatestarcodex/comments/1ij5dfm/i_legitimately_dont_understand_what_scotts_line/
Why is there a sub?
Back when Scott wrote at Slatestarcodex, enough people found the on-site commenting to be frustrating enough to set up a subreddit, and it became increasingly popular.
It was about as lacking in features as Substack comments, but at least the old comments could reach into the hundreds without struggling to load.
When trying to get cross-partisan and non-partisan support, it’s good to avoid expressing explicit political thoughts!
What an excellent initiative !
I look forward to the follow up one year later... what am I talking about, with this Trump administration it might well be in 3 months.
“ Regulatory Reciprocity: I will keep this one in here until somebody does something about it. It’s the idea that Americans should be allowed to buy medical products if they’ve been approved by some trusted ally, like the European Union, possibly in exchange for the EU giving FDA-approved products the same deal in Europe.”
Good luck with that. States don’t respect other states’ licenses of US trained physicians so do their own multi month process and health systems don’t trust state licensing as an indication of vetted training, requiring 3 months of their own vetting and confirmation process (credentialing). Have a hard time believing international regulation regimes have much of a shot.
I mean its a lot easier to be confident some drugs do what they say they do / aren't dangerous than to be confident that all medical professionals coming into your jurisdiction are up to your standards...
Licensing is mostly to form a labor cartel, hence the frequent grandfathering of incumbents.
Why does it need to be reciprocal in the first place? We could just have way looser regulations and just automatically approve anything the EU approves. The EU doesn't need to approve our drugs in turn, because they absolutely shouldn't trust us anymore.
Because that would encourage biotech companies to focus entirely on the EU and ignore US regulations entirely. Likely physically relocating there and crippling the US medical research industry.
But they could still sell drugs here that would never be approved in the EU.
Its probably is to convince president trade war
Make it "Americans should be allowed to buy medical products *with a prescription* if they’ve been approved by some trusted ally."
IMHO, while there are arguments that the FDA should have the power to deny people the right to have any drug they want, there are no good arguments why the FDA should have the power to prohibit doctors from prescribing drugs, even if the /aren't/ approved by some trusted ally. So this seems like a no-brainer to me.
This!!
I agree!
>there are no good arguments why the FDA should have the power to prohibit doctors from prescribing drugs
Granting every individual expert the power of granting access to X is barely a safeguard. Before long word will get out which doctors will prescribe each drug and people will choose the doctors who will give them what they want. Also, this would incentivize doctors to relax their standards to get more paying patients
This is /already/ the situation we're in, for things much more hardcore than the median EU-but-not-US-approved antacid or whatever (what will be more nanny-state-unapproved than oxycodone, methamphetamine, ketamine, ...?), so it's hard to see the rationale for "one more drop in the bucket is toooo far!"
There is nothing I hate in all the world more than the fact that credentialism applies even to the decision as to what substances I am allowed to consume. What am I, a fucking toddler?
.
(I know this is orthogonal to the thrust of your comment but to see it phrased so bluntly and blithely—as if /of course/ we'll need permission as to what we can eat, that goes without saying! ...and, unfortunately, it does—just scrapes at my soul)
I get it, there are quite a few cases where I'd like to be able to bypass doctors and think I could do a reasonably good job of it. But some drugs are very poisonous and some people are very stupid and as a society - not just doctors but everyone- we're totally unwilling to accept somewhere between hundreds and tens of thousands of people dying because they heard from a friend of a friend that Digoxin is really good for your skin tone or something. People just won't accept that- so the question is not whether we regulate, but how since regulation is a political inevitability.
Isn’t thalidomide the strong case against this? Mind you that may be horribly outdated by now, but it sure loomed large at the time.
Thalidomide is a case against it. 10,000-20,000 thalidomide babies were born according to Wikipedia. But we must weigh that against the number of people unable to buy drugs because they can't afford them, and the people unable to buy drugs because they were never made, because they couldn't be profitable.
Personally, I also weigh the fact that in my limited experience, the FDA approval process is worthless. I was studying the safety of long-term exposure to aspartame and saccharin in 2012 or so, and I read maybe 80 studies on aspartame done over a period of almost 50 years, about half of which said it was safe, & about half of which said it was terribly dangerous.
It was approved once in 1974, but this approval was revoked in 1975. It was approved again in 1981, just after Reagan was elected with the help of Searle CEO Donald Rumsfeld; there are suspicions this was political payback. In 1991 aspartame was linked to brain tumors, and it went thru another review process, and was finally approved in 1996.
I read the notes for the meeting at which it was approved. The committee had a large number of drugs to vote up or down in one meeting, and would have had about half an hour for each if they divided the time up equally. It was obvious that all they did was quote points from the conclusions of one review study of the safety data published shortly before that meeting. The study was so terrible and stupid--one of its arguments was that, sure, aspartame produces formaldehyde, but formaldehyde (they said) is not actually toxic to humans!--that I checked the biographies of the study's authors, and found that every one of them was employed by pharma companies with an interest in approving aspartame. The study did not mention this conflict of interest.
It makes me wonder how many of those babies would’ve been born. had that drug been approved for use in the United States. Still I take your point. I certainly won’t argue with you about it because I don’t have enough knowledge. I’ve heard some pretty crappy things about the FDA
It's very weird that 1) there are things that you CANNOT have access to, unless they are prescribed by a doctor; and 2) once a doctor has made it through any medical school and doctor process, they can prescribe whatever, with zero or no checking if it is necessary, more or less forever; and you can find such a doctor to prescribe you, say, a diabetes drug even though you don't have diabetes, for enough cash.
This was basically the process for my getting a prescription for regulated ADHD drugs: "Do you have ADHD?" "Um, well, I'm not a doctor, I guess I have trouble focusing sometimes..." "You have ADHD. Here's your prescription." Total conversation: 15 mins, total cost $350
I think the reason for having a lot of medications restricted to "must be prescribed by a doctor, any doctor, we aren't fussy" is to screen out hypochondriacs and people who a five-minute conversation will reveal do NOT actually have a need for the medication.
Every year, people die because of forgetting fairly basic stuff like "you really really shouldn't take Tylenol and drink alcohol at the same time." There are a lot of medications with side-effects much more complicated than this, or which need to be taken on very precise time schedules, or in conjunction with obscure secondary medications. We could abandon the requirement for prescriptions and just say "caveat emptor," but the guy saying "caveat emptor" probably isn't going to have to bury all the dead bodies.
Every year, millions of people blow thousands of dollars each on totally useless 'supplements' and random placebos like homeopathic medicines, because it's legal to talk people into spending a ton of money on pseudo-medicine that does nothing. If pharmaceutical companies, which in the US can already advertise direct to clients, could also SELL their products directly to clients without a prescription, then they'd be able to get into that market too, and a gullible person's money spent on medicine they absolutely don't need is going to spend just as well as the money of someone who does need the medicine.
Every year, tons of people mis-diagnose their own health complaints or decide they don't have problems they really do have. Every year people think "gee, I could get access to amphetamines if only I could convince someone I have a condition that makes it necessary." Every year people think "gee, some of these real medications would make great precursors for illegal drugs if only I could find them!"
The point isn't to make it super-duper-difficult to get medicine, it's that the combination of cost and risk that goes with a lot of medications is high enough that it would be very reckless for a society to just say "you can get literally any medicine you want and can pay for." If nothing else, health insurance companies would probably start shutting down their pharmacy plans immediately, to avoid being bankrupted by random superfluous spelling.
Licensing is not about distrusting the standards of other jurisdictions, though that's often the reason given; it's about people limiting their competition so they can reap the benefits of protection. It doesn't seem to me that reciprocity of drug approval would face the same hurdles, ie special interest groups wanting to maintain protective barriers against labor competition
This just strikes me as part of libertarianism. We should mostly just let the people involved (buying the drugs/ thing) decide what to do. But with some guard rails. Letting US residents buy get drugs from Canada or the EU, makes total sense to me.
NIH grants $48B/yr with no meaningful oversight of the quality and integrity of research data or the processes and systems labs use. We know how to do this - witness the Toyota Production System or the transformation in software quality due to Agile/DevOps. It’s time for a SciOps revolution. And it’s time to start auditing data and process quality in labs receiving public funds.
And / or, I'd like a de-emphasis on original research and a trend toward meta-analysis, retesting, and engineering.
So the NIH is going to put boots on the ground in every wet lab across American's R1 universities? Come on, this is absurd. Within a rounding error, nobody at NIH even knows what "quality" research looks like in a particular subdiscipline: that's why they convene study sections.
In practice this probably would just turn into another set of dumb forms for project PIs to have to fill out.
"Everyone knows the solution - compensating organ donors"
Being a wet blanket again, the solution isn't totally without its own problems. America compensates blood donors and this provides plasma for commercial treatment into useful products, both at home and abroad.
That's lovely. Until the commercial products use contaminated blood from people who desperately need money and are reduced to selling body parts for quick cash, and those contaminated blood products infect vulnerable people overseas:
Ireland (we've actually had *two* contaminated blood scandals, this is the one involving imported products):
https://www.independent.ie/irish-news/ireland-tackled-tainted-blood-scandal-decades-ago-and-it-has-cost-800m-so-far/a1239357165.html
"The Lindsay tribunal set up in 2000 examined the contamination of Factor 8 products used by men with haemophilia which were contaminated with HIV and hepatitis C.
The tribunal heard how home-produced blood clotting agent caused infection in seven haemophiliacs despite earlier claims that it was safe.
Evidence to the tribunal revealed how clotting agents were manufactured in the US from blood donated by homeless people and drug addicts. It was also revealed no effort was made to trace people who could have become infected. More than 1,200 received contaminated blood product.
Another 220 men with haemophilia were infected with HIV and hepatitis C. Most were infected from imported clotting concentrates manufactured by commercial firms."
UK:
https://www.bbc.com/news/health-48596605
"Two main groups of NHS patients were affected by what has been called the biggest treatment disaster in the history of the NHS.
Firstly, haemophiliacs - and those with similar disorders - who have a rare genetic condition which means their blood does not clot properly.
People with haemophilia A have a shortage of a clotting agent called Factor VIII, while people with haemophilia B do not have enough Factor IX.
In the 1970s, a new treatment using donated human blood plasma was developed to replace these clotting agents.
But whole batches were contaminated with deadly viruses.
After being given the infected treatments, about 1,250 people in the UK with bleeding disorders developed both HIV and hepatitis C, including 380 children.
About two-thirds later died of Aids-related illnesses. Some unintentionally gave HIV to their partners.
Another 2,400 to 5,000 people developed hepatitis C on its own, which can cause cirrhosis and liver cancer.
...The report said:
- too little was done to stop importing blood products from abroad, which used blood from high-risk donors such as prisoners and drug addicts
- in the UK, blood donations were accepted from high-risk groups such as prisoners until 1986
- blood products were not heat-treated to eliminate HIV until the end of 1985, although the risks were known in 1982
- there was too little testing to reduce the risk of hepatitis, from the 1970s onwards"
'Compensation for donors' sounds great, but in reality who is going to sell a kidney? People in dire straits. What donors are likely to be in poor health/at risk of having drug addictions or infections that compromise their organs? People in dire straits. Maybe the donated kidneys will be rigorously screened to make sure they're absolutely healthy, but if it's a case of "John needs a new kidney now or he'll die in three weeks", the pressure of time and need may work against such lengthy processes.
Thanks for this. There has to be a downside other than "ick".
Today does seem to be my day for going "Bah, humbug" but yeah;
"Representative Nicole Malliotakis has introduced a bipartisan bill to provide $50,000 in refundable tax credits for people who donate kidneys to strangers"
That is only an incentive to someone who needs/wants/earns enough for it to be worth having that much tax credits, and they're much less likely to be in dire enough straits that "selling my kidney is my only option here". I can see people in that tax bracket being willing to go "I'll donate a kidney to Uncle Bob *and* get a tax relief!" but not enough of them wanting to do it for a total stranger.
The people who will sell kidneys are those who need money fast and have no other way of getting it, and a tax credit when they're not earning enough to be liable for that much tax isn't much good to them. As the blood contamination scandals show, "let's increase donations by paying for them to incentivise people to donate, what could possibly go wrong?", well, the second part there often comes back to bite us.
I think you are misunderstanding.
"Refundable" tax credits are credits that you can get in full even if you do not owe offsetting tax. So if you are in a low tax bracket and only owe $1,000 in income tax, and you get a $50,000 *refundable* tax credit, that's $49,000 cash in your pocket.
Thank you for hte correction. So the benefits will be restricted to people who can provide proof of "I have income and a home address and am paying tax so you can set these credits against that", which will rule out the most desperate cases.
But will the people in those brackets step up enough to donate organs? Maybe there is a huge untapped pool of donors who will sell a kidney for $10,000-$40,000 (depending on tax bracket) but would otherwise not donate. It's possible. We'll have to see what happens if this is ever legalised.
And of course, because I'm cynical, I await the first heart-rending tale by a journo seeking a Pulitzer about "Lourdes-Maria, single mother of three, working two jobs, who was forced to sell a kidney to pay for her child's medical bills and is now on dialysis herself due to later health problems; if her remaining kidney fails, she could die and her kids will be left as orphans; why are we complacent about modern-day slavery????"
Idealistic college students might be one such pool.
In all fairness, that sounds like a pretty bad thing to happen to Lourdes-Maria and it doesn't seem unreasonable for a society to try to make it impossible for that to happen to people.
Libertarian principles work best when there is a broad degree of rough equality in what people can and cannot be pressured into doing by the 'nonviolent' force. When everyone actually DOES have the ability to say "no, I won't sell myself into slavery because that would be a negation of my basic worth as a human being," as opposed to there being some people who get to have worth as a human being and some people who get to have massive debt as the cost of getting to live and then get to have debt collectors play Metallica at 90 dB outside their houses 24/7 until they stagger out in a daze and sign a self-enslavement contract just to make it stop.
If we're going to accept that we live in a society where some people get to own multiple personal palaces and private rocketships, while other people get to worry that their little girl's gonna literally die because they can't scrape up $20,000 to pay to Palace Man's company in a hurry, and oh hey, you can sell one of your kidneys or retinas for $20,000, you get, well...
You get cyberpunk.
Cyberpunk is basically "libertarianism, in a society whose underlying conditions take a lot of the things that make libertarianism palatable in theory, and then discards those things to create a society that is unpalatable in practice."
The proposal is in favour of donors "to strangers" only so uncle bob is unlikely to qualify (and cheating is anyway easy to prevent by stipulating the donor has no say as to the identity of the donee)
The other problem is, this is Murica. In the UK you would just send kidneys to the NHS waiting list, in America how does it work?
If I can get a tax write-off for donating to a stranger but not to Uncle Bob who is just as in need of a kidney, how is that fair and equal treatment?
It's America, law suits are the answer to everything. I'm confident that any attempts to make it that "you can't get the tax credit for doing a charitable deed for a family member" is going to be challenged in court.
>I'm confident that any attempts to make it that "you can't get the tax credit for doing a charitable deed for a family member" is going to be challenged in court.
Yeah, I'd be surprised if it goes unchallenged for long, if that is indeed how it's proposed to work. It's sort of like punishing family-feelin' (you know, like fellow-feeling; I just made it up, and—wait, is "fellow-feeling" even an idiom of some kind? did I make /that/ one up too? uh–)
"Fellow-feeling" is indeed an idiom, you're safe there.
“You can’t get a tax credit for doing a charitable deed for a family member” is literally already how the tax code works.
You can’t write off money given to family members as charitable giving, but you can to your local soup kitchen.
If you believe 'ick' evolved to deal with pathogens, then 'ick' being right makes sense here!
You can donate blood once a month. You can only donate one kidney. I don’t think there are parallels here.
This is an execution problem though? The blood could have been tested? Yes, if money changes hands, it's more likely. But also, a kidney donation is much bigger a unit, nothing like a mass blood/plasma donation process. So testing easier.
I agree with you that people more likely to donate would be, maybe not in dire straits but at least poor or in specific need. But this in itself isn't a problem. I'd consider donating my kidney for 50k (sterling, a bit more in dollars) because that amount would be life-changing in the sense of sorting out the biggest material hurdle to improving both my life practically and my mental state, tho I might be too old. There's NO WAY I'd consider doing this for free for anyone that's not my child. If only because how would cover the cost of living, household help, daily care and human company in the recovery period?
I think there are quite a few people like me. And you'd have much better chance of filtering out dodgy donors because each is a much bigger part of the project.
Comparison of "desperation profile" with blood donors is imperfect: what I mean is for example the fees for plasma in the US appear really low. Probably not worth the hassle for anyone not REALLY desperate. Many even poor people could earn comparable amounts in the time needed to donate. It's not life changing. But 50k for let's say even 2 months of "work"? That's significantly better than surrogacy, and yes, it reflects the loss of an organ that could be needed later in life but still, imo much more likely to tempt more "normal", safer profile people.
Btw I'd include a clause that donors would automatically be put at the top of list if they ever needed a donated kidney in the future.
Isn't this already the case?
> Btw I'd include a clause that donors would automatically be put at the top of list if they ever needed a donated kidney in the future.
Isn't this already the case?
Yes, at least in the USA and UK. It varies by country but often also let's you bring someone to the top of the list with you.
I would sell my kidney if it was for 100k, I have been considering donating anyways since it seems to not be that dangerous. I think a lot of people who are on the edge of donating could be convinced by the right sum of money.
I agree the poor people problem seems difficult but maybe with having more donors available we could have very high health standards for the donors (to prevent them from suffering because of the donation) so that it wouldn't actually be a problem?
If the tax credits are capped at $50,000, you would need to be earning so little that your tax liabilities were minimal and to sell both kidneys to get that $100,000.
That, or arrange to sell to a billionaire who needs a new kidney *now* and doesn't want to wait around.
Or we could go the Chinese route and just cut up executed prisoners for spare parts. Waste not, want not!
https://bioethicstoday.org/blog/forced-organ-harvesting-and-transplant-tourism-will-chinas-new-regulation-make-a-difference/#
https://www.nbcnews.com/news/world/china-forcefully-harvests-organs-detainees-tribunal-concludes-n1018646
"Some of the more than 1.5 million detainees in Chinese prison camps are being killed for their organs to serve a booming transplant trade that is worth some $1 billion a year, concluded the China Tribunal, an independent body tasked with investigating organ harvesting from prisoners of conscience in the authoritarian state."
Why not? If paying for organs doesn't result in enough donations, what's the next step?
*Refundable* tax credits. That means that if you pay less than $50,000 in income taxes, you can filen a tax return saying that you owe "negative money", and the government sends *you* a check (or a direct deposit) for the difference. If your income tax owed happens to be literally zero, then that check will be the full $50,000. You do still have to file a tax return to get the money, but that's all.
Seems like the sort of thing liability law should handle.
The proposal is a tax credit though, so it's not at all "selling body parts for quick cash". I think a tax credit would filter out most of the riff-raff, so-to-speak.
It would, but that's my sticking-point. People who are in good health and take care of themselves and are doing okay enough that the tax credit doesn't make that much of a difference to them are not going to be tempted by it. People who are likely to sell body parts (because that is what "compensate donors" comes down to) are people who need that money/tax credit, and so are less likely to be in prime condition.
You may indeed hit the sweet spot of "healthy enough *and* in need enough" that the tax credit is tempting them to donate to strangers, but will that be enough people to meet the need for donors? One way to find out is "try it and see" but you have to try and plan around any downsides, not simply hope that the optimistic "tons of people who would otherwise not donate now will donate" approach works.
It didn't work out in liberal denominations that went all-in on gay etc. rights, when the selling-point there by the progressives was "there are all these LGBT people who would *love* to be Christians, except for the regressive stance on modern sexuality". A lot of churches junked traditional theology and (for example in the case of TEC) ended up with splits, schisms, conservative parishes leaving, and none of the mooted flood of LGBT people and their allies into the pews to replace them happened, because it wasn't about "we'd love to be Christians except...", it was about "bake the cake, bigot".
"I totally would donate one of my kidneys to a stranger, except the tax credits aren't good enough" sounds like one of those hopeful strategies that don't pan out in reality.
My gut feeling is that even if you only got donations from the most unhealthy drug addicts that is still miles better than no donation at all. 10 people dying from "bad" organs make the headlines while a thousand people dying waiting in line is just another Tuesday.
If Uncle Bob's transplant fails because the kidney came from Denny the Druggie, the family are going to hit the roof over "this was supposed to be safe!"
Try explaining to them that hey, if Bill died due to a bad kidney, that was just the luck of the draw and at least he lived six months longer. You'll end up the next organ donor due to being torn apart by the Furies.
This failure case is something that happens every day in medicine. There must be some kind of protocol in terms of managing expectations. Just doing a quick look it seems like the 1 year survival rate is between 90 and 95%. So the current system already has 1 in 10 or 1 in 20 dying and I would assume that the nephrologists murder rate isn't shooting through the roof
I think this is true, but I suspect the general public wouldn’t agree, or at least wouldn’t ’viscerally agree’, and this will be a perennial PR problem. Given that the public attitude in general is that it’s better for a hundred people to die due to the illegality of a type of transaction than one person to die due to said transaction type, there would likely be a backlash the moment one person dies from a bad transplant. Keeping kidney selling legal in the face of that inevitable backlash may be much harder than getting it legalized in the first place.
>Given that the public attitude in general is that it’s better for a hundred people to die due to the illegality of a type of transaction than one person to die due to said transaction type
This frustrates me a lot.
It's not exactly the same, but something similar: I have, once in my life, been in utterly incomprehensible agony—such that I'd have kilt myself if I could have done more than crawl around on the floor trying to remember my own name and waiting for my then-wife to get home—and when I got to the ER, retching and weeping and with some ungodly heart rate & BP (IIRC it was in the low 200s per minute resting; I dunno what metrics they use, but I'd have thought I was /obviously/ in horrible pain), I waited /hours/ while they decided if they dared risk giving pain relief to someone who MIGHT POSSIBLY be an addict or something.
I was too hazy to even really feel anything else, but my wife was furious. But better a false negative than a false positive; better someone writhe in agony than someone get a morphine shot who just /wanted/ it, sinfully. Or something.
Never understood it, tbh. You can also observe this sort of effect by just rephrasing things for people: phrased in the "active" way, they'll be against it, and mutatis mutandis for the "passive" phrasing, if you know what I mean.
For what it's worth, I was told by a cardiologist (when discussing my own bouts of atrial fibrillation) that they generally do wait and see if the high heart rate will come down of its own accord before they intervene with drugs.
If it reverts by itself within six or however many hours, great! If it goes on for longer than twenty-four hours, okay, maybe they need to do something.
I can't speak about pain relief but they may have wanted to avoid masking any symptoms that would then turn out to be "uh-oh we need to intervene now".
Just prohibit paid kidney donation from people who make less than (say) 200% the federal poverty level. Or whatever threshold. Problem solved.
But who else is desperate enough to sell their organs? We shouldn't be trusting people just because they're rich anyways. Plenty of drug-addled bourgeois around. Test all donators, sue the harvester if it's defective.
Agree
I think "the poor being coerced to sell body parts" is the central example of the ick we're talking about. Personally I'd rather just bite the bullet, allow life saving mutually beneficial transactions to occur rather than denying them because it forces us to confront the true reality of economic hardship
The underlying problem comes up if as a society we've effectively precommitted as to not actually tackling the reality of economic hardship and forcibly banishing it from reality, AND we keep embracing policies that potentially introduce new ways for economic hardship to be a hard reality.
Because then we're at risk of falling down the "Murder-Ghandi" slippery slope.
You've probably heard this one- Ghandi is very saintly, one reasons, so him taking a pill that would make him be only 99% as inclined to murder people would have effectively no effect, he'd still not be doing any murders. So if he could take such a pill for a million dollars, he should, since there's no downside.
But then he's confronted with the decision to take the same pill again, and with his new reduced scruples about murder, he sees no reason not to be only 99% as anti-murder as he was before, and again and again until he's a very rich serial killer. So the joke-example goes.
You can absolutely do the same thing with wealth inequality. Because adding "just one more" new way in which the condition of poverty is a harsh reality that makes people miserable in exchange for one more clearly good thing that seems net-beneficial isn't actually zero-downside. It makes the condition of poverty that little bit statistically worse and more prevalent and harder to escape. And if you keep making that decision a hundred times, going "the poor are always with us, their lot is hard, it's the nature of things" over and over... Well, you end up in a Dickensian nightmare world.
This has the flavor of moral panic to me- "dirty blood from homeless and drug users"! As well as obviously being, well, trivial compared to the issue of shortages. I mean a small risk of infection (accepting for the sake of argument that this policy would increase) is not even in the same ballpark as simply dying because you had no donor in the first place.
Tell the families of the dead that they were only engaging in a moral panic about dirty blood.
Additional to Deisach's important point, once you fundamentally internalize the idea that it's just "okay" that this thing happens, you lose a lot of the protection that KEEPS the risk of infection small.
Actually I mostly object to economic coercion being used to take organs from people, so a non-refundable tax credit capped at 50k is probably the best case scenario if this idea were enacted (I hope it is not). It would prevent the Musks and Zucks (or more realistically, Bryan Johnsons) of the world from using poor people as organ farms.
File this under "What Could Possibly Go Wrong?" Of course we can avoid the pay-for-organs problem if we simply revive our past enthusiasm for capital punishment. Larry Niven shows the way in his great story "The Jigsaw Man", in which the availability of life saving organs is dramatically increased by harvesting them from condemned criminals. One minor downside of this approach is that the public, seeing the benefits of organ transplants, demands that offenses such as shoplifting, reckless driving, etc. be reclassified as capital crimes.
I think a good starting point - which would likely be easier changes than paying kidney donors outright - would be to expand the scope of coverage for recipients. My understanding (although this may be flawed and I'd love for a medical professional to chime in), is that the medical costs for surgery and recovery are covered; however, there is still the opportunity cost of either hourly wage that is being lost, or otherwise needing to use sick days. Some kind of daily cost to cover living expenses, as well allowing time spent donating a kidney to not deduct from total sick leave would help to at least marginally make it easier for people may want to donate for altruistic reasons, but cannot due to the financial cost.
Additionally, my understanding is that countries that default organ donations to opt-out policy rather than the United States opt-in policy tend to have a significantly higher percentage of organ donors. I'd be curious to see if anyone has possibly run the numbers regarding to what extent increased organ donation would alleviate shortages of kidneys
If you saw a motorist with a flat, would you even think of stopping and offering them your spare?
If you really want to up kidney donations, guarantee preferential and free treatment to the donor should they later find they need a kidney themselves.
That's an excellent idea.
In the middle of a snowstorm on an interstate my spare was flat. A guy l did not know pulled over and gave me his spare. I later got it back to him. But that is not today's country.
Similar story, from just a few years ago. It still happens.
Is it not today’s country? We are still a relatively high trust society.
This is already a thing, no? From reading ACX accounts of donations, it sounds like by doing an undirected donation, not only are you moved to the top of the list, you can designate a relative to be moved to the top of the list as well (as you might have been able to donate to them).
https://www.astralcodexten.com/p/my-left-kidney?utm_source=publication-search
See the beginning of Part III and footnote 7.
> If you really want to up kidney donations, guarantee preferential and free treatment to the donor should they later find they need a kidney themselves.
This is already the case. If you make an undirected kidney donation, you shoot to the top of the list if you need a kidney, and you can designate five people, the first of whom to need a kidney also gets shot to the top of the list. (Of course, the only way you're going to be allowed to make an undirected kidney donation is if your kidneys are really good, so people who have altruistically donated a kidney actually have a lower risk of kidney issues than the general population.)
I'm in England. I've never heard of such a scheme here. If we don't have it we should. If we do have it we should talk about it more!
We do, although here it's just yourself plus one other person of your choice, not five others.
Only one of those five gets a kidney though. That’s important. It’s the first one to need it not all five. And what are the odds you pick five people who need a kidney transplant?
Some people here probably would.
> For example, you could set the goal of reducing airborne disease in military housing by 50% by the start of 2028. Because the government pays for military healthcare, this would save costs and also create the evidence needed for private industry (workplaces, nursing homes, cruise ships, etc.) to implement air quality interventions for themselves.
This is realy clever
Thanks!
I also can't think of any objection to this and hope this gets publicized enough to become a reality.
It sounds brilliant and I really wish I could bring myself to believe it will or would happen.
These all look reasonable to me, and it's a very good thing to be constructive, but I can't help feeling that Scott is simultaneously getting some second-order troll kicks out of this.
I am being a gloomy Gus today, but this part:
"Separating ARPA-H from the NIH will protect it it from this fate, help it deliver on its intended goals, and help NIH reducing the number of institutes and centers it oversees (granting more research dollars per center)."
Ah, didn't we just have a full entire post about "taking money from/shutting down one programme does not mean the clawed-back funding is going to go to the good things we want"?
Reorganization != shutting down. I don't think Scott would've made that post if they had simply shuffled PEPFAR from USAID to the NIH, so long as it didn't threaten its current or future operations.
It's the "granting more research dollars per centre" part; the objections Scott raises in his post apply here. The NIH now has more money that it's not spending on funding ARPA-H. That does not mean this extra funding can be kept by the NIH to give the excess to the centres it does oversee; the extra may well be clawed back into the main government budget and distributed elsewhere.
Claw-back does happen in government all the time; you aren't spending all the budget doesn't mean you get to keep it, it means "we notice you don't need as much money to run that service as you received, so we're taking back the excess left over *plus* we're reducing your funding next year because you don't need as much".
If the condition of the funding is "you will receive $X to fund the ARPA-H service" and then the ARPA-H is spun off into its own thing, then you lose that funding. You don't get to keep it to spend on other projects in that centre.
An example from an accounting website:
https://www.charteredaccountants.ie/knowledge-centre/technical-hub/financial-reporting/frs-102--need-to-know-more/accounting-for-government-grants
"Example 2- Specified future performance conditions
"AA CLG also received a grant of €1,000,000 from a local government authority. The conditions of the grant are that it must be spent on the building of a new community centre. Another condition of the grant is that the community centre must host the annual provincial youth boxing championships for each of the next 10 years. There is no certainty as to whether AA CLG will host this tournament as they must tender for it each year. If these terms are not complied with, the local government authority can clawback the grant, with the amount that can be clawed back equal to €100,000 for each year the condition is not met. AA CLG immediately spend the money on building the community centre.
In this instance, AA CLG should initially recognise the grant of €1,000,000 as a liability and then recognise €100,000 in income each year for the period of 10 years (when they meet the conditions each year). If AA failed to comply with the conditions of the grant then the balance repayable should be held as a liability until it is clawed back by the local government."
> It's the "granting more research dollars per centre" part; the objections Scott raises in his post apply here. The NIH now has more money that it's not spending on funding ARPA-H.
So you're kind of leaving off the first part of the phrase:
>help NIH reducing the number of institutes and centers it oversees (granting more research dollars per center).
I interpret that as NIH will save money on general overhead because it has less to oversee, not that ARPA-H funding is being given to NIH. Maybe I'm wrong but I don't see how you could spin off ARPA-H and not have it take it's allocated funding without Congressional approval
Sure, if we're talking "overhead costs come down because now we're not running three labs" or whatever out of the centre, I can see that point.
But I still don't think that converts into research funding; the money saved on electricity bills etc. will go into the general pot of funding to pay salaries and bills. Grants for research are generally earmarked as such and aren't fungible, as per Scott's own post:
"If you cancelled PEPFAR - the single best foreign aid program, which saves millions of foreign lives - the money wouldn’t automatically redirect itself to the single best domestic aid program which saves millions of American lives.
Instead, it would . . . well, technically it would sit unspent, because Congress earmarked it for PEPFAR, and the executive branch cannot re-earmark it. But probably something would happen, deals would be made, Congress would think about the extra money when deciding how much deficit spending to do, and eventually it would in some vague sense go back into the general pot of all other federal spending."
So they might have more money in the budget for overheads and general expenditure, but for 'more money for research' they'd need to seek out funding for that specifically.
>Increase funding for novel research: Bhattacharya co-authored a paper finding that projects which explore new ideas get less government funding than those confirming existing paradigms.
In light of the replication crisis and high-profile academic fraud issues we've seen, shouldn't we want the government to focus on confirming existing paradigms/studies more than exploring new ideas? Obviously NIH is big enough to do both, but it seems to me that we need someone to focus on the boring stuff like actually proving novel research will replicate and isn't fraudulent.
Hm, this depends on whether confirming studies can be trusted to avoid confirmation bias and actually disprove things that are wrong (I have no idea if they can; I do get the impression medical research has tightened up somewhat in recent years)
I mean if we can't trust confirming studies because of confirmation bias doesn't that sort of undermine the basis of scientific research in this field?
We should use replication prediction markets
https://www.overcomingbias.com/p/could-gambling-save-psychologyhtml
https://www.overcomingbias.com/p/let-gambling-save-sciencehtml
https://www.overcomingbias.com/p/could_gambling_html
*sigh* Here I go again:
"the health establishment chose paternalism and the moral high of trying to save volunteers from themselves."
Also perhaps trying to save themselves from being sued by the families of the volunteers who die, because healthy volunteers do die during clinical trials?
https://www.biospace.com/drug-development/navigating-deaths-during-clinical-trials
"Over the past decade, an average of 177,798 clinical trial participants have died each year in the U.S. For deaths that could be expected because of the patient’s condition, drug developers report the event to the FDA and business continues as usual.
But sometimes, deaths are unexpected or are linked directly to the investigational therapy.
...Anthony Japour, CEO of biopharma company iTolerance, has served as a clinical investigator, a member of an institutional review board and a medical monitor for clinical research studies with a CRO. He told BioSpace about a clinical trial that occurred early on in his career.
“I’ll never forget this,” Japour said, “because a healthy volunteer almost died—literally, almost died.” The trial assessed the safety of a combined therapy in which one of the products was already marketed and widely used.
The event was caused by “a rare, idiosyncratic response to the drug,” Japour explained. “We terminated the study immediately.”
In that case, the participant was treated in hospital and survived. “We had to pay all the hospital bills. There was a major lawsuit, which we settled out of court, and that was that,” Japour said."
https://pmc.ncbi.nlm.nih.gov/articles/PMC1173356/
"A 24 year old previously healthy woman has died as a result of participating in a research project as an experimental subject.
Her death raises serious questions about the safety and ethics of human experimentation. The woman, Ellen Roche, worked as a laboratory technician at the Johns Hopkins Bayview Medical Center's Asthma and Allergy Center in Baltimore, Maryland.
She volunteered as a research subject in a baseline physiological test, which induced asthmatic reactions in people without asthma to determine how bronchiolar reflexes differ between the two populations. Specifically, the study was designed to test a controversial theory of asthma, which holds that people with asthma and those without both react similarly to inhaled irritants—experiencing bronchiolar vasoconstriction—but that people without asthma are able to overcome this reaction through deep inspiration."
https://www.nature.com/articles/nature.2016.19189
"One person died, and five others were hospitalized, after a clinical trial of an experimental drug in France went tragically wrong.
...In recent years, there have been two major changes to French laws affecting the approval of drugs in clinical trials. France strengthened its medical-safety laws following the 2009 withdrawal of a diabetes drug that was suspected of causing hundreds of deaths: a 2011 law, in particular, tightened rules on conflicts of interest for people involved in the country’s drug-approval process, as well as giving authorities more power to demand safety tests of medications after they are approved. Then, in 2012, the government passed a separate law intended to streamline the rules for research involving humans, to speed up therapeutic progress and to make France a more attractive place for companies to carry out clinical trials."
https://www.nature.com/articles/440388a
"As Nature went to press, two previously healthy young men were in critical condition and another four seriously ill at Northwick Park Hospital in London. On 13 March, they received intravenous injections of TGN1412, an antibody made by Boehringer Ingelheim for TeGenero, a small, privately owned biotechnology firm in Würzburg, Germany. The drug was being developed to fight autoimmune diseases and leukaemia. Parexel International, a contract research organization based in Waltham, Massachusetts, that operates in 39 countries, was running the trial for TeGenero.
...Within one to two hours of being injected, the six volunteers suffered violent reactions that included headache, backache, nausea, a drop in blood pressure and, ultimately, multiple organ failure. The trial was the first test of the drug in humans; it was immediately suspended by the UK Medicines and Healthcare Products Regulatory Agency, which is now investigating."
Honest question: What are you saying we do about it?
We should fully expect healthy people to die during drug trials. There is no realistic way to get that number to 0. Many drugs have a low possibility of severe side effects, and yet are very useful to treat certain conditions. We have to test them on humans to determine their real efficacy, and that will always result in some number of life threatening illnesses/deaths in the healthy population.
Do you think there is some safety precautions we are not taking? Do you just want people to acknowledge that this is not a risk-free proposal?
I'm saying that the mass of people won't understand "yes, we expect healthy people to die but that's baked in and besides, the good of the many outweighs the good of the few".
"We had no idea bad outcome" is deemed less blameworthy than "we knew bad outcome was one possibility" in things like deaths.
We should shut down all fire and police departments. We know that sometimes fire fighters and police officers will die in the course of their jobs, and the mass of people won't let a cold utilitarian calculus tell us that this sacrifice is worth it because eliminating these jobs would cost more lives than it saves.
Yeah I agree. There are activities that are less than completely safe that are necessary in society. We can’t ban crossing the street
So pass a law preventing the families from suing
Good luck with that one, you might be able to have it done but most people will be "my healthy son/husband volunteered out of the goodness of his heart to help people, and he trusted this pharma company that it would be okay, but he died and they knew this might happen, so this must Not Be Permitted To Ever Happen Again".
What if we make them into heroes like soldiers, firefighters, and rescue workers? "Your son/husband is a hero who willingly risked his life and unfortunately lost it fighting to save the weak and the vulnerable." Family don't get to sue the military when their otherwise healthy family members die in battle. They don't sue the police or firefighters when people in those services die, except in extremely rare cases of negligence I think where procedures are not being followed. Give them the same legal protections so it can function, and social praise to try to keep the PR good.
Possibly, but you're asking for society to venerate martyrs once again, and I don't think that attitude has remained. We expect things like drug trials to be safe (at least not lethal) because we have expectations around "this is to help, not to harm".
Unforeseen side effects are one thing, but going in with "there's an X chance of death" will be another.
In the case of fireman, for example, there's the expectation that everything that can be done to avoid injury or death will be done, and if the fireman dies then that was a tragedy that could not have been prevented (and if the investigation shows it could have been prevented, then those held responsible are punished). If the job description was "we fully expect 10 out of every 300 firemen to kick the bucket and if you do die in the course of duty, we'll just go on as usual", I think you'd have much fewer people joining up.
How are those not the same? In challenge trials and dangerous service jobs both there is an expectation that everything that can be done (within reason) to avoid injury or death will be done. I say "within reason", because it's conditional on the job itself being done at all, and sometimes you need to take risks to do the job effectively and save lives, even if it puts the job-doer in more risk along the way. It's the exact same utilitarian calculation. And most importantly, it's voluntary and done knowingly. They know they're signing up for a risky job, on purpose, to help other people, and they're doing it willingly, not being forcibly drafted.
The difference between a hero and a martyr is that the martyr is being persecuted by someone and would no longer be in harm's way if that person simply stopped being evil. The hero is being harmed by reality: reality is set up that someone is going to suffer and the hero takes that suffering away from someone else and onto themselves and, ideally, in much less magnitude. If you get a 10% chance to die in exchange for saving 5 lives, that's better than simply having these 5 people die instead of those 5 people.
Again, I stress, it's voluntary, and people do volunteer. The problem is not that nobody wants to be a hero, it's that the government is making it illegal to be a hero and/or enabling family members to retroactively withdraw that consent from a dead family member and sue the people who enabled their heroic sacrifice.
The amount the government lost from the pandemic WAY outweighs expected deaths from a clinical trial.
Given just how much very, very angry sentiment got thrown around at the Biden administration for basing its public health policy on that observation, and on accusations that assorted extremely improbable but very nasty vaccine side effects were ignored, I question whether it's sustainable as a public policy matter to adopt this stance.
You're not wrong, but the kind of person who can say what you said and mean it isn't going to be able to get along with the anti-COVID-vaccine movement, and therefore has no chance of getting near the levers of power in the present administration's public health policy.
The anti-vaccine movement was ignored for a long time. It's entirely feasible.
running a challenge trial and paying large settlements to anyone who dies seems clearly preferably to doing neither of those things in a situation such as COVID?
Somewhat naive optimism that any good will come from this administration. Valuable attempt though.
Yeah it’s funny. They are just going to defund all the programs because they are “waste”. They don’t care about health of poor people outside or inside of US.
Some individuals involved in the administration almost certainly do. That said, the people at the top of the executive branch are unlikely to aid or empower them.
Trump is going to approve of it. What are you talking about?
Approve of what? To be clear, I'm saying that Trump and his immediate cabinet appointees are unlikely to help or empower people within their administration who care about health or poor people in this country or outside of it. I think it's entirely probable that some or all of the people Scott referenced in this article as potentially getting behind these policy proposals might genuinely want to do good for this country. But I don't think aiding them in doing so is a meaningful priority for Trump or his cabinet.
Of course he cares about poor whites, that's most of his own supporters! The challenge is in making sure the people getting screwed over are mostly people that didn't support him.
I don't think it's at all apparent that he cares about his support base, or is interested in enacting policies that benefit him, as long as he thinks he can maintain his own power. This may or may not involve trying to keep their approval depending on the degree to which he thinks he can rig the system in his favor, but either way he seems willing to lean quite heavily on simply lying to his supporters and trusting in their cognitive dissonance to justify whatever he does.
But even a dictator needs support. A regime needs its soldiers, in both the figurative and literal sense. Who else is going lynch the opposition?
A dictatorship needs support, but it doesn't need majority support. It's enough if the appearance of institutional legitimacy, and influence over the flow of information, makes it much easier for its supporters than its opponents to effectively coordinate.
Of course, of course, but uneducated proles are a decently large portion of his base. He really can't afford to mindless cut stuff like welfare due to the potential backlash.
A man can be a very happy dictator with many presidential palaces and an endless supply of hot and cold running showgirls, with dungeons and secret police and armies to take on all comers, even when the state of public health is so bad that the average citizen dies at the age of sixty. From the US's point of view, being reduced to such a condition would be the most terrible act of war ever committed against it by any enemy, foreign or domestic, but it's a thing that CAN happen.
The job of actually lynching the opposition can be taken by indoctrinated fanatics in their twenties and thirties whose health hasn't collapsed yet and who don't care that their families' health has collapsed because they've been told to blame the opposition.
You're begging the question that a voting base responds positively to policies that help them and negatively to policies that harm them. With effective marketing, that's not necessarily the case.
...It's pretty hard to fake giving people money. I understand there are ways around that, such as distraction and scapegoating, but people are always going to get pissed if you take away their bread and circuses.
That seems very unlikely. Plenty of departments are going to remain, and will have Trump supporters at their head. They might be unqualified, disagreeably politically and personally, and have some explicit policies I think will inherently despicable, unfeasible or will backfire.
Nevertheless ... the wild variance of the situation means they will try some things that wouldn't happen under more even keeled leadership. Even if they try 9 terrible things for every 1 bad one (or worse ratios) we still have a good chance of trying some worthwhile initiatives.
This is a very optimistic view. I haven't heard them doing one good thing yet.
I don't expect Trump to approve of anything pandemic-prevention-related. His handling of COVID was too embarrassing, and I think he would MUCH prefer the Chinese approach of sweeping it all under the rug:
https://edition.cnn.com/2025/01/30/health/bird-flu-mmwr-pause-trump-kff-partner/index.html
Your trump derangement is near terminal; rfk is a very public figure, was a democrat, and will be in charge of something health related; you may think he's insane but why would he do nothing when he's willing to talk so much about the topic?
Because his position of power depends on not goring the oxen of anyone else with more influence in the administration, and probably on not asking anyone for more money unless he can explain how that money will be routed as a kickback to one of the new rising class of oligarchs.
It's not Trump, or rather, it's not just Trump. It's the literal dozen billionaires around him, and all the billionaires who are giving Trump money. All you have to do is follow the money; the underlying pattern of the second Trump administration is very simple. We are being set up to be ruled by a Russian-style economic oligarchy centered on a president who may be autonomous or may be a puppet of one or more of the oligarchs depending on how the future unfolds.
Insofar as RFK Jr is not angling to become an oligarch himself, he cannot tread on the oligarchs' toes.
"They were not only opinionative, peevish, covetous, morose, vain, talkative; but incapable of friendship, and dead to all natural affection, which never descended below their grandchildren. Envy, and impotent desires, are their prevailing passions. But those objects against which their envy seems principally directed, are the vices of the younger sort, and the deaths of the old."
Swift on struldbruggs. There's a lot of other stuff to sort out before we start taking longevity research seriously. We would not be where we are now if American males popped their clogs at three score years and ten as the Lord intended.
Hitler was 56 when he died, for the record.
>There's a lot of other stuff to sort out before we start taking longevity research seriously.
No, there's not. Or, rather, one could make this argument about /anything/: there's a lot of other stuff to sort out before we start taking heart disease research seriously, cancer research seriously, poverty alleviation efforts seriously, ...
Just depends on what you value. I value longevity.
>We would not be where we are now if American males popped their clogs at three score years and ten as the Lord intended
Why stop at 70? Maybe we'd be even better off if we set the bar at 40!
I was referring to Psalm 90.
Longevity with all the good stuff would be great. With chronic disease, dementia, unemployability and consequent funding requirements, it's net undesirable
Agree
>I was referring to Psalm 90.
I'm aware. I assumed the point was meant to be something about the social desirability of a "natural" lifespan (thus "but perhaps even less than that is even better!", y'see?), not that you were advocating a literal hard cut-off at 70.
>Longevity with all the good stuff would be great. With chronic disease, dementia, unemployability and consequent funding requirements, it's net undesirable
I don't think "longevity but aging continues apace at the same time" is on the table, in both the sense that no one is advocating for or aiming at it, and the sense that it's not likely to be possible. [edit: Not to any great extent, I mean; we've plucked most of that fruit. Most longevity research that I've seen proposed aims to increase healthy lifespan.]
Scott, I remember a few years ago, you wrote something like the following:
"Doctors give you crappy advice about how to lose weight like 'eat less and exercise more' because no one knows what's making you fat in the first place. It's like someone is slipping a drug into the water supply that causes everyone to gain weight, and the obvious thing to do in that situation is stop drinking the tainted water, but that option isn't available since we don't know what or where the taint is actually coming from, so instead we have to fall back on this vastly inferior advice of 'just eat less and exercise more.'"
Semaglutide is great and all, but someone still needs to find the thing that's making everybody fat. Seems like this would be about the biggest thing that RFK's "Make America Healthy Again" slogan could achieve (way bigger than air quality), and if he managed to make a real contribution in this regard, I'd be willing to overlook a polio pandemic or two that might result from his anti vaccine craziness.
Calories consumed per day has risen since the mid 20th century by 15-25% (finding competing numbers, don't know who to trust). That, combined with a more sedentary lifestyle, seems like it would inevitably lead to weight gain. I don't know there is any "secret" thing making people fat.
Take it up with our host.
Well the question is really mainly why calorie intake has gone up. Plausible theories include things like "technology has made junk food more delicious" and "people have more money to spend on food" but those are not obviously sufficient. Many suspect there are also factors (possibly chemicals) disrupting the body's weight regulation system in some subtle way. Very roughly speaking, this might be kind of the opposite of what semaglutide does I guess?
As for energy expenditure, the population may be more sedentary overall now, but in 1950 obesity was pretty rare even among sedentary people, so I doubt it's a big part.
> Well the question is really mainly why calorie intake has gone up. Plausible theories include things like "technology has made junk food more delicious" and "people have more money to spend on food" but those are not obviously sufficient.
No, they're pretty sufficient by now.
KD Hall et al. Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake (2019)
Take 20 adults in their early thirties, 10 male, 10 female. Feed them unprocessed food for 2 weeks, then processed food for 2 weeks. For half of them flip it, and feed them the other one first. People ate ad libitum - ie whatever they chose and as much as they wanted.
When on the processed food portion, people ate ~500 more calories per day on average.
People gained ~0.9kg on the processed diet, and lost ~0.9kg on the unprocessed diet, regardless of order.
500 calories more per day is HUGE and can entirely account for average obesity trajectories. Also, you save money eating UPF. For these diets in the study, the "real food" diets cost $150 a week, and the UPF diets cost $100 a week.
There is some weak evidence that ultra-processed food causes "weight homeostat" imbalances in and of itself, too, due to the fat and sugar content and possibly due to the barely-regulated (in the US) additives and flavoring agents put into them:
Inflammation and hypothalamic impacts from high fat diets in humans:
https://pmc.ncbi.nlm.nih.gov/articles/pmid/22201683/
Microbiome and liposaccharides in humans:
https://www.frontiersin.org/journals/immunology/articles/10.3389/fimmu.2020.594150/full
Barely regulated additives:
https://performativebafflement.substack.com/i/154137017/food-is-basically-the-same-deal
To your "1950" point, there was basically no or very little UPF in the 1950's, in addition to the increased activity versus today.
Thread on causes of weight gain: https://x.com/cremieuxrecueil/status/1858704235853979878
https://xcancel.com/cremieuxrecueil/status/1858704235853979878
Evidence against contaminant theory: https://www.lesswrong.com/posts/NRrbJJWnaSorrqvtZ/on-not-getting-contaminated-by-the-wrong-obesity-ideas
Market on contaminant theory: https://www.lesswrong.com/posts/NRrbJJWnaSorrqvtZ/on-not-getting-contaminated-by-the-wrong-obesity-ideas
That is like saying that alcoholics are alcoholics because they drink more than non-alcoholics. True, but trivial.
What is the difference between someone who is craving drinks and someone who is not?
What is the difference between someone who feels compelled to eat more than necessary vs. someone who isn't? Why has the former set of people grown in the last 50 years? People in 1970 weren't hunters and gatherers (certainly New Yorkers, Londoners etc. weren't), but any street video from back then will show you just how much thinner everyone was.
Are environmental factors in play?
These are absolutely non-trivial questions and we don't know the answers yet.
As countries get richer, they get fatter.
Being rich makes large-scale obesity possible in the first place, but it's clearly more complicated than richer=fatter. Real wages in Japan have been stagnant for 30 years, and their obesity rate has been slowly rising anyway.
I bet you food is relatively much cheaper in Japan and calories ingested are going up.
It's been dirt cheap for a long time, and if anything food has been getting more expensive because the yen is collapsing.
But within rich countries, as they get richer they get thinner.
Probably because being rich correlates with being disciplined and being a workaholic/having a very active lifestyle.
Could be, though note that one portion of that:
>being a workaholic
can occur by spending 16 hours a day in meetings and reading and writing documents, all of which can be _physically_ quite sedentary
Yeah. I suspect that "workaholism" is outright disproportionately a white-collar disease, because it's at white-collar jobs that you can sit at your desk obsessively collating your notes and aligning the cover sheets on your TSP reports for twelve hours a day without just collapsing from exhaustion. A guy who builds roofs for a living is going to have actual aches and pains at the end of the day; he WANTS to get off shift and drink a couple of beers to take his mind off it.
Many Thanks! Agreed re blue collar occupations. You paint white collar occupations in an unjustifiably negative way, "obsessively collating", but so be it.
Why aren't semaglutides good enough? Why do we "need" any more?
They're expensive and there are questions about their long term efficacy.
The price is expected to go down over time. And "questions"? People can always question. I'm not aware of any indication of actual downsides.
The downside is people gain the weight back after they stop taking it. That's not nothing!
What are the downsides of just staying on it for life? Putting aside any financial concerns or insufficient supply concerns, which seem easy enough to get around.
The bone lose drugs suck; you may as well be asking why nicotine isn't good enough.
Theres 100s of drugs that are known to cause weight lost; chemotherphy, coke+caffeine+steroids, they are usually poisonous or most dangerous to the people who are actually are risk for heart attacks. Its insane to blanket such a radical interventions that fight so hard with a fundamental instinct of evolution.
From what I've heard on the studies done on semaglutides, not only do they not appear to have surprise downsides, instead they have surprise upsides of improving other things they weren't intended to! Completely unlike those other drugs.
Evolution brought people to the point where they are dying from eating too much rather than too little. At current margins this appears to be a clear improvement.
Bone lost is a known issue, you can claim its rare or worth the risk but not "non-existent".
20 year olds with the hips of 60 years is a surprise and they get to enjoy decades of learning the safety of the new drug the hard way.
Right, but your argument was "may as well ask why nicotine or chemotherapy isn't good enough", which are clearly (arguendo) risks of a different order.
I mentioned chemo to justify claiming 100's of drugs
I think nicotine patches are safer then the new fad with what must be a new way to make fraudulent studies(curing every illness) that rapidly has celebrities(a small subset of the population, i.e. not lottery winners) complaining about bone loss or extreme side effects
They do cause a lot of muscle loss. Probably any extreme diet does, and it's worth it generally, but it's not ideal.
I think “need” and “good enough” are red herrings. It seems like it could well be better to figure out the root cause than to treat the problem, and that’s reason enough to put significant effort into research, whether we “need” it or not.
People have been working on how to deal with obesity for a long time. I don't think people are likely to find a better solution than this unusually effective one any time soon.
I agree with that. But I don’t think that’s a reason not to continue spending as many resources in researching.
Having a solution is a reason not to invest more in finding another solution.
A “solution” means there is no problem any more. Very few significant problems admit of a solution in this sense.
Having a partial solution means that getting a better partial solution is less pressing than it used to be, but doesn’t automatically mean you should just give up.
"Doctors give you crappy advice about how to lose weight like 'eat less and exercise more' because no one knows what's making you fat in the first place."
That does not sound like something Scott would say.
If the fda doesn't do studies on efficacy who will. The man's? The distributors? Will it be a fool and his money scenario?
Safety is quicker and easier to come by, meaning you'd have to prove efficacy directly to doctors to expand adoption. Likely this wouldn't be an approval scenario, but one where you convince early adopters first, then gradually expand market share as the efficacy evidence mounts.
To make a system like that feasible, you need a different payment paradigm, so insurance and Medicare know how to reimburse. Investors aren't going to get on board unless you can prove there's a path to insurance reimbursement. (Speaking from personal experience, here.)
I like the idea, but I don't think you can do it whole-hog. It's too much of a disruption to the current system, so you'll get huge institutional push back - especially from small pharma and investors.
However, I think there are a few innovative ideas I've seen that can't get funding under the current model (because there's no path to reimbursement), where safety isn't a concern, and where large efficacy studies or indication/clinical idiosyncracies make it difficult to seek approval under the current system. This scheme could really work for them.
I propose separation of the two approvals:
1. Safety approval
2. Efficacy approval
This wouldn't impact current processes, since everything in the current development pipeline would continue to seek safety and efficacy approval. But some indications might work better looking for safety first, then later working toward efficacy. Then you'd need to find ways to reimburse for safety-only approvals, but there are already some ways to get there under the current system. A physician can prescribe off label (everything would be off label for a safety only approval), with clinical justification from the literature. Early on, this will be few docs, focusing on patients for whom none of the efficacy-approved drugs work. Later, is might expand to the extent efficacy data suggests the drug works.
Normally, we talk about "Marketing Authorization". I think you'd still not be allowed to market something for an indication unless you have efficacy approval. Or perhaps you could combine with an idea from the OP and allow marketing authorization reciprocity, so long as you first get FDA safety approval.
"...you'd have to prove efficacy directly to doctors to expand adoption"
Or just invite the doctors to "conferences" in swankier resorts with comelier hostesses than the competition, to discuss how awesome your new drug is. Four or five Mai Tais and they won't be able to read the powerpoint slide where you show the actual data.
This isn't a good description of the conferences I've been to. They still play hide the data, but in a more sophisticated way. For example, they have departments called "medical affairs", where the hire teams of PhDs to visit doctors and persuade them to prescribe more of their drugs.
Very hard to causally-validate aging biomarkers. For one, it necessarily requires one to wait long enough to know if aging really has occurred. Two, it requires observation of the change in those biomarkers in response to things we know change aging (which we don’t know exist).
The science of longevity is far, far from being ready for such efforts - many, many higher EV areas to focus on.
Mammals seem to age in a roughly similar way, but at very different speeds.
For a biomarker of aging, I would propose to observe it in rats, squirrels, cats, dogs, horses, lemurs, smaller monkeys etc. If the observations are consistent, it is likely that the same thing works in humans as well.
Vague recollection: I thought that most mammals live for about a billion heartbeats, while we live for about three billion? And that evolution has therefore already significantly extended metabolism-scaled human lifetime as compared to other mammals? Which weakens the applicability of animal models of aging to humans, making this area even harder than most areas of biomedical science?
But that means there's something special about human biology that extends are lifespan, right? If we can figure out the mechanism behind that, we might be able to extend it even further. It'll probably require human testing, but... that should become easier under the new administration.
>But that means there's something special about human biology that extends are lifespan, right?
Yup! Many Thanks!
>If we can figure out the mechanism behind that, we might be able to extend it even further.
Or it might already be maxed out. :-(
>It'll probably require human testing, but... that should become easier under the new administration.
Yes, but the time scale problem doesn't go away. :-(
It comes back to the same validation problem that Brian Locke, MD MSc described in his comment. :-(
What would make the field much easier would be if there was a mammal that just lived a year, but with such a fast metabolism that it had four billion heartbeats in that year. Such an animal would have a good shot at being a model for aging biomarkers and interventions with a time scale of a year instead of 80 for the experiments. AFAIK, no such animal exists :-(
There's no known physical law that mandates mortality. Entropy exists, of course, but as long as we have access to energy, there's no reason that something HAS to die. Mortality will still be naturally selected for in most cases because stagnation is death, but manually optimizing lifeforms solves that issue.
An alternative solution would be to somehow "reset" the body and its cells like the immortal jellyfish does, though I am slightly doubtful that's a viable option for more complex animals... https://en.m.wikipedia.org/wiki/Turritopsis_dohrnii
>There's no known physical law that mandates mortality. Entropy exists, of course, but as long as we have access to energy, there's no reason that something HAS to die.
Agreed. Many Thanks!
>An alternative solution would be to somehow "reset" the body and its cells like the immortal jellyfish does
Yes, though one would need to also get regeneration to work for structures that are "build once, then never refurbish". As someone with lots of floaters in my eyes, I'm all too aware that e.g. the vitreous humor in our eyes is in this category...
If I could deploy unlimited resources on solving aging, I'd be inclined to bet on building Drexler/Merkle nanotechnology, aka atomically precise manufacturing, then use _that_ to build "known good" replacement cells, tissues, and organs, and do massively parallel microsurgery to put them in place.
It would be wonderful if there was some cocktail of small-molecule medications which turned out to do something like upregulate repair enough to make our bodies accurately fix themselves faster than aging damaged them, but there is no existence proof that any such set of medications can exist. :-(
I don’t want to get into a screed but I’m pretty sure this is going to end badly for reasons that seem obvious to me
If they are that obvious it seems like you might be able to list them without falling into a screed. It’s not even clear to me what you mean by “this”.
The blog.
It's only a matter of time before a three-letter agency comes for Scott. Co-writer of the piece, Josh Morrison, is an anagram of Sir John's Room, which is famously used for dead-drops and private meetings in southwest England. Revealing this information as he did in an essay about health reforms is clearly a coded message regarding the next pandemic.
(Yes I'm making this up as I go along)
I enjoyed it.
Ha. Boy, you had me going for a minute.
Fortunately, as I learned by googling, there are apparently Sir John’s Rooms all over the British touring industry, so perhaps there is enough plausible deniability to protect Scott for a little longer.
If this follows the usual pattern, the "many reasons" are "I'm mad and don't like this administration", which is a lot easier to make /sound/ like "many *good* reasons" if you don't actually list anything.
I look forward to a thoughtful review in a year that grades these cheerful predictions/wishes.
Improved transparency and access to data, resources put into protecting air quality, and increasing funding for scientific research are all explicitly the opposite of what's happened under the Trump administration in the first two weeks. I'm not sure what word to use to describe a wishlist - even framed as an optimistic one - that all those will reverse entirely. And as an effective altruist who cares about global health and poverty alleviation, I'd been hoping Scott use his platform (which he says has a direct audience to the administration!) to throw his support behind USAID and similar initiatives being hamfistedly gutted right now. Maybe I'll put my own overly optimistic hat on and hope that's coming soon, and not that, like many others, Scott's begin to warp his public writing with an eye to "must start fitting in to avoid the gestapo coming for me."
Y'know what, I just saw there was a post defending PEPFAR yesterday that I missed! Mea cupla on that front, glad to see that support. I still grade today's post as comically optimistic but here's a prayer that I may continue to be proven wrong.
I talked to Josh about this a bit, and the result is the sentence "For practical reasons, we focus on upside only".
I agree that there are many ways that the Trump administration could mess up health. But I think screaming at them and telling them they suck would briefly feel good but accomplish nothing, and politely saying some good things they could do might result in them doing some of those things (I personally wouldn't expect them to be moved by blog posts, but the competent lobbyists I co-wrote this post with think the chance is low but nonzero). I would feel stupid if I screamed at them (in a way that doesn't even help - I'm sure enough people are screaming at them that they've already maxxed out how bad they feel) and lost a chance to actually convince them of some important lifesaving thing.
Trump Administration Live Updates: Trump Directly Calls for U.S.A.I.D. to Be Shut Down
Citing unspecified fraud and corruption at U.S.A.I.D., the government’s main provider of humanitarian and development aid worldwide, President Trump called on Friday to “CLOSE IT DOWN” in a post on social media. Virtually all employees at the agency were already set to be put on indefinite administrative leave on Friday…
https://www.nytimes.com/live/2025/02/07/us/trump-administration-updates?unlocked_article_code=1.vE4.Fsyf.DnPTc5fNoBac&smid=nytcore-ios-share&referringSource=articleShare
Gunflint, I've seen an awful lot of "Trump is shutting down programmes to heal the sick and feed starving kids" and so I wondered "well what exactly does USAID do or fund?"
And the answer seems to be "It's all about soft power" which sounds less to me about "we're doing this out of altruistic charity to help the needy" and more "we're doing this to make foreign countries come under our sphere of influence so they'll side with us".
https://www.cfr.org/article/what-usaid-and-why-it-risk
"USAID is a foremost tool of U.S. soft power" - that's now how *I* would start off an article about how this is a vital humanitarian endeavour, but that's just me.
"... strengthened development efforts abroad that proponents say have underpinned U.S. national security and cultivated goodwill toward the United States." I do understand the political logic here, but it also shows that the whole topic is a lot more complex than the simple "Trump is killing sick people and kids!" messaging.
It seems it did not start off with charity as the prime end in mind:
"President John F. Kennedy created USAID via executive order at the height of the Cold War in 1961—based on authority provided in the 1961 Foreign Assistance Act—to counter Soviet influence abroad."
"The agency’s range of activities is broad and it aims to, among other duties:
“- provide assistance to strategically important countries and countries in conflict,
- lead U.S. efforts to alleviate poverty, disease, and humanitarian need, and
- assist U.S. commercial interests by supporting developing countries’ economic growth.”
I guess it's too bad if you're not strategically important and in need, you're down the list of targets to be helped? Okay, that's a little sarcastic, but the fact remains that politics and all kinds of other considerations are tangled up in this.
If Trump's administration strips away the superfluous and does reduce USAID to "relieve poverty and disease", maybe that would both fulfil the aims people think it currently meets and reduce waste. I can think of a lot of social media warriors for great justice who would be *very* unhappy with that part about "assist US commercial interests", for example, as just more colonialism and resource extraction from underdeveloped nations.
"In early February, the White House followed up with a list of projects overseen by USAID that it identified as “waste and abuse.” This includes millions of dollars given to the U.S.-based nongovernmental organization EcoHealth Alliance, which was allegedly involved in research at the laboratory in Wuhan, China, where the COVID-19 pandemic broke out."
I know we're still fighting over the lab leak hypothesis, but Fauci for one was involved in this research funding (one of the reasons I said in a reply above that in the future his gleam may be tarnished). One of the 'waste and abuse' items was described as "$70,000 for production of a “DEI musical” in Ireland":
https://www.whitehouse.gov/fact-sheets/2025/02/at-usaid-waste-and-abuse-runs-deep/
This seems to be a concert that was put on by the US Ambassador, or hosted by them, in conjunction with Irish and other funding. I can't remember it because it's not something I would have been particularly interested in, but yeah - by the description, it sounds like somebody* got a nice little earner out of promoting a concert for an "equitable future" whatever that might be (the performers all seem to be white, so it's not exactly about minority voices):
https://www.othervoices.ie/events/other-voices-dignity-live-from-the-u-s-ambassadors-residence-dublin
I really don't see why a humanitarian aid organisation is part-funding a concert in Ireland which is already within the US sphere of influence. I would strip this out of the budget were it put before me as part of "tackling disease and poverty world-wide" for funding:
https://www.threads.net/@cordietvorst/post/DFpE6ZFslkJ
"The "DEI musical" was a public US/Irish live streamed cultural event co-sponsored by PwC & Coca Cola (they know that studies show that DEI policies improve corporate performance) hosted at the US Embassy in Ireland. Artists included the brilliant Grammy-winning duo Rhiannon Giddens & Francesco Turrisi"
Price Waterhouse Cooper, huh? Yeah, I can think of a *lot* of lefties who would not be one bit happy about the likes of that 😀
Take that seventy grand and put it towards a vaccination programme, I won't complain. A lot of conservatives won't complain. But funding a pleasant evening of schmoozing for the ambassador and guests? Where is that helping heal the sick and feed the hungry?
* https://gript.ie/who-is-the-irish-company-who-received-e70000-from-usaid-to-produce-a-live-musical-dei-event/
An Irish company is listed on filings published by the United States Government. The company is called Ceiliuradh, and has an address in Ventry, Co Kerry. It received a $70,000 payment in September 2022, the same month a live music event took place at the Irish Embassy, organised by a group called Other Voices. Other Voices Limited is registered at the same address, as is another company called South Wind Blows Limited.
The three companies in question are owned by a Mr P King, according to company filings. Ceiliuradh is described as a “minority owned business” and a non–profit. According to receipts from the US Department of State, it received the funding to “deliver a live musical event to promote the U.S. and Irish shared values of diversity, equity, inclusion and accessibility.”
The same month the payment was made to Ceiliuradh, an event took place at the Irish Embassy in Dublin called ‘Dignity 2022.’
A note on the event page said: “The Biden Administration is committed to principles of diversity, equity, inclusion, and access (DEIA). With this event we aim to highlight and celebrate the work that the Embassy, the Irish Government and our partners are doing to advance DEIA throughout Irish society. These ideals have long underpinned the strong relationship between both countries.” then-US Ambassador to Ireland Claire Cronin said ahead of the event.”
Other Voices also said: “Inspired by the shared cultural identity and history which bonds to the two places, these live performances will bookend a full day of events hosted by the U.S. Embassy and curated by Rethink Ireland celebrating DEIA in the civil society and business sectors.
“The event will bring together key stakeholders, leaders and social justice advocates with the aim of strengthening the equality landscape in Ireland, whilst also recognising ongoing inequalities in our society, current barriers to inclusion, and steps towards a more equitable Ireland.”
So yeah, USAID funds (funded?) a complicated mix of things, some of which you would sniff disapprovingly at, such as cultural festivals with a diversity committee to make the ethnic minorities feel welcome, and some of which you would hopefully not, such as HIV medication for babies born with the disease.
And yes, the ultimate goal of the agency is to maintain US standing and soft-power influence on the global stage, by giving lots of people all over the world various specific reasons to feel like Americans are helpful, friendly people, as opposed to a bunch of cruel domineering murderous jerks.
This is not actually a particularly sinister or unreasonable thing for a country to have a government agency for doing, when the country in question is a superpower that profits enormously from being in a position of economic and military pre-eminence at the head of a very large global alliance structure.
Having people in like 150 countries who think well of us because we did something good for them is a valuable asset, and cutting that money off abruptly and capriciously is going to undermine any attempt by the US to maintain its status as the hegemon in the coming decades as nations like China potentially step in to be the "nice, generous friendly people" that the US is resolved to no longer be.
>"Improved transparency and access to data"
Say what you want about Elon and DOGE hooking potentially-unsecured AI servers up to government health databases, it does in fact increase access to data.
>must start fitting in to avoid the gestapo coming for me
Nah. Scott's not a victim of TDS (yet?).
"not that, like many others, Scott's begin to warp his public writing with an eye to "must start fitting in to avoid the gestapo coming for me.""
Eh, he already had the Stasi coming after him, that's how (eventually by a commodius vicus of recirculation) we got to this Substack.
Regarding RFK ... I know this is an optimism thread but I take issue with this:
> RFK Jr’s “Make America Healthy Again” philosophy is a
See these stories:
https://nypost.com/2025/01/30/us-news/rfk-jr-in-cash-grab-to-market-maha-vitamins-crypto-t-shirts/
https://www.theguardian.com/us-news/2025/jan/30/rfk-maha-trademark
It's not a "philosophy", it's a trademark for various scam products. He isn't against "big pharma" out of some "everyone eat organic, no processed chemicals" type of thing, he's against it because he wants people to buy his BS nutritional supplements instead.
Why not both?
Typo:
>has resulted in an kidney shortage
Thanks, fixed.
>An impactful focus are for Makary could be addressing the practical and legal challenges that hinder
Grammar
>His contrarian COVID positions provoked censorship and harassment from Big Tech and the academic establishment; the experience seems to have low-key traumatized him
Maybe dont write this if you want to be nice to a righty.
Great article.
I recognize this is totally off-topic, but since this is the first time I'm seeing the HHS logo...
... am I the only one who sees animorphs in there?
I know it's a much smaller win but what about halting government from paying for subscriptions to these "exclusive" journals like Elsevier. And do something like "all government funded research will be available to the public for free" and create a very cheap online site that is fully searchable.
All government funded medical research must be published under a license that makes it open access after a year, I believe. They should extend that to all funded research, but they’ve got a good start already.
> JD Vance only lurks
I didn't see any indication at the link that he lurks here. Rather, someone in the subreddit read his tweet (which doesn't mention ACX/SSC) and linked to it.
Yep. I saw JD mentioning Scott`s SSC post-title: "Gay rights are civil rites" in his interview with Joe Rogan - saying sth like: "See, it's a religion" - not sure, this is proof he read it (I would comment: "See it is a mainstream tradition now"), but I guess he did.
https://slatestarcodex.com/2019/07/08/gay-rites-are-civil-rites/
Yeah, Vance's mention of it makes me feel like he read the article but didn't actually understand it.
(Maybe he should have tried reading Is Everything A Religion? instead: https://slatestarcodex.com/2015/03/25/is-everything-a-religion/)
Or he read it and forgot most of it, which seems defensible.
J. D. Vance strikes me as the kind of man who, given an intellectual work of philosophy to read, will selectively remember the bits that support whatever he wanted to believe anyway and then forget the rest. A man who was sincerely and deeply committed to objectivity, intellectual integrity, and prioritizing truth over feeling good about himself or what he was doing would probably not lead the life trajectory that he has.
Right. Scott's actually more influential on the right than he is on the left, despite being broadly on the left, because IMHO
1. He has this sort of 'neither left nor right' aura, so people read him for an extra viewpoint. Smart conservatives know they're 'on the outs' in the life of the mind to begin with, so they're more willing to read strange views.
2. He's discussed a lot of topics of interest to conservatives, and his blog has always been open to conservative commenters.
3. I think for whatever reason he vibes with conservatives more than liberals. In a lot of ways, like his pronatalism, appreciation for Chesterton's fence and old architecture, he's what a conservative born in a very liberal milieu might look like.
4. Most controversial: I think he's Jewish but not anti-white, so a lot of mildly racist people can read him without feeling like they're supporting the next Hitler.
Your suggestions seem to based on the idea that Scott is more influential on the right than the left because more people on the right read him. The best indication of readership would seem to be the ACX survey, and in the most recent ACX survey, about 2/3 of the respondents classify themselves in ways that I would consider on the left: liberal (35.7%), social democrat (29.0%), or marxist (1.64%). The remaining 1/3 classify themselves as conservative (10.1%), libertarian (19.7%), neoreactionary (1.99%), or alt-right (1.85%).
Excellent point and I was trying to figure out how to account for that. You've brought my enthymeme's assumption into the open.
I think despite his audience leaning majority left, he is more *influential* on the right, because he's known to have heterodox views no leftist can admit to (HBD, criticism of feminism and social-justice ideology). A left-winger can't admit to reading Scott, a right-winger can.
You could cite Richard Hanania on the right having a smaller bench of intellectuals, so that someone like Aaron Sibarium can be the most effective "rightwing" journalist even though he's a Obama-voter.
I didn't think of that, but that's exactly right!
Well, I certainly have no qualms about admitting to reading Scott. I’m sure there are people on the left who are too close minded to read Scott, but less sure there’s a contingent who read him but won’t admit it.
In any case, I agree that readership doesn’t necessarily correspond to influence. Perhaps a better measure would be something like a citation index. If there are more links to Scott’s articles from conservative bloggers than from liberal bloggers, that would be a pretty good indication of influence.
Agreed, citation analysis would probably be the best way. I don't know if this sort of thing makes money for Substack, but the technology is there. I'm going to leave this out there in case one of the many techies reading this blog decides to write a script to answer the question. You'd probably search Substack's website, categorize bloggers as conservative or liberal through network analysis, and then see what network ACX is in. I'd bet it probably tracks with 'intellectual dark web' or whatever they're calling the leftmost end of the online right now.
It's not that more righties read him, but that the righties who do read him are more influential. Like JD Vance, for instance, but also the likes of Peter Thiel and (probably) Elon Musk.
It's very hard to imagine Kamala Harris or Tim Walz reading and quoting SSC. Influential Democrats don't read anything other than absolute doctrinaire left-wing stuff, which is part of the reason the Democrats are in such trouble.
That's not to say that there's not a bunch of smart left-of-centre people reading here, just that those people have absolutely no influence on the sort of people who actually get to make decisions on the left.
Just how likely is a universal flu vaccine, and why don't we have it already?
Those families of flu-viruses keep changing AND the new shot each year works just fine (I get mine each year, zero side effects), so why spent a lot of resources (brain, time, money) on something that may work worse - even the post sees the real value in keeping the staff busy while waiting for a more urgent task. But sure: nice to have. Likelihood it will be better than the ones we have: low, imho. Because the ones we have are actually working fine for those who do no fear a tiny needle.
>I get mine each year, zero side effects
Same here.
>Because the ones we have are actually working fine for those who do no fear a tiny needle.
I thought it was closer to: fine _if_ the vaccine developers are successful at picking the right strain that winds up dominating this year's flu season else harmless but ineffective. My impression is that picking the right strain is pretty good (>50% ???) but not perfect.
If it works worse but a much larger portion of the population gets it (because they don't have to put any time or effort into getting the new shot every year), that may well be worth the tradeoff.
Flu vaccines have estimated to be less than 50% effective for the past 10 years.
https://www.cdc.gov/flu-vaccines-work/php/effectiveness-studies/index.html
Evolutionary impossible; solving all cancer is more likely
AIUI & IIRC, there's a particular site on every flu viral body – joining the variable H & N segments – that's conserved. A vaccine targeting that part could be effective against every flu.
I've seen the large list of things that even minor particulates in air qualify affect, like IQ https://marginalrevolution.com/marginalrevolution/2019/11/air-pollution-reduces-iq-a-lot.html and other health outcomes https://marginalrevolution.com/marginalrevolution/2019/07/air-pollution-kills.html but I wonder how many of them have replicated, for standard reasons things don't replicate.
Have we double-blinded putting air filters in schools and nursing homes and comparing outcomes? Even for places where we can't do an RCT, have the researchers, before looking at the data, come up with the theories they expect to see from it, ruling out other causes? (I am 0% surprised that poor areas have worse educational outcomes and more pollution, but that doesn't mean B caused A.) Can a group with access to all data except particulate count make as good predictions as a group with access to particulate count?
They tell me I shouldn’t have eaten all those paint chips as a kid. What do they know?
I hate having to do this but yeah a joke.
The issue with regulator reciprocity is that the moment it happens people venue shop for the lowest regulation barriers. This in turn tends to lead to regulatory harmonization to prevent that. Which in turn means you have international frameworks setting domestic regulation. In principle, this is fine... except that the EU wants to be protectionist, to favor domestic firms (and fine non-European firms a great deal), and have higher regulations than the US will agree to. And the US is not going to agree to let its rules be set in Europe. Nor will Europe let its rules be set by the US.
This is also why the EU and US don't have a free trade agreement. Europe is unwilling to accept American standards.
There's also the fact the US pays for, and produces, most medical research. Even most foreign medical products, like ozempic, is disproportionately funded by profits from sales in the United States. And the American medical industry (with some justification) thinks of Europeans as massive free riders. In fact they think most nations are free riders. And Europe is not going to concede the primary thing the US would want: to let drug prices rise there and fall in the US.
If you want to do this you need to either convince the EU to be a better partner or you need to go around it. And that's probably possible. The UK wants regulatory reciprocity. Canada and Australia can probably be convinced as well. Japan and South Korea also want a closer economic and research relationship. And those nations are about equal to the EU collectively without having its problems. You could maybe throw in Mexico if you want a cheap drug production base and to keep the USMCA intact.
Where there is will, there is way.
For example, regulatory reciprocity could be introduced for certain classes of drugs only. Say, antibiotics or monoclonal antibodies. The low-hanging fruit is probably in drugs which save acutely threatened lives: patients with serious infections or active cancer.
That's the issue. There is no will on the European side because they want to continue a system that benefits them and won't make concessions the US wants.
> The issue with regulator reciprocity is that the moment it happens people venue shop for the lowest regulation barriers
> the EU wants to be protectionist, to favor domestic firms (and fine non-European firms a great deal), and have higher regulations than the US will agree to
Putting these two together, it sounds like you're saying that the US regulations will be the ones businesses would target. If so, then unilaterally allowing EU rules in the US seems like it wouldn't be worse than the status quo?
What we see in practice is that the FDA is way more conservative than EU medical regulators, with the result that new medical devices and products are often available in the EU for years, sometimes decades, before being offered in the US.
No, that's not how it'd work. If America opens up unilaterally then regardless of which one is lower they will use the European one. Because that means using American standards won't let you into Europe but using European standards will let you into America.
If you want to outsource American medical regulation to Europe you can make that case. But I don't think it'll be politically sustainable. Especially because it would cause jobs to leave for Europe and mean the US would have to constantly watch European standards and lose that bit of sovereignty in exchange for nothing.
But aren't drug manufacturers already using European standards? Most drugs available in the US are also available in the EU - see e.g. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2795755 - so it seems most manufacturers do the testing, paperwork, etc, to both US and EU standards.
This almost certainly involves wasteful duplication of effort, so there would be at least some benefit to reciprocity. Or even unilateral half-reciprocity, so long as the Europeans aren't approving horribly unsafe or ineffective drugs.
No, they're validating and often producing the drugs in both markets sometimes to subtly different standards. Eg, a lot (I think a majority) of the ozempic in the US is made in North Carolina. Which is itself a political economy issue if you want to open up the US to European factories but not vice versa.
The actual middle ground here would be to have a fast track where the standards aren't harmonized but you allow the other company to submit evidence from compliance in the other market. These are called MRAs or GMP certifications (at least in non-medicine). And you could have one of those unilaterally without much issue. I'm not sure if we do.
For example, if US standards are you need to have no mercury based preservatives and at least 1 part per million of saline (or whatever) then the approval from the EU that shows it has at least 1 part per million of saline would be accepted by the US as evidence of that fact. They would then just have to prove it meets the mercury requirement.
"$50,000 in refundable tax credits for people who donate kidneys to strangers."
Claude 3.5 says that among living donors, approximately 60-70% are biologically related family members of the recipient. The restriction that only strangers can be paid will discourage relatives from donating, in the expectation that a non-related donor will come forward. If every related donor is replaced by a non-related donor, that might cancel out all the gains of the new policy.
If compensating kidney donation is so effective that family members are confident someone will come forward to donate, then mission accomplished! At that point what you're proposing is a situation where almost everyone who needs a kidney get one, which is an improvement over the current situation.
We don't know how many people would sell their kidneys at any chosen price. If the number of people eager to sell a kidney for $50,000 turns out to be about the same as the number of relatives able and willing to donate a kidney, you might end up with the same number of patients getting kidneys, due to related donors backing out. Then people could point to the program and say it had no effect, even though it motivated a lot of people to donate kidneys who otherwise would not have. The problem isn't that less people would get kidneys; the problem is that the program might be stopped for not increasing the number of kidneys donated as much as expected.
Meanwhile, on the other hand, I can think of no good reason not to pay relatives to donate their kidneys. It seems unjust.
> If the number of people eager to sell a kidney for $50,000 turns out to be about the same as the number of relatives able and willing to donate a kidney, you might end up with the same number of patients getting kidneys
But not the *same* patients getting them. Some of the patients who would otherwise have received a kidney donation from a relative will get stranger kidneys, but others won't. For those who don't receive a stranger kidney we would expect a family member to donate. This would increase the total number of kidneys donated.
You are right that it would be most efficient to pay everyone, regardless of family status.
Here's a suggestion for another item: Consider combination therapy. During Covid, there were several drugs or herbs which were shown to be effective with over 80% but less than 95% confidence. Advertising any of these for treating covid was forbidden by the FDA and denounced by the CDC as misinformation, even though one could combine 2 or 3 of these therapies and say that combination therapy had a greater than 95% chance of being effective.
I don't know how to implement that. Maybe just enforce a policy at the CDC of not calling things "proven ineffective" when they were proven effective with less than 95% confidence. Maybe make it very easy (no studies) for the FDA to approve a combination therapy of multiple therapies each of which was proven safe by current standards, and which taken together, with an independence assumption, can be proven effective to current standards just by doing the math on the p-values of the studies for the effectiveness of each separately.
Which drugs or herbs had >80% confidence in being effective? Also you can’t just multiply confidences like that. You could do a study which compares a combination therapy to a placebo and see if that is effective.
We could re-fight the Great Ivermectin Drag-Down again, or I could direct you to the posts Scott did on it.
https://www.astralcodexten.com/p/ivermectin-much-more-than-you-wanted
https://www.astralcodexten.com/p/higlights-from-the-comments-on-ivermectin?utm_source=publication-search
https://www.astralcodexten.com/p/response-to-alexandros-contra-me?utm_source=publication-search
There were a metric shit-ton (to use the technical term) of experiments done during the early days of the pandemic world-wide by everyone trying their favourite theory that "megadoses of vitamin D will cure it or at least help people recover!" and some of them, according to the bodies carrying them out, totes worked absolutely.
I'm not joking about the vitamin D, by the way:
https://www.astralcodexten.com/p/covidvitamin-d-much-more-than-you?utm_source=publication-search
Except when digging deeper, as some meta-studies did, those studies weren't worth spit. Ivermectin was a popular one, alone or in combination with the kitchen sink thrown in. Scott also did a post way back on the meta-study comparing all those studies, and I did some digging through and a lot of them were very shaky, to say the least (e.g. "we started on this dose, half our subjects dropped out, halfway through we switched to this drug instead, and now we're saying that of our remaining subjects, not all of them died").
Some people are still convinced that "this one Brazilian hospital experiment proved that clover in combination with doing six hours of tap-dancing weekly shortened hospital stays and overall mortality rates".
That’s not how p values work. If you change your protocol so that you’ll allow approval on its own if it passes one threshold, and also allow approval as part of a combination if they all pass some second threshold, then there are two possibilities for error instead of just one. The p value is the probability of any error resulting from your protocol, so this new protocol creates higher p values for the same threshold. You’re not allowed to change the protocol after you’ve got the results.
This is great, more of this please! Identifying good policies that this administration might implement would be great. If we have to go through the next four years of trump we might as well get something out of it.
Withdrawing the new final, but not yet implemented, FDA rule to regulate Laboratory Developed Tests should be on the FDA wishlist.
Can we please stop pretending effective altruists are any significant percentage of clinical trial volunteers? You guys didn’t invent clinical trials, you just discovered them a very few years ago. It feels insulting to all the other volunteers to see their work credited to a movement they likely never heard of.
I think this is literally true for human challenge trials? There aren't that many of them and it's pretty weird to get involved. Most of the news articles I've seen on human challenge trials mention the EA connection.
I mean...wanna bet? I think you're getting misled by what you hear from your acquaintances and EA-focused news sources, whereas the typical clinical trial volunteer is never likely to cross your radar.
I can tell you I've been in five clinical trials and never encountered any participants with known EA motivations, nor did researchers seem to expect EA motivations. I expect this is different for a few particularly trendy human challenge trials (like those that get advertised on major blogs), but overall I would expect participants in human challenge trials to be similar to the demographic of people in clinical trials more generally.
It IS weird to be in a challenge trial, but it's even more weird to be an EA, and getting paid is a very salient motivation that draws most of the volunteers—you can get roughly a few thousand dollars for non-full-time non-skilled work. Many clinical trial volunteers are "repeats" who have been doing this for years. EAs, on the other hand, only got interested in challenge trials within the last few years.
Were any of the clinical trials you were involved in, human challenge trials? Because it seems quite plausible that the demographics there would be substantially different than for more ordinary clinical trials.
Yeah, I disagree, because although challenge trials are legally different from other clinical trials, the experience of the volunteer is similar. The same people who are willing to take experimental drugs for money are willing to get infected for money. The main difference is that many challenge trials require you to be isolated for infection control purposes, but they also pay you more to make up for it.
To answer your question, I haven’t actually been in a challenge trial, but i’ve gotten close enough to understand how they work
I think human challenge studies for vaccines are a good idea and I appreciate 1daysooner championing them. But I find the focus on vaccines a little odd, given how much more useful challenge studies would seem for other research.
Here are some questions that are difficult to answer without challenge studies but easy to do with them:
- How much does the dose of a virus you're exposed to effect the likelihood and severity of illness?
- If I had close contact with a sick person already, how much does additional exposure to them increase my odds of catching their illness?
Does anyone know if we have good answers to these questions? Have we at least done the obvious experiments on animals?
That is a good point. When life gives you lemons, make lemonade. When life gives you a fascist revolution, do all the research you couldn't do before!
https://en.m.wikipedia.org/wiki/Nazi_human_experimentation#Experiments
This is what I was saying during the pandemic. A challenge trial on the vaccine alone wouldn’t tell you what you want to know, unless you had also done challenge trials prior to the vaccine. And these challenge trials could tell us more about the effectiveness of masks and spacing and outdoor activity as well.
>"A challenge trial on the vaccine alone wouldn’t tell you what you want to know, unless you had also done challenge trials prior to the vaccine."
Wouldn't double blinded challenge trials vs. placebo suffice?
They would help but you’d want to know if this is ecologically valid, and you’d need the first round of challenge trials to establish that.
The downside of regulatory reciprocity is that you probably wind up with all drug approvals being dumped on whichever country provides the friendliest process. So every gets considered by the National Agency for Medicines and Medical Devices of Romania or something, and all other countries just follow suit. Pretty soon, all other countries have shut down their drug approvals bureaucracy and forgotten how to do it, so we're all dependent on the vagaries of the Romanian agency and hoping it doesn't turn corrupt.
I suspect that what you really want is temporary reciprocity. If something has been approved in one country, then it is available in all other partners for two years, giving your agency time to catch up or shut things down.
"support 'Americans should be allowed to buy any and all medical products as they damn well please' "
Don't worry, Grim Trigger, I fully support your right to consume as much adulterated products as you desire to bring you to an early grave. Why should I step in to prevent you killing yourself?
Banned for this comment, but I mostly do support "Americans should be allowed to buy any and all medical products as they damn well please" - it's just not a realistic policy recommendation, even for this administration.
I think you’re making the same mistake here that you made in the USAID piece yesterday: facilitating a con against MAGA voters by making it seems as if doomed half-proposals certain to be largely stopped by the courts represent “getting something done.” They don’t. Nothing, least of all destruction of bureaucracy, has been accomplished here. It is a proposal, and so far one that is likely to fail in its core elements.
Many Thanks! It is nice to see some of the news of the _positive_ impacts of the Trump administration on health policy!
> Bhattacharya is a rare doctor and medical professor who also has a PhD in economics. His contrarian COVID positions provoked censorship and harassment from Big Tech and the academic establishment; the experience seems to have low-key traumatized him…
Scott: You do your readers a great disservice by trying to whitewash Bhattacharya’s behavior. Let’s do some fact-checking.
Re: his qualifications: Bhattacharya has an MD, but he never undertook nor completed a medical residency — nor has he a license to practice medicine. Rather than becoming a medical professional, he hopped over to get a PhD in economics. Since he never completed a residency in preventive medicine, he can’t really be called an expert in communicable diseases or epidemiology — nor does his PhD in economics equate to a research fellowship in infectious diseases or microbiology — and it doesn't qualify him to be an expert in public health. Yet he's being treated as such.
Re: his claims of harassment and censorship: It’s funny how rightwing talking heads get all upset when people push back on their opinions. This is the man who never passed up a chance to denigrate Dr. Anthony Fauci — calling him, among other things, "probably the number one anti-vaxxer" in America. (And Fauci, BTW, happens to have an MD and completed his residency, and he spent his career involved in basic and applied research to prevent, diagnose, and treat infectious diseases such as HIV/AIDS, respiratory infections, diarrheal diseases, tuberculosis, malaria, and Ebola.) Despite all the “censorship” directed at Bhattacharya, he was a regular on Faux News, and the Murdoch media empire gave him plenty of coverage in publications such as the Wall Street Journal.
Worst of all, he’s either intellectually dishonest or a crank. Despite being confronted with the evidence that he was wrong about so many things during the pandemic, he’s doubled down and claimed he’s been vindicated. Among his most egregious errors were stating that COVID was just the flu while mass burials were happening in NYC. He fabricated data about the rate of SARS2 asymptomicity. And he fought tooth and nail against non-pharmaceutical interventions such as masking and social distancing — even when confronted with the evidence that the SF Bay Area and Seattle area counties that imposed these policies early saw many fewer deaths than places like NYC that implemented NPIs late. That meme that COVID is just the flu is still echoing through the right-wing media.
Sadly, he’s whining about the trauma of being criticized and snubbed by his peers while ignoring the trauma his actions caused tens of thousands, perhaps hundreds of thousands, of people who lost family members because they didn’t take precaution or bother to get vaccinated because COVID was “just the flu.”
Everybody can remember what they got right about this brand new phenomenon and nobody can remember what they got wrong about the pandemic.
Dr. Bhattacharya's studies in the spring of 2020 did an excellent job debunking his own theory that so many people were infected that covid was approach herd immunity already. For example, from the Los Angeles Times:
"Fewer than 1% of MLB employees test positive for COVID-19 antibodies
"By BILL SHAIKIN STAFF WRITER
"MAY 10, 2020 3:26 PM
"The coronavirus outbreak largely has spared the baseball world, with data released Sunday to prove it.
"Of the 5,603 major league employees who submitted to what researchers called the largest national antibody study to date, only 60 tested positive, researchers said Sunday.
"... The researchers announced an estimated positive rate of 0.72% after adjusting the results for what they said were false positives and false negatives. ...
"Still, the minute percentage of positive tests provided a data point as scientists determine how wide the coronavirus has spread within the United States. Bhattacharya said he expected a larger positive rate.
"“The epidemic has not gotten very far,” he said. “We have quite a way to go.”"
Hmmm. Here's the timeline of the links I have in my notes.
In March of 2020, Bhattacharya co-authored a Wall Street Journal op-ed titled "Is the Coronavirus as Deadly as They Say?" In it, he questioned the estimated fatality rate of COVID-19, suggesting it might be closer to that of the seasonal flu. It was picked up by Faux News and re-echoed around rightwing media outlets. Note: There were yet no seroprevalence studies, but he was already claiming its IFR (the Infection Fatality Ratio) was no worse than the flu based on no data at all. So, Bhattacharya was just bullshitting at that point.
https://www.wsj.com/articles/is-the-coronavirus-as-deadly-as-they-say-11585088464
Late in April 2020, Bhattacharya et al. released the Santa Clara Seroprevalence Study. The study concluded that COVID-19 infections were 50–80x more common than reported cases. It put the COVID IFR between 0.12–0.2% — which is suspiciously close to the range of seasonal flu IFRs (0.01% – 0.1%) and conveniently less than the IFRs of 2009 H1N1 Swine Flu (IFR of 0.01% – 0.03%), the 1957–1958 H2N2 Pandemic (est IFR of 0.1% – 0.3%), the 1968 H3N2 Pandemic (est. IFR of 0.2% – 0.4%). Meanwhile, NYC was setting up temporary ICUs, refrigerated trucks were brought in to serve as temporary morgues, and 100+ COVID victims were being buried each day in mass graves on Hart Island.
The Santa Clara Seroprevalence Study never went through peer review. When the data was examined, other researchers raised serious questions about the study's methodology. Bhattacharya and his co-authors used Facebook ads to recruit participants. The study was criticized because of likely selection bias — i.e., people who had symptoms or believed they had been exposed might have been more likely to volunteer, leading to an overestimation of the actual seroprevalence. Also, the study used antibody tests for Premier Biotech — and it later came out that they gave an extremely high false positive rate. Some experts questioned whether the authors hadn't P-hacked their conclusions. Also, David Neeleman, co-founder of JetBlue Airways, who was fighting for fewer COVID restrictions, reportedly funded the study (conflict of interest, anyone?) At any rate, the samples were not representative of Santa Clara County’s demographics.
There were calls to retract the study, but Bhattacharya and his co-authors never did so. Instead, they circulated it to media to make their case that COVID was no worse than the flu.
https://academic.oup.com/ije/article/50/2/410/6146069
Throughout 2020, Bhattacharya continued to argue that COVID-19's risk was highly stratified by age and that for most people and it posed a risk similar to the flu for younger age cohorts. For instance, in a December 2020 interview with the Ron Paul Liberty Report, he stated that for young and healthy individuals, COVID-19 was "less deadly than the flu." (Sorry, but the link I have for this interview gives me a 404.)
Meanwhile, a slew of studies had been done that showed the IFR and CFR for COVID was higher than the flu even for younger age cohorts. John Ioannidis (ironically, from Stanford University) published a meta-analysis early in 2021 that put the IFR for COVID for ages 25-34 at between 0.01%–0.02%. The IFR for ages 35-44 was 0.02% – 0.05%. and it increased progressively with age.
In flu seasons before 2020, young adults (20s-30s) had extremely low IFRs, close to 0.005% or lower, while those in their late 30s approached 0.01%.
In October of 2020, Bhattacharya was one of the lead authors of the Great Barring Declaration. The American Institute for Economic Research, a conservative free-market think tank located in Great Barrington, MA, commissioned the opinion piece. The AIER also funds studies that claim to refute anthropogenic climate change. The Great Barrington Declaration claimed that NPIs were more harmful than beneficial for most of the population, but it provided no evidence for this assertion.
Frankly, I think Bhattacharya's behavior over the course of the pandemic was despicable. Given his history with SARS2 and COVID-19, If an A(H5) pandemic revs up, I doubt if he'll be there to throw us a life preserver.
Why is it despicable to publish an important hypothesis and then quickly conduct and publish several studies -- such as Bhattacharya's study showing very low coronavirus infection rates among employees of 26 major league baseball teams around the country -- that debunk your own theory?
Is it because Bhattacharya's opponents tended to be too stupid to realize that his own studies proved them right?
I feel like very few people distinguished themselves intellectually during covid. I certainly didn't get that much right, but at least I could read Bhattacharya's studies and see that they falsified his own theory.
Shouting fire in a crowded theater (when there isn't one) is considered to be reckless endangerment—and if people die in the resulting panic, it's considered to be a felony with harsh prison terms. Wouldn't gaslighting people and telling them that there's no fire in the theater (when there is one), and that it's all smoke and mirrors, also be reckless endangerment?
Yes, there were all sorts of early studies and models put forth that turned out to be wrong. In fact, I'd say that with SARS-CoV-2 and COVID-19, never have so many experts been so wrong about so many things! I’d respect them if they said, "Oops, I was wrong." That means they’re learning from their mistakes. But Bhattacharya still denies that NPIs reduced the mortality rate among the general population. And he continues to claim that COVID-19 wasn't much worse than the flu among the general population. That he continues to insist on these things despite the evidence to contrary suggests he's either a fool or a con man. Well, our culture is full of fools and con men, but what I find despicable is that his foolishness or his con contributed to the death COVID-19 death toll by downplaying the seriousness of the pandemic.
> Shouting fire in a crowded theater (when there isn't one) is considered to be reckless endangerment—and if people die in the resulting panic, it's considered to be a felony with harsh prison terms.
That case was partially overturned though. The standards for punishing speech is extremely high nowadays.
> In that ruling, the Court wrote that the First Amendment prohibits state regulation of advocacy unless that advocacy "is directed to inciting or producing imminent lawless action and is likely to incite or produce such action." Inslee's press release omitted any mention of an imminence requirement. As First Amendment scholar and Volokh Conspiracy blogger Eugene Volokh told Reason, imminence is a high bar. An example of imminent lawless action, Volokh said, is "standing outside a police station and yelling 'burn it down.'" Claiming fraudulent election results, Volokh said, is not incitement.
https://reason.com/2023/10/24/how-to-yell-fire-in-a-crowded-theater/
I blogged about that Bhattacharya's Santa Clara study on April 17, 2020. My headline read:
"Infection Rate in Silicon Valley in Early April Was 1% to 6%, Suggesting Infection Fatality Rate Is Much Lower Than Case Fatality Rate, But That Herd Immunity Is Far Off"
"Today, Santa Clara County has 1,870 official cumulative cases, with a current doubling rate of every three weeks, one of the lower in the country. Today, it has 73 official deaths. So that’s a Case Fatality Rate of 3.9% (which I don’t think anybody believes anymore).
"On the other hand, that looks like a long way from herd immunity, which is usually assumed to be over 50%.
"There have been two popular arguments for optimism:
"Infection Fatality Rate has been much lower than the Case Fatality Rate
"We are practically to Herd Immunity already
"This new paper seems to support the first proposition, but not the second."
https://www.unz.com/isteve/infection-rate-in-silicon-valley-was-under-5-in-early-april/
There is nothing wrong with any of this.
I can't get around the paywall to access that full article, but from the bits I can see, they're suggesting the infection fatality rate may be 10 or maybe 100 times smaller than the case fatality rate of 2-4%. My own best estimate is about 0.2-0.5% for people under the age of 75, so this seems about right. The whole thing is worded with the amount of uncertainty I'd expect of something published in spring 2020 and does reference the data available then, rather than just "bullshitting".
A 0.2% fatality rate across NYC's population would be about 16,000 deaths. Obviously not everyone in NYC got infected, but there's no contradiction between this number and mass graves.
It is not normal to retract a study over small inaccuracies such as you list, especially when they are hearsay. If other researchers had a problem with it, they should publish a rebuttal or perform their own study. This is a good example of attempted censorship.
> Bhattacharya continued to argue that COVID-19's risk was highly stratified by age
Looks like it's about 175x more dangerous for ages 50-64 than for ages 0-17: https://www.statista.com/statistics/1191568/reported-deaths-from-covid-by-age-us/
> "less deadly than the flu."
I'll grant you that one, he goofed.
Oh no, he wrote an opinion piece for conservatives! Who think conservative things! But I see no evidence that "The Great Barrington Declaration claimed that NPIs were more harmful than beneficial for most of the population, but it provided no evidence for this assertion.", rather what I see in the piece is "Simple hygiene measures, such as hand washing and staying home when sick should be practiced by everyone" which sure sounds like recommending non-pharmaceutical interventions to me.
I think covid's in a really awkward spot for being able to communicate its severity accurately. Because before vaccines, it really was about 10x worse than the flu (excluding the elderly). And people round the flu to 0, so they round 10x that to 0 as well. But it's really not, so everyone makes sure to say extra hard that it's an awful pandemic so nobody gets confused. But then when I think awful pandemic I'm thinking smallpox or black death or at least measles or polio, which is even farther from being an accurate comparison. If I really have to shove it in one of those boxes, it better go in the flu one.
Edit: Now that I'm actually looking up the measles fatality rate, it's a good bit lower than I'd thought and actually not too far from covid. Today I learned.
"he was a regular on Faux News"
Please don't do this. The rest of online activity is bad enough with everybody calling everybody else insulting names, I'd like if we could be better than that on here. I've never liked Murdoch nor his opportunistic media empire (which he directed to switch allegiances as to what political party to back, depending on how he thought it would grow his bottom line) but Fox News is as valid a news station as MSNBC and the rest of them (note, that does not mean it is not partisan nor that it is particularly excellent, but as a non-American I'm probably more used to media being openly partisan than Americans so this is something I both expect and know to discount).
As for Fauci, well I think he's not someone whose basket you should put all your eggs in. I think he'll end up like Avenatti one day - the skeletons will tumble out of the closet and all the enthusiasm for him as heroic fighter against orange man bad will come back to embarrass the enthusiasts.
I'm happy to read you laying out the facts about this Bhattacharya guy, but please try not to revert to Bluesky posting name-calling. We seem to already have Grim Trigger in a comment doing the good old "I'm going to call people I don't like names" with "Dempanic neurotics" and such like (presumably that would refer to Democrat supporters and that might include you, beowulf888?)
Point taken, but I guess the question is: should we be publicly respectful to fools and charlatans? I find the COVID hysterics to be just as obnoxious and annoying, but at least they didn't try to gaslight people into believing the pandemic wasn't serious.
I was considering putting together a list of what Fauci got wrong and what Fauci got right during the pandemic. It would also have to include how his words and his actions have been distorted by both the rightwing mouthpieces as well as some of the aforementioned COVID hysterics. I'll try to get that done for not the upcoming open thread but the following week's open thread.
Please consider the possibility that insulting him in a post intended to convince him to do things would have been a bad idea.
I admit writing a post intended to convince people to do things is dangerous because it creates incentives to say false things, but I tried my best to balance these considerations.
At the beginning of covid in the spring of 2020, Jay Bhattacharya put forward an important hypothesis: that the coronavirus wasn't much of a threat because a huge fraction of Americans had already had it so the public was getting close to herd immunity. He then quickly put out, if I recall correctly, three studies he'd done of this question, all of which showed he was wrong. My favorite was his study of how he'd gotten 26 of the 30 major league baseball teams to each have 200 of their employees tested for coronavirus antibodies. To Bhattacharya's surprise, the results for the 5000+ baseball franchise employees, players, coaches, and office workers, showed that infection rates were in the low single digit percentages.
All this strikes me as admirable. He put forward a theory that might have been true that he strongly wished was true, and then he disproved his own theory with good scientific studies.
Exactly. His assumptions about this turned out incorrect, he bravely admitted it but he was basically right about everything else.
The fact that this community is so much against him made me rethink and lose faith in rationalists. They even did many other things not based on evidence, like demanding Paxlovid for non-risk groups etc.
Covid restrictions were assault on my freedom, my rights and also an insult to science. Possibly these all was due to fear of death. Many rationalists speaks endlessly about immortality projects and their own plans to achieve it through cryopreservation etc. I consider it all unnecessary. Even if admirable in principle, we don't have such technologies yet, maybe will not have for several hundreds of years. Accept your mortality and spend your time in the best way.
An FDA that approves based on safety but not efficacy…..yikes.
Welcome to “safe” but useless therapeutics.
Most of your suggestions sound promising. Hopefully some of them catch on.
The main function of the FDA proving efficacy of drugs is telling doctors what they should prescribe and insurance companies what they should cover. That function might be better served by a different agency or by a non-governmental organization. But it's clearly a job that needs at least some centralization, as we can't expect doctors to follow the entire literature.
Fair enough. My point is that “safe but useless” makes it no different, and no better, than placebos. Whatever agency that job falls upon, if the bar is “safe but useless”, you’d be getting placebos approved.
> consider these the Venn-diagram-union of the ideas we’re most excited about, and the ones we think *they* might be most excited about
Did you mean to say Venn-diagram-intersection?
I think "whatever, you know what I mean" is an excellent answer to this, btw. I'm just scrutinizing it because I'm agonizing about what this ACX post means for the following Manifold market: https://manifold.markets/JamesGrugett/will-prominent-rationalists-judge-t
(probably not a lot)
> There was a movement to have some of these during COVID - which would have sped up vaccines, shortened lockdowns, and saved tens of thousands of lives
I’m 100% in favor of vaccine challenge trials, for any disease out there. But specifically for Covid, is that actually true? Let’s say they got together a bunch of EAs and all 3 leading vaccines (Pfizer, Moderna, AstraZeneca) got approved. By how much would this have sped up the manufacturing capabilities in practice? My understanding is that a lot of the constrains were logistical and at least Pfizer operated under the assumption their stuff is going to work.
There were also plenty of restrictions *after* mass vaccination was complete. The U.S. didn’t lift the absurd Europe travel ban until November 2021, even though the ban didn’t make sense since Day 1 given that it exempted US citizens, as if Americans were magically more immune to the virus. Same deal with China that finished vaccinations and then… spent another year and a half in pointless restrictions.
This is pure fantasy on the part of the author. The changes to health policy advocated here depend on the vast apparatus of government health bureaucracy still being in place, like it or not. What we have going on here is the wholesale destruction of our bureaucratic apparatus, to be replaced by ideologically aligned loyalists.
You are not going to be able to get these magical policy improvements if the apparatus for funding, directing, regulating and implementing them has been destroyed.
This post might have been interesting to think about before the inauguration, but now that we see the current path of this deliberately broken executive branch, looking around to see which pet-causes might be favored is an act to be done only by the un-serious.
Hear, hear!
On kidney donation, it would be great if someone could build and most importantly enable a marketing/publicity machine support it, a system that let's people know about those in need about 2 steps removed.
I would know if my immediate or even extended family needed my kidney and would donate if I could. I already know that many fellow citizens would benefit ... but I am too selfish to donate. But what about someone in my kid's hockey league? I probably have seen them at games. They would be in my broader tribal circle. Or living in my neighborhood? Or fellow patron of a certain blog/substack.
The weak form of this (sympathetic recipient, much publicity) seems to happen regularly. Some cute little girl gets some local TV publicity and some local (maybe the assistant manager at the local grocery store) sees it and donates. Seems like targeted social media and better access to data could weaponize tribal sympathy.
this is a great idea. It seems like social networks mostly have the information needed to do this, i wonder what the best way to motivate them to do it would be
My suspicion is that the more we centralize these requests, the less effective each appeal will be, psychologically. Compare with medical expenses kickstarters: people often donate a small amount to acquaintances when the link is shared socially, but hardly anyone just goes to kickstarter.com and scrolls through the "medical" tag. Tribal sympathy is only triggered through the tribe's ordinary communication channels.
OMG, I love you! I'm subscribing here again, (After a hiatus.. giving my limited $ elsewhere.) The Trump train is a potential time of change, and you can just get on one of the cars. And still not support any of those other cars. (Though we are all cars on the same train, and there remains some connection... )
Personally I really like Bobby and Tulsi and Kash. A time of change I hope.
Oh an idea for an ambitious post. The exact amount of waste in all the federal departments is hard to know. But let's make a guess for each one. And how much we could potentially save. Defense contractors seem like a highly centralized part of spending. What if we took 1/3 of the defense budget and sent it out for bids by smaller companies? Or some other idea to make better guns (things) for cheaper. I guess the hard nut to crack is Social Security (SS). My next door neighbor is a few years younger than me. But his body is way more broken, because he was a bricklayer for much of his life.
The defense procurement budget mostly goes to things that can't realistically be made by smaller companies. You're not going to get anyone smaller than Huntington-Ingalls to build a fleet aircraft carrier. You could maybe imagine something midway between Lockheed-Martin ($71E9 gross revenue) and Saab AB ($5E9 gross revenue) that could develop our next-generation combat aircraft, but that wouldn't save all that much and it runs into the problem that no such company exists.
Are you following Anduril? I am not trying to start an argument with you, but I am curious.
"...focus are for Makary..." ? "...focus Marty Makary..." would make more sense to me. But how does a focus have an impact? I can't really understand this sentence. Our host did better without coauthors.
A lot of these are great ideas.
I'd be surprised if the Trump administration acts on any of them, but if even one gets read by all the conservatives who secretly and not-so-secretly read your blog it will do some good. So, thanks.
Another suggestion for the FDA to avoid repeating their COVID mistakes: stop overregulating tests.
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