489 Comments

> Expertise isn't a sham.

Tetlock begs to differ: https://spot.colorado.edu/~huemer/papers/passivity.htm

"In light of the ignorance of typical political leaders and members of the general public, we might be tempted by the idea of rule by experts, as in Plato’s Republic. 18 Unfortunately, when it comes to descriptive social theory, even the experts’ knowledge is unimpressive, as demonstrated recently by the social psychologist Phillip Tetlock. Tetlock conducted a fifteen-year study in which he collected tens of thousands of predictions from hundreds of political experts concerning matters within their areas of expertise (for example, would the economy slide into recession, would the Soviet Union survive, who would win the next Presidential election, and so on). Tetlock’s finding, in brief, was that the best experts did only slightly better than chance at predicting outcomes. When asked to assign probabilities to their predictions, experts proved systematically overconfident; for example, events predicted with 100% confidence happened less than 80% of the time."

Expand full comment

I don't think this is a fair characterization. There are definitely subjects where expertise is real (infectious disease is probably actually one of the clearer-cut ones). Much of Tetlock's work is about identifying which subjects have real expertise and which ones don't.

Expand full comment

What I quoted did note, "when it comes to descriptive social theory". I think it was Scott's claim that "Expertise isn't a sham" which isn't a fair characterization and is too broad. There's a separate and more complicated philosophical question of whether mental health fits into social theory or neurophysiology.

Expand full comment

Medicine, even physical medicine, still seems much less scientific than something like aerospace engineering. As Greg Cochran & Nassim Taleb like to point out, doctors were on net harmful for most of the very long existence of their profession. And "public health experts" if anything seem to be more captured by political activism than your typical never-heard-of-Bayesian-probability doc.

Expand full comment

My impression is that public health experts were pretty impressive when public health was a major concern -- say, during the Panama Canal era of the first half of the 20th Century.

But as infectious disease became less of a problem, public health experts tended to become more politicized and less useful. Few public health experts in the 1980s dared enunciate the chief cause of the AIDS epidemic in the US, Gay Liberation, which led to a lot of unnecessary paranoia among heterosexuals who had never been close to Castro Street, Santa Monica Boulevard, or Christopher Street. And in recent decades, public health experts who, deep down, know better, have shamefully countenanced the popular myth that AIDS was, somehow, due to the supposed homophobia of Ron and Nancy Reagan.

Expand full comment

Wasn't the AIDS crisis actually a big problem caused by infectious disease? My understanding is that it was the biggest cause of death for adults under a certain age. Granted, it was highly concentrated in certain populations and not actually as prone to "breaking out" as the experts warned.

Expand full comment

Polio got worse during the 20th Century in the US, with the 1952 outbreak being the worst in US history. My vague impression is that the post WWII fight against polio was more or less the climactic chapter of the heroic age of the struggle against infectious disease, which had included the triumph over yellow fever at the Panama Canal.

Over the next few decades, public health, especially in the US, became more routine. That's a good thing, but it also meant that less top talent flowed into the field and practitioners got less practice at dealing with novel crises. Perhaps this caused problems when AIDS and COVID came along?

Expand full comment

Interestingly/bizarrely, there are or were a bunch of qualified experts who believe(d) that AIDS is not caused by HIV. They believe both exist but that HIV is a relatively harmless virus that was in effect 'framed' by bad science. The people in question had long careers in virology, microbiology or in one case as a journalist who covered the AIDS epidemic over a period of about a decade for a major national newspaper.

One of their many arguments is that it shouldn't be possible for a virus to express a preference for homosexuals, or at least not for very long, because they're too small and simple to be able to 'know' the orientation of their host. The long-predicted break-out into the heterosexual community never happened. Even today most AIDS cases are gay and male, except in Africa where AIDS affects both genders the same. This is also posited as being inexplicable if African AIDS is the same phenomenon as western AIDS, because again, a virus is too small and simple to prefer men in the west but have no gender preference in Africa.

Past tense used because I'm not sure if those people are still around. I found out about this because one of them was the inventor of PCR testing, but he's dead now.

Expand full comment

The name familiar to me for that is Duesberg, and I believe his argument is that AIDS is actually caused by drug use, which was common for many of the victims at the time. The difference between sub-Saharan Africa and the rest of the world does seem odd. Here's the one theory I'm aware of to attempt to explain it: https://www.overcomingbias.com/2010/02/africa-hiv-perverts-or-bad-med.html

Expand full comment

> Few public health experts in the 1980s dared enunciate the chief cause of the AIDS epidemic in the US

Early named for AIDS were literally "GRID" for "gay-related immune deficiency" and "4H" for the four groups (including "homosexuals") among which it initially clustered.

You can't seriously claim no one was considering orientation when they literally named the damn thing after it and then got a whole New York Times article to themselves entitled "NEW HOMOSEXUAL DISORDER WORRIES HEALTH OFFICIALS" (https://www.nytimes.com/1982/05/11/science/new-homosexual-disorder-worries-health-officials.html)

But of course this comment section being what it is, this claim got five upvotes despite this being common knowledge among anyone with even the slightest familiarity with the history of AIDS. Hey, fellow lurkers, I suggest you look up this person's name and tell me if you think that's the sort of person you want making undebunked claims in your intellectual space.

Expand full comment

Obviously, the doctors and scientists dealing with Castro Street AIDS patients in the early 1980s knew how it was being spread.

Over the years, however, the Establishment has managed to obfuscate, such as by angrily denouncing anyone who points out the history, the role that Gay Liberation played in AIDS. So that today few seem aware anymore of the historical connection. I wouldn't be surprised if more people today thought AIDS was caused by homophobia.

Expand full comment

Your claim wasn't about today. You literally said:

> Few public health experts *in the 1980s*

If public health experts are talking about it in the New York Times, it's not a victim of a hypothetical early-80s cancel-culture. Plain and simple.

---------

As to the rest of your claim:

I believe, and would discuss and have discussed with other members of the queer community, that being the receptive partner in anal sex is the riskiest common sexual activity with respect to HIV transmission.

No one (well, almost no one, there's always a crazy person or three) objects to this claim. You'll find this claim in a pamphlet on the table in every student queer group in America, in the waiting room of every LGBT-inclusive therapist's office, in the sidebar of every LGBT subreddit. I know this because I spent a good chunk of my 20s in those rooms and got really, really sick of it. And in fact, we can go to the CDC website right now (https://www.cdc.gov/hiv/basics/hiv-transmission/ways-people-get-hiv.html) and find exactly that claim in black and white:

"Anal sex is the riskiest type of sex for getting or transmitting HIV.

Being the receptive partner (bottom) is riskier for getting HIV than being the insertive partner (top)."

So your claim, basically, is that the feared "Establishment"'s best shot at suppressing news of the risks of anal sex is to promote them in every channel it has. If that's their best shot, well, I don't think you have much to worry about.

Expand full comment

It seems rather likely that if we had legalized gay marriage back in the 1970s, HIV would have been less severe in the gay community.

The gay community was (and is) both promiscuous and engaged in the most dangerous type of sex (anal sex) regularly. It is still the highest risk factor in the US. The second highest is being black - 42% of HIV diagnoses are in black people, and it is likely actually worse than that because black people are probably less likely to get diagnosed because of anti-doctor sentiments in the black community.

Gay liberation wasn't really the issue; gay promiscuity was.

Expand full comment

Aerospace engineering was also net-harmful before the 20th century.

Expand full comment

There wasn't nearly as much of it as there was medicine.

Expand full comment

"infectious disease is probably actually one of the clearer-cut ones"

Doesn't seem like it.

Expand full comment

This is a mischaracterization of Tetlock's work which he himself has rebutted in the first chapter of Superforecasting

> But I realized that as word of my work spread, its apparent meaning was mutating. What my research had shown was that the average expert had done little better than guessing on many of the political and economic questions I had posed. “Many” does not equal all. It was easiest to beat chance on the shortest-range questions that only required looking one year out, and accuracy fell off the further out experts tried to forecast—approaching the dart-throwing-chimpanzee level three to five years out. That was an important finding. It tells us something about the limits of expertise in a complex world—and the limits on what it might be possible for even superforecasters to achieve. But as in the children’s game of “telephone,” in which a phrase is whispered to one child who passes it on to another, and so on, and everyone is shocked at the end to discover how much it has changed, the actual message was garbled in the constant retelling and the subtleties were lost entirely. The message became “all expert forecasts are useless,” which is nonsense. Some variations were even cruder—like “experts know no more than chimpanzees.” My research had become a backstop reference for nihilists who see the future as inherently unpredictable and know-nothing populists who insist on preceding “expert” with “so-called.”

And, it should be noted that not all experts were equally overconfident. Tetlock found that experts who used a particular framing 100% of the time were systematically overconfident and bad at forecasting, while experts who used multiple different framings of the issue and a variety of different philosophies of analysis were much more accurate. He dubbed the former "hedgehogs", and the ladder "foxes".

> One group tended to organize their thinking around Big Ideas, although they didn’t agree on which Big Ideas were true or false. Some were environmental doomsters (“We’re running out of everything”); others were cornucopian boomsters (“We can find cost-effective substitutes for everything”). Some were socialists (who favored state control of the commanding heights of the economy); others were free-market fundamentalists (who wanted to minimize regulation). As ideologically diverse as they were, they were united by the fact that their thinking was so ideological. They sought to squeeze complex problems into the preferred cause-effect templates and treated what did not fit as irrelevant distractions. Allergic to wishy-washy answers, they kept pushing their analyses to the limit (and then some), using terms like “furthermore” and “moreover” while piling up reasons why they were right and others wrong. As a result, they were unusually confident and likelier to declare things “impossible” or “certain.” Committed to their conclusions, they were reluctant to change their minds even when their predictions clearly failed. They would tell us, “Just wait.”

> The other group consisted of more pragmatic experts who drew on many analytical tools, with the choice of tool hinging on the particular problem they faced. These experts gathered as much information from as many sources as they could. When thinking, they often shifted mental gears, sprinkling their speech with transition markers such as “however,” “but,” “although,” and “on the other hand.” They talked about possibilities and probabilities, not certainties. And while no one likes to say “I was wrong,” these experts more readily admitted it and changed their minds

> ...

> Foxes beat hedgehogs. And the foxes didn’t just win by acting like chickens, playing it safe with 60% and 70% forecasts where hedgehogs boldly went with 90% and 100%. Foxes beat hedgehogs on both calibration and resolution. Foxes had real foresight. Hedgehogs didn’t.

How did hedgehogs manage to do slightly worse than random guessing? To answer that question, let’s meet a prototypic hedgehog.18

> Larry Kudlow hosted a business talk show on CNBC and is a widely published pundit, but he got his start as an economist in the Reagan administration and later worked with Art Laffer, the economist whose theories were the cornerstone of Ronald Reagan’s economic policies. Kudlow’s one Big Idea is supply-side economics. When President George W. Bush followed the supply-side prescription by enacting substantial tax cuts, Kudlow was certain an economic boom of equal magnitude would follow. He dubbed it “the Bush boom.” Reality fell short: growth and job creation were positive but somewhat disappointing relative to the long-term average and particularly in comparison to that of the Clinton era, which began with a substantial tax hike. But Kudlow stuck to his guns and insisted, year after year, that the “Bush boom” was happening as forecast, even if commentators hadn’t noticed. He called it “the biggest story never told.” In December 2007, months after the first rumblings of the financial crisis had been felt, the economy looked shaky, and many observers worried a recession was coming, or had even arrived, Kudlow was optimistic. “There is no recession,” he wrote. “In fact, we are about to enter the seventh consecutive year of the Bush boom.”19

Expand full comment

What an excellent reply. Thanks for spending the time to add it.

Expand full comment

Thanks. I will ask Dr. Huemer to see what he responds.

Expand full comment

That would be very cool. If he has any criticisms I'd like to know them.

Expand full comment

As I was crafting my message to Dr. Huemer, I fail to understand what he mischaracterized. He wrote that experts' knowledge is "unimpressive" and characterized Tetlock's research as "the best experts did only slightly better than chance at predicting outcomes".

Is that incorrect? Your paragraphs on foxes and hedgehogs were interesting subset analyses but didn't cite any numbers. Did foxes do much better than chance?

Tetlock writes, "The message became “all expert forecasts are useless,” which is nonsense"

But I think this does not apply to the linked Huemer paper. Huemer ends with accepting that experts are often the best that we have:

"Political leaders, voters, and activists are well-advised to follow the dictum, often applied to medicine, to “first, do no harm.” A plausible rule of thumb, to guard us against doing harm as a result of overconfident ideological beliefs, is that one should not forcibly impose requirements or restrictions on others unless the value of those requirements or restrictions is essentially uncontroversial among the community of experts in conditions of free and open debate. Of course, even an expert consensus may be wrong, but this rule of thumb may be the best that such fallible beings as ourselves can devise."

Expand full comment

I'll preface this by saying I only know that Tetlock thinks that

> As I was crafting my message to Dr. Huemer, I fail to understand what he mischaracterized. He wrote that experts' knowledge is "unimpressive" and characterized Tetlock's research as "the best experts did only slightly better than chance at predicting outcomes".

Here's a graph summarizing some results from Expert Political Judgement https://imgur.com/a/3rxoNAx

It's very hard to read, and would certainly benefit from some color-coding, but the best experts do slightly better than chance in calibration, and much better than chance in discrimination, even though the majority of experts, and the group's average do worse. Assuming the dotted lines indicate some kind of equivalence gradient, then the best experts do significantly better than random chance.

(Note too that "mindless competition" ranges from chimps throwing darts to "moderate and extreme case-specific extrapolation" (I have no idea what this means, since I haven't read Expert Political Judgement). Not everything in that category is pure chance. I made this mistake when first looking at the graph, and became very confused.)

> Tetlock writes, "The message became “all expert forecasts are useless,” which is nonsense"

> But I think this does not apply to the linked Huemer paper.

It's plausible that the paper's conclusion survives this relatively minor mistake, especially when it ends up concluding that despite the lack of high predictive-power experts, we still have nothing better (which I'd disagree with because a) superforecasters exist, and many others are anecdotally able to beat the experts very often, and b) points #35-37 do significantly better on discrimination and calibration than experts, dilettantes, foxes, and hedgehogs. Though as I've said I don't know what "moderate and extreme case-specific extrapolation" nor "generalized autoregressive distributed lag" are. Though I haven't read Huemer's essay in full, so maybe he addresses this, or it's irrelevant to his case.).

I was mainly arguing that Tetlock's work does not support the conclusion that expertise is a sham. Even if there are important considerations and grains of salt which you should take when making use of expert forecasts.

On reflection, I don't think Tetlock's work is even very highly relevant to the question of whether expertise is a sham. He was testing experts' ability to forecast general questions, while the whole point of expertise is to be *really good* at only one particular thing. I like Matt Yglesias's framing here http://static1.1.sqspcdn.com/static/f/468275/28400876/1612383295720/rs251transcript.pdf?token=heYBwKmPnUMuTcXxQ4rRIEXSyEQ%3D

> A lot of what we get is adjacent expertise. So somebody who studies viruses, and maybe knows a lot about the protein structure of viruses, will opine about masks, right? And you’ve got to ask yourself, "Do they have subject matter expertise in this mask thing? Whose expertise do we need here?"

> Because one thing that I think clearly came out of the whole masks controversy is that public health experts underrated how easy it would be to get cloth masks in everybody's hands. It didn't occur to them as a solution to the PPE shortages that we could just get everybody a cloth mask.

> And that's because they're not experts in textile manufacturing. And it's no shame on them for not being experts in textile manufacturing. But they were thinking about, “Will masks give people a false sense of security?” Which is a psychology question. They were thinking about “Can we substitute away from surgical masks?” Which is a textile supply chain question. They were thinking about “Well, what are the antiviral properties of cloth masks?” Which again is a textile question. That's not a public health -- it's obviously relevant to public health, but it's a material science question.

> They didn't have expertise in those areas, and were in fact just on a par with me, or anybody else, right? But they had the, sometimes, arrogance that comes with believing you're being asked about your area of expertise.

Expand full comment

Oops. That first sentence should be deleted. Curse you Substack for your lack of editable comments!

Expand full comment

> I don't think Tetlock's work is even very highly relevant to the question of whether expertise is a sham

IIRC, he taught or organized generalists to dominate DARPA forecasting competitions, no?

Isn't his later work highly suggestive that you can actually train (some) people to excel at forecasting itself, across domains?

Expand full comment

As a general point, there are many kinds of experts. It looks like Tetlock is using "expert" as shorthand for "experts in fields related to political prediction". His work probably doesn't tell you anything about medical predictions.

Expand full comment

Perhaps this could be an objective definition of an expert: An expert is somebody who is usually right about a topic too boring for the average person to have a strong opinion about. For example, most practicing tax lawyers are, under this definition, experts on what the IRS will and won't let you deduct on your 1040. They get the various questions right the great majority of the time. But they seldom get nationally famous for their expertise.

On the other hand, topics that huge numbers of people find interesting, such as who will win the Super Bowl, tend to be ones that are hard to predict. The NFL is set up so that if you can predict the eventual Super Bowl winner at the start of the NFL 10% of the time, you are doing well. And even predicting the winner right 70% of the time at the opening kickoff is pretty hard. You can be a famous expert Super Bowl forecaster on TV without being right very much at all if you are at least interesting in the way you defend your wrong predictions.

As for Dr. Fauci, I don't watch much TV, so I have less of an opinion about him that almost everybody. I presume that most of the time during Dr. Fauci's long career, practically nobody among the general public was interested in him. I imagine he was pretty accurate during those boring times, thus meeting my definition of an expert.

During the two times when people were interested in Dr. Fauci, AIDS and Covid, he was probably less accurate. Not because he changed, but because the topics at hand became less predictable by expertise and thus less boring.

So, if experts are people who are usually right about boring topics, interesting topics are those which even the experts are frequently wrong about.

Expand full comment

I would imagine that there are hundreds of little known NFL obsessives who have a better track record predicting who will win NFL games than the famous people who give their opinion of who will win on TV.

It's also possible that there are also amateur tax experts with better track records at predicting IRS behavior than the paid experts. But, I suspect, there are more amateur hobbyists following the NFL for fun than following the tax code for grins.

Expand full comment

Tetlock can be interpreted as not saying "experts are wrong", but rather "experts aren't great at probabilities". The people who do well in Tetlock's research are non-experts but they do consult experts. Most of their advantage comes from being well calibrated to produce probabilities based on interpretations of the experts.

Expand full comment

Yes, I'm one of Tetlock's Superforecasters and I like this framing. I like to point out that Superforecasters *are* experts - at making and assigning probabilities to predictions.

Expand full comment

Many 'experts' actually are bad (think stereotypical pundits). But plenty of experts do have real expertise but are just bad at thinking quantitatively or rigorously about uncertainty, and they could be competent forecasters with training.

Expand full comment

It's useful to hold the tension between

A: We're monkeys who more or less only *just* upgraded from feudalism. Things are going well considering we just need to keep iterating

B: Decisions get made that so clearly go against everyone's best interest on the regular. We can glimpse a better world and what we've build (while keeping us safe) is blocking us from moving forward.

I think the more fully we can recognise both the better, but A is a lot less represented in the current discourse, thanks for the reminder.

Expand full comment

Ada Palmer puts it this way in her Terra Ignota series:

Is there anything important enough that you would destroy this world for it? Would you destroy this world to build a better one? Or would you destroy the chance of a better world, to save this flawed but in many ways utopian society?

(The society in her books is more clearly utopian than ours, but also clearly flawed in recognizable ways.)

Expand full comment

Gosh I love those books. Though I'm still holding out hope for iteration rather than choosing between stagnation or revolution. Ideally Atlantis never has to fall.

Expand full comment

onically, with the WebMD example, if you want the most precise I formation without political/legal intfluence you would choose an even more specialist (or professional) resource, such as the BNF (for drugs in the UK, which definitely doesn't list all side effects; I find it odd when a patient asks me about a side effect of a drug that I've prescribed for them that they've read in the leaflet yet the side effect is not significant enough to warrant listing in the British National Formulary so when I look it up I can't find it), fpnotebook, CKS etc

Expand full comment

So? Is it true that disproportionately many borderline personality cases are young women with lots of piercings and tattoos? What does that tell us about diagnosis and etiology?

Expand full comment

Scott has written before about how the same symptoms get labelled differently on different people. So I'd guess self reinforcing stereotypes are to blame

Expand full comment

Or perhaps lots of piercings, tattoos, and, especially, nose rings are a warning sign?

Expand full comment

who hurt you

Expand full comment

If x is mildly correlated with y, that still doesn't mean it makes sense to treat x like a "warning sign", especially when y isn't that common. Bayesian rules still apply here.

Especially when x is in this case is something like "having a non-conformist appearance", which I'm sure does have some minimal correlation with certain psychological disorders, but also tens to correlate much more strongly with traits I actively seek out, like "being a highly creative person" or "having a tolerant worldview towards LGBT people."

Expand full comment

Yes! Keeping power vs. being right is a great constraint to point out. I would maybe suggest expanding "being right" to "competence" though -- I'm willing to buy that Zvi is really good at being right, but he might not be nearly as good at hiring, leadership, working with other people, keeping schedules or any of the other things that are sometimes completely unimportant and sometimes absolutely critical to a job.

The head of the CDC job and benevolent dictator in particular probably require a LOT more in terms of managerial than predictive skills. Zvi would, I suspect, be most useful as an advisor to the benevolent dictator than the dictator himself. It's a shame that governments don't employ advisors anymore.

Expand full comment

Yes, expand it to general competence. The head of the CDC is chosen for keeping power at the expense of being a good manager.

Expand full comment

That’s true to some degree certainly. But this article could easily be a very different article, based around “the CDC director is chosen based on skill at managing all disease needs, and Dr Fauci is the best person out there who can handle the management of a large agency, making public health decisions on new pandemics, and spearheading efforts to deal with existing diseases. It’s doubtful that he’s the best at all three, but I’m also doubtful that Zvi is superior at that combination, even ignoring need to do politics. Zvi’s skills, based on his blogposts about COVID, are focused around things like statistical analysis and observing new research. But those are not at all the same skills as managing a large agency. One response then might be that we should split up those tasks to different people - the head person manager, the head disease predictor, etcetera. But of course then you get back to politics - what do you do when those people disagree about how to handle a situation?

Expand full comment
founding

Governments absolutely have advisors (for example, POTUS has 'senior advisors,' who are not confirmed by the Senate). Frequently, these advisors are part of the problem that Scott has identified, in that they frequently push their nominal superiors towards complying with the will of special interest rather than acting in the general interest, and/or to whatever is most likely to maintain the superior's power, which in turn is good for their power.

They're also frequently and more straightforwardly part of the corruption that makes being right difficult; often, such jobs are handed out as patronage or given to figures who would not (for instance) survive confirmation, or to tick special interest boxes themselves on an org chart.

Of course, the other kind, which you envision, exist as well. Smart and driven professionals who, by the nature of their appointments, are unbounded by the need to pander to the political breeze of the day or to special interests and who might be able deploy their skills towards the singular goal of being right as often as possible.

The key, I suppose, is to optimize for the latter over the former. I'm not sure there's a good way to do that, since it's always going to depend to a large degree on the character and priorities of the appointer. If the appointer is themselves appointed or elected, we know well that their characters vary widely and in ways that aren't straightforward to control (as in, who gets elected, and who those elected people then appoint to [for instance] Senate-confirmed posts, who then appoint advisors).

I'm sure our current system doesn't do a good job of optimizing for this. Even if we assume that there is one of the 'good' kind for every one of the 'bad' kind (which I doubt; I suspect the real distribution favors the 'bad'), the best you're likely to get is for them to cancel each other out. An advisor that makes the right call doesn't count for anything if her superior acts instead on the recommendation of another advisor who prioritizes power. And, under our current system, it's likely that there's more than one realpolitker for every truth-seeker.

In this regard, despite many efforts to curb patronage (that, historically speaking, have been unquestionably and extremely successful), it still definitely exists. Especially these days, when people desiring patronage frequently have impeccable CVs themselves, studded with degrees and honors from tier 1 institutions, work experience in tier 1 private entities, or government experience in tier 1 or 2, and reams of glowing recommendations. With an elite culture as credentialed and extensive as ours, it can be very difficult, even for an appointer who wants to stock their kitchen cabinet with the 'good' kind to pick them out of such a crowd. Frequently, the solution chosen is to pick people you've known your whole career, which of course has its own pitfalls.

And then these pitfalls lead to their own, and so and so on ad infinitum until you really do have to fall back on Scott's thesis, and hoping that we've built a sufficiently resilient and effective system that actually does optimize, in any marginal way, for obtaining the right outcome.

Expand full comment
author

These are good points.

Expand full comment

I went to college, Rice U., with the head of the CDC, Steve Hahn, and was the friend of Steve Hahn at Rice.

But, it turns out, they are two different Steve Hahns.

Expand full comment

Cool hominid party trick: The world is abominably complex, so we call up organizational superstructures from the depths of meme hell and put them to work managing said abominable complexity. This is adaptive, apparently.

The dread blueprint of the FDA lurks latent in the collective unconscious, waiting to manifest and consume the souls of unsuspecting hunter-gatherers.

Expand full comment

Only when our self created kafkaesque systems are as impentrable and complex as external reality can they succeed in taming it

Expand full comment

Killing someone to take all their stuff is adaptive for the killer, but probably not adaptive for society at large. Summoning the FDA is adaptive for Anthony Fauci, but...

Expand full comment

Are you referring to the articles on lorienpsych.com as your small database? I thought you meant more like a weighted average of patient ratings like when you recently compared different amphetamines.

Expand full comment
author

Yes, I'm referring to Lorien Psych.

Expand full comment

Best post since you came back online, Scott!

Yes - the amazing thing is that our society works far better than we have any right to expect. (And far better than it would if 99% of reform proposals were adopted.)

And...just put a link to this post on your database (BTW, where is it?).

That *ought* to be sufficient, but of course it won't be for some people. You just have to live with that - valuable info online will help many people and hurt a few who misuse it. But it does net positive good.

The alternative is to become WebMD. They're *cowards*. They know they're destroying the utility of the information they offer, but they have shareholders to appease and lawyers to fear.

You can, and must, be braver. Probably you won't get sued over this, and if you do you'll probably win. But you're in the lucky position - unlike WebMD - of having a large fanbase who appreciate what you do and will bail you out if all goes pear shaped. I can (and do) guarantee that you'll never have to worry about financial hardship because of losing a lawsuit over this stuff - somebody in your fanbase will ensure you have a well-paying job (in the unlikely event you need help).

Expand full comment
founding

> you're in the lucky position - unlike WebMD - of having a large fanbase who appreciate what you do and will bail you out if all goes pear shaped. I can (and do) guarantee that you'll never have to worry about financial hardship because of losing a lawsuit over this stuff - somebody in your fanbase will ensure you have a well-paying job (in the unlikely event you need help).

in other words, scott has his own political capital he can draw on to do things in the world, much as faucci has his political capital. i wonder if there's something here... for instance, what if faucci had his own circle of fans who would protect him if things went "pear shaped"? i guess he actually probably does, but he still wouldn't be able to continue occupying his current position in his current power structure.

is it just the problem that faucci's power structure is too big, and his enemies too diffuse in too many other competing power structures? going too far, does our utopian future lie in smaller, more distributed power structures?

Expand full comment

Fauci clearly has a lot of political capital. He has survived in his current role since at least the 1980s, through two pandemics that he partially mismanaged, but then greatly improved his management of (and improved more than any of the obvious replacements seem like they would have). He seems to be one of the very few Trump administration executive officers that survived long past crossing Trump many times.

Expand full comment

"What I sometimes call Marx's Fallacy is that if we burnt down the current system, some group of people who optimized for things other than power would naturally rise to the top. Wrong. People who most brutally and nakedly optimized for power would gain power; that's what "optimize" means. The interesting thing about the current system is that, after millions of very smart and altruistic people have contributed to it over generations, sometimes gaining and keeping power within it is modestly correlated with being good and right."

This is so brutally insightful and hilarious at the same time.

Expand full comment

Where did Marx say anything like that? If it's an "insight" it has to correlate to something Marx wrote. Scott Alexander provided absolutely no evidence that this fallacy can be traced to Marx.

Expand full comment

I don't know a whole lot about Marxism (despite the profile picture), but I'm actually under the impression that he believed the opposite - that to get to communism, after destroying capitalism an intermediate strong government would be needed to gradually transition the country to communism.

Perhaps he underestimated the difficulty in ensuring such an intermediate government would remain true to the goals of the revolution that got them there, but he certainly didn't think communist utopia would naturally emerge.

Expand full comment

As a former citizen of the USSR I would say that the socialistic government always remained true to the goal of building communism and that's why they were a failure. In this I totally agree with Scott Alexander and I am even surprised how he can have such great insights. Most Americans simply don't get it and they think of the USSR only in terms of a culture war – that they were bad because they wanted to take over the world or something like that.

Expand full comment

Being a former citizen of the USSR doesn't make you an expert in Marxist thought. If you want to defend Scott's point here you should quote Marx using primary sources - not give us anecdotes.

Expand full comment

It makes me a test subject and my verdict is – it doesn't work and experts were wrong.

I actually had to study Marxism-Leninism at school. It does not matter if Marx said precisely those words or not. It is something what a reasonable person looking at the history would conclude.

Expand full comment

Test subjects aren't the one writing scientific reports and conclusions, so your metaphor doesn't make sense.

>It does not matter if Marx said precisely those words or not.

If Scott Alexander wants to call something "Marx's fallacy" then I suggest he prove that Marx thought something along those lines. This really should not be too difficult (if Marx indeed made such a mistake) using primary sources. Otherwise it seems more like Scott Alexander is failing an Ideological Turing Test.

Expand full comment

"What Is Marxism? Marxism is a social, political, and economic philosophy named after Karl Marx. It examines the effect of capitalism on labor, productivity, and economic development and argues for a worker revolution to overturn capitalism in favor of communism." - https://www.investopedia.com/terms/m/marxism.asp#:~:text=Was%20Marx%20Right%3F-,What%20Is%20Marxism%3F,capitalism%20in%20favor%20of%20communism.

"Marx believed that all world history was a “history of class struggles.” According to Marx, oppressor and oppressed have always “stood in constant opposition to one another.” One group—the oppressors—owned the means of production, such as land, raw materials, and money. They controlled government and society. The other group—the oppressed—owned nothing and depended on the owners of the means of production. Marx believed he saw a society that was "more and more splitting up into two great hostile camps, into two great classes directly facing each other: Bourgeoisie and Proletariat." The bourgeoisie—the middle class—were the oppressors. The proletariat (PROH•luh•TEHR•ee•uht)—the working class—were the oppressed. Marx predicted that the struggle between the two groups would finally lead to a revolution. The proletariat would violently overthrow the bourgeoisie. After their victory, the proletariat would form a dictatorship to organize the means of production. However, because the proletariat victory would essentially abolish the economic differences that create separate social classes, Marx believed the final revolution would ultimately produce a classless society. The state itself, which had been a tool of the bourgeoisie, would wither away." -Mcgraw Hill Education company. (if you think this one is inaccurate, it's literally being used in schools)

Expand full comment

I don't think he needs to correlate it because it's the foundation of Marxism.

Marx revised to define exactly what communism is because it must arise from the conditions of the world when the revolution comes.

That is: Marx believed so strongly in the fact that the revolution would make things perfect that he refused to guide that revolution at all.

Here is a relevant quote:

"Communism is for us not a state of affairs which is to be established, an ideal to which reality [will] have to adjust itself. We call communism the real movement which abolishes the present state of things. The conditions of this movement result from the premises now in existence."

That is, Marx defined communism as the complete overthrow of the current state of affairs. This is the basis of communism.

Expand full comment

"That is: Marx believed so strongly in the fact that the revolution would make things perfect"

He doesn't say anything about the revolution making things "perfect" in the quote you offered. Neither does it say anything about " if we burnt down the current system, some group of people who optimized for things other than power would naturally rise to the top".

Expand full comment

He's saying that Marxism says that communism will naturally arise from revolution/when the current state of affairs are overthrown. It's saying that communism (the "perfect" system) will naturally rise to the top.

Expand full comment

Where does Marx call communism a "perfect" system? If we're attributing words and ideas to Marx we should probably be very careful about finding primary sources. I also think people are putting an undue emphasis on "naturally" here, as if it occurs without foresight. Marx is talking about very deliberate political movements, which yes, arise from the seeds sown by capitalism.

Expand full comment

For anyone wondering, MarxBro is a dedicated troll of the rationalish community, coming out of the woodwork anytime Marx is mentioned to make ever escalating demands for rigor. No criticism or even mention of Marx or Marxism is well-founded unless it engages with primary sources to MarxBro's standards, a standards which tellingly has never been met by any interlocutor ever. Don't waste your time.

Expand full comment

When someone has claimed Marx has made a "fallacy" I'm well within my rights (and indeed, common sense in general) to ask where that fallacy exists in their original works. Using citations. If that seems like an "escalating demand" then I'm very happy to escalate the rationalist community by uplifting their standards.

Expand full comment

As a reader with no dog in this hunt, I'm not sure what to make of this ad hominem comment about marxbro1917. Maybe my troll-o-meter is not very sensitive.

I thought Marx argued that capitalism bore the seeds of its own destruction, that this was a core tenet of dialectical materialism, not that Marx was a kind of crass "burn it down" accelerationist nor a theorist ignorant of how power corrupts. So it seemed reasonable to me that someone might ask why is Scott attributing this very common human fallacy to Marx specifically.

There are legions of people fantasizing in our present-day moment about how if we burned everything down, something better would just naturally kind of spring up. Of all the ideological lineages that feed this kind of naivete, I wouldn't associate it mainly with Marxism. So in that sense, I'm sympathetic to the request for greater precision.

I guess I would wish for more tolerance in our conversational norms around calling people out for politely requesting greater precision or clarity or whatever to any given point. If we have a dedicated Marxist in our midst who can do that around Marx-adjacent thoughts, isn't that a good thing?

We have libertarian economists on here who can press fine points around their arenas of concern and anti-feminists around their arenas of concern, and I've done my share around the finer points of Buddhist philosophy or non-pharmaceutical mental healthcare, or the particular brokenness of the U.S. health insurance system. If someone's not just ranting angrily but is bringing some (dare I say?) expertise to the conversation, is that not welcome, even if they only have one arena of expertise they tend to bring?

I guess maybe this raises a larger question about where is the line between troll, hobby horse, and desire for clarity around things one knows something about?

Expand full comment

"As a reader with no dog in this hunt, I'm not sure what to make of this ad hominem comment about marxbro1917. Maybe my troll-o-meter is not very sensitive."

You perhaps were not around for previous interactions with Marxbro before he came back as Marxbro1917. But even in this exchange, can you not see his modus operandi? "I don't care that you grew up in a country that implemented Communism, you had to study Marxist-Leninism, and you can comment on how the theory works out in practice, I still maintain that flying elephants are totally possible!" He's not honest in his interactions.

Expand full comment

I'm very honest in my interactions. And if I'm being honest, I'm not impressed by people who say "I've studied Marxism-Leninism" but then fail to produce the primary sources and citations I've been asking for. My point here is very simple, Marx regards socialism as developing and superseding capitalism from within the capitalist system itself. He does not advocate to "burn it all down" (not sure what this would even mean when we're talking about international economies), nor does he have the naive analysis of power that Scott Alexander attributes to him (without citation, of course).

Therefore, I am asking for evidence, please. If "Marx's fallacy" exists in Marx's writings then someone should be able to find it, using quotes from the source.

Expand full comment

I'm very suspicious of the troll label based on the comments of others who have a social history with the accused -- especially when the accused appears transparent and thus vulnerable in advocating for their project. As a relative newcomer here, this forum appears above average when it comes to the expression of independent thought (rather than piling on socially with the intent to suppressing others).

But, perhaps, Marxbro, you are guilty of pedanticism, which is nowhere in the neighborhood of trolling. Trolling employs a very wide and shallow focus, while pedanticism is laser focused -- and your defensively-trained laser may be missing a wider, more social point about Marxism writ large. I.e., "Marxism" today is an enormous trope that we all play around with for various reasons -- which your project naturally bristles at.

When it comes to primary source material, the thing that's more relevant to me than whether Marx actually penned certain words, is how ideas and history actually merged, and I was blown away (and thoroughly entertained) recently by the English-dubbed "Comrade Detective" series (the dubbing making it primarily a primary source) -- which helped give me a glimpse of both how huge and complex the commitment to socialism still was by that time, but also, simultaneously, how correct the notion seemed that, in human cultures, those who optimize for power always seem to perform the act of power most efficiently.

Expand full comment

"I'm very honest in my interactions".

Well, yes, for a certain value of "honest". We can always depend on you to tell us that no matter who, no matter what, no matter that you did live in a country basing itself on an understanding of Marx's thought that "she doesn't have the range" https://www.youtube.com/watch?v=zq97J-7Mwzc

You do remind me of the literalists going "Where is that in the Bible?"

Expand full comment

I definitely don't have the insight into what Marx actually meant that say, his 103-year-old brother might possess. But when he writes: "The Communists disdain to conceal their views and aims. They openly declare that their ends can be attained only by the forcible overthrow of all existing social conditions. Let the ruling classes tremble at a Communistic revolution. The proletarians have nothing to lose but their chains. They have a world to win." in The Communist Manifesto (part IV) it seems to me that he is advocating "burn it all down" when he says "forcible overthrow of all existing social conditions". Of course, I'm sure I probably didn't even cite it in the proper formatting (MLA? APA? USSR?) Full disclosure, I don't know a lot about Marx [insert your own Duck Soup joke here] nor have I studied Marxism-Leninism. I also don't know why I'm posting here, I feel like I'm giving a whining 3-year-old the sucker they've been throwing a tantrum about only to have them tell me it's not the right flavour (just wait, it'll happen).

Expand full comment

I think that Scott described his view leading him to call it Marx's Fallacy in his Marxism related book reviews. I think it was this one in particular: https://slatestarcodex.com/2014/09/13/book-review-singer-on-marx/ . But there might be other related ones that I've forgotten.

Expand full comment

I have covered Scott Alexander's misunderstandings of Marx here:

https://www.reddit.com/r/SneerClub/comments/gc27k5/author_reacts_to_ssc_book_review/fpbulfv/

I do not think that Scott Alexander has undertaken an accurate reading of Marx. His presentation of "Marx's fallacy" - which I, as a Marxist, do not recognise at all. I think Scott is failing the Ideological Turing Test here. This is why I'm challenging him to find a primary source where Marx says anything like

"if we burnt down the current system, some group of people who optimized for things other than power would naturally rise to the top."

If that's "Marx's fallacy", if that's what Marx said, then it should be easy for Scott Alexander (or anybody else) to find Marx saying this in his writings. I believe in evidence, and I'm asking for evidence on this matter.

Expand full comment

I've read both Scott's piece and your response. I didn't find your response convincing. I'll take one argument to explain why, rather than go through every single one.

Marx says: "But the essence of man is no abstraction inherent in each single individual. In reality, it is the ensemble of the social relations." Scott/Singer summarise this as he "believed there was no such thing as human nature and everything was completely malleable".

That seems like an accurate summary to me. Marx is saying quite clearly that merely being human tells you nothing whatsoever about how that person might behave, think or live their life. Nothing. Zero. Whether you call it "essence of man" or "human nature", in normal English these terms mean "that which is common to every [developed] human regardless of their experience of background".

Yet here Marx claims that this thing, which is literally defined as "that which is inherent to any individual" is actually not inherent at all, it's rather socially constructed and is thus, by definition, malleable, because the "ensemble of the social relations" is neither fixed or inherent. Indeed Marx's entire philosophy was that by changing that ensemble, humanity could become greater.

You keep demanding primary sources, but in your review Scott/Singer literally quote Marx word for word and you just claim their rephrasing into more modern English is wrong. If Marx is so hard to interpret that people can read completely opposite things into the same sentence then he is just an objectively terrible writer, but I don't think this passage is actually hard to interpret. He rejects the notion of a fixed, immutable human nature and claims that what makes people act the way they do is purely social in nature (implication: and thus can be changed via social means, like revolution).

Expand full comment

Marx could certainly have been philosophically and theoretically correct about human nature, while still being clueless about pragmatics (such as scope and timeframe and other material complexities). Maybe it's not so fair to judge philosophers by how politicians and societies attempted to adopt and manifest (and fight against) their philosophies?

Expand full comment

>Marx is saying quite clearly that merely being human tells you nothing whatsoever about how that person might behave, think or live their life. Nothing. Zero.

He doesn't say that, though. He says that " the essence of man is no abstraction inherent in each single individual. In reality, it is the ensemble of the social relations." i.e that generalisation about human nature are only describing wide ensembles of human behavior, not any particular individual. "Malleable" is also different to "completely malleable" - notice the shifting goalposts here.

> If Marx is so hard to interpret

Marx isn't really hard to interpret, which is why I suspect that Scott Alexander simply didn't read it very carefully.

Expand full comment

For another point of data, I would call myself a Marxist. I have read Kapital but not the Communist Manifesto or any of his other works. I think Marx was notably good in diagnosis of the political economy of his time, but notably poor in prescription of how to fix it, and particularly what a better functioning political economy would look like. I don't begrudge him this, the latter are much harder problems.

I think he was conflicted about the question of who would rise to the top after a revolution. On the one hand, a lot of what I read from him was at pains to try and conceive of an organisation that could ensure that future leaders better represented working class people. I don't think he did a particularly good job of describing or building that organisation but he certainly tried and recognised it to be a hard problem. On the other, he seemed to maintain a confidence that revolution was inevitable and that the world would be better afterwards. A contradiction between faith and rationality, perhaps? I sorta recognise that you have to maintain some kind of faith in the possibility that things will ever get better to remain sane in this world.

Expand full comment

I agree with this analysis of "politics vs being right/doing the right thing" but it creates another obvious problem: the good of being right in the moment is bounded, but the good of being right in the future is unbounded

One of my favorite scenes from the Wire is when the newly-elected mayor of Baltimore has a problem. He needs money to bail out the public school system, which he can get from the governor, but if he does, he becomes "the mayor whose failing public schools forced the governor to get involved and the state as a whole to contribute tax dollars to bail him out," thus ending his future ambitions of becoming governor himself. And of course, once he is governor, his ability to do good things will be much greater than his ability as mayor. So he decides to let the school system continue to collapse to preserve his opportunity at future success, and future good.

I think almost every politician or person who has a political component to their job has made this calculation at some point in their lives. And in some sense its hard to say they are making the wrong call. Because if that fictional politician goes on to become President and signs a bill which ends child poverty, whose to say it wasn't worth a few thousand kids in Baltimore?

I don't have a solution to this problem, except to say that at some point everybody in every position that might even have a glimmer of power has to ask themselves "what's the absolute amount of good worth sacrificing today for the prospect of being able to do good tomorrow?" And to think really hard about the answer.

Expand full comment

Flip side- nobody who habitually compromises the public good for advancement will ever, ever, sign a bill that ends child poverty. The selection process weeds out the ones who would.

The Wire also depicts the same problem with lawyers; anyone who presses real cases that could a difference would upset the apple cart and prevent career advancement. The prosecutors who don’t play politics never become judges. The solution presented- STOP TRYING TO BE JUDGES.

I recently read an interesting blog post somewhere (I misremember where) carving out a workable, useful definition of decadence. Rather than resort to stereotypes about Manly Men Becoming Comfortable and Weak or sex orgies or drug use, it defined decadence as when the elites of a society stop competing with each to see who can provide the greatest benefit to the community, and start jockeying for the greatest *status* within the community. The moment you take what power you have and start scheming on how to get ahead of the pack to higher honors and more power instead of focusing on doing the best damn job you can do today, you have left virtue behind and are now part of the problem.

Expand full comment

Regarding decadence, I think you're referring to DePonySum's recent post https://deponysum.com/2021/01/26/reflections-occasioned-by-reading-michael-sandels-the-tyranny-of-merit-part-1/

Expand full comment

Heyyyy there it is. I should bookmark that site.

Expand full comment

"History isn’t going to rap you on the knuckles because people are having a bit too much gay sex or men have long hair now, history is going to rap you on the knuckles if people aren’t committed to larger projects than themselves."

Not exactly-- it's important for people to be committed to projects (of whatever size and requiring however much commitment) which actually work.

Expand full comment

That sounds like Peter Turchin's theories about an overproduction of elites who squabble against each other for the few available spots at the top. Of course, he borrowed his logic from Ibn Khaldun.

Expand full comment

Sounds like what Ibn Khaldun said about North African politics 700 years ago.

Expand full comment
founding

> at some point everybody in every position that might even have a glimmer of power has to ask themselves "what's the absolute amount of good worth sacrificing today for the prospect of being able to do good tomorrow?" And to think really hard about the answer.

this is almost the opposite of the discount rate -- what is the amount of good in the future that i can discount to get a smaller amount of good right now. in ksr's recent "ministry for the future" there's a section arguing that we place too *high* a value on present good, at the cost to our future selves/descendants. i find the same problem occurs with thinkers like, e.g., tyler cowen -- "ignore climate change now and focus on getting rich, and we'll be so rich in the future that climate change will be super-cheap to solve relative to our newfound wealth"

Expand full comment

You are missing the HCQ elephant in the room (and the Ivermectin rhino too....). This makes your otherwise excellent post dismayingly close to worthless, until you can come to terms with the extraordinary number of lives lost due to the corruption of the process that Fauci, putting it enormously too mildly, allowed to occur.

Expand full comment

Can you be more explicit?

Expand full comment

While there are some side effects, I really don't think the emergency prescription of HCQ caused an extraordinary number of lives to be lost, main harm would be the money wasted and some nausea in patients who wouldn't otherwise need to feel it

Expand full comment

That is so unbelievably backwards that I’m not going to even argue with you, you’re a hopeless case. The consensus is FINALLY coming around to “HCQ and Ivermectin are effective treatments if given EARLY”, which most of the rest of the world has known for many months, but which people who only consume US media have been shockingly gaslighted about.

Expand full comment

Could you point me to some high quality research, so I can be de-gaslighted? Preferentially research in which the control group wasn't significantly older or more comorbid than the HCQ group, or meta-analysis that know you can't just multiply p-values?

Expand full comment

I gave a link which is somewhat polemical but full of references to both studies and meta-analyses. In this very special case indeed, polemics are appropriate, because there has been intentional bad faith and lying. The bad faith and lying is so shocking that you may need to see the references in the context of the narrative given in this article to overcome the initial reaction that 95% of English-speaking medical professionals have (“this can’t possibly be right because my sources have so universally told me it is wrong therefore I do not need to pay attention to it”).

https://truthabouthcq.com/hcq-works/

Expand full comment

Sadly, when looking at the individual studies, you can always spot very important methodological flaws (usually, the placebo group will be significant older or have more diseases previous to COVID infection, when compared to the HCQ group). Whenever this selection effect is corrected by proper randomization of patients into treatment/placebo group, HCQ fails to show an effect. You can check this by yourself, usually on table 1 of any paper about the treatment. This raises the question: if the treatment is so effective, why don't the researchers publish a well-researched study, to actually convince people that it works? Why are all positive studies filled with so much shoddy statistics? Dexamethasone, a cheap over-the-counter drug IS accepted as a treatment, so why wouldn't HCQ be too?

Expand full comment

(for context: I am a Brazilian physician working in emergency care, so I am familiar with the narrative purported by Filipe Rafaeli in the original publication)

Expand full comment

Did you look at the subgroup analysis of the NEJM prophylaxis study?

The study (which claims to show HCQ doesn't help) is here: https://www.nejm.org/doi/full/10.1056/NEJMoa2016638

and the subgroup analysis is in the "Supplementary Materials" here: https://www.nejm.org/doi/suppl/10.1056/NEJMoa2016638/suppl_file/nejmoa2016638_appendix.pdf

In the Supplementary Materials: look at page 17, titled "Figure S1. Forest Plot of A Priori Identified Subgroups" (based on page 13, titled "Table S6. Subgroup Analysis of Risk of New Covid-19 Compatible Illness"). Look especially at the "days exposure" section of page 17.

When I look at Figure S1 overall what jumps out is that using the protocol of this study nearly *every* subgroup did better with HCQ than without it but *how* well they did is *time-dependent*, meaning *the sooner post-exposure treatment started, the larger the positive effect*. That looks to me like a dose-response relationship! 1 day worked *very* well, 2 days worked well, 3 days worked kind-of-okay, and waiting as long as 4 days was worse than placebo.

If you take that set of results and toss ALL the data together in one bucket the "4-days" negative result and "3-days" marginal result drag down the average effectiveness but if you just look at day 1 or days 1 and 2, treatment was effective at the .05 level. Based on that study one should assume HCQ DOES help (especially for younger people) if started right away or better yet if started *prior* to exposure. The results suggest that young medical workers should keep it on hand and start taking it right away upon any accidental exposure unless and until there's a better option.

(one worrisome fly in the soup is that subgroup "age>50" also failed to be helped by HCQ. Maybe the older patients were less likely to start treatment right away? Dunno, that's something to look at in a larger followup study, but it shouldn't have stopped us from at LEAST advocating that younger medics use HCQ early on).

Expand full comment

How are those results significant? They are a very small relative risk reduction, with a wide confidence interval that covers both "no effect" and "may increase risk"

Expand full comment

The confidence interval is very wide because the N is too small. A drug that on its own (without help from any other assisting intervention) reduces your risk of covid symptoms by merely ~33% (rather than the intended 50%) is still worth taking and would save thousands of lives, but needs a larger N than was used to show a .05 certainty level in a study such as this. If you re-ran this study with twice the participants the confidence interval would narrow; assuming a similar pattern for the mean expected result the interval wouldn't have to narrow *much* to exclude "may increase risk" for days=1, right?

(I take back the claim that days={1,2} are *already* shown to be "effective at the .05 level" - I was reading the wrong data column. Drat this interface that doesn't let you revise after posting!)

Expand full comment

The paper I linked has a long analysis of the NEJM Boulware study and shows how the data of that study was misinterpreted. I had come to similar conclusions at the time it was published. The study really shows that HCQ has a benefit but the statistical significance of the effect was underestimated.

https://arxiv.org/abs/2007.09477

Expand full comment

Ivermectin I'll grant you, but my impression is that boosters of antivirals still aren't enthusiastic about HCQ.

Expand full comment

As I said, there is a big difference between USA and areas very influenced by it, and other parts of the world (much of which has a great deal of experience with HCQ over the last 75 years and knows things about its toxicity profile that writers and researchers here have sometimes been quite ignorant of). The most recent work seems to show that Ivermectin is at least as good; but I already knew last April that HCQ was good and last May that Ivermectin was good because I was paying attention to the entire world. Much more on this at my link.

Expand full comment

This kind of gratuitous personal attack is the antithesis of what I come here for.

Expand full comment

not sure if you're right or wrong but I am sure your being a dick sapped my energy to find out

Expand full comment

The most recent This Week in Virology had a really interesting paper they discussed going into the details as to why HCQ did so badly in *in vivo* studies despite doing so well *in vitro*. https://www.microbe.tv/twiv/twiv-715/

Expand full comment

It failed when given late, succeeded when given early, and there was an unbelievably intense effort in the USA to obliterate all knowledge of this distinction in order to portray it as “HCQ doesn’t work” full stop.

Details here:

https://truthabouthcq.com/

Expand full comment

Boy, that site looks something that is definitely trustworthy and free from bias! /s

Expand full comment

Congratulations on being part of the 95%. I TOLD you there were references to both studies and meta-analyses, I EXPLAINED that this was a special case where it was necessary to read something even though it had a polemical tone, but STILL you sought and found an excuse to avoid it. F*** off, I’m done here.

Expand full comment

Apologies, I now realize you may have been responding to one of my previous two replies without having seen the other one, due to delays in comments showing up on the site.

Expand full comment

Nobody is going to read 50,000 words filled with irrelevant minutiae presumably designed to answer every argument this dude has ever heard from anyone. Just link what you consider to be the best studies, otherwise you come off like guys who can only "prove their point" with rambling 90 minute youtubes.

Expand full comment

There’s a big difference between a 90 minute youtube and a paper written in several dozen numbered sections with hyperlinks to actual studies. The whole point is that it is a complicated story so I am not going to over simplify it, I am instead giving you the best summary I know of of the entire STORY which is about not only medical truth but a great deal more!

Enjoy it, or enjoy the feeling of satisfaction finding an excuse to snarkily avoid it gives you, I won’t presume to tell you which of those to prefer.

Expand full comment

This is not "a polemical tone." This is 90% polemics. I could flip to literally any paragraph and find either an irrelevant side-story or a ramble about why the establishment got it wrong. He spends 7 paragraphs saying that the scientific establishment wouldn't have believed Yuri Gagarin when he said the Earth is blue.

You're correct, I didn't see your other post saying that this was a special case, but "this is a special case" is hardly convincing either way. Every crackpot claims that they're not like all those other conspiracy theorists, they're a special case, and just this once, you should read 15,000 words about how the establishment is lying and suppressing the truth.

Just the facts, please. I've seen many websites like this and approximately 0% of them have been worth my time. I'm not going to dig through all this crap about Yuri Gagarin and pandas, just link to the scientific evidence that supports your case.

Expand full comment

Oh wait, not 15,000 words, there are like 5 different essays on that site and I have no way of knowing which one you're actually referring to, and they're all equally long and equally crackpot-looking. You are literally telling me to read a novel's worth of text on the hopes that there are actual studies somewhere in there.

Expand full comment

I'd like to think I read about all the major studies on HCQ that came out over the summer and I don't think that's a fair summary of the evidence. Dosing time has been a routine cofounder as people do RCTs on people who show up in the hospital 7 to 10 days after symptom onset for drugs like broad spectrum antivirals, monoclonal antibodies, and vitamin D. But the only study I'd say looked good for HCQ was one out of India looking a prophylactic dosing and that wasn't a RCT so I don't think I trust it.

Expand full comment

Your tone and choice to be hyperbolic are disappointingly out of keeping with the spirit of the SSC community. It's still an open question whether inflammatory phrasing and hot takes like yours becomes the norm due to this new blog transition or whether behavior like yours is discouraged well enough that people either self-regulate or go elsewhere. I hope it's the latter.

Expand full comment

Sorry, but that’s totally wrong. My ORIGINAL reply was quite “normal” in tone, and I shall re-paste it here:

“It failed when given late, succeeded when given early, and there was an unbelievably intense effort in the USA to obliterate all knowledge of this distinction in order to portray it as “HCQ doesn’t work” full stop.”

AFTER I posted that reply, I encountered resistance and snark, and responded in kind, so don’t go lecturing me about the “spirit” of the “community”.

Expand full comment

My understanding is that HCQ is effective when combined with another medication to block another pathway for the virus for transmit, but not especially otherwise, and this explains the divergent results in studies. __ice9 has written about this, although unfortunately on twitter rather than blogging like a civilized person.

Expand full comment

The combination with another drug such as azithromycin is important, but much more important is the fact that it is proven effective when given in the first few days (outpatient basis) after symptoms appear, and a large number of studies which showed no effectiveness or low effectiveness for patients who had already become sick enough to be hospitalized were systematically misrepresented (I know because I was paying very close attention all along) so that early use was discouraged or discontinued (including some actually fraudulent studies!).

Expand full comment

I see one snarky comment from beleester, but other than that it's mostly people being extremely charitable to a position that you've so far only defended by linking to one website that pings an awful lot of red flags for being conspiracy theory nonsense.

I'm certainly not seeing anything that would warrant replies like:

>>That is so unbelievably backwards that I’m not going to even argue with you, you’re a hopeless case.

Expand full comment

On the contrary. It was *precisely* backwards to think that when I spoke of the “HCQ elephant in the room”, I was referring to deaths FROM using HCQ, rather than deaths from NOT using HCQ.

Here is an extremely transparently done very thorough and complete ongoing meta-analysis:

https://c19study.com/

Expand full comment

I get that, but you could have phrased that very differently, for example:

"Actually, I think you got that backwards, the elephant in the room is the deaths from using HCQ, rather than the deaths from NOT using HCQ. You see, HCQ and Ivermectin are actually effective treatments as long as they are given early."

Rather than calling the person you respond to "a hopeless case" and saying they are "being gaslit by US media".

Expand full comment

I think this is a wildly uncharitable take on the situation. One can argue about whether Trump or Fauci is culpable; one cannot _not_ argue about it and just say it's Fauci.

Expand full comment

You seem to be willing to argue in good faith as long as you don't feel attacked, so let me try to start this discussion over. If you feel like any of my claims needs better substantiation, please tell me and I'll provide sources.

You linked https://truthabouthcq.com/hcq-works/ , a mostly narrative review by a layperson who doesn't claim to know biostatistics. While a thorough debunking of his over 50 points is more than what I'm willing to do, I will debunk some of them, and if you feel like I glossed over anything important, let me know and I will check, but here's why you shouldn't put too much stock into that narrative:

Point 1 cites Raoult's original paper, one of the first to be released regarding HCQ therapy. While finding positive results, this paper has several limitations, which bring it's validity in question. You can see, on page 10 of the manuscript cited by your source, that "Six hydroxychloroquine-treated patients were lost in follow-up ... three patients were transferred to intensive care unit, including one transferred on day2 post-inclusion who was PCR-positive on day1 ... one patient died on day3 post inclusion ... One patient decided to leave the hospital ... finally, one patient stopped the treatment on day3 post-inclusion because of nausea".

This is extremely relevant, as not adoption an "intentional-to-treat" protocol basically changes the result from "HCQ works" to "When you don't count the cases that didn't work, HCQ works"

It is also of note that on this foundational paper, reference to "early treatment" is found absolutely NOWHERE. You will see that arguing for early treatment only became a thing AFTER results from other trials came back negative.

Your source also spends lots of time purporting a "big pharma conspiracy", in which the cheap, widely available HCQ was being passed over to benefit redemsevir, an expensive, patented drug. The problems with this narrative are: we know redemsevir ALSO doesn't work, and approved interventions for covid include Dexamethasone, also a cheap, widely available drug, and pronated position, which is LITERALLY free.

Are there any other important points that you feel like I glossed over? The graphs at the end haven't aged especially well since July, when it seems last updated, but I don't know if you feel they are integral to the narrative

Expand full comment

I disagree with your analysis — that corruption/self-preservation explains why Dr Fauci does not always say the truth. Externalities and/or the possibility of being misunderstood are more important factors IMO. For instance, while an unknown blogger can say in March 2020 "we should all wear mask now", Dr Fauci or the NYTimes cannot say the same because they're afraid it will push people to hoard masks.

Expand full comment

But he didn't have to say "we shouldn't wear masks because they don't do much good and might make things worse," which is roughly what he did say.

Expand full comment

But there is a cost to this--many people bought masks anyway, because enough people had figured out masks were probably a good idea based on other pandemics/countries. It delayed people making makeshifts masks. And it also created confusion, as guidance switched overnight from "you don't need a mask, you silly germaphobe" to "MASK OR ELSE", and it caused trust issues--if the government is willing to lie about masks, what else might they lie about?

Expand full comment

I'm pretty convinced that the real reason was actually that they didn't believe it worked due to cognitive dissonance. That is, Western health authorities don't recommend that the populace wear masks, western health authorities give good advice, therefore there must be a good reason for that and we have to figure out what it is.

Expand full comment
author

I don't think that was behind the anti-mask decision - see the beginning of Part 3 of https://slatestarcodex.com/2020/04/14/a-failure-but-not-of-prediction/ .

But if it was, I still think it's relevant that Zvi can just say whatever is true, and Fauci has to optimize for a bunch of other things based on the consequences of people listening to him (even if he is doing this in a prosocial way and his decision was ethical)

Expand full comment

What do you make of Adler-Bell's point that there is some point (presumably in the thousands of dead people) past which you are obligated to noisily give up power instead of make those compromises?

Expand full comment

Who enforces it?

Expand full comment

Such a tough call. If you wield power imperfectly in order to keep it and 10K people die because of your compromises, would you be better off noisily giving up power and being replaced by someone who is worse and results in more deaths? Some people who we think are power-hungry collaborators may in fact be selling their souls in public at great personal cost because they think the next in line would do way worse. I may be being too charitable, but I sometimes felt like that was Fauci not resigning when working with Trump.

Expand full comment

This comes up with statistics a lot. E.g. when Nate Silver says that candidate A has an 80% chance of winning, people in general interpret that as "certain" and if they don't people get mad and say he was wrong. So he can give correct information knowing it will be constantly misunderstood, and people may make bad decisions based on it (e.g. not turn out and vote for candidate A). Or he could change his prediction to be incorrect, but people be more likely to get the correct impression from it

Expand full comment

This is a really excellent post. It certainly makes me feel grateful we have a magic machine for consistently extracting pretty-good people with pretty-good ideas out of the population.

That said, there's a related issue: Why has the magic machine's performance seemingly decline over the course of the last ~80 years? Maybe it's an inevitable result of Moloch (for example, because as you optimize more aggressively, the gap between the most competitive and most good-producing ideas grows, or something). If so, too bad, guess we're screwed. If not, then we could sure benefit from figuring out what's causing the machine to function worse.

(As this post argues, any tinkering we do trying to fix the magic machine should be very cautious, because it sure would be a shame if something were to happen to it.)

Expand full comment

Hasn't the magic machine been generally doing better? I mean, life expectancies and median incomes and press freedom and all those good indicators generally seem to have been on an upward trajectory, with occasional decade-long blips on some of them (like crime in the US in the '70s and '80s, opioid deaths and pedestrian fatalities in the US in the past decade, various things in Syria in the past decade, etc.)

Expand full comment

I think what you're referring to is not the same machine I'm referring to. The "magical machine" I'm referring to is the process by which we select leaders/bureaucrats/experts. Even if those people are somewhat less competent than in the past (which many think they are), you would still expect things to get better because of improving technology, increasing wealth, general progress, etc.

Expand full comment

I think you're both right in your own way. I think our institutions have gotten better (dare I compliment our bloated bureaucracies?) on the whole, and generally the people who run their day-to-day operations have gotten more competent. But at the same time some of our processes for selecting the figureheads haven't produced the best results. Kind of like when The Imperial Bureaucracy was opened up to freedmen but at the same time the Praetorian guard was selling the right to be Roman Emperor. Parallel question - how long can a competent bureaucracy sustain an incompetent set of rulers? Okay I'm taking the example too far, soon CommodusBro180 will be posting asking me to cite documents lost in the Library at Alexandria.

Expand full comment

Perhaps they've continued upward but with a lower slope. Great Stagnation and all that.

Expand full comment

Has it declined? 80 years ago was the Tuskegee Experiments - I think I like our current medical experts a lot more than those from 80 years ago.

What examples of 'decline' are you thinking about here? The present always looks worse than the past because you're there to notice the flaws, but beyond that are there specific issues you're thinking about?

Expand full comment

I want to give basically the same reply here that I gave to Kenny above. But I guess I'll try to say it more clearly this same.

I agree that the present is way better than the past in a whole lot of ways. But I also think this is expected, due to technology improvements, wealth accumulation, and general progress. Nevertheless, there is one way in which the present looks somewhat worse than the past: leader/expert/bureaucrat selection. A common complaint is that it would be impossible to build the interstate highway system nowadays -- our modern government is too ineffective to get anything on that scale done. (Of course, great things on that scale still get done. They just get done by Elon Musk or whoever while the government is spending lots of money failing to lay train tracks.)

In the case of the Tuskegee Experiments, my guess is that the general population back then was way more okay with stuff like that than we are now -- that's a form of moral progress. So even if you're doing a pretty good job of selecting the top, say, 40% most ethical doctors out of society, you'll probably still gonna end up doing unethical stuff. My worry is that we're now selecting from society less effectively (e.g. only getting the top 50% most ethical doctors). But because society as a whole is more ethical, things still look more ethical overall.

Expand full comment

I think in some sense Tuskegee may be a clue to why sclerosis has grown in so many institutions, back then researchers could perform unethical research with relatively little scrutiny, and lots of freedom to experiment etc. The backlash to such programs lead to lots of process restrictions that lead to an increase in the percent of decisions made to 'cover your ass', or 'follow the process', as well as an overstrong embrace of the precautionary principle

Expand full comment

Sometimes I wonder if it's always been this way, but we're only able to notice it more now. A few decades ago, being as informed as we can be today would have required vastly more effort.

Expand full comment

So the central claim is that the experts at the top are genuinely super-capable, but corrupted by incentives. It's a fine hypothesis, but what evidence is there in favor of it? In academia at least I can point to an ocean of crappy research whose existence benefits no-one, so you can't blame the incentives. A Stanford epidemiologist attending a conference in March tweeted:

>At AHA #EpiLifestyle20 in a room full of epidemiologists and scientists and not ONE person is wearing a mask. Lots of hand washing & sanitizer stations. If 800 epidemiologists aren't wearing masks, you don't need to either!

We're talking about (tenured) people personally putting themselves in the way of harm here, can we really blame corruption and incentives?

I think you need to more seriously entertain the hypothesis of genuine incompetence.

Expand full comment

Do you have a link or archived link to the Tweet somewhere? I'm trying to compile a list of sources for and against the "noble lie" hypothesis. (FTR I mostly think the noble lie hypothesis is wrong).

Expand full comment
founding

This is the only source I could find. I assume it was deleted, though it's also possible it was fake (to be clear, I don't know; it doesn't look fake, but I don't want to rule out the possibility).

https://ifunny.co/picture/michelle-vote-odden-michelleodden-being-an-epidemiologist-right-now-is-WyOz8OJz7

Expand full comment

> So the central claim is that the experts at the top are genuinely super-capable, but corrupted by incentives.

I think this is a mild misreading of Scott's point. It's more like "the process that selects experts is not optimizing for competence, but rather some mixture of competence + political savvy + careerism." So the claim isn't that Fauci is secretly is secretly a public health super-genius who is hiding his true ability, but rather that the version of Fauci who is a public health super-genius doesn't get into as high a position as real-Fauci did.

Expand full comment

That's how I interpreted this part:

>The Director of the CDC could generate opinions as accurate as (or more accurate than) Zvi's, if she wanted to. Maybe she's even doing that internally, when she decides what precautions she and her family should take.

On the lighter claim that selection happens on competence + political savvy + careerism I agree entirely.

Expand full comment
author

I agree my post focused more on the competent-but-corrupted narrative, but I hope I also at least nodded to the possibility that there are some Fauci equivalents who suck at epidemiology but are good at networking and got their positions that way.

Expand full comment

Makes me think of those studies that show that markets can allocate well, even if the people in the market are trading randomly.

If the system is setup correctly it doesn’t matter about the competence of the people involved.

Could be that people are generally only competent at the networking element, and that it’s the general system design that leads to better outcomes generally.

Expand full comment

The problem is that the government doesn't involve a lot of trading. It does what it does by force or fiat. I can't elect to do business with the CDC head which I prefer. I only get the one which is there.

Expand full comment

Do you have a link to any of those studies? Sound interesting

Expand full comment

I think this is the more important part, particularly if expanded beyond "networking" which I think is a trivialization of the kind of skills that are necessary to become a top-level political appointee. I personally think if someone just appointed Zvi he would do much better at the public communication portion of the job, at least. Maybe there are other aspects of agency management that are not within his competency that also are important.

Expand full comment

The issue presumably is that even if they are super competent the outcome is the same as if they are mediocre, because the incentives constrain the actions they can take

Expand full comment

> So the central claim is that the experts at the top are genuinely super-capable, but corrupted by incentives.

No, I think the central claim is that experts at the top must be competent at playing political games in order to arrive at the top, but in our system they also tend to have some baseline of technical competence. The related point is that if they were super competent, they still wouldn't be able to act like it because of the need to toe the political line.

Expand full comment

> "A machine which takes Moloch as input and manages - after spending billions of dollars and the careers of thousands of hard-working public servants - to produce Anthony Fauci as output. This should be astonishing"

I think this is indeed a v good approximate account of our situation, & it shows both how well we usually do, considering how bad things could go, & also how tenuous is our toehold above the abyss. So far we've avoided the really terrible outcomes (the last four years of D.T. notwithstanding), but there have indeed been some terrible outcomes for some, & some very close calls -- some of which we know about (Bay of Pigs, Three Mile Island) & some we don't. There have also been some heartbreaking misses (eg the history Nathaniel Rich details in his (doubtless imperfect) _Losing Earth_). How well will our luck hold as we move on into 21st Century Climate Change -- to name just a single one of the many fun, um, opportunities staring us in the eye? I too am a reformer not a revolutionary, if I have my choice, but that choice is "all other things being equal," & more & more, they aren't.

Expand full comment

Is there some reason why WebMD couldn't include information about how common various side effects? The severity of reported side effects?

Expand full comment

Don't know how it works in the US but in Germany (and I think in the EU in general) drugs always list their side effects by frequency (e.g. "very often: more than 1 in 10 people treated", "frequently: less than 1 in 10 but more than 1 in 100 people treated", etc.)

Expand full comment

I just searched for "uk drug database". It seems like at https://products.mhra.gov.uk/ you can actually access the UK medicine leaflets. (Search by active ingredient, as the brand names may be different in your country.) The leaflets list the definitions of the frequencies somewhere (e.g. common means 1 in 10 to 1 in 100, uncommon means 1 in 100 to 1 in 1000, rare means 1 in 1000 to 1 in10000). You can probably find similar databases from any other European country; I searched for UK to get an English language one.

Expand full comment

Speaking of which, isn't crazymeds that Scott has blogged about before a counterexample to the WebMD dilemma? What's their secret? (I'm guessing the answer is probably just "not big enough to fall under as much scrutiny", but I'm prepared to be wrong about that if there's something more interesting going on.)

Expand full comment
founding

My uninformed guess would be that the infrastructure to collect that data in a reasonably-high-confidence way doesn't exist and so they don't know.

Expand full comment

I would be surprised if that data is collected to a high degree of accuracy once drugs are beyond clinical trial.

You'd basically have to have a centralized database that somehow knew every time a drug was prescribed and then cross-reference that with patients reporting (to whom?) specific symptoms. But the doc who proscribes isn't always part of the same system where a patient is subsequently admitted, and how can you say it's because of Drug X and not Drug Y that the patient was also taking, etc. And then if you wanted to share that info with a drug company, you'd have to anonymize it, and at some point, who's paying for all of this tracking?

So yeah, you could report out the clinical trial data, but my impression is that the rest is still word-of-mouth, case studies, and rumor.

I'd be happy to have someone familiar with medical record-keeping disabuse me of this pessimism.

Expand full comment

Where does WebMD get its list of side effects from? Is there really no record at all of how common or severe the side effects are?

Expand full comment

Mostly speculating here but ...

I'd guess that there are hundreds if not thousands of records of how common or severe the side effects are. But they're not organized or shared. They exist in the notes of individual doctors and the databases of individual hospitals, which aren't connected. AFAIK, doctors are pretty good at keeping records of *individual patients* but pretty shit at organizing that information in a way that can be analyzed on a massive scale. That type of thing can be done with deliberate forethought, focus, and funding, but not in a way that's just like "do it for every drug, ever."

The best bet might be the large-scale HMOs like Kaiser, which at least keep everything for individuals in-house. Maybe you could do something like query everyone's records for whether or not they were ever proscribed a certain drug, and then also query them for specific notations of side effects to that specific drug? But again, I'm not sure how you get at the causal question.

Again, happy for an individual with hands-on experience with these types of systems to correct me if I'm wrong. I'd mostly categorize this as educated guesswork.

Oh, and I have no idea where WebMD gets their lists. Probably from the drug manufacturers plus randos who email them and get their complaints through whatever Process they've created, per Scott's description above.

Expand full comment

Most likely from the FDA-approved patient information or prescribing information. If WebMD is just regurgitating the FDA-approved text they are almost certainly in the clear (even if they are wrong and know they are wrong). When you start providing non-FDA-approved medication information you start having to worry about legal risk.

Expand full comment

A very good piece and essentially correct, unfortunately. The one part I'm not sure of is the implicit assumption that even mediocre expertise feeding into a political decision mechanism is better than no political mechanism.

Consider Covid. The advice that was given by Fauci and others was probably better than what most people would have done with no advice, better on average than what most would have done (although possibly worse than what you and I would have done) relying on whatever sources of information they trusted. On the other hand, the vaccines we are now getting took about a week to design and eleven months to get FDA approval. In a world without the FDA and other political constraints, a month of challenge trials would have shown that they were effective and not very dangerous, after which they could sell them to all comers as fast as they could ramp up production. It's hard to believe that that wouldn't have saved a couple of hundred thousand lives in America, a million or so in the world. So if you look at the overall effect, it may be negative. We might be better off with the same level of mediocre expertise and no levers of power for it to be applied to.

At a tangent ... . Your description of Fauci reminded me of my conclusion about Nixon. There's a bit of the tapes where he is talking with one of his people about the idea of ending the interest equalization tax, which was a restriction on capital mobility. Nixon points out that one or two people have said doing it would be a good idea (true). The aide points out that there are no votes in it. Nixon says (by memory, not a quote) "What the hell. Let's do something just because it's good for a change." My feeling was that he had spent his life getting power in order, as he saw it, to do good things, and then found that he had to use the power almost entirely in order to keep power.

The current dramatic case of people choosing the wrong expert to believe in is the election. Something like a quarter of the population, if polls can be believed, thinks Trump really won. Their experts say so — and they have concluded (correctly, although not in this case) that the official experts can't be trusted.

Expand full comment

"So if you look at the overall effect, it may be negative. We might be better off with the same level of mediocre expertise and no levers of power for it to be applied to."

It gets complicated. Without authority to begin with, no challenge trials would matter, as we need validated sources to back them up.

In any ideal world, a hierarchy of knowledge will emerge, that will adjudicate these conflicts. This hierarchy will never be perfect.(it's comprised of the interaction of many people with the potential of making many mistakes) But it's a similar sort of problem whether it's bureaucracy accountable to democrats, the Soviet Union, or Consumer Reports.

And to be honest, it's really hard to actually reliably say anybody is the expert who beats "the experts". Or let me put it this way: If Zvi announces changed results at 90% confidence and the CDC waits for 95%, then Zvi will generally lead the CDC, and we may not be able to identify a significant error rate. But that doesn't mean the CDC is bad to wait. And separating out results like that can also be hard, as they bleed into the same "politics is bad" message here.

Expand full comment

I think the failure to develop a test in good time for a known problem is different than lagging in terms of adopting advice.

Or to put it another way: a counter argument on whether it is bad to wait requires identifying the risk of both types of errors: adopting an idea too quickly(and finding it wrong) vs adopting an idea too slowly(and finding it correct).

Expand full comment
author

I think advice (where people can take it or not) has a different calculus than things like requiring FDA approval (which actively prevents people who are smarter than you from doing the right thing).

I remain broadly libertarian, but I think even in a world without governments we would have this same problems with expertise. WebMD's problems are mostly non-governmental (though arguably the government is responsible for the lawsuit situation).

Expand full comment

"In a world without the FDA and other political constraints, a month of challenge trials would have shown that they were effective and not very dangerous, after which they could sell them to all comers as fast as they could ramp up production."

A wonderful dream. But in reality, you would recruit 1000 people for the trial, then have them sign an airtight waiver absolving you of any harm. 4 people would get terribly sick and/or die and then their families would sue you to oblivion. If that doesn't work, they would take the story to the news and the resulting public outrage would force your business to close. Public trust in vaccines falls and we end up with no vaccine ever.

Oops.

Expand full comment

Why are you positing your scenario as the reality to David's dream? I could see presenting it as a different possible outcome but in this particular case people didn't get sick and die and the chances of healthy people dying would be super low anyway, so I don't see any reason to believe your scenario is more likely.

Expand full comment

If you're imagining a world with no FDA, then how do you prevent fake drug companies from making fake vaccines with this profile?

Expand full comment

I'm a bit unclear on the relevance of this question. You think without an FDA a bunch of popup vaccine companies would have been competing against Pfizer with fake vaccines that killed people and would have made lots of quick profits and then fled?

Anyway, the FDA could be purely advisory, or there could and likely would be a private advisory group like UL. There's an extensive literature on alternatives to the FDA. Of course there was no requirement by the FDA to prove effectiveness prior to 1962. There would obviously be very serious civil and criminal liabilities for making a fake vaccine that would likely deter most psychopaths from trying.

Also, most people would probably be reluctant to take novel medicines in such a world without a strong basis for doing so, like a bunch of experts being convinced and supporting it publicly. While many people believe outlandish things with little evidence, I think that is somewhat less likely to be an issue when we're talking about injecting an unknown substance into your own body. People might be happy to take a vaccine from Pfizer with $100B pockets who put out extensive testing data and with support of public health figures, but a fake pop-up vaccine company? I doubt it.

Expand full comment

What is UL? (Sorry, I'm fed up with the proliferation of unexpanded, not-universally-known acronyms, so I'm going to ask when I see one.)

Expand full comment

Huh. It's a surprise to me that somebody doesn't know UL. I thought it was "in the water" for the past 80 years or so.

It's Underwriter's Laboratories, which is a private consortium founded by insurance underwriters to certify electronics so they don't start fires. Pick up pretty much anything that plugs into the wall and you can see their logo on it.

Expand full comment

"The advice that was given by Fauci and others was probably better than what most people would have done with no advice"

Wrong, wrong, wrong: https://www.today.com/video/dr-fauci-on-coronavirus-fears-no-need-to-change-lifestyle-yet-79684677616

Expand full comment

Do you think most people would have adapted earlier than they did in reality in the absence of advice? This particular advice was bad, but if we count all official advice throughout the pandemic, they probably did good on the net.

Expand full comment

First of all, I'm not sure the world without the FDA looks like 'an effective vaccine is found and distributed within a month and hundreds of thousands of lives are saved'.

I've done some historical research on the bad old days of patent medicines and the like, and I suspect it would look more like '100,000 vaccines are released within a week, most of them being sugar water, possibly mixed with mild doses of cocaine, everyone takes something random and then believes they're protected and takes no precautions, and rejects the 'proven' vaccines experts recommend because they've already taken a vaccine, lots more people die over a longer period.'

Of course, the response may be 'I'm not saying have *no* regulations or expert oversight, just not the nightmare of the FDA,' but the people who made the FDA weren't *trying* to create a nightmare, and I'm not sure that the imagined 'good' regulation/oversight is possible/practical without a concrete proposal and a reviewable test case.

Second, even if everything you say about the Covid vaccines is 100% correct, I think this is still cherry-picking the absolute worst-case scenario for the FDA. Like, yes, a once-in-a-century global pandemic is a bad time to have a slow, measured process, but what about all the other times and all the other conditions? Again, snakeoil salesmen are a very real and omnipresent threat to patient health and medical advancement, and I'm not confident to say that the FDA hasn't saved more than 400K lives over the last hundred years by tamping down on them.

Of course, I'd agree that the FDA should have different, highly expedited procedures for emergencies like this one. But that's not 'the FDA is the problem' so much as 'the FDA needs one minor tweak.'

Expand full comment

David, Scott - any advice for a public servant functionary who wants to both do good and one day be in a position to do good?

Expand full comment

> Even if this flattering story is true, it doesn't scale... Compared to the median person who disagrees with the experts, the experts look pretty good.

This is an interesting way of phrasing it. I would say that the problem you're pointing at - the incentives for getting and holding power mean you get mediocre experts is, _itself_, a scaling problem.

Here are two thought experiments to illustrate my point:

a) Imagine there's a single unified government for the entire solar system, with population in the hundreds of billions of people, and levels of wealth substantially beyond what's available today. Billionaires are a dime a dozen - any pop star or athlete easily makes it there. There are people who own entire planets. Are the incentives for being honest and accurate _more_ aligned with getting and holding power, or less? How corrupt would you imagine the official councilor on health, for the entire solar system, which includes multiple alien races and sentient robots and the bio-corporations of titan?

b) Imagine that the federal government basically doesn't exist and almost all power - taxation, trade regulation, everything else - falls on the individual states. Each state has its own experts, who compete for power in _much_ smaller games. How corrupt is the state health controller for each state?

It seems to me that the more people involved in a competition, the greater the disparity between 'strategies to get and hold power and status' and 'strategies to be accurate.

The lesson of moloch, to me, is that we should try to avoid, as much as possible, massive, winner-take-all games of power. _That_ seems to be the thing that doesn't scale - i.e., it works OK when you do it with smaller numbers of people, but it falls apart as you start to add more and more people to the system.

There's likely a lower limit here too - with too few people, there's not enough of a pool of capable people to select from. With too many people involved, the selective pressures get so insane that the winners must be corrupted.

Expand full comment

Ah, the old *Archipelago Paradox*:

Many small, independent states are ideal, except that if we care about people (esp. children) having the ability to leave a given state and enough knowledge to choose, we need an umbrella government with sufficient power to punish or threaten the largest state, which means quite a bit of power actually, which means it will inevitably, eventually, be given to someone who will abuse it and usurp the power of the many independent states.

Expand full comment

> if we care about people (esp. children) having the ability to leave a given state and enough knowledge to choose, we need an umbrella government with sufficient power to punish or threaten the largest state

Why? I understand that this is what lots of people believe. It just seems like a laser focus on one proposed solution, which we know doesn't work.

Are we saying we've searched the entire space of solutions to this problem, and this is the best answer?

Expand full comment

I can't say that I have personally done the kind of universe-searching you're talking about, but Scott lays out a pretty convincing case in *Archipelago and Atomic Communitarianism* - https://slatestarcodex.com/2014/06/07/archipelago-and-atomic-communitarianism/

Expand full comment

I don't know about searching the entire possible solution space, but I think a lot of cultures are quite good at keeping at least some of their people trapped.

Expand full comment

I don't actually want an umbrella government. I want enough decentralization to ensure there's no suicide-by-singularity. https://www.overcomingbias.com/2018/11/world-government-risks-collective-suicide.html

Expand full comment

Doh, that should be "suicide-by-singleton".

Expand full comment

This is essentially the logic behind the old American and Canadian practice of "Indian schools." Allowing children to be brought up in pagan religions and uncivilized cultures was thought to deny them the choice to embrace Christianity and modern civilization and removing them from their parents and tribes to educate them 'properly' was judged as a small imposition relative to that. It is not a fondly remembered policy today.

Parents generally look after the interests of their children: there are horrific exceptions, but as with most cases of 'market failures' those exceptions become the rule when church or state bureaucrats are given control. The same rule applies to a lesser extent in natural communities like tribes or small towns, and we would be wiser to adopt a policy of subsidiarity and leave people minding their own business well-enough alone.

Expand full comment

I love that you conclude that we are "insufficiently grateful" for Anthony Fauci, while belittling his free-agency in the same breath. It's surprisingly effective, and somewhat hilarious in light of the Fauci-is-Jesus-reincarnate memes that people are worryingly sincere about.

Expand full comment