On inequality and disease.

On inequality and disease.

I should preface these remarks by stating that my political views qualify as “extremely liberal” in the United States.

I’m a well-trained economist – I completed all but the residency requirement for a masters at Northwestern – but I don’t give two shits about the “damage we’re doing to our economy,” except insofar as financial insecurity causes psychological harm to people in poverty.  Our economy should be slower, to combat climate change and inequality.

One of my big fears during this epidemic is that our current president will accidentally do something correctly and bolster his chances of reelection.  The damage that his first term has already caused to our environment and our judiciary will take generations to undo – imagine the harm he could cause with two.

And yet, in arguing that our response to the Covid-19 epidemic is misguided, I seem to be in agreement with our nation’s far right. 

As far as I can tell, the far right opposes the shutdown because they’re motivated by philosophies that increase inequality.  Many of them adore Ayn Rand’s “Who will stop me?” breed of capitalism, as though they should be free to go outside and cough on whomever they want.  They dislike the shutdown because they think our lives are less important than the stock market.

By way of contrast, I care about fairness.  I care about the well-being of children.  I care about our species’ future on this planet.  It’s fine by me if the stock market tanks!  But I’ve written previously about the lack of scientific justification for this shutdown, and I’m worried that this shutdown is, in and of itself, an unfair response.

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Quarantine could have prevented this epidemic from spreading.  If we had acted in December, this coronavirus could have been contained.  But we did nothing until several months after the Covid-19 epidemic began in the United States. 

Then schools were closed: first for two weeks, then a month, then the entire year.

Stay-at-home orders were issued: first for two weeks, then extended to a month.  No data supports the efficacy of these orders – haphazard, partial attempts at social distancing, from which certain people, like my buddy doing construction for a new Amazon facility, have been exempted.  And no metrics were announced that might trigger an end to the shutdown.

Currently, the stay-at-home orders last until the end of April.  But, as we approach that date, what do people expect will be different?  In the United States, we still can’t conduct enough PCR tests – and even these tests yield sketchy data, because they might have false negative rates as high as 30%, and they’re only effective during the brief window of time — perhaps as short as one week — before a healthy patient clears the virus and becomes invisible to testing.

Based on research with other coronaviruses, we expect that people will be immune to reinfection for about a year, but we don’t know how many will have detectable levels of antibody in their blood.  As of this writing, there’s still no serum test.

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In the United States, New York City has the largest concentration of risk – densely populated elderly people with constant exposure to unclean air. But even the New York Times has begun to print articles describing the folly of our response to Covid-19.

The Italian government is considering the dystopian policy of drawing people’s blood to determine if they’ll be eligible for a permit to leave their homes.  If you were worried about the injustice that the virus itself imposed on people who are elderly or immunocompromised, this is worse!

We can’t evaluate our response without tests.  Missteps by the CDC (which was gutted by the Trump administration) have left us blind to the progression of the epidemic.  And we can’t evaluate our response if we have nothing to compare it to – we will have to end the shutdown to see what happens next (with the option of resuming these safety measures if our test shows they were necessary).

We know, clearly, that the shutdown has been causing grievous harm.  Domestic violence is on the rise.  This is particularly horrible for women and children in poverty, trapped in close quarters with abusers.  The shutdown is creating conditions that increase the risk of drug addiction, suicide, and the murder of intimate partners.

We don’t know whether the shutdown is even helping us stop the Covid-19 epidemic.  And we still don’t know whether Covid-19 is scary enough to merit this response.  As of this writing, our data suggest that it isn’t.

Covid-19 is a rare breed, though: a communicable disease where increased wealth correlates with increased risk.

And so we’re taking extreme measures to benefit the most privileged generation to ever walk the face of this Earth, at the cost of great harm to vulnerable populations.  This is why I feel dismayed.

Hopefully I can present some numbers simply enough to explain.

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Many diseases are more likely to kill you if you’re poor.

Malaria kills between 400,000 and one million people every year.  The vast majority are extremely poor, and many are children – the World Health Organization estimates that a child dies of malaria every thirty seconds.

Wealth protects against malaria in two ways.  Wealthy people are less likely to live in parts of the world with a high prevalence of malaria (most of the deaths each year occur in Africa and India), and wealthy people can buy effective anti-malarial medications. 

I took prophylactic Malarone when I visited Ecuador and India.  Lo and behold, I did not get sick. 

I believe Malarone costs about a dollar per day.  I am very privileged.

HIV kills between 700,000 and one million people every year.  Again, the vast majority are poor.  HIV is primarily transmitted through intimate contact – exposure to blood, needle sharing, or sex – so this virus rarely spreads across social boundaries in stratified communities. 

In the United States, HIV risk is concentrated among people living in our dying small towns, people without homes in inner cities, and people trapped inside the criminal justice system. 

It seems that these people are all easy to ignore.

Wealth will protect you even if you do contract HIV.  We’ve developed effective anti-retroviral therapies.  If you (or your government) can pay for these pills, you can still have a long, full life while HIV positive.  About 60% of the people dying of HIV happen to have been born in Africa, though, and cannot afford anti-retrovirals.

Even the myriad respiratory infections that plague our species – of which Covid-19 is but one example – are more likely to kill you if you’re poor.  The World Health Organization lists the top causes of death for people living in low-income versus high-income countries.  The death rate from respiratory infections is twice as high for people living in low income countries.

The second-highest cause of death among people in low-income countries is diarrhea.  Diarrhea kills between one million and two million people each year, including about 500,000 children under five years old.

These deaths would be easy to treat and even easier to prevent. 

Seriously, you can save these people’s lives with Gatorade!  (Among medical doctors, this is known as “oral rehydration therapy.”)  Or you could prevent them from getting sick in the first place by providing clean water to drink.

We could provide clean water to everyone – worldwide, every single person – for somewhere between ten billion and one hundred billion dollars.  Which might sound like a lot of money, but that is only one percent of the amount we’re spending on the Covid-19 stimulus bill in the United States.

We could do it.  We could save those millions of lives.  But we’re choosing to let those people die.

Because, you see, wealthy people rarely die of diarrhea.  Clean water is piped straight into our homes.  And if we do get sick – I have, when I’ve traveled – we can afford a few bottles of Gatorade.

Instead, wealthy people die of heart disease.  Stroke.  Alzheimer’s.  Cancer.

If you’re lucky enough to live past retirement age, your body will undergo immunosenescence.  This is unfortunate but unavoidable.  In old age, our immune systems stop protecting us from disease.

Age-related immunosenescence explains the high prevalence of cancer among elderly people.  All of our bodies develop cancerous cells all the time.  Usually, our immune systems kill these mutants before they have the chance to grow into tumors.

Age-related immunosenescence also explains why elderly people die from the adenoviruses and coronaviruses that cause common colds in children and pre-retirement-age adults.  Somebody with a functional immune system will get the sniffles, but if these viruses are set loose in a nursing home, they can cause systemic organ failure and death.

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I haven’t seen this data presented yet – due to HIPAA protections, it can’t easily be collected – but Covid-19, on average, seems to kill wealthier people than influenza.

On a personal level, wealth will protect you from Covid-19.  We know that early treatment saves lives, which is a reason why Germany’s death rate is so low, and wealthy people are less likely to postpone going to the hospital.  Wealthy people can afford the medications that might keep you out of the ICU. Wealthy people are less likely to experience the stresses, sleep loss, and discrimination that have caused disproportionate numbers of Black people in the United States to succumb to Covid-19.

But on a population level, wealth is correlated with increased risk.

Part of this wealth gap is due to age.  Currently we don’t have enough data to know exactly where the risk curves for seasonal influenza and Covid-19 intersect, but it seems to be around retirement age.  If you’re younger than retirement age, seasonal influenza is more deadly.  If you’re older than retirement age, Covid-19 is more deadly.

And in the United States, if you’re older than retirement age, you’re more likely to be wealthy.

Covid-19 is also more dangerous if you’re already sick.  A study of Covid-19 deaths found that 97% of the people killed were already sick with at least one serious medical condition.  The average person killed by Covid-19 had 2.7 other serious diseases.

Because these people were receiving expensive medical care, they were able to survive despite their other diseases.  Imagine what would have happened if these people had chanced to be born in low-income countries: they would already be dead. 

This is a tragedy: all over the world, millions of people die from preventable causes, just because they had the bad luck of being born in a low-income country rather than a rich one.

We don’t have data on this yet, but it’s likely that Covid-19 will have a much smaller impact in Africa than in Europe or the United States.

When my father was doing rounds in a hospital in Malawi, his students would sometimes say, “We admitted an elderly patient with …”  And then my father would go into the room.  The patient would be 50 years old.

Covid-19 is particularly dangerous for people in their 80s and 90s.  Great privilege has allowed so many people in Europe and the United States to live until they reached these high-risk ages.

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Our efforts to “flatten the curve,” in addition to increasing many people’s risk of death (from domestic violence, suicide, and the lifelong health repercussions of even a few months of sedentary living), will save relatively few lives, even among our country’s at-risk population.

The benefit of this shutdown is simply the difference between how many people would die if we did nothing, compared to how many people will die if we “flatten the curve.” 

Assuming that our efforts to flatten the curve succeed – and neglecting all the other risks of this strategy – we’ll be able to provide ventilation to everyone.  But there will still be a lot of deaths.  The shutdown will not have helped those people.  The shutdown is only beneficial for the small number who would be treated in one scenario, would not be treated in another, and who actually benefit from the treatment.

The Lancet reported that in the initial wave of the Covid-19 epidemic, 97% of patients receiving invasive ventilation died.  Later on, the death rate among people receiving ventilation was still over 80%

Their lives matter, too.  Many of us have a friend or relative whose life was cut short by this. But something that we have to accept is that we all die.  Our world would be horrible if people could live forever.  Due to immunosenescence, it becomes increasingly difficult to keep people alive after they reach their late 70s and 80s.

And the priorities of elderly people are different from mine.  I care deeply about the well-being of children and our planet’s future.  That’s why I write a column for our local newspaper discussing ways to ameliorate our personal contribution to climate change.  That’s why my family lives the way we do.

These priorities may be quite different from what’s in the short-term best interests of an 80-year-old.

Schools are closed.  Children are suffering.  Domestic violence is on the rise.  All to protect people who have experienced such exceptional privilege that they are now at high risk of dying from Covid-19.

Our national response to Covid-19 is being directed by a 79-year-old doctor.  I haven’t gotten to vote in the presidential primary yet, but if I get to vote at all, I’ll be allowed to choose whomever I prefer from a selection of a 77-year-old white man or a 78-year-old white man.  Then comes the presidential election, where there’ll be an additional 73-year-old white man to choose from.

It makes me wonder, what would our national response be like if we were facing a crisis as risky as Covid-19, but where elderly people were safe and children were most at risk?

And then I stop wondering.  Because we are facing a crisis like that. 

It’s climate change.

And we have done nothing.

On scrutiny.

On scrutiny.

We can be attentive to only a small sliver of the world.

We’re constantly surrounded by so much noise, so many smells, so many different colors, textures, tastes.  The amount of sensory information that we’re bombarded with every moment would be overwhelming if we weren’t so good at ignoring our environment.

Consider smells.  Chemicals waft through the air, bind to olfactory receptors in our nose, and cause a signal to ping our brain: there’s the floral scent of an ethyl acetate here …  But, if we stay near the source of that chemical, our brain will keep receiving that signal.  Thankfully, this information is discarded by our subconscious minds.  As long as the types of smells in a space aren’t changing, we soon notice nothing.

If our clothes feel the same against our skin from one moment to the next, all the tactile information being sent from the surface of our body is similarly ignored.  But the information is still there.  If we focus your attention on your shirt, you can feel it.

The-Pearl-294878In The Pearl, John Steinbeck reveals how this glut of information can cause us to be hoodwinked.  A poor diver becomes suddenly wealthy when he finds a giant pearl.  The diver’s infant child was stung by a scorpion and has begun to recover … but a greedy doctor would rather the child receive an expensive cure.  The doctor knows that he can fool the diver by drawing his attention to details that never seemed important before.

It is as I thought,” [the doctor] said.  “The poison has gone inward and it will strike soon.  Come look!”  He held the eyelid down.  “See – it is blue.”  And Kino, [the diver], looking anxiously, saw that indeed it was a little blue.  And he didn’t know whether or not it was always a little blue.  But the trap was set.  He couldn’t take the chance.

If we scrutinize the world, we can always find something that looks strange.

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When I was in high school, I had to get a medical physical each year.  Those cost $5 – a school nurse would measure my blood pressure, listen to my heart, and look at the curvature of my spine.  I felt healthy enough when I signed up for these physicals, and the nurses invariably agreed.  Even repeatedly-concussed football and soccer players were given a clean bill of health.

Queensland_State_Archives_2832_Medical_examination_with_the_School_Health_Services_October_1946

This $5 exam was insufficient to find anything wrong with us.  But if we’d been subjected to a $25,000 battery of diagnostic scrutiny instead, I’m sure we’d have seemed flawed.

Indeed, in a recently-published study designed to shill the new $25,000 physical from a company called “Health Nucleus” in California – which includes DNA sequencing, metabolite analysis, full-body MRI, two weeks of heart monitoring, and more – 40% of their seemingly-healthy study participants were diagnosed with “something seriously wrong.”  In several study participants, doctors found clusters of aberrant cells: pre-cancer.

In sexually-reproducing multicellular organisms, most cells carry DNA instructions to sacrifice themselves for the sake of the whole.  Some of these instructions code for contact inhibition, which means that cells stop growing when their edges bump into neighbors.  Other DNA sequences code for apoptosis, which means that cells commit suicide once they’re no longer needed.

But the mechanism for transmitting these instructions is imperfect.  DNA is copied again and again by jiggling protein machines called polymerases, and these make about 60 mistakes each time they copy our genomes.  Worse, DNA is copied from copies, so the mistakes pile up over time.  Like classroom handouts that have been photocopied from photocopies so many times that the words blur into static, DNA sequences that instruct our cells to cooperate can become unreadable.  At which point a cell is cancerous.

4.0.4Cancer cells continue growing without regard for the neighbors they’re crowding.  They carry on dividing – spewing forth copies of themselves – long after a team-player would’ve snuffed itself.

Most human adults harbor cancer cells.  All the time, they lurk in us.  And our immune systems destroy them.  Chemotherapy drugs do not kill cancerous cells – they slow the growth of all cells, giving a patient’s own immune system time to fight the menace.

So it’s unsurprising that doctors found pre-cancer in some of the study participants who underwent this $25,000 physical.  Study participants were as old as 98.  Their average age was 55.  After so much time alive, of course some of their cells had gone bad.

Early detection of cancer does boost a patient’s chance of survival, but sometimes in a trivial way.  Healthy patients whose immune systems would have destroyed a population of aberrant cells without any intervention … who might never have realized that anything was ever wrong … are counted as “cancer survivors.”  Extremely sensitive diagnosis can identify cancers early enough to be cured, but has the drawback of mis-labeling healthy people as diseased.

Every diagnosis of disease leads to harm – from worry, from the risks inherent in all medical treatment – and so has to be balanced against the expected outcome from doing nothing.  With some conditions, doing nothing would be deadly.  But by scrutinizing healthy people, you can always find something that looks strange.  Of course you’ll find “evidence of age-related chronic disease or risk factors” when you subject older people to a $25,000 battery of medical tests.  If you aggressively treat all of these, you’ll cause more harm than good.

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Because overdiagnosis can cause so much harm, the search for pre-cancer reminds me of the search for pre-criminals.  We can always find something wrong when we look hard enough.

I assume the researchers investigating children to find “pre-criminals” mean well.  I can imagine a world in which at-risk children are given more resources.  If it’s true, for instance, that a brief assessment of 3-year-olds or surveys filed by the teachers of 6-year-olds can predict future criminal behavior, we should cut spending on prisons and law enforcement to fund childhood nutrition, education, and enrichment instead.

Instead, we respond to intimations of future disobedience by watching people more closely.

Adorable Preschooler Playing with Colorful Dough

Our predictions of criminality become self-fulfilling: lifelong mistrust makes people criminals.  The racial injustice of mass incarceration is caused in part by unequal enforcement.  As far as we know, U.S. citizens of all ethnicities break laws equivalently often, but police scrutinize minority neighborhoods more closely, so that’s where they find crimes.

Similarly, when an elementary teacher decides that a student is trouble, that student gets scrutinized.  Equivalent misbehavior reaps unequal discipline.  In the U.S., children in preschool are targeted for school suspension based on the color of their skin.  A suspension disrupts education, pushing students further behind.  When a teacher decides that a student won’t learn, that student is prevented from learning.

And researchers have developed an automated image analysis that predicts the likelihood that someone is a criminal just from a photograph of his clean-shaven face.  Which isn’t as evil as it sounds.  Or, rather, it is evil, but not because a computer is doing it – the computer algorithm is simply revealing and quantifying the evil way we humans judge people by their appearances.

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Genetics differences are real, and they do make a substantial contribution to people’s proclivities.  But human brains are so plastic that the way we’re treated matters more: if you’re curious, you might want to check out this inadvertent identical twin study.

With a glance, we form strong opinions about people’s characters.  Some children we brand “pre-criminals.”  Is it shocking that, after decades of mistreatment and scrutiny, these children become the lawbreakers we always expected them to be?