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 produce a small benefit for 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 antiretroviral 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 antiretrovirals.

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 Albuterol inhaler 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.  I’ve made a rough sketch of the risk of death versus age for both Covid-19 and seasonal influenza.  Currently we don’t have enough data to know exactly where these risk curves 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.

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 hope is that we won’t exceed the capacity of our hospitals.  If someone’s condition deteriorates after a Covid-19 infection, they need invasive ventilation.

Please note that we can often prevent people’s condition from deteriorating by giving them Albuterol inhalers.  And these used to be so cheap!  In the early 2000s, you could buy an inhaler for about five dollars.  But pharmaceutical companies were allowed to re-patent these and the price has soared to nearly four hundred dollars.

Many news reports have included sensational numbers about how many people in their 30s and 40s have gone to the hospital for Covid-19.  These reports rarely mention that many of these hospitalizations could be prevented with a five dollar inhaler.

But we’re allowing drug companies to charge people four hundred dollars a pop for these now, which puts them out of reach for many people.

When I caught what I assume to be Covid-19, I took an inhaler.  I am very privileged.

Some young people can’t afford an inhaler, and many elderly people develop symptoms too severe to be treated with Albuterol, so they need care in an ICU.

But 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 now. 

In a recent essay, I gave an estimate for how many people would die if we’d done nothing.  New data suggests that my estimate was too low – the numbers out of Italy (where they did nothing until it was probably too late) suggest that around 80,000 people might have died in the United States.  Hospitals would have been overwhelmed, and some people whose condition required invasive ventilation would have been denied that treatment.

Even with the shutdown, though, we’re doing a crappy job.  Our numbers are pretty much guaranteed to be worse than Germany’s, which has a more equitable health care system overall and is testing enough people to track the spread of the disease and treat people early.  With this shutdown, all we’re hoping for is that the severe cases will be spread enough in time that everyone whose condition deteriorates to the point of needing invasive ventilation can have it.

Maybe.  The shutdown is so slapdash that hospitals in certain high-risk areas, like New York City, will still be overwhelmed.

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%

So we’d actually be saving only a fifth of the people who would have to be triaged if we’d exceeded our hospitals’ capacity to provide care.  This could be as few as 10,000 at-risk people.

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 70s or 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 a few thousand 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 Robert Gordon’s ‘The Rise and Fall of American Growth.’

On Robert Gordon’s ‘The Rise and Fall of American Growth.’

k10544I read Robert Gordon’s The Rise and Fall of American Growth during nap time. My daughter was just shy of two years old. She liked to sleep curled against my arm; I was left with just one hand to hold whatever book I was reading during her nap.

If you’re particularly susceptible to carpal tunnel syndrome, I’d recommend you not attempt to read Gordon’s book one-handed. I had a library hardcover. My wrists hurt quite a bit those weeks.

But I was pleased that Gordon was attempting to quantity the economic value of my time. After all, I am an unpaid caretaker for my daughter. My contribution to our nation’s GDP is zero. From the perspective of many economists, time spent caring for my daughter is equivalent to flopping down on the couch and watching television all day.

Even very bright people discount this work. My best friend from college, a brilliant urologist, was telling me that he felt sad, after his kid had been in day care, that he didn’t know how to calm her down anymore, but then laughed it off with “Nobody remembers those early years anyway.”

I understand that not everyone has the flexibility to sacrifice career progress for children. But, I reminded him, it isn’t about episodic memory. These years build the emotional pallet that will color my daughter’s experiences for the rest of her life.

And it’s important, as a feminist, to do what I can to demonstrate a respect for caretaking. I believe, obviously, that someone’s gender should not curtail their choices; people should be allowed to pursue the careers they want. But I think it’s silly to imply that biology has no effect. Hormones are powerful things, and human males & females are awash in different ones. This isn’t destiny. But it does suggest that, in large populations, we should not be surprised if people with a certain set of hormones are more often drawn toward a particular type of work.

I think it’s important for a feminist to support not only women who want to become cardiac surgeons, but also to push back against the societal judgment that surgery is more worthy of respect than pediatrics. As a male feminist, there is no louder way for me to announce that I think caretaking is important than to do it.

Your_WASHING_MACHINE...Helps_Keep_Clothes_Clean...Make_Your_Equipment_Last._-_NARA_-_514669I felt pleased that Gordon attempted to quantify the economic value of unpaid work like I was doing. Otherwise you would come to the bizarre conclusion that time-saving home appliances – a washing machine, for instance – have no economic value because a stay-at-home mother gains only worthless time. Those extra minutes not spent washing dishes still contribute nothing to the GDP.

Gordon argues – correctly – that better health, more attentive parenting, and more leisure do have value.

So I was happy with the dude. But I still disagreed with his main conclusion.

Gordon also argues that we will have low economic growth for the foreseeable future – and I’m with him here – because our previous growth rate was driven by technological innovation.

Here’s the rub: once you invent something, nobody will invent it again. Learning to harness electricity was great! A world with electrical appliances is very different from, and probably better than, a world without.

refrigerator-158634_960_720But the massive boost in productivity that accompanied the spread of electrical appliances can’t happen twice. Once everybody already has an electrical refrigerator, that opportunity for growth is gone.

The same is true of any technology. Once everybody has clean water (setting aside for a moment the fact that many people in the United States do not have clean water piped into their homes), you won’t see another jump in quality of life from water delivery. At that point the changes would be incremental: perhaps delivering clean water more efficiently or wasting less of that water once it arrives. Important, sure. But those are tiny changes. Low growth. Nothing like difference between turning on a tap versus hauling water back to the house in buckets.

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One of these seems easier than the other.

Gordon thinks that the major technologies were all invented by the 1970s. Just like the physicists who thought their field would devolve into more precise measurement of the important constants, Gordon feels that there is little more to be made. Which has led to a pattern in reviews of his book: the reviewer feels obliged to rattle off potential inventions that have not yet been made. For the New York Times, Steven Rattner mentioned driver-less cars. For the New York Review of Books, William D. Nordhaus posits the development of artificial intelligence smarter than we are.

Speculating on future technologies is fun. I could offer up a few of my own. Rational enzyme design, for instance, would have many productivity-boosting consequences. If you consider farm animals to be machines for food production, they are woefully inefficient. You could do better with enzyme design and fermentation: then you’d use yeast or bacteria to produce foods with the exact same chemical composition as what we currently harvest from animals. (Former Stanford biochemist Pat Brown is developing technologies that use roughly this idea.)

Complex pharmaceuticals, too, could be made more cheaply by fermentation than by organic synthesis. Perhaps solar panels, too, could be manufactured using biological reagents.

But, honestly, none of this would contravene slow growth. Because the underlying problem is most likely not that our rate of technological innovation has slowed. I’ve written about the fallacy of trying to invent our way out of slow growth previously, but perhaps it’s worth using another contemporary example to make this point.

At one time, you needed to drive to a different store each time you wanted to buy something. Now you can sit down at a computer, type the name of whatever it is you want to buy – running shoes, books, spices, video cameras – pay by credit card, and wait for it to show up at your home. The world now is more efficient. You might even save a few dollars on whatever it was you’d wanted to buy.

But many people received money in the old world. There’d be a running shoe store in every town. A book store. A camera store. In the new world, the dude who owns the single website where all these items can be purchased receives all the money.

And the distribution of income might soon narrow further. At the moment, many delivery people receive money when they deposit those purchased items at your doorstep. But these delivery people may soon be replaced by robotic drones.

drone.PNGThis is even more efficient! No humans will be inconvenienced when you make a purchase. You chose what you want and wait for the robot.

Also, no humans need be paid. The owner of the website – who will also own the fleet of drones – keeps even more of the money. The erstwhile delivery people find worse jobs, or are unemployed. With less income now, they buy less.

After the development of a new technology – delivery drones! – the economy could produce more. It could boost the growth rate. But the actual growth might be low because the single person receiving money from the new invention doesn’t need to buy much, and the many people put out of work by the invention are buying less.

The same problem arises with the other posited technologies. If our foods were all produced by fermentation, farmers would go out of business (of course, concentrated animal feeding operations and other industrialized practices have already sunk most small farmers) and only the owner of the fermentation vats and patented micro-organisms would receive money.

If someone patents a superhuman artificial intelligence, then no other humans would need to be paid ever again. The AI could write newspapers, opinion sections and all, better and faster than we could. It could teach, responding to students’ questions with more clarity and precision than any human. It could delete us when it learns that we were both unnecessary and unpleasant.

Which is why I think it’s irrelevant to argue against Gordon’s technological pessimism in a review of The Rise and Fall of American Growth. I may disagree with his belief that the important technologies were all invented before 1970, but my more substantive complaint is with his theory that our nation’s growth slowed when we ran out of things to invent. I believe the nature of our recent inventions have allowed the economy to be reorganized in ways that slow growth.

Gordon does mention inequality in the conclusion to his work, but he cites it only as a “headwind,” a mild impediment to overcome, and not a major factor in the shift between pre- and post-1970 growth:

The combined effect of the four headwinds — inequality, education, demographics [more old people], and government debt — can be roughly quantified. But more difficult to assess are numerous signs of social breakdown in American society. Whether measured by the percentage of children growing up in a household headed by one parent instead of two, or by the vocabulary disadvantage of low-income preschool children, or by the percentage of both white and black young men serving time in prison, signs of social decay are everywhere in the America of the early twenty-first century.

economic-worriesI found it worrisome that he did not explain that this social breakdown – which will cause slower growth in the future – is most likely caused by slow economic growth. It’s a feedback loop. Growing up in a one-parent household makes it more likely that someone will be poor, but the stress of poverty makes it more difficult to maintain a relationship. When you’re not worried about money, you can be a better spouse.

So I would argue that the best way to address these economic headwinds and restore growth would be a guaranteed basic income. Technological advances in communication and automation have made it possible for ever-smaller numbers of people to provide all the services we need. As we invent more, the set of people who receive money for this work should continue to shrink. You might think, well, there will always be nurses, there will always be janitors, but, setting aside the fact that it’d be a bleak world in which this was the only work available for humans to do, this isn’t even true. A flesh-coated robot with lifelike eyes and superhuman AI could be a better, more tireless, less fallible nurse than any human.

Despite carrying a flip-phone, I’m no Luddite. I don’t want human ingenuity to stop. But it’s worth recognizing that our current system for wealth distribution will inevitably yield wretched results as technological progress continues.

And that’s without even mentioning the ways in which a guaranteed basic income – worldwide, funded by a similarly worldwide tax on wealth – would compensate for past sins.