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 punishment as criminal deterrent.

On punishment as criminal deterrent.

crimeLike a lot of people interested in prison reform, I am skeptical of the idea that draconian punishments are good crime deterrents.

The basic logic behind the belief in crime deterrence is totally sensible.  If people are rational, they’re probably weighing the costs and benefits of their actions before making any decision.  If you’re considering whether to go to college, you’d consider the tuition bills and your lost wages while you’re sitting in classrooms instead of working and the effort it’d take to pass all your classes, then you’d balance that against increased earning potential and personal satisfaction and whatever else you might hope to gain (incredible beer pong prowess?). 

If you’re considering whether to stab somebody and steal his wallet, you’d consider the risk of being caught, the likely punishment you’ll face, the moral qualms you’ll feel later, and balance that against how much cash you think the dude is carrying.

For that latter calculation, increasing the length of prison terms, and making prisons more miserable places to be in, should make potential criminals less likely to stab & rob people.

All very sensible.  Unfortunately, it doesn’t seem to be true.  There’s some empirical evidence suggesting that it’s false, like similar crime rates in adjacent states with differing severity of punishment, and similar crime rates before and after bills affecting the severity of punishment were passed.  The data suggest that actual criminals simply are not making that sort of risk/benefit calculation.

(For someone else’s take on this, check out p. 11 of this reference from the Federal Judicial Center… from 1994.  And yet only now, over a decade after we realized that mandatory minimums weren’t helping, is there tentative talk from politicians about fixing them.)

paddleAnd there are reasons why we might’ve anticipated that the relationship (the “more punishment = less crime” idea) would not hold.  For one thing, behavioral economists have documented countless ways in which humans are not very rational creatures.  We pay too much for gym memberships.  We eat poorly, even though we know we don’t really want to eat that whole bag of jellybeans tonight (I too spend many evenings roiling in bed, clutching my belly, moaning whhhyyyyy ).  Males routinely underestimate risks and overestimate rewards, especially if there’s money involved, and especially if there’s sex involved.

That’s for the populace as a whole.  None of us are very rational.  It’s probably reasonable to assume that the sort of person whose circumstances are so dire as to make petty crime seem like the only option is even less likely to make accurate, level-headed assessments of risks and rewards.

Furthermore, a lot of criminals act upon the passions of the moment.  Not everyone –hardly anyone, I’d say — who commits murder is like Raskolnikov, plotting out the perfect crime in advance.  If you feel mad, pick up a gun, and shoot someone, there’s hardly time to think about how many years you might spend in prison, or whether or not you’ll receive the death penalty, or even how much remorse you’ll feel ten minutes later.

I attended a class at Bloomington Woodworks recently, and the instructor gave an interesting answer to the question, “If the joiner can do all that in a minute, why were we leveling all those boards by hand?”

He told us, “The machines make your work go faster.  But, if you make a mistake?  They make your mistakes go faster too.  While you’re working by hand, you can stop and check your progress and if something looks wrong, you can fix it.  If you made that mistake on a machine, it’d already be too late.”

firearm-409000_640Violent, impassioned people often kill people with guns.  Yes, they could kill people with knives or hammers or their bare hands, too.  But guns kill people faster.  That’s why the risk of successful suicide skyrockets in homes with guns — the time from a bad thought to being dead is so short.  Similarly, if you get angry and pick up a gun, there’s little time to think.  If you grab somebody by the neck, there’s at least a few extra seconds for the little voice in your head to ask, “Um, dude, what are you doing??”

So I’m skeptical that the absurdly long mandatory minimums in the U.S. actually accomplish anything.  Huge numbers of people in prison should not be there still.  I don’t think anyone whose behavior caused no harm to others should’ve ever been incarcerated.  But, beyond that, a lot of harmful people shouldn’t be in prison still.  Their sentences are often too long, too.

A big problem is our country’s dismal efforts toward rehabilitation.  We put convicted criminals into stressful, violent prisons, let them languish for many years, spend little or nothing on their education or job training… and then don’t want to let them out because they’re still “scary.”

Instead, criminals should be locked away for shorter periods of time, treated better while they’re in prison, and given the training they’ll need to successfully re-enter the outside world.  But few politicians would vote for that.  The problem is, people would argue that curtailing punishment makes crime more attractive.  They’d base their reasoning on that same inaccurate theory that criminals are making cold calculations of the risks and benefits of each illegal act in advance.

As I mentioned, for most crime, that theory doesn’t seem to be true.

And that’s why I was so pleased that Gretchen Morgenson’s recent “Fair Game” column brought my attention to a study documenting a type of crime for which that theory does hold.  Apparently there are some criminals out there who appear to be making nuanced risk / benefit calculations before their misdeeds.

Kedia et al., in their study “Evidence on Contagion in Earnings Management” (which I haven’t had a chance to read, sadly.  It’s still in press, so even though I can read all the fancy academic journals through the local university library, I can’t access it yet), showed a significant inverse correlation between regulatory action and earnings manipulations by others within an industry.  In other words, more punishment = less crime.  Exactly what politicians had been claiming was true for poor people selling drugs or stealing socks or vandalizing alleyways.

handcuffs-257995_640The relationship does not hold in general, but Kedia et al. provided evidence that high-level financial crime can be held in check by the threat of punishment.

In a way, it makes a lot of sense that this would be the case.  Humans aren’t very rational, but I think it’s safe to say that accountants are more rational than the rest of us.  Financial crimes also take a long time and only slowly build enough momentum as to seem irreversible.

If you get mad, pull out a gun, and shoot your spouse, it doesn’t matter how you feel that evening.  Your spouse is dead.  You screwed up.  The end.  But, if you’ve cooked the books?  You could go back the next day and correct the spreadsheet.  You could fix it next week.  You could probably fix it next year.

Many financial crimes require constant renewed commitment to criminal behavior.  Another good example is the — thankfully illegal, unfortunately still common — tendency for lenders to deny mortgages to black borrowers, or charge them much higher interest rates than they charge whites.  If you’re a banker and you turn away a qualified black borrower, well, maybe you can’t call that person up later that day to say, “I’m sorry, I was a racist jerk, I’ve reconsidered.”  But you could very easily approve the loan of the next qualified black borrower.

Criminal lending practices afforded the perpetrators hundreds, sometimes thousands of opportunities to stop breaking the law and instead do the right thing.

So, yes, it seems sensible that for these types of crime, the threat of punishment really would alter how much crime occurs.

Is it time for the sad coda to this essay now? 

For types of crimes that are not deterred by heavy punishment, the U.S. ruthlessly pursues draconian sentences.  But for the sort of financial crime that would be deterred by the threat of serious punishment?  In the U.S., perpetrators are typically let off scott-free.  They’re treated more gently than kindergarteners: they’re often not required to admit they did anything wrong or offer an apology.

(“Associated Bank denies any allegation that it engaged in discriminatory lending on a prohibited basis…”)