Health

COVID and The Young

Jeremy Horpedahl2 Comments

The CDC just approved vaccines from Americans aged 5-11. That’s great news! But today, I want to talk about another age group: mine.

A few months ago I wrote a post summarizing data for COVID-19 deaths among people in their 30s and 40s. While we have primarily thought of COVID as a disease impacting the elderly (and indeed in the aggregate, it is), there have been major health consequences for those under 65 too. Including major health consequences for the age group 30-49 (which I believe is the age range of all our bloggers here at EWED).

I wanted to update that data because a few new things have come to light. First, I highly recommend reading a recent paper by my friend Julian Reif and co-authors. They estimate the number of Years of Life Lost and Quality-Adjusted Years of Life Lost for different age groups from COVID-19. Their data runs through mid-March 2021, so before vaccines probably had much of a chance to impact the aggregate death numbers (though vaccines were being rolled out at the time).

Here’s their main result: while most of the deaths from COVID were among those aged 65 and older (80% through March 2021), most of the life lost in terms of years was for Americans under 65 (54% of QALYs). And even for very young adults, the risk in terms of years of life lost was not minimal. A comparison from the paper: “Adults aged 85 years or older faced 70 times more excess risk for death than those aged 25 to 34 years but only 3.9 times more individualized loss of QALYs per capita.” Compared to the 35-44 age group, the relevant factor is 2.8 times more individualized loss for the 85+ group.

It’s a great paper, but it only goes through March. What has happened since March 2021? While 80% of the COVID deaths up through March 2021 were among the elderly (65 and older), since April 2021 only 60% of the COVID deaths have been among the elderly. Part of this is because deaths are down among the elderly, but it’s also because deaths are up for the non-elderly. The table is my attempt to show this effect, looking at the period from March-September in both 2020 and 2021 (data is current as of October 27, so the September 2021 data is still not complete, but instructive).

For the oldest Americans, COVID deaths fell by 50%. That’s great! But for younger Americans, COVID deaths roughly doubled. Not good!

Continue reading →

Joy Recommends Running Products

Joy BuchananLeave a comment

Late October is a nice time to get outside in Alabama. I have answered the primal call to suburban moms and signed up for a 5K running race at the end of the month. To make running practice safe and fun, I dropped a few hundred dollars this month on products.

Now that I’m old, my first concern is not injuring myself. Having good new shoes that absorbs some of the impact from running is important. I went to a local running store and ended up getting Asics Gel Nimbus.

I really like them. Amazon link. It seems like the price ($150) in the boutique store and the Asics website and Amazon is all the same.

Assuming you are not considering getting these shoes for yourself, do not buy a woman running shoes for Christmas, obviously, unless you’ve discussed it with her. You could buy a family member the other big purchase I made for running: AirPods.

Many people already have AirPods but I’ll review them anyway. I bet there are at least 10 people out there just like me who view them as newfangled and unnecessary.

My primary reason for getting them was so that I can listen to music while I run and not have the annoying headphones cord in my face. They are great for running. By the way, I got the cheapest version since I only use them occasionally.

AirPods are more than wireless headphones.  They are smart. They allow you to take hands free phone calls when your phone is two rooms away (which can be a reason to keep them in even when you are not listening to music). They respond to voice commands and prompt you on what to say. Maybe I shouldn’t be, but I was surprised by how easy it was to start using them.

I use a free application called RunKeeper. Without any fiddling from me, the AirPods give me useful feedback on my run from RunKeeper. I don’t have to stop the music or pull out my phone to get this feedback. It just knows, and the AI is correct about what I want to hear when.

While I was at the Apple store getting AirPods, I considered getting an Apple Watch. It turns out that the Apple Watch does not have a long range from the phone. So, I cannot run a mile away from my phone and still get all services on the Watch. Since I’m not a serious runner, I did not want to spend hundreds of dollars on a new watch plus pay for a separate cellular plan for the device. I run while holding my small-ish iPhone.

Apple Watch records your heart beat. I can be a privacy grump, even though I use a lot of tech. Apple Corp. can C it’s way right out of my vital signs. I don’t even want data on my heart rate and sleep patterns, for myself. I’m already mentally overloaded, so I don’t want more data to think about.

Here’s a song I like to put at the beginning of my running song playlist: https://www.youtube.com/watch?v=FxmkYugYu7Q

Lastly, for your holiday shopping list, I will make one plug for the shirts in our Blog Store. These make a fun gift for math majors or Econ Ph.D. folk.

La Dolce Vita Economica

mdmakowskyLeave a comment

I thought about writing about soccer (again). I thought about writing about time management and personal production functions. I considered writing about Lebron James or how I manage multiple research projects. I thought about writing about a classic, and entirely addictive to the point of career ruination, video game. They all seem a little redundant at the moment, though, because they are all the same basic story.

One soccer manager is over-exhausting their resources because of a confluence of bad contractual incentives while another team is witnessing a renaissance in a player they essentially forced to take 7 weeks off. While so many NBA careers of the 80s evaporated in a cloud of cocaine and clubbing, Lebron James’ entire life is built around managing the only two resources whose limits are salient to his life: his body and relationship with his family. Playing baseball growing up I watched pitchers blow out their arms before they finished puberty in service to Little League glory, while modern professional pitchers are (finally) on strictly managed pitch counts to maximize their expected output.

There are two manners in which I armchair quarterback the rest of the world. One is the things in which I have just enough knowledge to be frustrated by others decisions, but no so much as to actually know what I am talking about. These frustrations are ephemeral, they flatter myself to the point of mild embarrassment upon reflection, and, if I am being honest with myself, are fun.

The other manner is resource management. These are the times when armchair quarterbacking is less fun and more exasperating because they are the moments when outsiders, with inferior levels of narrowly-applicable expertise, are often actually right. Which is not to say the knowledge that resources are being poorly managed is uniquely held by outsiders. Insiders are more often than not quite aware of the suboptimal deployment and conservation of resources, but are unable to overcome the status quo institutions, incentives, or inertia of decision-making power loci. It’s obvious to lots of people that athletes, CEOs, doctors, and congressional representatives are over-extended. What’s not obvious is how to get out of these equilibria.

When I see most attempts at self-improvement, I am generally skeptical of anything that doesn’t start with the identification of a key resource that is salient to outcomes and the options available to better manage it. Maybe its calories and how to budget them. Maybe its time and how to better partition and conserve it. It could always be money, but in general I find that money is so immediately identifiable as a finite resource and entirely fungible that people who ostensibly are managing it poorly are, in actuality, failing at managing a different resource (time, emotional energy, vices, etc) that is intertwined with financial resources.

When I see successful firms, teams, and individuals, what I most often find myself admiring is not (just) a worldly talent, but a facility with managing resources that others haven’t yet adopted or mimicked. An appreciation for sleep, a protection of time blocked for creativity, an adeptness trading low opportunity competitive minutes for higher opportunity cost moments on the biggest stages. Or even just the ability to recognize that this is the moment to savor a 600 calorie dessert with a loved one because the emotional sustenance will make it easier to walk away from three vending machine Hostess pies during the high-stress moments in the week to come.

Once you learn to manage your donut-based caloric intake, the spreadsheet of your life will be revealed before you, an endless cascade of resources to be managed and optimized. A life with the right donuts at the right time. The dolce vita economica.

Weigh costs, benefits, and evidence quality

James Bailey1 Comment

Living means making decisions with imperfect information. But Covid provides many examples of how people and institutions are often still bad at this. A few common errors:

  1. Imperfect evidence = perfect evidence. “Studies show Asprin prevents Covid”. OK, were the studies any good? Did any other studies find otherwise?
  2. Imperfect evidence = “no evidence” or “evidence against”. In early 2020, major institutions like the WHO said “masks don’t work” when they meant “there are no large randomized controlled trials on the effectiveness of masks”
  3. Imperfect evidence = don’t do it until you’re sure Inaction is a choice, and often a bad one. If the costs of action are low and the potential benefits of action high, you might want to do it anyway. Think masks in 2020 when the evidence for them was mediocre, or perhaps Vitamin D now.
  4. Imperfect evidence = do it, we have to do something Even in a pandemic, it is possible to over-react if the costs are high enough and/or the evidence of benefits bad enough (possibly lockdowns, definitely taking up smoking)

Any intro microeconomics class will explain the importance of weighing both costs and benefits. But how do we know what the costs and benefits are? For many everyday purchases they are usually obvious, but in other situations like medical treatments and public policies they aren’t, particularly the benefits. We have to estimate the benefits using evidence of varying quality. This creates more dimensions of tradeoffs- do you choose something with good evidence for its benefits, but high cost? Or something with worse evidence but lower costs? Graphing this properly should take at least 3 dimensions, but to keep things simple lets assume we know what the costs are, and combine benefits and evidence into a single axis called “good evidence of substantial benefit”. This yields a graph like:

Applied to Covid strategies, this yields a graph something like this:

This is not medical advice- I say this not merely as a legal disclaimer, but because my real point is the idea that we should weigh both evidence quality and costs, NOT that my estimates of the evidence quality or costs of particular strategies are better than yours

Judging the strength of the evidence for various strategies is inherently difficult, and might go beyond simply evaluating the strength of published research. But when evaluating empirical studies on Covid, my general outlook on the evidence is:

Of course, details matter, theory matters, the number of studies and how mixed their results are matters, potential fraud and bias matters, and there’s a lot it makes sense to do without seeing an academic study on it.

Dear reader, perhaps this is all obvious to you, and indeed the idea of adjusting your evidence threshold based on the cost of an intervention goes back at least to the beginnings of modern statistics in deciding how to brew Guinness. But common sense isn’t always so common, and this is my attempt to summarize it in a few pictures.

Racial Gaps and Data Gaps

Jeremy HorpedahlLeave a comment

Are there racial gaps in the distribution of the COVID-19 vaccine? This is an important and interesting question in its own right. But I’ll talk about this question today because it’s an interesting example of how confusing and sometimes misleading data can be.

How do we answer this question? One is by surveying people. There are a number of surveys that ask this question, but a recent one by the Kaiser Family Foundation finds that among adults 70% of Blacks and 71% of Whites report being vaccinated. And given the sampling error possible with surveys, we would say that these are virtually identical. No racial gap! (Note: there was a racial gap when they did the same survey back in April, with 66% of Whites and 59% of Blacks vaccinated.)

But, surveys are just a sample, and perhaps people are lying. Maybe we shouldn’t trust surveys! And shouldn’t there be hard data on vaccines? Indeed, the CDC does publish data on vaccinations by race. That data shows a fairly large gap: 42.3% of Whites and only 36.6% of Blacks vaccinated. This is for at least one dose, and the percentages are of the total population (which is why it’s lower than the survey data). So maybe there is a racial gap after all!

But wait, if you look closely at the footnotes (always read the footnotes!), you’ll see something curious: the CDC admits that the race data are only available for 65.8% of the data. We don’t have the race information for over one-third of those in this data. Yikes! And given the exist disparities we know about in terms of income and access to healthcare, we might suspect that the errors are not randomly distributed. In other words, if there is probably good reason to suspect that Blacks are disproportionately reflected in the “unknown” category. But we just don’t know.

So what can we do? Since this data comes from US states, we can look at the individual state data and see if perhaps some of it is better (fewer unknowns). What does that data show us?

Continue reading →

Purchasing Drinks with Push-ups.

Zachary Bartsch1 Comment

Early in the summer of 2021, I was having fun. The semester was ended and traveling was on the horizon. Due to changes at my wife’s job I began driving to work instead of making the 20 minute trek by foot. And there was plenty of time to be social. And social I was — several days of the week. And, inevitably, drinks would be served. I was doing a lot less walking and a lot more drinking alcohol (responsibly).

I was footloose and fancy free. Until… The bathroom scale reminded me that I had surpassed the age of 30 years old. Being sedentary and drinking were starting to add up.

Right then and there, I made a decision. I would disincentivize my drinking, but I would also make drinking beneficial rather than detrimental to my waist line.

I made a deal with myself. For each drink that I had, I would have to ‘pay’ 25 push-ups. No exceptions. And, no borrowing from myself. Push-ups *had* to come first. None of this “I owe myself push-ups” nonsense (it’s a trap!). I could *save* for the future, however. Knowing that a social event was approaching, I’d build myself a nice little balance. And the exchange rate was constant: 25 push-ups per drink – always.

Who held me accountable? Me, myself, and I… And some incentive compatible approbation.

I wasn’t shy about any of it. At a outdoor beer garden with my wife and her cousin, I had prepared by banking 50 push-ups. But round 3 was impending… and I’m no square. So, over to the side, quite out of the way on the outdoor patio, I knocked out a quick 25. Round 4 came after still another 25.

Now let’s talk incentives. Requiring push-ups of myself increased my physical activity, so I felt better about my body. Further, if I hadn’t banked push-ups ahead of time, paying prior to each drink limited how many push-ups I could comfortably do. Once push-ups became uncomfortable, I stopped drinking.

That’s all great. But the social incentives were pivotal in keeping me dedicated. Upon seeing the push-ups in action, female friends would talk to my wife who quickly developed a well-crafted dialogue for each new observer, complete with convincingly spontaneous gesticulations and eye-rolls. I can’t say that I didn’t enjoy the attention.

Other men provided direct positive approval. I combined 3 activities that were already ‘manly’ when separate: muscle building, drinking, and dispassionate self control. Men would praise me immediately and similarly feel compelled to do there own sets of push-ups in my presence — as if being sedentary in my presence convicted them as guilty of something. At least one wife sent me a text after we had left town that included a picture of her husband knocking out some of his own pre-drink push-ups (Is this what it feels like to be an influencer??).

Aristotle would be proud.

I was very consistent for months. Being the summer and seeing a lot of friends and family, I did a lot of push-ups. But, as time passed, the exercise habit stuck even as the drinking began to pass by the wayside. What began as an arbitrary, self-imposed rule soon became a legit change in behavior. And then, that change in behavior became a practice. Did that practice improve my temperance and fortitude through habituation? Idk. But wouldn’t that be nice?

Behavioral Economics Conversation: Cutler and Glaeser

Joy Buchanan1 Comment

I haven’t written a formal response, yet, to the “behavioral economics is dead” claim going around Twitter. I’m too busy doing my referee reports on behavioral papers to write in depth about why behavioral is not dead. Incidentally, I’m not loving the most recent paper I was sent, so maybe that’s a point in the column of Team Death. I’ll write a few posts intersecting with the arguments being had.

First, I’ll point out two places in a CWT discussion of health and cities where the phrase “behavioral” was used. This is obviously a current conversation. David Cutler probably wouldn’t say that behavioral economics is his field, but here’s how he describes puzzles in decision making over health issues. (bold emphasis mine)

Everything that we know in healthcare is that people have difficulty choosing on the basis of price and quality. It goes back a little bit to some of the behavioral issues that we were talking about, but I think it’s slightly different. If you go to the doctor, and the doctor says you should take medication X, and you go to the pharmacy, and the pharmacy says that’ll be $30, a fair number of people will walk away and say, “I don’t have $30.”

What we would hope they would do is go to their doctor and say, “Doctor, is there any way that there could be a cheaper medicine that might work because $30 is hard for me this month?” In practice, people are extremely uncomfortable doing that. They really don’t like to go to their doctor and say, “Doctor, how do I trade off the money here versus the medicine?”

David Cutler

The previous issues Cutler mentioned had to do with time preference and delayed gratification. The turmoil over dieting alone is evidence that people don’t always make the best decisions.

Here’s the second of two appearances of the word “behavioral”, in response to Tyler’s question about how to make cities healthier.

I certainly join the crowd of economists who have argued that congestion pricing is the best way to deal with urban traffic jams. There’s no reason not to charge people for the social cost of their actions on that. And giving away street space for free is just crazy, especially since we now have technologies that can handle this.

And if we introduce autonomous vehicles without congestion pricing, you have just lowered the cost of sitting in traffic, which means the first-order behavioral response is that more people will sit in traffic, and our congestion will get even worse unless we introduce this from the beginning. So I think pricing is really good.

Ed Glaeser

In the second use of the word, it sounds like an individually-rational decision to sit in your autonomous vehicle and read blogs until your arrive at your destination. Maybe we can use mechanism design to reduce traffic congestion and improve life for all.

Whether or not you think behavioral economics is dead, economists are going to keep using the word “behavioral” for a long time.

I did a quick Ngram to get a sense of how common the word is, although this does not restrict the search to books about economics. Ngrams are easier to interpret if there is a comparison word. I choose the word “clustering” because it’s also a relatively new technical term. Both words were quite rare before 1930.

If you missed the small discussion about behavioral econ, Mike Munger did a link round-up here. Tomorrow’s post will be Vernon Smith’s view of behavioral economics.

Why do Costa Ricans outlive Americans?

James Bailey1 Comment

Which country in the Western Hemisphere has the longest life expectancy?

Unsurprisingly its Canada, at 82.2 years (pre-Covid).

But which country in the Americas comes in second?

Surprisingly, its Costa Rica at 80.8 years.

Source

The United States, by far the richest country in the Americas, had a life expectancy of 78.4 years that was falling even before Covid.

How is it that Costa Rica outperforms not only the much richer United States, but also other somewhat richer countries like Panama, Mexico, Argentina, and the Dominican Republic?

Clearly they don’t do it by outspending us- Costa Rica spends the equivalent of $1600 dollars per person per year on health care, compared to nearly $12000 in the US (7.3% of their GDP goes to health care vs 16.8% for the US).

Source

So what exactly is Costa Rica doing right? Atul Gawande tackles this question in his latest article for the New Yorker.

He argues that the key has been Costa Rica’s investment in primary care and public health. The US might may have many more of the world’s best (and most expensive) hospitals, but the easiest and cheapest health benefits come from keeping people out of hospitals in the first place.

the country has made public health—measures to improve the health of the population as a whole—central to the delivery of medical care. Even in countries with robust universal health care, public health is usually an add-on; the vast majority of spending goes to treat the ailments of individuals. In Costa Rica, though, public health has been a priority for decades.

In the nineteen-seventies, Costa Rica identified maternal and child mortality as its biggest source of lost years of life. The public-health units directed pregnant women to prenatal care and delivery in hospitals, where officials made sure that personnel were prepared to prevent and manage the most frequent dangers, such as maternal hemorrhage, newborn respiratory failure, and sepsis. Nutrition programs helped reduce food shortages and underweight births; sanitation and vaccination campaigns reduced infectious diseases, from cholera to diphtheria; and a network of primary-care clinics delivered better treatment for children who did fall sick. Clinics also provided better access to contraception; by 1990, the average family size had dropped to just over three children.

The strategy demonstrated rapid and dramatic results. In 1970, seven per cent of children died before their first birthday. By 1980, only two per cent did. In the course of the decade, maternal deaths fell by eighty per cent. The nation’s over-all life expectancy became the longest in Latin America, and kept growing. By 1985, Costa Rica’s life expectancy matched that of the United States.

Gawande goes on to describe how every Costa Rican gets a home visit from a health care worker at least once per year. This is quite the contrast to the US, where even getting primary care doctors to let you see them in their office can be a fight. I moved to Rhode Island last year and this week finally tried getting a primary care doctor here. I looked through the list of doctors covered by my insurance that my insurer said were accepting new patients and started making calls (by the way, why calls? do any doctors book appointments online?). 2 said that they actually weren’t taking new patients. 9 never answered the phone. The 12th doctor I tried, one farther away and lower-rated than I’d like, finally agreed to see me- in 3 months.

For anyone with less free time, determination, or insurance coverage, it would be natural to just give up after the 5th or the 10th “no”. Clearly many Americans do, leading manageable conditions like diabetes or high blood pressure to turn into acute health crises and expensive hospital visits.

I do think individual doctors could do better here by thinking through their appointment process from the patient’s perspective. But at its core this is simply a numbers issue- we don’t have enough primary care doctors to go around. We actually have fewer doctors per capita than Costa Rica, and relatively high share of specialists means that we have even fewer primary care doctors to go around. More medical school spots, more primary care residency spots, and fewer restrictions on immigrant doctors could go a long way way toward helping to US catch up to…. Costa Rica.

That, or their secret is just the volcanoes. This is surprisingly plausible- the US state with the longest life expectancy is also the one best known for volcanoes, Hawaii.

GDP Losses and COVID Deaths (6 month update)

Jeremy Horpedahl2 Comments

Back in March of this year, I wrote blog posts providing data on GDP losses and COVID-19 deaths for 2020, both for selected countries and US states. Since we’ve now had another 6 months of GDP data and the pandemic continues to take lives, I thought it would be useful to update that data.

I will update the data for US states in a future post, but here is the most recent data for about 3 dozen countries (mostly European and North American countries, since they have the most believe COVID data).

*indicates that the GDP data is only through the first quarter of 2021
Continue reading →

Institutions Getting Smarter on Covid

James BaileyLeave a comment

Two weeks ago I argued for 4 non-coercive anti-Covid policies I thought were under-rated. I haven’t generally been impressed by the institutional response to the pandemic, and so I wasn’t expecting the policies I mentioned to get traction any time soon. But some did!

I argued for:

  1. Full vaccine approval
  2. Emergency vaccine approval for children
  3. Ventilation
  4. Outpatient treatments that work

Since then, the big news is that the FDA fully approved the Pfizer vaccine. This seems to have increased the pace of new vaccinations.

I really wasn’t expecting the FDA to move that fast- they have generally learned to be slow because Congress has been much more likely to complain about them approving a bad drug than about them denying or slow-walking a good drug. But Congress itself seems to be changing in response to Covid, with 108 House members pushing the FDA for a timeline on approving vaccines for 5 to 11 year-olds.

I don’t know of a good way to gauge progress on ventilation overall, but I was pleased to see HEPA filters show up in the classrooms at Providence College:

Likewise, I don’t know if Fluvoxamine prescriptions are up in the weeks since a good sized study showed it reduced Covid hospitalizations 31%, but the popular press articles about it keep coming (don’t be deterred by “Vox”, the linked article is by Kelsey Piper and its excellent).

So some institutions seem to be getting smarter, and perhaps coincidentally, we seem to be at the peak of the Delta wave. According to Covidestim.org, Rt is now below 1 in 31 states, and falling in 45 states, including all of the Southern states hit hardest by Delta. Barring a new twist (another worse variant? Winter Delta wave in the North?), things just get better from here.