This is the…monthly? bimonthly? occasional?…classified thread. Post advertisements, personals, and any interesting success stories from the last thread.
Under the circumstances, you can also ask for financial support (eg link a GoFundMe) if you need to. Nobody has to donate to people who do this, but please at least be respectful.
This is the bi-weekly visible open thread (there are also hidden open threads twice a week you can reach through the Open Thread tab on the top of the page). Post about anything you want, but please try to avoid hot-button political and social topics. You can also talk at the SSC subreddit – and also check out the SSC Podcast. Also:
1. The next virtual SSC meetup will be May 10th, 10:30 AM PDT. Scott Aaronson of Shtetl-Optimized will be giving a talk on a quantum computing topic to be decided later, followed by discussion. See here for more information, especially variations on the theme of “because [last meetup] someone came in the form of a dachshund the size of a small apartment building, I have instituted a rule that you cannot have an avatar larger than an SUV”.
2. The SSC podcast (no extra content, just somebody reading posts) is now available on Spotify at this link.
3. Highlighting some good comments from the Amish health care system post: Sam Chevre’s brother is an Amish/Mennonite deacon and gives us some better numbers. ConstantConstance is also a Mennonite and gives her perspective. Bhalperin is an economist and discusses evidence around what fraction of per capita health spending can be explained by the rise of health insurance (answer: some papers say half, but check the caveats). Matt M on the incentives leading to the rise of health insurance in the US (the 1940s and ’50s had very high taxes on income, so companies tried to find untaxable ways to compensate workers). It was awkward for me to postulate that health insurance made people stop trying to limit their own health care costs, so thanks to those of you who came out and admitted that your health insurance made you stop trying to limit your own health care costs (1, 2).
4. And also some great comments on the uric acid post! Emil Kierkegaard has access to an unpublished study of 4450 Vietnam vets and finds “no relationship of gout to IQ, income, education, and no interactions either.” Yashabird discusses related issues in Lesch-Nyhan syndrome and Tourette’s. Ambimorph is an expert on uricase and refers us to her paper and talk. And testosterone elevates uric acid and seems relevant to questions like who becomes an ambitious executive.
5. Unfortunately, not all comments have reached this level of excellence. Some of the problem is a predictable consequence of the blog getting more publicity because of a few popular articles. But I want to catch this before it gets out of hand. In particular, I’m worried about the thing I see on Twitter, where everyone feels so threatened by people attacking their ideas in really exaggerated ways that they preemptively respond in kind and the temperature goes up and up forever. I’m going to be a little stricter for the next few months to reverse a trend toward that happening here. The first set of victims, some sample offending comments, and the length of ban are:
– Secretly French (1, 2, 3, 4), indefinite
– Jermo Sapiens (1, 2, 3, 4, 5, 6), indefinite.
– An Firinne (1, 2, 3), indefinite.
– HeelBearCub (1, 2, 3, 4, 5), six months.
– Brad (1, 2, 3, 4, 5), six months.
– EchoChaos (1, 2), six months
– HowardHolmes (1), one month
– Clutzy (1), one month
– Alexander Turok (1), one month
This is only about 10% of the people I secretly want to ban, but I am trying to show restraint. People who are on thin ice: Nybbler, Plumber, Le Maistre Chat, ThisHeavenlyCongjugation. You can avoid being banned by consistently following the rules on this page, by trying not to make broad hostile generalizations about groups that contradict their own understand out of nowhere (eg “the only reason to be a Republican is that you hate the poor”, “Democrats say they’re trying to help people, but really they’re just after power”), and by making a common sense effort to keep this a friendly and high-quality place.
Feel free to discuss these bans, but keep in mind that the way I ban people is by putting their screen name into the censorship filter, so you might want to put their name in Pig Latin or stick some random characters in the middle if you mention it in your post.
At the beginning of every year, I make predictions. At the end of every year, I score them. So here are a hundred more for 2020.
Rules: all predictions are about what will be true on January 1, 2021. Some predictions about my personal life, or that refer to the personal lives of other people, have been redacted to protect their privacy. I’m using the full 0 – 100 range in making predictions this year, but they’ll be flipped and judged as 50 – 100 in the rating stage, just like in previous years. I’ve tried to avoid doing specific research or looking at prediction markets when I made these, though some of them I already knew what the markets said.
Feel free to get in a big fight over whether 50% predictions are meaningful.
CORONAVIRUS:
1. Bay Area lockdown (eg restaurants closed) will be extended beyond June 15: 60%
2. …until Election Day: 10%
3. Fewer than 100,000 US coronavirus deaths: 10%
4. Fewer than 300,000 US coronavirus deaths: 50%
5. Fewer than 3 million US coronavirus deaths: 90%
6. US has highest official death toll of any country: 80%
7. US has highest death toll as per expert guesses of real numbers: 70%
8. NYC widely considered worst-hit US city: 90%
9. China’s (official) case number goes from its current 82,000 to 100,000 by the end of the year: 70%
10. A coronavirus vaccine has been approved for general use and given to at least 10,000 people somewhere in the First World: 50%
11. Best scientific consensus ends up being that hydroxychloroquine was significantly effective: 20%
12. I personally will get coronavirus (as per my best guess if I had it; positive test not needed): 30%
13. Someone I am close to (housemate or close family member) will get coronavirus: 60%
14. General consensus is that we (April 2020 US) were overreacting: 50%
15. General consensus is that we (April 2020 US) were underreacting: 20%
16. General consensus is that summer made coronavirus significantly less dangerous: 70%
17. …and there is a catastrophic (50K+ US deaths, or more major lockdowns, after at least a month without these things) second wave in autumn: 30%
18. I personally am back to working not-at-home: 90%
19. At least half of states send every voter a mail-in ballot in 2020 presidential election: 20%
20. PredictIt is uncertain (less than 95% sure) who won the presidential election for more than 24 hours after Election Day. 20%
POLITICS:
21. Democrats nominate Biden, and he remains nominee on Election Day: 90%
22. Balance of evidence available on Election Day supports (as per my opinion) Tara Reade accusation: 90%
23. Conditional on me asking about Reade on SSC survey, average survey-taker’s credence in her accusation is greater than 50%: 70%
24. …greater than 75%: 10%
25. …greater than credence in Kavanaugh accusation asked in the same format: 40%
26. Trump is re-elected President: 50%
27. Democrats keep the House: 70%
28. Republicans keep the Senate: 50%
29. Trump approval rating higher than 43% on June 1: 30%
30. Biden polling higher than Trump on June 1: 70%
31. At least one new Supreme Court Justice: 20%
32. I vote Democrat for President: 80%
33. Boris still UK PM: 90%
34. No new state leaves EU: 90%
35. UK, EU extend “transition” trade deal: 80%
36. Kim Jong-Un alive and in power: 60%
ECON AND TECH:
37. Dow is above 25,000: 70%
38. …above 30,000: 20%
39. Bitcoin is above $5,000: 70%
40. …above $10,000: 20%
41. I have bought a Surface Book 3 laptop: 60%
42. Crew Dragon reaches orbit: 80%
43. Starship reaches orbit: 40%
SSC, ETC:
44. I do another Nootropics Survey this year: 70%
45. I do another SSC Survey this year: 90%
46. I start a Reader SSC Survey this year: 60%
47. I start a SSC Book Review Contest this year: 70%
48. I run another Adversarial Collaboration Contest this year: 10%
49. I publish [redacted]: 20%
50. I publish [redacted]: 50%
51. I publish [redacted]: 60%
52. I publish [redacted]: 80%
53. …conditional on being published, it gets at least 40,000 pageviews: 10%
54. I publish [redacted]: 60%
55. …conditional on being published, it gets at least 40,000 pageviews: 50%
56. More hits this year than last: 70%
57. Most hits ever this year: 20%
58. I finish Unsong revision this year: 40%
59. New co-blogger with more than 3 posts: 10%
FRIENDS:
60. No new long-term (1 month +) residents at group house by the end of the year: 70%
61. Koios has said his first clear comprehensible word: 50%
62. [redacted]: 40%
63. [redacted]: 60%
64. [redacted]: 80%
65. [redacted]: 80%
66. [redacted]: 95%
67. [redacted]: 10%
68. [redacted]: 95%
69. [redacted]: 80%
70. [redacted]: 80%
71. [redacted]: 50%
PROFESSIONAL
72. I’ve gotten at least one new patient to do a full wake therapy protocol: 60%
73. I have specific, set-in-motion plans to quit work / start my own business: 5%
74. I work the same schedule and locations I did before the coronavirus: 80%
75. I get a bonus for 2020: 20%
PERSONAL:
76. [redacted]: 70%
77. [redacted]: 70%
78. [redacted]: 95%
79. I travel to Alaska this year: 60%
80. [redacted]: 40%
81. [redacted]: 20%
82. I go on at least three dates with someone I haven’t met yet: 20%
83. [redacted]: 10%
84. [redacted]: 30%
85. [redacted]: 10%
86. I try one biohacking project per month x at least 5 of the last 6 months of 2020: 30%
87. I find at least one new supplement I take or expect to take regularly x 3 months: 20%
88. Not eating meat at home: 40%
89. Weight below 200: 50%
90. Weight below 190: 10%
91. [redacted]: 90%
92. [redacted]: 30%
93. [redacted]: 5%
94. I travel outside the country at least once: 10%
95. I get back into meditating seriously (at least ten minutes a day, five days a week) for at least a month: 10%
96. At least ten tweets in 2020: 80%
97. I eat at/from Sliver more than any other restaurant in Q4 2020: 50%
98. [redacted]: 30%
99. I do pushups and situps at least 3 days/week in average week of Q4 2020: 60%
100. I write the post scoring these predictions before 2/1/21: 70%
I.
Actually, no. You should not do this. Most of you were probably already not doing this, and I support your decision. But if you want a 2000 word essay on some reasons to consider this, and then some other reasons why those reasons are wrong, keep reading.
Gout is a disease caused by high levels of uric acid in the blood. Everyone has some uric acid in their blood, but when you get too much, it can form little crystals that get deposited around your body and cause various problems, most commonly joint pain. Some uric acid comes from chemicals found in certain foods (especially meat), so the first step for a gout patient is to change their diet. If that doesn’t work, they can take various chemicals that affect uric acid metabolism or prevent inflammation.
Gout is traditionally associated with kings, probably because they used to be the only people who ate enough meat to be affected. Veal, venison, duck, and beer are among the highest-risk foods; that list sounds a lot like a medieval king’s dinner menu. But as kings faded from view, gout started affecting a new class of movers and shakers. King George III had gout, but so did many of his American enemies, including Franklin, Jefferson, and Hancock (beginning a long line of gout-stricken US politicians, most recently Bernie Sanders). Lists of other famous historical gout sufferers are contradictory and sometimes based on flimsy evidence, but frequently mentioned names include Alexander the Great, Charlemagne, Leonardo da Vinci, Martin Luther, John Milton, Isaac Newton, Ludwig von Beethoven, Karl Marx, Charles Dickens, and Mark Twain.
Question: isn’t this just a list of every famous person ever? It sure seems that way, and even today gout seems to disproportionately strike the rich and powerful. In 1963, Dunn, Brooks, and Mausner published Social Class Gradient Of Serum Uric Acid Levels In Males, showing that in many different domains, the highest-ranking and most successful men had the highest uric acid (and so, presumably, the most gout). Executives have higher uric acid than blue-collar workers. College graduates have higher levels than dropouts. Good students have higher levels than bad students. Top professors have higher levels than mediocre professors. DB&M admitted rich people probably still eat more meat than poor people, but didn’t think this explained the magnitude or universality of the effect. They proposed a different theory: maybe uric acid makes you more successful.
Before we mock them, let’s take more of a look at why they might think that, and at the people who have tried to flesh out their theory over the years.
Most animals don’t have uric acid in their blood. They use an enzyme called uricase to metabolize it into a harmless chemical called allantoin. About ten million years ago, the common ancestor of apes and humans got a mutation that broke uricase, causing uric acid levels to rise. The mutation spread very quickly, suggesting that evolution really wanted primates to have lots of uric acid for some reason. Since discovering this, scientists have been trying to figure out exactly what that reason was, with most people thinking it’s probably an antioxidant or neuroprotectant or something else helpful if you’re trying to evolve giant brains. Other researchers note that in lower animals, uric acid is a “come out of hibernation” sign which seems to induce energetic foraging and goal-directed behavior more generally.
Some of these people note the similarity between uric acid and caffeine:
If uric acid had caffeine-like effects, then high levels of uric acid in the blood would be like being on a constant caffeine drip. The exact numbers don’t really work out, but you can fix this by assuming uric acid is an order of magnitude or so weaker than straight caffeine. Add this fudge factor, and Benjamin Franklin was on exactly one espresso all the time.
But you can’t actually be hyperproductive by being on one espresso all the time, can you? Don’t you eventually gain tolerance to caffeine and lose any benefits?
Although uric acid is structurally similar to caffeine, it’s even more similar to a chemical called theacrine. In fact, theacrine is just 1,3,7,9-tetramethyl-uric acid:
Theacrine (not the same as theanine, be careful with this one!) is a caffeine-like substance found in an unusual Chinese variety of tea plant. It’s recently gained fame in the nootropic community for not producing tolerance the same way regular caffeine does – see eg Theacrine: Caffeine-Like Alkaloid Without Tolerance Build-Up. This makes the theory work even better: Franklin (and other gout sufferers) were constantly on one espresso worth of magic no-tolerance caffeine. Seems plausible!
II.
This theory is hilarious, but is it true?
I was able to find eleven studies comparing achievement and uric acid levels. I’ve put them into a table below.
| Study | sample size | finding | significant at | awfulness |
| Kasi | 155 tenth-graders | r = 0.28 w/ test scores | 0.001 | significant |
| Bloch | 84 med students | r = 0.23 w/ test scores | 0.05 | immense |
| Steaton & Herron | 817 army recruits | r = 0.07 w/ test scores | 0.02 | significant |
| Mueller & French | 114 professors | r = 0.5 with achievement-oriented behavior | 0.01 | astronomical |
| Montoye & Mikkelsen | 467 high-schoolers | negative result | N/A | unclear |
| Cervini & Zampa | 270 children | positive result | unknown | what even is this? |
| Inouye & Park | ??? | r = 0.33 with IQ | 0.025 | what even is this? |
| Anumonye | 100 businessmen, 40 controls | r = 0.21 with drive | 0.05 | immense |
| Ooki | 88 twins | r = 0.17 with 'rhathymia' | 0.05 | how is this even real? |
| Dunn I | 58 executives | positive | ??? | immense |
| Dunn II | 10 medical students | negative | N/A | astronomical |
Nine out of eleven are positive. But I find it hard to be confident in any of them. Modern studies can be pretty bad, but studies from the 1960s ask you to take even more things on trust, while inspiring a lot less of it. Many of these studies were unable to find the outcomes that the others found, but discovered new outcomes of their own. Many failed to report basic pieces of information. The largest experiments usually found the least impressive results. Overall this looks a lot like you would expect from something forty years before anyone realized there was a replication crisis.
I also notice that the most positive studies compare business executives to people in other walks of life, and the least positive studies compare good students with bad students. Business executives get a lot of chances to differ from the general population – maybe they still eat more meat and richer food? Maybe they’re stressed and stress affects uric acid levels?
What about the list of very famous people with gout? I agree it’s a lot of people, but what’s the base rate? Kings were born to their position, so we have no reason to think they were especially high achievers (someone in their family might have been, but that gene could have gotten pretty diluted). Since so many kings got gout, this suggests rich old people in the past had gout pretty often regardless of achievement. Also, this was before people invented good medical diagnosis, so probably arthritis, injuries, and any other form of joint pain got rounded off to gout too. What percent of rich old people in the past had some kind of joint pain? I’m prepared to guess “a lot”.
The biochemists report equally confusing results around the uric acid / caffeine connection. Caffeine mostly works by antagonizing adenosine, a chemical involved in sleepiness. According to Hunter et al, Effects of uric acid and caffeine on A1 adenosine receptor binding in developing rat brain, uric acid does not affect adenosine, and so probably does not have a caffeine-like mechanism of action. On the other hand, caffeine probably has a small additional effect on catecholamine (eg dopamine, norepinephrine) release, and a different paper finds that uric acid does share this mechanism. So it doesn’t have caffeine’s main effect, but it does seem to have some kind of mild stimulant properties.
Given this level of uncertainty around every step in the hypothesis, I would describe any link between uric acid and achievement as kind of a stretch at this point. I feel bad about this, because it’s an elegant theory with mostly positive studies in support, but I’m just not feeling like it’s met its burden of proof.
III.
But some recent research is trying to bring this field back from the dead. At least this is what I get from Ortiz et al, Purinergic System Dysfunction In Mood Disorders, which synthesizes some more modern evidence that “uric acid and purines (such as adenosine) regulate mood, sleep, activity, appetite, cognition, memory, convulsive threshold, social interaction, drive, and impulsivity”. It argues that we know there are neurorecptors for adenosine (another similar-looking molecule) and ATP (adenosine triphosphate, the body’s main form of chemical energy). These seem to be involved in depression and mania, in the predicted direction (manic people have too much ATP, depressed people have too little, and treatments for both conditions seem to normalize ATP levels). These results seem to be daring someone to make up a theory where mania is just too much chemical energy floating around, but if Ortiz et al are doing that, it’s sandwiched in between so many dense paragraphs on receptor binding that I can’t make it out.
More interesting for us, uric acid is related to all these chemicals and also seems to be involved in mania. See eg de Berardis et al, Evaluation of plasma antioxidant levels during different phases of illness in adult patients with bipolar disorder, which finds that uric acid is elevated in manic patients, and the more manic, the higher the uric acid levels. And Machado-Vieria claims to have gotten pretty good results treating bipolar mania with allopurinol, a gout medication that decreases uric acid – and the more the allopurinol decreased uric acid, the better the results. There’s also a little evidence that depressed people have lower uric acid than normal. None of this is a large effect – there are still a lot of depressed people with higher-than-normal uric acid and a lot of manic people with lower – but it’s around the same size as all the other infuriatingly suggestive effects we find in psychiatry that never lead to overarching theories or go anywhere useful.
Future studies should try to replicate the link between uric acid and mania, and come up with a better understanding of why it might be true – maybe since uric acid is a decay product of ATP, the body interprets it as a sign that energy is plentiful? They should try to explain away anomalies – if gout is maniogenic, how come so many people with gout are depressed? Is it just because having a painful illness is inherently depressing? And then it should investigate how mania bleeds into normal personality. Is someone with slightly higher uric acid a tiny bit hypomanic all the time?
If they can fill in all those steps, I’ll be willing to take a fresh look at the old papers linking gout and achievement. Until then, you should probably hold off on eating megadoses of venison to become the next Ben Franklin.
My last post didn’t really go into why I dislike the way we do health insurance so much.
Of course, there are the usual criticisms based on compassion and efficiency. Compassion because poor people can’t get access to life-saving medical care. Efficiency because it’s ruinously expensive compared to every other system around. I agree with these arguments. And they’re strong enough that asking whether there are any other reasons is kind of like the proverbial “But besides that, Mrs. Lincoln, how did you like the play?”
But I had already internalized the compassion and efficiency critiques before becoming a doctor. After starting work, I encountered new problems I never would have expected, ones which have yet to fade into the amorphous cloud of injustices we all know about and mostly ignore. Most of my patients have insurance; most of them are well-off; most of them are intelligent enough that they should be able to navigate the bureaucracy. Listen to the usual debate around insurance, and you would expect them to be the winners of our system; the rich people who can turn their financial advantage into better care. And yet barely a day goes by without a reminder that it doesn’t work this way.
Here are some people I have encountered – some of them patients, some of them friends – who have made me skeptical that our system works for anyone at all:
— The elderly man who had a great relationship with his last psychiatrist, who saw him for twenty years, and who knew every detail of his issues. He switched jobs, got a new insurance, the old psychiatrist was no longer in network, and so he had to see me instead. I know nothing about him and it will take several evaluation sessions before I can even consistently remember who he is and what he needs from me.
— The businesswoman who was seeing me and doing well until the HR person at her job told her that she didn’t need to submit any forms to renew her insurance that year. That turned out to be wrong, and she missed The One Month Of The Year When You Are Allowed To Renew Insurance. She lost her insurance and can’t afford to keep seeing me.
— The bipolar man on a very important daily medication. He changed insurance plans. The new insurance refused to pay for his drugs until they got a form explaining why he needed the medication. I sent in the form. They said they couldn’t find the patient in their system and so couldn’t process the form. We argued about this for several days, during which he ran out of medication and decompensated.
— The would-be entrepreneur who wanted to save up enough money to live on for a year or two, quit her dead-end job, and start a startup – but who wouldn’t be able to afford health insurance outside of her dead-end job’s plan. She is still at her dead-end job.
— The young gay man with conservative religious parents. He had a supportive friend group and should have been able to come out to his parents without caring what they thought – except that he’s on his parents’ insurance and has no good alternative. He remains in the closet.
— The young woman in a not-quite-abusive but far-from-acceptable marriage, who stays in it because she’s on her husband’s insurance and has no good alternative.
— The depressed guy who was doing well on a complicated antidepressant regimen for a while, changed insurances, and was too depressed to do the work of finding a new psychiatrist. Now he comes to me saying it’s been five years, he’s been depressed all that time, and he would like to get back on the medications that he knows work well for him.
— The endless train of patients I saw when I worked in a hospital emergency room, whose stories started with “So I lost my insurance, but I figured I could get along fine without the medication…”
— The other endless train of patients I saw when I worked in a hospital emergency room, whose stories started with “So I lost my insurance, but I was smart, and I had saved up a stockpile of my medication, and I figured, how hard could it be to manage it myself without a doctor’s advice…”
— The other endless train of patients I saw when I worked in a hospital emergency room, whose stories started with “So I changed insurance, and I got a new doctor, and he said he didn’t see a good reason why I had to be on this medication…”
— The Oklahoman who wants to move to California where he has more friends and better job prospects, but he’s on Oklahoma state insurance for the needy. Although California also has a state insurance for the needy, there is no way to figure out whether it will accept him or cover the care he needs other than by moving to California, applying, and seeing what happens. Also, the application process takes weeks to months, during which time he will not have either state’s insurance (though California promises he will get reimbursed for care he gets during this period later). He decides to stay in Oklahoma.
— The well-off Oklahoman with good private insurance who visits California on a business trip, gets sick, and finds that surprise! his Oklahoman insurance doesn’t have any in-network providers in California and he has to pay $20,000 out-of-pocket for care.
— The depressed guy who was in remission for years and had a great job with great insurance. Then he had a relapse, became too depressed to go to work, got fired, and lost his insurance right at the moment when it finally could have been useful for him.
— The woman who had a minor breakdown and was brought to the hospital by police. The hospital admitted her against her will, on the grounds that her minor breakdown sounded potentially dangerous, treated her, and released her. Her insurance refused to pay, on the grounds that it was just a minor breakdown and didn’t really require hospitalization, by the standards of This Particular Insurance Company. She is on the hook for the entire cost of the involuntary hospitalization.
— Anything involving Kaiser [EDIT: I’m getting some pushback on this who say Kaiser is good at everything except mental health; I only deal with them in a mental health capacity so I can’t speak to this]
— The trauma victim who needs trauma therapy – which means reliving all your traumas in order to come to terms with them – but is reluctant to start because her work situation is unstable. She knows that if she changes insurance, she’ll have to restart the therapy from the beginning and relive all her traumas all over again.
— The young schizophrenic man who is on his parents’ insurance. Because so many schizophrenics are poor, all of the expertise in treating schizophrenia is concentrated in Medicaid clinics. But a rich kid on his parents’ excellent insurance can’t access Medicaid, he can’t go off his parents’ insurance for other reasons, and he can’t find any private psychiatrists who know how to treat his particular schizophrenia-related complications. I am sure there is some good solution to this which I am missing, but I haven’t been able to find it and his family hasn’t either.
— The anorexic woman who has Blue Cross, and the only good anorexia therapist in town only takes Aetna. The sex-addicted man who has Aetna, and the only good sex addiction therapist in town only takes Blue Cross.
Any other system would fix these problems. A public system like Medicare For All would fix them. A communal system like the Amish have would fix them. A free market system like our grandparents had would fix them. The prepaid doctor cooperatives Reason talks about would fix them. A half-assed compromise like Joe Biden’s Medicare For All Who Want It would fix them. But here we are, stuck with a system that somehow manages to fail everybody for different reasons.
I.
Amish people spend only a fifth as much as you do on health care, and their health is fine. What can we learn from them?
A reminder: the Amish are a German religious sect who immigrated to colonial America. Most of them live apart from ordinary Americans (who they call “the English”) in rural communities in Pennsylvania and Ohio. They’re famous for their low-tech way of life, generally avoiding anything invented after the 1700s. But this isn’t absolute; they are willing to accept technology they see as a net positive. Modern medicine is in this category. When the Amish get seriously ill, they will go to modern doctors and accept modern treatments.
The Muslims claim Mohammed was the last of the prophets, and that after his death God stopped advising earthly religions. But sometimes modern faiths will make a decision so inspired that it could only have come from divine revelation. This is how I feel about the Amish belief that health insurance companies are evil, and that good Christians must have no traffic with them.
And Deists believe that God is like a watchmaker, an artisan who built the world but does not act upon it. But by some miracle, the US government played along and granted the Amish exemptions from all the usual health care laws. They don’t have to pay Medicare taxes or social security. They aren’t included in the Obamacare mandate. They can share health care costs the way they want, ignoring any regulations to the contrary. They are genuinely on their own.
They’ve ended up with a simple system based on church aid. Everyone pays tithes to their congregation (though they don’t call it that). The churches meet in houses and have volunteer leaders, so expenses minimal. Most of the money goes to “alms” which the bishop distributes to members in need. This replaces the social safety net, including health insurance. Most Amish go their entire life without needing anything else.
About a third of Amish are part of a more formal insurance-like institution called Amish Hospital Aid. Individuals and families pay a fixed fee to the organization, which is not-for-profit and run by an unpaid board of all-male elders. If they need hospital care, AHA will pay for it. How does this interact with the church-based system? Rohrer and Dundes, my source for most of this post, say that it’s mostly better-off Amish who use AHA. Their wealth is tied up in their farmland, so it’s not like they can use it to pay hospital bills. But they would feel guilty asking their church to give them alms meant for the poor. AHA helps protect their dignity and keep church funds for those who need them most.
How well does this system work?
The Amish outperform the English on every measured health outcome. 65% of Amish rate their health as excellent or very good, compared to 58% of English. Diabetes rates are 2% vs. 8%, heart attack rates are 1% vs. 6%, high blood pressure is 11% vs. 31%. Amish people go to the hospital about a quarter as often as English people, and this difference is consistent across various categories of illness (the big exception is pregnancy-related issues – most Amish women have five to ten children). This is noticeable enough that lots of health magazines have articles on The Health Secrets of the Amish and Amish Secrets That Will Add Years To Your Life. As far as I can tell, most of the secret is spending your whole life outside doing strenuous agricultural labor, plus being at a tech level two centuries too early for fast food.
But Amish people also die earlier. Lots of old studies say the opposite – for example, this one finds Amish people live longer than matched Framingham Heart Study participants. But things have changed since Framingham. The Amish have had a life expectancy in the low 70s since colonial times, when the rest of us were dying at 40 or 50. Since then, Amish life expectancy has stayed the same, and English life expectancy has improved to the high 70s. The most recent Amish estimates I have still say low seventies, so I think we are beating them now.
If they’re healthier, why is their life expectancy lower? Possibly they are less interested in prolonging life than we are. R&D write:
Amish people are more willing to stop interventions earlier and resist invasive therapies than the general population because, while they long for healing, they also have a profound respect for God’s will. This means taking modest steps toward healing sick bodies, giving preference to natural remedies, setting common-sense limits, and believing that in the end their bodies are in God’s hands.
The Amish health care system has an easier job than ours does. It has to take care of people who are generally healthy and less interested in extreme end-of-life care. It also supports a younger population – because Amish families have five to ten children, the demographics are weighted to younger people. All of these make its job a little bit simpler, and we should keep that in mind for the following sections.
How much do the Amish pay for health care? This is easy to answer for Amish Hospital Aid, much harder for the church system.
Amish Hospital Aid charges $125 monthly per individual or $250 monthly per family (remember, Amish families can easily be ten people). Average US health insurance costs $411 monthly per individual (Obamacare policies) or $558 monthly per individual (employer sponsored plan; employers pay most of this). I’m not going to bother comparing family plans because the definition of “family” matters a lot here. On the surface, it looks like the English spend about 4x as much as the Amish do.
But US plans include many more services than AHA, which covers catastrophic hospital admissions only. The government bans most Americans from buying plans like this; they believe it’s not enough to count as real coverage. The cheapest legal US health plan varies by age and location, but when I take my real age and pretend that I live near Amish country, the government offers me a $219/month policy on Obamacare. This is only a little higher than what the Amish get, and probably includes more services. So here it seems like the Amish don’t have much of an efficiency advantage. They just make a different tradeoff. It’s probably the right tradeoff for them, given their healthier lifestyle.
But remember, only a third of Amish use AHA. The rest use a church-based system? How does that come out?
It’s hard to tell. Nobody agrees on how much Amish tithe their churches, maybe because different Amish churches have different practices. R&D suggest families tithe 10% of income, this article on church-based insurances says a flat $100/month fee, and this “Ask The Amish” column says that churches have twice-yearly occasions where they ask for donations in secret and nobody is obligated to give any particular amount (“often husbands and wives won’t even know how much the other is giving.”) So it’s a mess, and even knowing the exact per-Amish donation wouldn’t help, because church alms cover not just health insurance but the entire social safety net; the amount that goes to health care probably varies by congregation and circumstance.
A few people try to estimate Amish health spending directly. This ABC story says $5 million total for all 30,000 Amish in Lancaster County, but they give no source, and it’s absurdly low. This QZ story quotes Amish health elder Marvin Wengerd as saying $20 – $30 million total for Lancaster County, which would suggest health spending of between $600-$1000 per person. This sounds potentially in keeping with some of the other estimates. A $100 per month tithe would be $1200 per year – if half of that goes to non-health social services, that implies $600 for health. The average Amish family earns about $50K (the same as the average English family, somehow!) so a 10% tithe would be $5000 per year, but since the average Amish family size is seven children, that comes out to about $600 per person again. So several estimates seem to agree on between $600 and $1000 per person.
One possible issue with this number: does Wengerd know how much Amish spend out of pocket? Or does his number just represent the amount that the official communal Amish health system spends? I’m not sure, but taking his words literally it’s total Amish spending, so I am going to assume it’s the intended meaning. And since the Amish rarely see doctors for minor things, probably their communal spending is a big chunk of their total.
[Update: an SSC reader is able to contact his brother, a Mennonite deacon, for better numbers. He says that their church spends an average of $2000 per person (including out of pocket).]
How does this compare to the US as a whole? The National Center For Health Statistics says that the average American spends $11,000 on health care. This suggests that the average American spends between five and ten times more on health care than the average Amish person.
How do the Amish keep costs so low? R&D (plus a few other sources) identify some key strategies.
First, the Amish community bargains collectively with providers to keep prices low. This isn’t unusual – your insurance company does the same – but it nets them better prices than you would get if you tried to pay out of pocket at your local hospital. This article gives some examples of Amish getting sticker prices discounted from between 50% to 66% with this tactic alone; Medicare gets about the same.
Second, the Amish are honorable customers. This separates them from insurance companies, who are constantly trying to scam providers however they can. Much of the increase in health care costs is “administrative expenses”, and much of these administrative expenses is hiring an army of lawyers, clerks, and billing professionals to thwart insurance companies’ attempts to cheat their way out of paying. If you are an honorable Amish person and the hospital knows you will pay your bill on time with zero fuss, they can waive all this.
But can this really be the reason Amish healthcare is cheaper? When insurance companies negotiate with providers, patients are on the side of the insurances; when insurance companies get good deals (eg a deal of zero dollars because the insurance has scammed the hospital), the patient’s care is cheaper, and the insurance company can pass some of those savings down as lower prices. If occasionally scamming providers meant insurance companies had to pay more money total, then they would stop doing it. My impression is that the real losers here are uninsured patients; absent any pressure to do otherwise, hospitals will charge them the sticker price, which includes the dealing-with-insurance-scams fee. The Amish successfully pressure them to waive that fee, which gets them better prices than the average uninsured patient, but still doesn’t land them ahead of insured people.
Third, Amish don’t go to the doctor for little things. They either use folk medicine or chiropractors. Some of the folk medicine probably works. The chiropractors probably don’t, but they play a helpful role reassuring people and giving them the appropriate obvious advice while telling the really serious cases to seek outside care. With this help, Amish people mostly avoid primary care doctors. Holmes County health statistics find that only 16% of Amish have seen a doctor in the past year, compared to 54% of English.
Fourth, the Amish never sue doctors. Doctors around Amish country know this, and give them the medically indicated level of care instead of practicing “defensive medicine”. If Amish people ask their doctors to be financially considerate – for example, let them leave the hospital a little early – their doctors will usually say yes, whereas your doctor would say no because you could sue them if anything went wrong. In some cases, Amish elders formally promise that no member of their congregation will ever launch a malpractice lawsuit.
Fifth, the Amish don’t make a profit. Church aid is dispensed by ministers and bishops. Even Amish Hospital Aid is run by a volunteer board. None of these people draw a salary or take a cut. I don’t want to overemphasize this one – people constantly obsess over insurance company profits and attribute all health care pathologies to them, whereas in fact they’re a low single-digit percent of costs (did you know Kaiser Permanente is a nonprofit? Hard to tell, isn’t it?) But every little bit adds up, and this is one bit.
Sixth, the Amish don’t have administrative expenses. Since the minister knows and trusts everyone in his congregation, the “approval process” is just telling your minister what the problem is, and the minister agreeing that’s a problem and giving you money to solve it. This sidesteps a lot of horrible algorithms and review boards and appeal boards and lawyers. I don’t want to overemphasize this one either – insurance companies are legally required to keep administrative expenses low, and most of them succeed. But again, it all adds up.
Seventh, the Amish feel pressure to avoid taking risks with their health. If you live in a tiny community with the people who are your health insurance support system, you’re going to feel awkward smoking or drinking too much. Realistically this probably blends into a general insistence on godly living, but the health insurance aspect doesn’t hurt. And I’m talking like this is just informal pressure, but occasionally it can get very real. R&D discuss the case of some Amish teens who get injured riding a snowmobile – forbidden technology. Their church decided this was not the sort of problem that godly people would have gotten themselves into, and refused to help – their families were on the hook for the whole bill.
Eighth, for the same reason, Amish try not to overspend on health care. I realize this sounds insulting – other Americans aren’t trying? I think this is harsh but true. Lots of Americans get an insurance plan from their employer, and then consume health services in a price-insensitive way, knowing very well that their insurance will pay for it. Sometimes they will briefly be limited by deductibles or out-of-pocket charges, but after these are used up, they’ll go crazy. You wouldn’t believe how many patients I see who say things like “I’ve covered my deductible for the year, so you might as well give me the most expensive thing you’ve got”, or “I’m actually feeling fine, but let’s have another appointment next week because I like talking to you and my out-of-pocket charges are low.”
But it’s not just avoiding the obvious failure modes. Careful price-shopping can look very different from regular medical consumption. Several of the articles I read talked about Amish families traveling from Pennsylvania to Tijuana for medical treatment. One writer describes Tijuana clinics sending salespeople up to Amish Country to advertise their latest prices and services. For people who rarely leave their hometown and avoid modern technology, a train trip to Mexico must be a scary experience. But prices in Mexico are cheap enough to make it worthwhile.
Meanwhile, back in the modern world, I’ve written before about how a pharma company took clonidine, a workhorse older drug that costs $4.84 a month, transformed it into Lucemyra, a basically identical drug that costs $1,974.78 a month, then created a rebate plan so that patients wouldn’t have to pay any extra out-of-pocket. Then they told patients to ask their doctors for Lucemyra because it was newer and cooler. Patients sometimes went along with this, being indifferent between spending $4 of someone else’s money or $2000 of someone else’s money. Everything in the US health system is like this, and the Amish avoid all of it. They have a normal free market in medical care where people pay for a product with their own money (or their community’s money) and have incentives to check how much it costs before they buy it. I do want to over-emphasize this one, and honestly I am surprised Amish health care costs are only ten times cheaper than ours are.
I don’t know how important each of these factors is, or how they compare to more structural factors like younger populations, healthier lifestyles, and less end-of-life care. But taken together, they make it possible for the Amish to get health care without undue financial burden or government support.
II.
Why look into the Amish health system?
I’m fascinated by how many of today’s biggest economic problems just mysteriously failed to exist in the past. Our grandparents easily paid for college with summer jobs, raised three or four kids on a single income, and bought houses in their 20s or 30s and never worried about rent or eviction again. And yes, they got medical care without health insurance, and avoided the kind of medical bankruptcies we see too frequently today. How did this work so well? Are there ways to make it work today? The Amish are an extreme example of people who try to make traditional systems work in the modern world, which makes them a natural laboratory for this kind of question.
The Amish system seems to work well for the Amish. It’s hard to say this with confidence because of all the uncertainties. The Amish skew much younger than the “English”, and live much healthier lifestyles. Although a few vague estimates suggest health care spending far below the English average, they could be missing lots of under-the-table transactions. And again, I don’t want to ignore the fact that the Amish do live a little bit shorter lives. You could tell a story where all of these add up to explain 100% of the difference, and the Amish aren’t any more efficient in their spending at all. I don’t think this is right. I think the apparent 5x advantage, or something like it, is real. But right now this is just a guess, not a hard number.
What if it is? It’s hard to figure out exactly what it would take to apply the same principles to English society. Only about a quarter of Americans attend church regularly, so church-based aid is out. In theory, health insurance companies ought to fill the same niche, with maybe a 10% cost increase for profits and overhead. Instead we have a 1000% cost increase. Why?
Above, I said that the most important factor is that the Amish comparison shop. Everyone needs to use other people’s money to afford expensive procedures. But for the Amish, those other people are their fellow church members and they feel an obligation to spend it wisely. For the English, the “other people” are faceless insurance companies, and we treat people who don’t extract as much money as possible from them as insufficiently savvy. But there’s no easy way to solve this in an atomized system. If you don’t have a set of thirty close friends you can turn to for financial help, then the only institutions with enough coordination power to make risk pooling work are companies and the government. And they have no way of keeping you honest except the with byzantine rules about “prior authorizations” and “preferred alternatives” we’ve become all too familiar with.
(and as bad as these are, there’s something to be said for a faceless but impartial bureaucracy, compared to having all your neighbors judging your lifestyle all the time.)
This is a neat story, but I have two concerns about it.
First, when I think in terms of individual people I know who have had trouble paying for health care, it’s hard for me to imagine the Amish system working very well for them. Many have chronic diseases. Some have mysterious pain that they couldn’t identify for years before finally getting diagnosed with something obscure. Amish Hospital Aid’s catastrophic policy would be useless for this, and I feel like your fellow church members would get tired of you pretty quickly. I’m not sure how the Amish cope with this kind of thing, and maybe their system relies on a very low rate of mental illness and chronic disease. A lot of the original “hygiene hypothesis” work was done on the Amish, their autoimmune disease rates are amazing, and when you take out the stresses of modern life maybe a lot of the ailments the American system was set up to deal with just stop being problems. I guess my point is that the numbers seem to work out, and the Amish apparently remain alive, but when I imagine trying to apply the Amish system to real people, even assuming those real people have cooperative churches and all the other elements I’ve talked about, I can’t imagine it doing anything other than crashing and burning.
Second, I don’t think this is actually how our grandparents did things. I asked my literal grandmother, a 95 year old former nurse, how health care worked in her day. She said it just wasn’t a problem. Hospitals were supported by wealthy philanthropists and religious organizations. Poor people got treated for free. Middle class people paid as much as they could afford, which was often the whole bill, because bills were cheap. Rich people paid extra for fancy hospital suites and helped subsidize everyone else. Although most people went to church or synagogue, there wasn’t the same kind of Amish-style risk pooling.
This makes me think that the Amish method, even though it works, isn’t the method that worked for past generations. It’s an innovation intended to cover for health care prices being higher than anything that traditional societies had to deal with.
Why did health care prices start rising? I’ve wondered about this a lot before – see here, here, and here. Looking into this issue, I noticed glimpses of a different possibility. The increase started around the same time that health insurance began to spread. In one sense, this is unsurprising – of course health insurance would become a thing around the time care became unaffordable. But I’ve never seen someone really try to tease out causality here. Might the two trends have been mutually self-reinforcing? The price of care rises due to some original shock. Someone invents health insurance, which seems like a good idea. But this creates a series of perverse incentives, which other actors figure out how to exploit (eg the Lucemyra example above). Insurance-based-health-care becomes less efficient, but hospitals can’t or don’t internalize this to the insured patients – they just raise the price for everyone, insurance or no. That makes even more people need health insurance, and the cycle repeats as prices grow higher and higher and insurance becomes more and more necessary. This syncs well with some explanations I’ve heard of rising college prices, where once the government made easy loans and subsidies available to everyone, prices rose until they consumed all the resources available.
I have no idea if this is true or not. If it is, the Amish succeed partly by successfully forcing providers to internalize the costs of insurance to insurance patients. Sometimes they do this by literally asking hospitals for better prices because they are not insured (eg the “honest customer” example above). Other times they flee the country entirely to reach a medical system that doesn’t deal with insured patients (eg Tijuana). This seems to work well for them. But their reliance on church alms and Amish Hospital Aid suggests that their care is still more expensive and burdensome for them than past generations’ care was for them. They’ve just learned ways to manage the expense successfully.
This is the bi-weekly visible open thread (there are also hidden open threads twice a week you can reach through the Open Thread tab on the top of the page). Post about anything you want, but please try to avoid hot-button political and social topics. You can also talk at the SSC subreddit – and also check out the SSC Podcast. Also:
1. There’s an online SSC “meetup” happening next Sunday, April 26, at 10:30 PDT. See here for more details.
2. Berkeley’s rationalist community center, REACH, has also gone online, so their meetings and talks and so on are now open to anyone who’s interested. Learn more at their Facebook page here.
3. You may previously have seen the sidebar ad for Altruisto, a browser app that automatically donates a portion of your online shopping spending to effective charity at no cost to you. They want me to let you know that there’s an updated version available.
4. Thanks to everyone who sent me comments about “A Failure, But Not Of Prediction” (though as always I prefer you post the comments on the blog so other people can see them). An especially common concern was that my dichotomy between “official sources” (wrong) and “random smart people online” (right) was unfair in a few ways. First, because some official sources (like independent expert epidemiologists) got things right early. Second, because many of the smart people online I mentioned didn’t get things right until late February/early March, by which time some of the media was also starting to get things right (see Anonymous Bosch’s complaint here, Scott Aaronson’s response here, and Sarah Constantin’s comment here). I’m sorry I’m not up for the amount of work it would take to respond to these concerns fairly and correct all my inconsistencies here, but there’s some good discussion at the linked comments.
Another frequent topic was nominations of worthy people who deserved public praise for getting things right early. I was trying to avoid having this be a “hall of shame, hall of fame” post, because there are so many people who deserve mention in both that it would inevitably be unfair. I tried to sidestep this entire issue by quoting a previous list someone else had made. But two names that came up a lot were Steve Hsu (see eg January post here, check also the comments) and Curtis Yarvin (February 1st article here). I’m sure I’m still forgetting many great people who deserve recognition.
A third frequent topic was people who said the pandemic was actually easy to predict; some of these people backed this up with proof that they in fact predicted it, and an explanation of the (completely logical) thought processes they used to do that. Again, these people are great and deserve praise. But I don’t consider a few people getting it right proof that it was “easy to predict” in a meaningful way. If predictions regarding some event follow a standard distribution from overly denialist to overly alarmist, then every event that turns out to be alarming will necessarily have some people who correctly predicted it (eg were the right level of alarmed) before the fact. But to do anything useful, we need to be able to identify those people beforehand. So for me, the interesting question is whether there’s some consistent way for a bird’s-eye Outside View observer to predict something before the fact, eg by using certain prediction aggregators or known reliable experts. If you can’t do that, I think it’s fair to call an event “hard to predict” from a social standpoint, even if it was easy for some people, and even if it should have been easy for everyone based on how logical it was.
5. Some people have brought up that my thrive vs. survive theory of the political spectrum does an unusually bad job predicting current events, especially the thing where Democrats mostly want to maintain lockdown and Republicans mostly want to take their chances. I don’t have much to say about this, but I acknowledge it’s true, and you should update your models accordingly.
Depressed people have worse sense of smell, and people with worse sense of smell are more likely to get depressed. Kohli 2016 tries to figure out what’s going on.
They review six studies testing how well depressed people can smell things. Most use something called “The Sniffin’ Sticks Test” (really!) where people are asked to say which of two sticks has an odor; the strength of the odorous one is then decreased until the subject can no longer consistently get it right. This determines olfactory threshold – how sensitive the subject’s smell is. Depressed subjects did marginally (but significantly) worse on this test than controls (6.31 ± 1.38 vs. 6.78 ± 0.88; P = 0.0005) – I think this corresponds to an effect size of about 0.2. They also do a couple more tests to see if depressed people are worse at identifying odors and get similarly small results. Also, some neuroimaging studies directly correlate depression and olfactory bulb volume, and find that olfactory areas of depressed people’s brains shrink.
Next they look at three studies of people who have various known respiratory diseases that impair sense of smell, and see how many of them are depressed. The answer: lots! Normosmics (people with a normal sense of smell) have an average score of 5 on the Beck Depression Inventory. Anosmics (people with no sense of smell) have an average score of 14. Hyposmics (people with weak sense of smell) are in between. This seemed true independent of respiratory disease level (ie it’s not just that having a worse respiratory disease makes your smell worse and makes you more depressed).
The two most common diseases studied were chronic rhinosinusitis and post-upper respiratory infection olfactory dysfunction. One of the studies, Jung, Lee, & Park (2014), compares them. They find that 40% of CRS patients are depressed, vs. 76% of PURIOD patients, a significant difference (also, both much higher than the ~5-10% of depressives in the general population). They note that CRS involves a gradual loss of smell, and PURIOD a sudden loss of smell, and that maybe people adjust to gradual loss better than sudden.
We can easily come up with alternative hypotheses. You can never actually control for confounders properly, and having a respiratory disease sounds depressing. Also, the sorts of people who have respiratory diseases probably differ from the rest of the population in various ways. Biologically, they might have worse immune systems, or end up with worse oxygenation and chronic infections, or just be generally sickly. Sociologically, they might be poorer, or have worse diets, or more comorbidities. Sinus problems themselves are linked to depression for a bunch of reasons, probably relating to the sinus being so closely linked to the brain that sinus inflammation screws up your brain chemistry. Also, most chronic diseases have high depression rates – sickle cell anemia (chosen kind of at random) is 44%.
There really aren’t that many causes of anosmia that are 100% exogenous and have no chance at all of contributing to depression themselves. But animal researchers can take Gandhi’s advice and become the exogenous cause they wish to see in the world. Yuan and Slotnick (2014) discuss experiments where researchers remove the olfactory bulbs of rats. These rats tend to consistently become depressed. That seems like pretty strong evidence to me.
So why would depression reduce olfactory acuity? And why would reduced olfaction cause depression?
Maybe depression reduces olfactory acuity because it reduces sensory acuity in general. We already know that depression decreases visual contrast, causing the world to literally look washed-out and gray. If I’m reading this study right, it claims depression also decreases auditory threshold – ie depressed people are less able to hear very quiet sounds. I can’t find similarly good studies on taste or touch, although they should be easy to do. If anyone knows any studies on eg two-point discrimination in depressed vs. non-depressed subjects, let me know. If not, this would be an easy project that a college psychology student could do in a few weeks, and it would add to our understanding of this subject. But right now I think the evidence is consistent with a general decline in perceptual abilities. This fits my understanding of depression as a systemic disorder – the low mood is the most noticeable symptom, but you’re also getting everything from poor digestion to worse hearing. Probably this is because whatever is affecting the emotional centers of the brain is affecting the lower parts of the brain (and nervous system?) too.
Is the opposite of this true? Does any form of decreased sensory acuity cause depression? I’m leaning toward no. This study claims to find that myopia is linked to depression, but the association is so weak that I take it as a strike against the hypothesis. These two studies find hearing loss is associated with depression, but it’s still pretty weak and it could easily be because poor hearing hurts your opportunities to socialize. I’m most struck by discussion of monochromacy, ie total colorblindness, which absolutely fail to mention depression at all. If I’m going to be splitting hairs about how depressed people see slightly duller colors, the lack of any excess depression in people without color vision seems pretty important. Blind and deaf people have pretty high rates of depression, but being blind or deaf is really hard and I don’t want to draw too many conclusions there. Overall it doesn’t seem to me like decreased sensory acuity causes depression full stop, though I could be wrong. This would mean that loss of smell is unique in its emotional effects.
The sense of smell is pretty emotionally salient. Everyone always says that “smell is the sense most linked to memory” – though I can’t figure out exactly which study discovered it and whether it considered (for example) how reliably seeing a picture of my mother reminds me of my mother. Body odor seems to be closely linked to who we’re attracted to. Smell is responsible for all taste sensation beyond sweet/salty/sour/bitter/umami, and eating food is one of life’s most visceral pleasures. From fifthsense.org.uk:
Anosmia sufferers often talk of feeling isolated and cut-off from the world around them, and experiencing a ‘blunting’ of the emotions. Smell loss can affect one’s ability to form and maintain close personal relationships and can lead to depression. An important issue here is the fact that smell loss is invisible to all but the patient; how would you know that you had met an anosmia sufferer unless they themselves told you? This is one of the reasons, alongside the general lack of understanding of the impact that smell has on our lives, why anosmia has never received much attention – you really do not know what you have got until it is gone.
But also, Yuan and Slotnick’s rat paper gives a more biological explanation. The olfactory bulb is the beginning of pathways that stimulate many other parts of the brain. When it’s removed (and presumably also when it just never gets any incoming stimuli) it stops doing that, and the downstream parts of the brain shrink. For some reason this also causes decreased brain-wide synthesis of serotonin, maybe because the olfactory bulb is a net positive stimulus on the raphe nuclei. Sure, sounds like the kind of thing that might cause depression.
What does this imply about treating depression?
SSRI antidepressants probably decrease sense of smell as an immediate side effect. Awkward. But they seem to improve sense of smell long term as part of their general treatment of depression. In studies fluoxetine (Prozac) causes nerve growth in the olfactory bulb after a few weeks. Does that suggest a story where SSRIs work by improving smell? Probably not – more likely they work by [a cascading system of effects involving] causing nerve growth more generally, and the olfactory bulb benefits along with everything else.
Could you treat depression through improving olfactory sensitivity? Maybe, but I have no idea how to do that. Yuan and Slotnick suggest directly stimulating the olfactory regions of the brain, but this is pretty invasive, and there are probably already better treatments for the small minority of patients who are going to let you directly stimulate brain regions. Maybe before we worry about this problem, we should investigate the more general question of sensory enhancement for depression. What would happen if you made people wear glasses that enhanced the color saturation of everything they saw?
Finally, what about just exposing depressed people to really strong smells? You will be excited to know that real scientists have studied this ridiculous idea, and it seems promising, at least in extremely sketchy experiments on mice (1, 2, 3). I have never seen any studies done on humans unless this is actually how “aromatherapy” works, which would be hilarious. Aromatherapy seems to get positive results for depression with the same kind of bad studies that let all quackery generate positive results for everything. I can’t say more than that and I’m pretty skeptical here.
I.
Vox asks What Went Wrong With The Media’s Coronavirus Coverage? They conclude that the media needs to be better at “not just saying what we do know, but what we don’t know”. This raises some important questions. Like: how much ink and paper is there in the world? Are we sure it’s enough? But also: how do you become better at saying what you don’t know?
In case you’ve been hiding under a rock recently (honestly, valid) the media not only failed to adequately warn its readers about the epidemic, but actively mocked and condescended to anyone who did sound a warning. Real Clear Politics has a list of highlights. The Vox tweet saying “Is this going to be a deadly pandemic? No.” Washington Post telling us in February “Why we should be wary of an aggressive government reponse to coronavirus (it might “scapegoat marginalized populations”). The Daily Beast complaining that “coronavirus, with zero American fatalities, is dominating headlines, while the flu is the real threat”. The New York Times, weighing in with articles like “The pandemic panic” and “Who says it’s not safe to travel to China”. The constant attempts to attribute “alarmism” over the virus to anti-Chinese racism. Etc, etc, etc.
One way people have summed this up is that the media (and the experts they relied on) did a terrible job predicting what would happen. I think this lets them off too easy.
Prediction is very hard. Nate Silver is maybe the best political predicter alive, and he estimated a 29% chance of Trump winning just before Trump won. UPenn professor Philip Tetlock has spent decades identifying “superforecasters” and coming up with complicated algorithms for aggregating their predictions, developing a prediction infrastructure that beats top CIA analysts, but they estimated a 23% chance Britain would choose Brexit just before it happened. This isn’t intended to criticize Silver or Tetlock. I believe they’re operating at close to optimum – the best anyone could possibly do with the information that they had. But the world is full of noise, and tiny chance events can have outsized effects, and there are only so many polls you can scrutinize, and even geniuses can only do so well.
Predicting the coronavirus was equally hard, and the best institutions we had missed it. On February 20th, Tetlock’s superforecasters predicted only a 3% chance that there would be 200,000+ coronavirus cases a month later (there were). The stock market is a giant coordinated attempt to predict the economy, and it reached an all-time high on February 12, suggesting that analysts expected the economy to do great over the following few months. On February 20th it fell in a way that suggested a mild inconvenience to the economy, but it didn’t really start plummeting until mid-March – the same time the media finally got a clue. These aren’t empty suits on cable TV with no skin in the game. These are the best predictive institutions we have, and they got it wrong. I conclude that predicting the scale of coronavirus in mid-February – the time when we could have done something about it – was really hard.
I don’t like this conclusion. But I have to ask myself – if it was so easy, why didn’t I do it? It’s easy to look back and say “yeah, I always secretly knew it would be pretty bad”. I did a few things right – I started prepping half-heartedly in mid-February, I recommended my readers prep in early March, I never criticized others for being alarmist. Overall I give myself a solid B-. But if it was so easy, why didn’t I post “Hey everyone, I officially predict the coronavirus will be a nightmarish worldwide pandemic” two months ago? It wouldn’t have helped anything, but I would have had bragging rights forever. For that matter, why didn’t you post this – on Facebook, on Twitter, on the comments here? You could have gone down in legend, alongside Travis W. Fisher, for making a single tweet. Since you didn’t do that (aside from the handful of you who did – we love you, Balaji) I conclude that predicting it was hard, even for smart and well-intentioned people like yourselves.
Does that mean we can’t put everyone’s heads on spikes outside the Capitol Building as a warning for future generations? I would be very disappointed if it meant that. I think we can still put heads on spikes. We just have to do it for more subtle, better-thought-out reasons.
II.
I used to run user surveys for a forum on probabilistic reasoning…
(I promise this will become relevant soon)
A surprising number of these people had signed up for cryonics – the thing where they freeze your brain after you die, in case the future invents a way to resurrect frozen brains. Lots of people mocked us for this – “if you’re so good at probabilistic reasoning, how can you believe something so implausible?” I was curious about this myself, so I put some questions on one of the surveys.
The results were pretty strange. Frequent users of the forum (many of whom had pre-paid for brain freezing) said they estimated there was a 12% chance the process would work and they’d get resurrected. A control group with no interest in cryonics estimated a 15% chance. The people who were doing it were no more optimistic than the people who weren’t. What gives?
I think they were actually good at probabilistic reasoning. The control group said “15%? That’s less than 50%, which means cryonics probably won’t work, which means I shouldn’t sign up for it.” The frequent user group said “A 12% chance of eternal life for the cost of a freezer? Sounds like a good deal!”
There are a lot of potential objections and complications – for one thing, maybe both those numbers are much too high. You can read more here and here. But overall I learned something really important from this.
Making decisions is about more than just having certain beliefs. It’s also about how you act on them.
III.
A few weeks ago, I wrote a blog post on face masks. It reviewed the evidence and found that they probably helped prevent the spread of disease. Then it asked: how did the WHO, CDC, etc get this so wrong?
I went into it thinking they’d lied to us, hoping to prevent hoarders from buying up so many masks that there weren’t enough for health workers. Turns out that’s not true. The CDC has been singing the same tune for the past ten years. Swine flu, don’t wear masks. SARS, don’t wear masks. They’ve been really consistent on this point. But why?
If you really want to understand what happened, don’t read any studies about face masks or pandemics. Read Smith & Pell (2003), Parachute Use To Prevent Death And Major Trauma Related To Gravitational Challenge: Systematic Review Of Randomized Controlled Trials. It’s an article in the British Journal Of Medicine pointing out that there have never been any good studies proving that parachutes are helpful when jumping out of a plane, so they fail to meet the normal standards of evidence-based medicine. From the Discussion section:
It is a truth universally acknowledged that a medical intervention justified by observational data must be in want of verification through a randomised controlled trial. Observational studies have been tainted by accusations of data dredging, confounding, and bias. For example, observational studies showed lower rates of ischaemic heart disease among women using hormone replacement therapy, and these data were interpreted as advocating hormone replacement for healthy women, women with established ischaemic heart disease, and women with risk factors for ischaemic heart disease. However, randomised controlled trials showed that hormone replacement therapy actually increased the risk of ischaemic heart disease, indicating that the apparent protective effects seen in observational studies were due to bias. Cases such as this one show that medical interventions based solely on observational data should be carefully scrutinised, and the parachute is no exception.
Of course this is a joke. It’s in the all-joke holiday edition of BMJ, and everyone involved knew exactly what they were doing. But the joke is funny because it points at something true. It’s biting social commentary. Doctors will not admit any treatment could possibly be good until it has a lot of randomized controlled trials behind it, common sense be damned. This didn’t come out of nowhere. They’ve been burned lots of times before by thinking they were applying common sense and getting things really wrong. And after your mistakes kill a few thousand people you start getting really paranoid and careful. And there are so many quacks who can spout off some “common sense” explanation for why their vitamin-infused bleach or colloidal silver should work that doctors have just become immune to that kind of bullshit. Multiple good RCTs or it didn’t happen. Given the history I think this is a defensible choice, and if you are tempted to condemn it you may find this story about bone marrow transplants enlightening.
But you can take this too far. After highlighting the lack of parachute RCTs, the paper continues:
Only two options exist. The first is that we accept that, under exceptional circumstances, common sense might be applied when considering the potential risks and benefits of interventions. The second is that we continue our quest for the holy grail of exclusively evidence based interventions and preclude parachute use outside the context of a properly conducted trial. The dependency we have created in our population may make recruitment of the unenlightened masses to such a trial difficult. If so, we feel assured that those who advocate evidence based medicine and criticise use of interventions that lack an evidence base will not hesitate to demonstrate their commitment by volunteering for a double blind, randomised, placebo controlled, crossover trial.
Did you follow that? For a good parachute RCT, half the subjects would have to jump out of a plane wearing a placebo parachute. The authors suggest maybe we enlist doctors who insist too stringently on RCTs over common sense for this dubious honor.
(good news, though, a parachute RCT did eventually get done)
Sometimes good humor is a little too on the nose, like those Onion articles that come true a few years later. The real medical consensus on face masks came from pretty much the same process as the fake medical consensus on parachutes. Common sense said that they worked. But there weren’t many good RCTs. We couldn’t do more, because it would have been unethical to deliberately expose face-mask-less people to disease. In the end, all we had were some mediocre trials of slightly different things that we had to extrapolate out of range.
Just like the legal term for “not proven guilty beyond a reasonable doubt” is “not guilty”, the medical term for “not proven to work in several gold-standard randomized controlled trials” is “it doesn’t work” (and don’t get me started on “no evidence”). So the CDC said masks didn’t work.
Going back to our diagram:
Goofus started with the position that masks, being a new idea, needed incontrovertible proof. When the few studies that appeared weren’t incontrovertible enough, he concluded that people shouldn’t wear masks.
Gallant would have recognized the uncertainty – based on the studies we can’t be 100% sure masks definitely work for this particular condition – and done a cost-benefit analysis. Common sensically, it seems like masks probably should work. The existing evidence for masks is highly suggestive, even if it’s not utter proof. Maybe 80% chance they work, something like that? If you can buy an 80% chance of stopping a deadly pandemic for the cost of having to wear some silly cloth over your face, probably that’s a good deal. Even though regular medicine has good reasons for being as conservative as it is, during a crisis you have to be able to think on your feet.
IV.
But getting back to the media:
Their main excuse is that they were just relaying expert opinion – the sort of things the WHO and CDC and top epidemiologists were saying. I believe them. People on Twitter howl and gnash their teeth at this, asking why the press didn’t fact-check or challenge those experts. But I’m not sure I want to institute a custom of journalists challenging experts. Journalist Johann Hari decided to take it upon himself to challenge psychiatric experts, and wrote a serious of terrible articles and a terrible book saying they were wrong about everything. I am a psychiatrist and I can tell you he is so wrong that it is physically painful to read his stuff (though of course I would say that…). Most journalists stick to assuming the experts know more about their subject of expertise than they do, and I think this is wise. The role of science journalists is to primarily to relay, explain, give context to the opinions of experts, not to try to out-medicine the doctors. So I think this is a good excuse.
But I would ask this of any journalist who pleads that they were just relaying and providing context for expert opinions: what was the experts’ percent confidence in their position?
I am so serious about this. What fact could possibly be more relevant? What context could it possibly be more important to give? I’m not saying you need to have put a number in your articles, maybe your readers don’t go for that. But were you working off of one? Did this question even occur to you?
Nate Silver said there was a 29% chance Trump would win. Most people interpreted that as “Trump probably won’t win” and got shocked when he did. What was the percent attached to your “coronavirus probably won’t be a disaster” prediction? Was it also 29%? 20%? 10%? Are you sure you want to go lower than 10%? Wuhan was already under total lockdown, they didn’t even have space to bury all the bodies, and you’re saying that there was less than 10% odds that it would be a problem anywhere else? I hear people say there’s a 12 – 15% chance that future civilizations will resurrect your frozen brain, surely the risk of coronavirus was higher than that?
And if the risk was 10%, shouldn’t that have been the headline. “TEN PERCENT CHANCE THAT THERE IS ABOUT TO BE A PANDEMIC THAT DEVASTATES THE GLOBAL ECONOMY, KILLS HUNDREDS OF THOUSANDS OF PEOPLE, AND PREVENTS YOU FROM LEAVING YOUR HOUSE FOR MONTHS”? Isn’t that a better headline than Coronavirus panic sells as alarmist information spreads on social media? But that’s the headline you could have written if your odds were ten percent!
So:
I think people acted like Goofus again.
People were presented with a new idea: a global pandemic might arise and change everything. They waited for proof. The proof didn’t arise, at least at first. I remember hearing people say things like “there’s no reason for panic, there are currently only ten cases in the US”. This should sound like “there’s no reason to panic, the asteroid heading for Earth is still several weeks away”. The only way I can make sense of it is through a mindset where you are not allowed to entertain an idea until you have proof of it. Nobody had incontrovertible evidence that coronavirus was going to be a disaster, so until someone does, you default to the null hypothesis that it won’t be.
Gallant wouldn’t have waited for proof. He would have checked prediction markets and asked top experts for probabilistic judgments. If he heard numbers like 10 or 20 percent, he would have done a cost-benefit analysis and found that putting some tough measures into place, like quarantine and social distancing, would be worthwhile if they had a 10 or 20 percent chance of averting catastrophe.
V.
This is at risk of getting too depressing, so I want to focus on some people who deserve recognition for especially good responses.
First, a bunch of generic smart people on Twitter who got things exactly right – there are too many of these people to name, but Scott Aaronson highlights “Bill Gates, Balaji Srinivasan, Paul Graham, Greg Cochran, Robin Hanson, Sarah Constantin, Eliezer Yudkowsky, and Nicholas Christakis.” None of these people (except Greg Cochran) are domain experts, and none of them (except Greg Cochran) have creepy oracular powers. So how could they have beaten the experts? Haven’t we been told a million times that generic intelligence is no match for deep domain knowledge?
I think the answer is: they didn’t beat the experts in epidemiology. Whatever probability of pandemic the experts and prediction markets gave for coronavirus getting really bad, these people didn’t necessarily give a higher probability. They were just better at probabilistic reasoning, so they had different reactions to the same number. There’s no reason generic why smart people shouldn’t be better at probabilistic reasoning then epidemiologists. In fact, this seems exactly like the sort of thing generic smart people might be.
Zeynep Tufekci is an even clearer example. She’s a sociologist and journalist who was writing about how it was “our civic duty” to prepare for coronavirus as early as February. She was also the first mainstream media figure to spread the word that masks were probably helpful.
Totally at random today, reading a blog post on the Mongol Empire like all normal people do during a crisis, I stumbled across a different reference to Zeynep. In a 2014 article, she was sounding a warning about the Ebola pandemic that was going on at the time. She was saying the exact same things everyone is saying now – global institutions are failing, nobody understands exponential growth, travel restrictions could work early but won’t be enough if it breaks out. She quoted a CDC prediction that there could be a million cases by the end of 2014. “Let that sink in,” she wrote. “A million Ebola victims in just a few months.”
In fact, this didn’t happen. There were only about 30,000 cases. The virus never really made it out of Liberia, Sierra Leone, and Guinea.
I don’t count this as a failed prediction on Zeynep’s part. First of all, because it could have been precisely because of people like her sounding the alarm that the epidemic was successfully contained. But more important, it wasn’t really a prediction at all. Her point wasn’t that she definitely knew this Ebola pandemic was the one that would be really bad. Her point was that it might be, so we needed to prepare. She said the same thing when the coronavirus was just starting. If this were a game, her batting average would be 50%, but that’s the wrong framework.
Zeynep Tufecki is admirable. But her admirable skill isn’t looking at various epidemics and successfully predicting which ones will be bad and which ones will fizzle out. She can’t do that any better than anyone else. Her superpower is her ability to treat something as important even before she has incontrovertible evidence that it has to be.
And finally, Kelsey Piper. She wrote a February 6th article saying:
The coronavirus killed fewer people than the flu did in January. But it might kill more in February — and unlike the flu, its scope and effects are poorly understood and hard to guess at. The Chinese National Health Commission reports 24,324 cases, including 3,887 new ones today. There are some indications that these numbers understate the situation, as overwhelmed hospitals in Wuhan only have the resources to test the most severe cases. As of Tuesday, 171,329 people are under medical observation because they’ve had close contact with a confirmed case.
It is unclear whether China will be able to get the outbreak under control or whether it will cause a series of epidemics throughout the country. It’s also unclear whether other countries — especially those with weak health systems — will be able to quickly identify any cases in their country and avoid Wuhan-scale outbreaks.
The point is, it’s simply too soon to assert we’ll do well on both those fronts — and if we fail, then the coronavirus death toll could well climb up into the tens of thousands. It also remains to be seen if vaccines or effective antiviral treatments will be developed. That’s just far too much uncertainty to assure people that they have nothing to worry about. And misleadingly assuring people that there’s nothing to worry about can end up doing harm.
“Instead of deriding people’s fears about the Wuhan coronavirus,” Sandman, the communications expert, writes, “I would advise officials and reporters to focus more on the high likelihood that things will get worse and the not-so-small possibility that they will get much worse.”
She concluded that “the Wuhan coronavirus likely won’t be a nightmare pandemic, but that scenario is still in play”, and followed it up with an article urging people to prepare by buying essential food and supplies.
If we interpret her “likely won’t be a nightmare pandemic” sentence as a prediction, she got the prediction wrong. Like Zeynep, she has no special ability to predict whether any given disease will end in global disaster. But that didn’t matter! She gave exactly the correct advice to institutions (prepare for a worst-case scenario, stop telling people not to panic) and exactly the correct advice to individuals (start prepping). When you’re good enough at handling uncertainty, getting your predictions exactly right becomes almost superfluous.
The Vox article says the media needs to “say what it doesn’t know”. I agree with this up to a point. But they can’t let this turn into a muddled message of “oh, who knows anything, whatever”. Uncertainty about the world doesn’t imply uncertainty about the best course of action! Within the range of uncertainty that we had about the coronavirus this February, an article that acknowledged that uncertainty wouldn’t have looked like “We’re not sure how this will develop, so we don’t know whether you should stop large gatherings or not”. It would have looked like “We’re not sure how this will develop, so you should definitely stop large gatherings.”
I worry that the people who refused to worry about coronavirus until too late thought they were “being careful” and “avoiding overconfidence”. And I worry the lesson they’ll take away from this is to be more careful, and avoid overconfidence even more strongly.
Experts should think along these lines when making their recommendations, but if they don’t, the press should think along them as part of its work of putting expert recommendations in context. I think Kelsey’s article provides an shining example of what this should look like.
Maybe other people got this right too. I’m singling out Kelsey because of a personal connection – I met her through the same probabilistic reasoning forum where I did my cryonics survey years ago. I don’t think this is a coincidence.
[Related: Book Review: The Precipice; Two Kinds Of Caution]
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