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Book Review: The Precipice

I.

It is a well known fact that the gods hate prophets.

False prophets they punish only with ridicule. It’s the true prophets who have to watch out. The gods find some way to make their words come true in the most ironic way possible, the one where knowing the future just makes things worse. The Oracle of Delphi told Croesus he would destroy a great empire, but when he rode out to battle, the empire he destroyed was his own. Zechariah predicted the Israelites would rebel against God; they did so by killing His prophet Zechariah. Jocasta heard a prediction that she would marry her infant son Oedipus, so she left him to die on a mountainside – ensuring neither of them recognized each other when he came of age.

Unfortunately for him, Oxford philosopher Toby Ord is a true prophet. He spent years writing his magnum opus The Precipice, warning that humankind was unprepared for various global disasters like pandemics and economic collapses. You can guess what happened next. His book came out March 3, 2020, in the middle of a global pandemic and economic collapse. He couldn’t go on tour to promote it, on account of the pandemic. Nobody was buying books anyway, on account of the economic collapse. All the newspapers and journals and so on that would usually cover an exciting new book were busy covering the pandemic and economic collapse instead. The score is still gods one zillion, prophets zero. So Ord’s PR person asked me to help spread the word, and here we are.

Imagine you were sent back in time to inhabit the body of Adam, primordial ancestor of mankind. It turns out the Garden of Eden has motorcycles, and Eve challenges you to a race. You know motorcycles can be dangerous, but you’re an adrenaline junkie, naturally unafraid of death. And it would help take your mind off that ever-so-tempting Tree of Knowledge. Do you go?

Before you do, consider that you’re not just risking your own life. A fatal injury to either of you would snuff out the entire future of humanity. Every song ever composed, every picture ever painted, every book ever written by all the greatest authors of the millennia would die stillborn. Millions of people would never meet their true loves, or get to raise their children. All of the triumphs and tragedies of humanity, from the conquests of Alexander to the moon landings, would come to nothing if you hit a rock and cracked your skull.

So maybe you shouldn’t motorcycle race. Maybe you shouldn’t even go outside. Maybe you and Eve should hide, panicked, in the safest-looking cave you can find.

Ord argues that 21st century humanity is in much the same situation as Adam. The potential future of the human race is vast. We have another five billion years until the sun goes out, and 10^100 until the universe becomes uninhabitable. Even with conservative assumptions, the galaxy could support quintillions of humans. Between Eden and today, the population would have multiplied five billion times; between today and our galactic future, it could easily multiply another five billion. However awed Adam and Eve would have been when they considered the sheer size of the future that depended on them, we should be equally awed.

So maybe we should do the equivalent of not motorcycling. And that would mean taking existential risks (“x-risks”) – disasters that might completely destroy humanity or permanently ruin its potential – very seriously. Even more seriously than we would take them just based on the fact that we don’t want to die. Maybe we should consider all counterbalancing considerations – “sure, global warming might be bad, but we also need to keep the economy strong!” – to be overwhelmed by the crushing weight of the future.

This is my metaphor, not Ord’s. He uses a different one – the Cuban Missile Crisis. We all remember the Cuban Missile Crisis as a week where humanity teetered on the precipice of destruction, then recovered into a more stable not-immediately-going-to-destroy-itself state. Ord speculates that far-future historians will remember the entire 1900s and 2000s as a sort of centuries-long Cuban Missile Crisis, a crunch time when the world was unusually vulnerable and everyone had to take exactly the right actions to make it through. Or as the namesake precipice, a place where the road to the Glorious Future crosses a narrow rock ledge hanging over a deep abyss.

Ord has other metaphors too, and other arguments. The first sixty pages of Precipice are a series of arguments and thought experiments intended to drive home the idea that everyone dying would be really bad. Some of them were new to me and quite interesting – for example, an argument that we should keep the Earth safe for future generations as a way of “paying it forward” to our ancestors, who kept it safe for us. At times, all these arguments against allowing the destruction of the human race felt kind of excessive – isn’t there widespread agreement on this point? Even when there is disagreement, Ord doesn’t address it here, banishing counterarguments to various appendices – one arguing against time discounting the value of the future, another arguing against ethical theories that deem future lives irrelevant. This part of the book isn’t trying to get into the intellectual weeds. It’s just saying, again and again, that it would be really bad if we all died.

It’s tempting to psychoanalyze Ord here, with help from passages like this one:

I have not always been focused on protecting our longterm future, coming to the topic only reluctantly. I am a philosopher at Oxford University, specialising in ethics. My earlier work was rooted in the more tangible concerns of global health and global poverty – in how we could best help the worst off. When coming to grips with these issues I felt the need to take my work in ethics beyond the ivory tower. I began advising the World Health Organization, World Bank, and UK government on the ethics of global health. And finding that my own money could do hundreds of times as much good for those in poverty as it could do for me, I made a lifelong pledge to donate at least a tenth of all I earn to help them. I founded a society, Giving What We Can, for those who wanted to join me, and was heartened to see thousands of people come together to pledge more than one billion pounds over our lifetimes to the most effective charities we know of, working on the most important causes. Together, we’ve already been able to transform the lives of thousands of people. And because there are many other ways beyond our donations in which we can help fashion a better world, I helped start a wider movement, known as “effective altruism”, in which people aspire to use prudence and reason to do as much good as possible.

We’re in the Garden of Eden, so we should stop worrying about motorcycling and start worrying about protecting our future. But Ord’s equivalent of “motorcycling” was advising governments and NGOs on how best to fight global poverty. I’m familiar with his past work in this area, and he was amazing at it. He stopped because he decided that protecting the long-term future was more important. What must he think of the rest of us, who aren’t stopping our ordinary, non-saving-thousands-of-people-from-poverty day jobs?

In writing about Ord’s colleagues in the effective altruist movement, I quoted Larissa MacFarquahar on Derek Parfit:

When I was interviewing him for the first time, for instance, we were in the middle of a conversation and suddenly he burst into tears. It was completely unexpected, because we were not talking about anything emotional or personal, as I would define those things. I was quite startled, and as he cried I sat there rewinding our conversation in my head, trying to figure out what had upset him. Later, I asked him about it. It turned out that what had made him cry was the idea of suffering. We had been talking about suffering in the abstract. I found that very striking.

Toby Ord was Derek Parfit’s grad student, and I get sort of the same vibe from him – someone whose reason and emotions are unusually closely aligned. Stalin’s maxim that “one death is a tragedy, a million deaths is a statistic” accurately describes how most of us think. I am not sure it describes Toby Ord. I can’t say confidently that Toby Ord feels exactly a million times more intense emotions when he considers a million deaths than when he considers one death, but the scaling factor is definitely up there. When he considers ten billion deaths, or the deaths of the trillions of people who might inhabit our galactic future, he – well, he’s reduced to writing sixty pages of arguments and metaphors trying to cram into our heads exactly how bad this would be.

II.

The second part of the book is an analysis of specific risks, how concerned we should be about each, and what we can do to prevent them. Ord stays focused on existential risks here. He is not very interested in an asteroid that will wipe out half of earth’s population; the other half of humanity will survive to realize our potential. He’s not completely uninterested – wiping out half of earth’s population could cause some chaos that makes it harder to prepare for other catastrophes. But his main focus is on things that would kill everybody – or at least leave too few survivors to effectively repopulate the planet.

I expected Ord to be alarmist here. He is writing a book about existential risks, whose thesis is that we should take them extremely seriously. Any other human being alive would use this as an opportunity to play up how dangerous these risks are. Ord is too virtuous. Again and again, he knocks down bad arguments for worrying too much, points out that killing every single human being on earth, including the ones in Antarctic research stations, is actually quite hard, and ends up convincing me to downgrade my risk estimate.

So for example, we can rule out a high risk of destruction by any natural disaster – asteroid, supervolcano, etc – simply because these things haven’t happened before in our species’ 100,000 year-odd history. Dino-killer sized asteroids seem to strike the Earth about once every few hundred million years, bounding the risk per century around the one-in-a-million level. But also, scientists are tracking almost all the large asteroids in the solar system, and when you account for their trajectories, the chance that one slips through and hits us in the next century goes down to less than one in a hundred fifty million. Large supervolcanoes seem to go off about once every 80,000 years, so the risk per century is 1/800. There are similar arguments around nearby supernovae, gamma ray bursts, and a bunch of other things.

I usually give any statistics I read a large penalty for “or maybe you’re a moron”. For example, lots of smart people said in 2016 that the chance of Trump winning was only 1%, or 0.1%, or 0.00001%, or whatever. But also, they were morons. They were using models, and their models were egregiously wrong. If you hear a person say that their model’s estimate of something is 0.00001%, very likely your estimate of the thing should be much higher than that, because maybe they’re a moron. I explain this in more detail here.

Ord is one of a tiny handful of people who doesn’t need this penalty. He explains this entire dynamic to his readers, agrees it is important, and adjusts several of his models appropriately. He is always careful to add a term for unknown unknowns – sometimes he is able to use clever methods to bound this term, other times he just takes his best guess. And he tries to use empirically-based methods that don’t have this problem, list his assumptions explicitly, and justify each assumption, so that you rarely have to rely on arguments shakier than “asteroids will continue to hit our planet at the same rate they did in the past”. I am really impressed with the care he puts into every argument in the book, and happy to accept his statistics at face value. People with no interest in x-risk may enjoy reading this book purely as an example of statistical reasoning done with beautiful lucidity.

When you accept very low numbers at face value, it can have strange implications. For example, should we study how to deflect asteroids? Ord isn’t sure. The base rate of asteroid strikes is so low that it’s outweighed by almost any change in the base rate. If we successfully learn how to deflect asteroids, that not only lets good guys deflect asteroids away from Earth, but also lets bad guys deflect asteroids towards Earth. The chance that an dino-killer asteroid approaches Earth and needs to be deflected away is 1/150 million per century, with small error bars. The chance that malicious actors deflect an asteroid towards Earth is much harder to figure out, but it has wide error bars, and there are a lot of numbers higher than 1/150 million. So probably most of our worry about asteroids over the next century should involve somebody using one as a weapon, and studying asteroid deflection probably makes that worse and not better.

Ord uses similar arguments again and again. Humanity has survived 100,000 years, so its chance of death by natural disaster per century is probably less than 1 / 1,000 (for complicated statistical reasons, he puts it at between 1/10,000 and 1/100,000). But humanity has only had technology (eg nuclear weapons, genetically engineered bioweapons) for a few decades, so there are no such guarantees of its safety. Ord thinks the overwhelming majority of existential risk comes from this source, and singles out four particular technological risks as most concerning.

First, nuclear war. This was one of the places where Ord’s work is cause for optimism. You’ve probably heard that there are enough nuclear weapons to “destroy the world ten times over” or something like that. There aren’t. There are enough nuclear weapons to destroy every major city, kill the overwhelming majority of people, and cause a very bad nuclear winter for the rest. But there aren’t enough to literally kill every single human being. And because of the way the Earth’s climate works, the negative effects of nuclear winter would probably be concentrated in temperate and inland regions. Tropical islands and a few other distant locales (Ord suggests Australia and New Zealand) would have a good chance of making it through even a large nuclear apocalypse with enough survivors to repopulate the Earth. A lot of things would have to go wrong at once, and a lot of models be flawed in ways they don’t seem to be flawed, for a nuclear war to literally kill everyone. Ord gives the per-century risk of extinction from this cause at 1 in 1,000.

Second, global warming. The current scientific consensus is that global warming will be really bad but not literally kill every single human. Even for implausibly high amounts of global warming, survivors can always flee to a pleasantly balmy Greenland. The main concern from an x-risk point of view is “runaway global warming” based on strong feedback loops. For example, global warming causes permafrost to melt, which releases previously trapped carbon, causing more global warming, causing more permafrost to melt, etc. Or global warming causes the oceans to warm, which makes them release more methane, which causes more global warming, causing the oceans to get warmer, etc. In theory, this could get really bad – something similar seems to have happened on Venus, which now has an average temperature of 900 degrees Fahrenheit. But Ord thinks it probably won’t happen here. His worst-case scenario estimates 13 – 20 degrees C of warming by 2300. This is really bad – summer temperatures in San Francisco would occasionally pass 140F – but still well short of Venus, and compatible with the move-to-Greenland scenario. Also, global temperatures jumped 5 degree C (to 14 degrees above current levels) fifty million years ago, and this didn’t seem to cause Venus-style runaway warming. This isn’t a perfect analogy for the current situation, since the current temperature increase is happening faster than the ancient one did, but it’s still a reason for hope. This is another one that could easily be an apocalyptic tragedy unparalleled in human history but probably not an existential risk; Ord estimates the x-risk per century as 1/1,000.

The same is true for other environmental disasters, of which Ord discusses a long list. Overpopulation? No, fertility rates have crashed and the population is barely expanding anymore (also, it’s hard for overpopulation to cause human extinction). Resource depletion? New discovery seems to be faster than depletion for now, and society could route around most plausible resources shortages. Honeybee collapse? Despite what you’ve heard, losing all pollinators would only cause a 3 – 8% decrease in global crop production. He gives all of these combined plus environmental unknown unknowns an additional 1/1,000, just in case.

Third, pandemics. Even though pathogens are natural, Ord classifies pandemics as technological disasters for two reasons. First, natural pandemics are probably getting worse because our technology is making cities denser, linking countries closer together, and bringing humans into more contact with the animal vectors of zoonotic disease (in one of the book’s more prophetic passages, Ord mentions the risk of a disease crossing from bats to humans). But second, bioengineered pandemics may be especially bad. These could be either accidental (surprisingly many biologists alter diseases to make them worse as part of apparently legitimate scientific research) or deliberate (bioweapons). There are enough unknown unknowns here that Ord is uncomfortable assigning relatively precise and low risk levels like he did in earlier categories, and this section generally feels kind of rushed, but he estimates the per-century x-risk from natural pandemics as 1/10,000 and from engineered pandemics as 1/30.

The fourth major technological risk is AI. You’ve all read about this one by now, so I won’t go into the details, but it fits the profile of a genuinely dangerous risk. It’s related to technological advance, so our long and illustrious history of not dying from it thus far offers no consolation. And because it could be actively trying to eliminate humanity, isolated populations on islands or in Antarctica or wherever offer less consolation than usual. Using the same arguments and sources we’ve seen every other time this topic gets brought up, Ord assigns this a 1/10 risk per century, the highest of any of the scenarios he examines, writing:

In my view, the greatest risk to humanity’s potential in the next hundred years comes from unaligned artificial intelligence, which I put at 1 in 10. One might be surprised to see such a high number for such a speculative risk, so it warrants some explanation.

A common approach to estimating the chance of an unprecedented event with earth-shaking consequences is to take a sceptical stance: to start with an extremely small probability and only raise it from there when a large amount of hard evidence is presented. But I disagree. Instead, I think that the right method is to start with a probability that reflects our overall impressions, then adjust this in light of the scientific evidence. When there is a lot of evidence, these approaches converge. But when there isn’t, the starting point can matter.

In the case of artificial intelligence, everyone agrees the evidence and arguments are far from watertight, but the question is where does this leave us? Very roughly, my approach is to start with the overall view of the expert community that there is something like a 1 in 2 chance that AI agents capable of outperforming humans in almost every task will be developed in the coming century. And conditional on that happening, we shouldn’t be shocked if these agents that outperform us across the board were to inherit our future.

The book also addresses a few more complicated situations. There are ways humankind could fail to realize its potential even without being destroyed. For example, if it got trapped in some kind of dystopia that it was impossible to escape. Or if it lost so many of its values that we no longer recognized it as human. Ord doesn’t have too much to say about these situations besides acknowledging that they would be bad and need further research. Or a series of disasters could each precipitate one another, or a minor disaster could leave people unprepared for a major disaster, or something along those lines.

Here, too, Ord is more optimistic than some other sources I have read. For example, some people say that if civilization ever collapses, it will never be able to rebuild, because we’ve already used up all easily-accessible sources of eg fossil fuels, and an infant civilization won’t be able to skip straight from waterwheels to nuclear. Ord is more sanguine:

Even if civilization did collapse, it is likely that it could be re-established. As we have seen, civilization has already been independently established at least seven times by isolated peoples. While one might think resources depletion could make this harder, it is more likely that it has become substantially easier. Most dissasters short of human extinction would leave our domesticated animals and plants, as well as copious material resources in the ruins of our cities – it is much easier to re-forge iron from old railings than to smelt it from ore. Even expendable resources such as coal would be much easier to access, via abandoned reserves and mines, than they ever were in the eighteenth century. Moreover, evidence that civilisation is possible, and the tools and knowledge to help rebuild, would be scattered across the world.

III.

Still, these risks are real, and humanity will under-respond to them for predictable reasons.

First, free-rider problems. If some people invest resources into fighting these risks and others don’t, both sets of people will benefit equally. So all else being equal everyone would prefer that someone else do it. We’ve already seen this play out with international treaties on climate change.

Second, scope insensitivity. A million deaths, a billion deaths, and complete destruction of humanity all sound like such unimaginable catastrophes that they’re hardly worth differentiating. But plausibly we should put 1000x more resources into preventing a billion deaths than a million, and some further very large scaling factor into preventing human extinction. People probably won’t think that way, which will further degrade our existential risk readiness.

Third, availability bias. Existential risks have never happened before. Even their weaker non-omnicidal counterparts have mostly faded into legend – the Black Death, the Tunguska Event. The current pandemic is a perfect example. Big pandemics happen once every few decades – the Spanish flu of 1918 and the Hong Kong Flu of 1968 are the most salient recent examples. Most countries put some effort into preparing for the next one. But the preparation was half-hearted. After this year, I bet we’ll put lots of effort into preparing for respiratory pandemics the next decade or two, while continuing to ignore other risks like solar flares or megadroughts that are equally predictable. People feel weird putting a lot of energy into preparing for something that has never happened before, and their value of “never” is usually “in a generation or two”. Getting them to care about things that have literally never happened before, like climate change, nuclear winter, or AI risk, is an even taller order.

And even when people seem to care about distant risks, it can feel like a half-hearted effort. During a Berkeley meeting of the Manhattan Project, Edward Teller brought up the basic idea behind the hydrogen bomb. You would use a nuclear bomb to ignite a self-sustaining fusion reaction in some other substance, which would produce a bigger explosion than the nuke itself. The scientists got to work figuring out what substances could support such reactions, and found that they couldn’t rule out nitrogen-14. The air is 79% nitrogen-14. If a nuclear bomb produced nitrogen-14 fusion, it would ignite the atmosphere and turn the Earth into a miniature sun, killing everyone. They hurriedly convened a task force to work on the problem, and it reported back that neither nitrogen-14 nor a second candidate isotope, lithium-7, could support a self-sustaining fusion reaction.

They seem to have been moderately confident in these calculations. But there was enough uncertainty that, when the Trinity test produced a brighter fireball than expected, Manhattan Project administrator James Conant was “overcome with dread”, believing that atmospheric ignition had happened after all and the Earth had only seconds left. And later, the US detonated a bomb whose fuel was contaminated with lithium-7, the explosion was much bigger than expected, and some bystanders were killed. It turned out atomic bombs could initiate lithium-7 fusion after all! As Ord puts it, “of the two major thermonuclear calculations made that summer at Berkeley, they got one right and one wrong”. This doesn’t really seem like the kind of crazy anecdote you could tell in a civilization that was taking existential risk seriously enough.

So what should we do? That depends who you mean by “we”.

Ordinary people should follow the standard advice of effective altruism. If they feel like their talents are suited for a career in this area, they should check out 80,000 Hours and similar resources and try to pursue it. Relevant careers include science (developing helpful technologies to eg capture carbon or understand AI), politics and policy (helping push countries to take risk-minimizing actions), and general thinkers and influencers (philosophers to remind us of our ethical duties, journalists to help keep important issues fresh in people’s minds). But also, anything else that generally strengthens and stabilizes the world. Diplomats who help bring countries closer together, since international peace reduces the risk of nuclear war and bioweapons and makes cooperation against other threats more likely. Economists who help keep the market stable, since a prosperous country is more likely to have resources to devote to the future. Even teachers are helping train the next generation of people who can help in the effort, although Ord warns against going too meta – most people willing to help with this will still be best off working on causes that affect existential risk directly. If they don’t feel like their talents lie in any of these areas, they can keep earning money at ordinary jobs and donate some of it (traditionally 10%) to x-risk related charities.

Rich people, charitable foundations, and governments should fund anti-x-risk work more than they’re already doing. Did you know that the Biological Weapons Convention, a key international agreement banning biological warfare, has a budget lower than the average McDonald’s restaurant (not total McDonald corporate profits, a single restaurant)? Or that total world spending on preventing x-risk is less than total world spending on ice cream? Ord suggests a target of between 0.1% and 1% of gross world product for anti-x-risk efforts.

And finally, Ord has a laundry list of requests for sympathetic policy-makers (Appendix F). Most of them are to put more research and funding into things, but the actionable specific ones are: restart various nuclear disarmament treaties, take ICBMs off “hair-trigger alert”, have the US rejoin the Paris Agreement on climate change, fund the Biological Weapons Convention better, and mandate that DNA synthesis companies screen consumer requests for dangerous sequences so that terrorists can’t order a batch of smallpox virus (80% of companies currently do this screening, but 20% don’t). The actual appendix is six pages long, there are a lot of requests to put more research and funding into things.

In the last section, Ord explains that all of this is just the first step. After we’ve conquered existential risk (and all our other problems), we’ll have another task: to contemplate how we want to guide the future. Before we spread out into the galaxy, we might want to take a few centuries to sit back and think about what our obligations are to each other, the universe, and the trillions of people who may one day exist. We cannot take infinite time for this; the universe is expanding, and for each year we spend not doing interstellar colonization, three galaxies cross the cosmological event horizon and become forever unreachable, and all the potential human civilizations that might have flourished there come to nothing. Ord expects us to be concerned about this, and tries to reassure us that it will be okay (the relative loss each year is only one five-billionth of the universe). So he thinks taking a few centuries to reflect before beginning our interstellar colonization is worthwhile on net. But for now, he thinks this process should take a back seat to safeguarding the world from x-risk. Deal with the Cuban Missile Crisis we’re perpetually in the middle of, and then we’ll have time for normal philosophy.

IV.

In the spirit of highly-uncertain-estimates being better than no estimates at all, Ord offers this as a draft of where the existential risk community is right now (“they are not in any way the final word, but are a concise summary of all I know about the risk landscape”):

Again, the most interesting thing for me is how low most of the numbers are. It’s a strange sight in a book whose thesis could be summarized as “we need to care more about existential risk”. I think most people paying attention will be delighted to learn there’s a 5 in 6 chance the human race will survive until 2120.

This is where I turn to my psychoanalysis of Toby Ord again. I think he, God help him, sees a number like that and responds appropriately. He multiplies 1/6th by 10 billion deaths and gets 1.6 billion deaths. Then he multiplies 1/6th by the hundreds of trillions of people it will prevent from ever existing, and gets tens of trillions of people. Then he considers that the centuries just keep adding up, until by 2X00 the risk is arbitrarily high. At that point, the difference between a 1/6 chance of humanity dying per century vs. a 5/6 chance of humanity dying may have psychological impact. But the overall takeaway from both is “Holy @!#$, we better put a lot of work into dealing with this.”

There’s an old joke about a science lecture. The professor says that the sun will explode in five billion years, and sees a student visibly freaking out. She asks the student what’s so scary about the sun exploding in five billion years. The student sighs with relief: “Oh, thank God! I thought you’d said five million years!”

We can imagine the opposite joke. A professor says the sun will explode in five minutes, sees a student visibly freaking out, and repeats her claim. The student, visibly relieved: “Oh, thank God! I thought you’d said five seconds.”

When read carefully, The Precipice is the book-length version of the second joke. Things may not be quite as disastrous as you expected. But relief may not quite be the appropriate emotion, and there’s still a lot of work to be done.

SSC Journal Club: MacIntyre On Cloth Masks

[Content warning: this is a complicated analysis of something people care about a lot right now. I’m not confident in my analysis, the post comes to no clear conclusion and there are no easy answers about how to proceed. If I see this on Twitter with some headline about it DESTROYING somebody, I am going to be so mad.]

The New York Times says that It’s Time To Make Your Own Face Mask. But MacIntyre et al (2015) says it isn’t.

The surgical masks used in hospitals are made out of non-woven fabrics that are pretty different from anything you have at home. But in some developing countries, health care workers instead use masks made of normal cloth. Laboratory tests find that improvised cloth masks block 60 – 80% of virus particles. Respirators and real surgical masks block 95%+, but 60-80% still seems better than nothing. And most of the masks ordinary people wear in Asian countries are cloth, and they seem to do pretty well. So there’s some circumstantial evidence that these cloth masks might be helpful. Most experts in the early 2000s agreed that these masks were probably better than nothing. In 2015, an Australian team set out to prove it with a randomized controlled trial.

They went to a hospital in Vietnam and randomized workers there to a normal mask group, a cloth mask group, or a control group. Because it would have been unethical to tell the control group not to wear masks, they left the control group alone. Most control group workers did end up wearing masks sometimes, but less than the experimental groups did.

After a month, they counted how many infections each group had, for three different categories of infection. Here are the results:

Technically significant only in the ILI category, but later the authors do various post hoc adjustment for confounders and find it’s significant everywhere

For all three categories, people wearing the real surgical masks were the healthiest, the control group was in the middle, and people wearing the cloth masks were the sickest.

This shows real surgical masks work better than cloth masks. It’s a little bit unclear about how well cloth masks work. They do worse than the control group, but you could tell two stories about that. In one, cloth masks are worse than no mask at all. In the other, cloth masks have zero-to-slight-positive efficacy, but because some people in the control group were wearing real surgical masks some of the time, they did better than the cloth group overall. So it depends a lot what the control group was doing.

Unfortunately, the paper doesn’t give us all the data we want. It tells us that about 57% of both the surgical mask group and the cloth mask group wore masks regularly (defined as more than 70% of the time) but only 24% of the control group did. But there is no way of knowing whether the rest of the control group wore masks 69% of the time or 0% of the time.

A separate paragraph tells us that 37% of the control group used surgical masks, 8% cloth masks, and 53% used a combination of both. These numbers don’t make a lot of sense in the context of the last paragraph, so I’m going to assume they meant that on the infrequent occasions they did wear masks, those were the masks they used. But we don’t know if the compliant workers were disproportionately using cloth masks, disproportionately using medical masks, or both evenly. It’s hard to just eyeball these numbers and get a good sense for whether cloth masks really are worse than nothing.

But the authors themselves lean towards the hypothesis that that cloth masks are actively bad. First, because after some calculations I cannot quite follow, they find that the difference between surgical masks and cloth masks is so high that either the surgical masks are absurdly good, or the difference is being augmented by the cloth masks being actively bad. But nobody has previously found surgical masks to be absurdly good. The authors cite two previous studies of theirs which did include a no-mask control group; surgical masks did not significantly outperform nothing (they did show a trend towards doing so, and the studies were probably underpowered).

Second, because they compare the numbers from this study to numbers from those other two studies directly. They find the rate of infection in surgical mask users is not-significantly-different throughout the three studies, and the rate of infection in surgical mask users and no-mask controls was also not-significantly-different, and therefore surgical masks are the same as nothing and so probably the cloth masks are actively bad.

I am very unimpressed by this. First, you are really not supposed to compare things across multiple different studies. The authors protest that they did all three studies along pretty similar designs, but also admit they were different hospitals during different seasons. But second, almost no differences anywhere are significant, because all of these studies were at least a little underpowered. The current study found no significant difference between cloth masks and surgical masks in two of the three categories, even though the trend was in the expected direction. The other studies found no difference between wearing a medical mask and not wearing a medical mask, even though previous studies have suggested medical masks should work. They couldn’t even find any difference between wearing an N95 respirator and not wearing any protection at all. So when you need a chain of “x is not significantly different from y, which is not significantly different from z” in a bunch of studies that wouldn’t have been able to notice significant differences even if they existed, I stop believing it pretty quickly.

(In fact, I think you could use the same logic to draw the exact opposite conclusion. The cloth mask group in the current study didn’t have a significant difference from the surgical mask group in the other study, and the surgical mask group was no different from placebo, therefore cloth masks cannot have a negative effect. I find it hard to believe the authors missed this, so let me know if I am confused here.)

But MacIntyre et al take it seriously, and conclude:

The study suggests medical masks may be protective, but the magnitude of difference raises the possibility that cloth masks cause an increase in infection risk in HCWs. Further, the filtration of the medical mask used in this trial was poor, making extremely high efficacy of medical masks unlikely, particularly given the predominant pathogen was rhinovirus, which spreads by the airborne route. Given the obligations to HCW occupational health and safety, it is important to consider the potential risk of using cloth masks […] The physical properties of a cloth mask, reuse, the frequency and effectiveness of cleaning, and increased moisture retention, may potentially increase the infection risk for health care workers. The virus may survive on the surface of the face-masks, and modelling studies have quantified the contamination levels of masks. Self-contamination through repeated use and improper doffing is possible. For example, a contaminated cloth mask may transfer pathogen from the mask to the bare hands of the wearer. We also showed that filtration was extremely poor (almost 0%) for the cloth masks. Observations during SARS suggested double-masking and other practices increased the risk of infection because of moisture, liquid diffusion and pathogen retention. These effects may be associated with cloth masks.

Why am I focusing on this one weird study so much? Because it’s the only RCT of cloth face masks we have! Millions of people, egged on by top newspapers, are about to start wearing cloth face masks during a pandemic, when right now the authors of the only randomized trial on them conclude they’re probably net harmful. This should be really scary! Somebody with more experience and statistical knowledge than I have should be looking this over with a fine-toothed comb and trying to figure out what we should do.

Until then, should people stay away from cloth masks? I’m not sure, and this is so not a recommendation, but I lean toward no. The prior that they should work or at least be neutral is too high for a study this weak to convince me otherwise. More important, this study only examines incoming pathogens. Even if they are harmful for blocking incoming pathogens, there are still reasons to think they are helpful for blocking outgoing ones. If I had to hang out with a coronavirus patient for a while, and I had to choose between both of us wearing cloth masks, or neither, I would go with the masks. Only until we could get real surgical masks, which are much better. But I’d go with the cloth ones instead of nothing.

But right now that’s a gut judgment, and the evidence says I’m wrong. This is one of those times where people have to make a life-or-death decision in conditions of high uncertainty, and it really sucks.

[EDIT: Bolded a passage I think is important to make sure people don’t miss it]

Legal Systems Very Different From Ours, Because I Just Made Them Up

[with apologies to the real Legal Systems Very Different From Ours. See also the List Of Fictional Drugs Banned By The FDA]

I.

The Clamzorians are animists. They believe every rock and tree and river has its own spirit. And those spirits are legal people. This on its own is not unusual – even New Zealand gives rivers legal personhood. But in Clamzoria, if a flood destroys your home, you sue the river.

If you win, then the river is in debt to you. The government can assign a guardian to the river to force it to pay off its debts, and that guardian gets temporary custody of all the river’s property. He or she can collect a toll from boats, sell water to reservoirs, and charge rent to hydroelectric dams. Once the river has paid off its debt, the guardian is discharged, and the river becomes free to use once again.

Clamzorian precedent governs when you may or may not sue objects. If you swim in the freezing river in the dead of winter, and catch cold, that’s on you. But if a hurricane destroys your property, you can absolutely sue the wind for damages, and collect from windmills. Suits against earthquakes, volcanoes, and the like are dead common. Suits against diseases happen occasionally. Sometimes someone will sue something even more abstract – a custom, an emotion, a concept.

Legend tells of a lawyer who once sued Death itself for wrongful death, a class action suit on behalf of everyone who ever lived. The judge found in favor of the plaintiff, but the appointed custodian despaired at ever collecting the judgment – the few morticians and undertakers in the realm couldn’t afford even a fraction of the damages. In a stroke of genius, he went after the military, and charged them for the right to kill enemy soldiers. The military grumbled, but eventually gave in: fair is fair.

II.

Fixed fines are inherently unfair to the poor. If you fine people $50 for running a red light, you’ve charged someone who makes $10,000 0.5% of their income, but someone who makes $100,000 gets off with only 0.05% of their income.

But prison sentences are inherently unfair to the rich. After all, if you already live in a crowded slum much like a prison cell, and your life is prison-level boring and oppressive already, then going to prison barely costs you anything. But if you live in a mansion and spend all day indulging in the finest luxuries on offer, going to prison is a massive decrease in your quality of life.

The people of Pohjankaupunki thought long and hard about this problem, and came up with a solution: crimes will be punished by neither fines nor prison. They will be punished by government mandated prescription of rimonabant, a prodepressant medication which directly saps your ability to feel happiness. Running a red light may get you 5 mg rimonabant for a month. Murder may get you 80 mg rimonabant twice a day for ten years.

There is no capital punishment in Pohjankaupunki, but if a criminal decides to commit suicide rather than continue to take their medication, they are considered to have voluntarily upgraded to the death penalty, and their debt to the state has been repaid.

III.

Sloviria is an enlightened country. They do not blame criminals for their actions. They realize it is Society’s fault for making criminals that way. So when someone commits a crime, they punish Society.

Sloviria is very technologically advanced, with plenty of social networking sites and GPS tracking of cell phones and all the other systems that create a nice objective social graph. When someone commits a crime, the government lets them go free, and punishes everyone else, in proportion to how close they were to the offender on the social graph. If the punishment for a certain crime is a $1000 fine, perhaps each of their parents and their partner pays $200, their boss and best friend pay $100, some of their teachers a few tenners each, and more distant friends and relations a few dollars or less. If a friend of a friend who you met at a dinner party once commits murder, you may be out a couple of cents.

This isn’t to say perpetrators get off scot-free; Sloviria isn’t that enlightened. The punishment for perpetrators is that nobody wants to interact with them, for fear that they might perpetrate again. Once a person is a known criminal – or a suspected criminal, or just the sort of person who seems like they might become a criminal – their friends, families, and business relations shun them, trying to minimize their potential loss. This threat enough is to discourage crime and every form of crime-adjacent misbehavior.

The Slovirian Radical Party is even more enlightened than Sloviria as a whole, and opposes social punishment. They believe that such punishment prevents rehabilitation, since criminals and at-risk youth find it impossible to make the connections they need to succeed, and are forced to hang out with other people as criminal as themselves. They propose a complete inversion of Sloviria’s justice system; when anyone commits a crime, the people closest to them are rewarded. They envision a future where, once somebody shows any sign of being at risk for antisocial behavior, they are love-bombed by dozens of people hoping to get rich off their acquaintance, people who want to employ them, adopt them, date them, or just serve as mentors and parental figures. But wouldn’t all these people encourage the potential criminal to offend? The Radicals debate this among themselves, with one solution being that this could just be a perfectly normal crime punished by jail time.

IV.

Nova-Nishistan’s legal system is based on blackmail. It’s not just blackmail. There are courts and jails and so on. But few people use them. If you have evidence that someone committed a crime, you are expected to threaten to report them unless they give you money.

The system has many advantages. The person most likely to have evidence of a crime is the victim. The victim can choose how much money they want as damages, and have a good chance of receiving it. Fines are automatically calibrated to the wealth of the victim, so poor people are not stuck with debts that are impossible to pay. If a crime is victimless, or the victim chooses not to prosecute, any other witnesses are incentivized to take up the cause of punishing the wrongdoer of their own initiative. Few crimes make it to the courts or prisons, so everyone is assured a speedy trial and an jail cell free of overcrowding.

In order to maintain their system, the Nova-Nishistanis need many laws related to blackmail itself. One of their most serious crimes is to blackmail someone, receive the requested ransom, but report them anyway; anyone convicted of this will be in for a lengthy prison sentence. Indefinite blackmail – “pay me $100 now, but I might ask for more later” – is forbidden. So is non-monetary blackmail; too easy to abuse. There are a host of similar regulations.

One regulation they don’t need is laws about retaliating against blackmailers. You might expect this to be a problem – blackmailing the mob sounds pretty scary. But there are lots of individuals, companies, and (let’s face it) rival gangs happy to provide dead-man’s-switch-as-a-service. Tell them your secret (which they promise not to disclose without your consent), and if anything happens to you, they prosecute it. Even better, if anything happens to you, they’re almost guaranteed to investigate your death, since their special evidence gives them a leg up in what could be a very lucrative blackmail case.

Of course, this only works on people who are rational enough to respond to incentives. If someone is a complete unpredictable psycho, you probably don’t want to try blackmailing them, even with a dead-man’s-switch as insurance. But these are probably the people who should be in jail anyway!

V.

The people of Bogolia thought it was unfair that rich people could hire better lawyers than poor people. But they didn’t want to take the authoritarian step of banning rich people from buying good lawyers, if they thought skilled representation was important. Instead, they just mandated that in any legal case, both sides had to have equally-priced counsel. A rich person could hire as expensive a defense attorney as they wanted, as long as they donated an equal sum to the plaintiff to hire star attorneys of their own. You could sue someone with as highly-priced an attorney as you wanted, but you needed to give them the same amount to spend on their defense.

(this rule applied to the state too, and so implied the right to a public defender worth however much the state was paying to prosecute you, even if you were poor and couldn’t otherwise afford one)

Some trolls tried launching hundreds of frivolous lawsuits against companies they didn’t like, assuming that the company would have to pay both sides of the lawsuit and eventually go broke. They were punished through the normal anti-frivolous-lawsuit rules, and it turned out that companies that did not go broke having to pay one side of a lawsuit don’t go broke having to pay both sides either.

But there were some weirder unintended consequences. How good a lawyer to get became a highly strategic decision for rich clients facing poorer ones. If you thought you were in the right, you’d get a good lawyer, since two equally good lawyers facing off will likely produce truth. If you thought you were in the wrong, you’d try to get a crappy lawyer, since then your opponent would also have a crappy lawyer, and two crappy lawyers facing off will likely produce random results. Not paying for a good lawyer started to be seen as an admission that one’s case was weak.

But also, lawyer salaries started to get wacky. If a random criminal hurt a rich person somehow, and the rich person hired a good lawyer, the random criminal might receive tens of thousands of dollars to spend on legal advice. But random criminals generally are not savvy at evaluating lawyer skill, so thousands of predatory lawyers sprang up, willing to cater to these people by looking impressive and accepting very high salaries. For the savviest of political operators, an equal and opposite caste of underpriced lawyers sprang up, who would accept very low pay in exchange for vague social credit to be doled out later. More and more political scandals started to center on prestigious lawyers defending politicians for free in exchange for favors, and so depriving the opposing party of their right to equally-matched counsel.

Finally the authorities handed down a change to the system: the plaintiff and defendant would agree on two lawyers to conduct the trial. Then the judge would flip a coin, and one of the two would be assigned at random to each party.

VI.

Sanzorre accidentally became an anarcho-capitalist state under the dominion of malpractice insurance companies.

They started off by insuring doctors. Doctors know a bad malpractice case could ruin them. And although being a good doctor helps, it’s not 100%. Even the best doctor can get unlucky, or have somebody with a grudge fabricate a case against them. For that matter, even very bad doctors can get lucky and never have to deal with a case at all. So doctors have malpractice insurance, and if they seem to be practicing medicine badly their insurance company will raise their premiums.

This worked well enough that other industries started adopting it too. If a factory’s pollutant byproducts got discovered to cause cancer ten years later, their industrial malpractice insurance would pay for it. If someone slipped and fell and broke their back on a restaurant floor, their restaurant malpractice insurance would pay for it. Of course, these insurance companies worked closely with factories to monitor how many they were polluting, and gave discounts to restaurants which followed best practices on floor cleaning.

Finally, they branched out to serving ordinary people. If you accidentally hit someone’s dog with your car and got sued for damages, better to have a personal malpractice insurance pay them than get hit for tens of thousands of dollars yourself. Having malpractice insurance became to Sanzorrians what having health insurance is to Americans – a necessity if you don’t want to court disaster.

The plaintiffs in all these cases were usually being covered by lawyers who took contigency fees. But as malpractice insurance companies became better at their jobs, the contingency fees began to dry up. Finally, lobbyists from the insurance companies got contingency fees banned entirely. This presented a dilemma for ordinary people with grievances against bad actors. Thus the rise of the grievance insurance.

If you suffered harm from a doctor’s medical error, and had grievance insurance, the insurance company would pay the cost of the malpractice suit. If you were poisoned by industrial runoff, the insurance company would pay the cost of suing the factory. Grievance insurance soon became as essential as malpractice insurance. Without it, you wouldn’t be able to stand up for your rights.

Like malpractice insurance, grievance insurance was only available cheaply to people who agreed to avoid risks. If you wanted to be able to sue for malpractice, you had to avoid going to quacks. If you wanted to be able to sue factories for pollution, you couldn’t live right next to a coal plant. Gradually, grievance insurances placed more and more restrictions on people’s behavior, and people generally complied.

As malpractice insurances incentivized potential defendants to avoid actions that could harm others, and grievance insurances incentivized individuals to avoid risk, the number of lawsuits gradually got fewer and fewer. Those that happened were generally settled between malpractice insurers and grievance insurers, without ever having to go to court, and sometimes with both companies changing their policy to avoid repeats in the future. Soon, even this formality was eliminated – each malpractice insurance company paid a negotiated amount to each grievance insurance company each year, and the grievance insurance company paid complainants from its own bank account as per its own policies whenever they complained.

It wasn’t quite full anarcho-capitalism. The state still intervened in a few very serious crimes, like murder. But the insurance companies had replaced the civil courts and the regulatory apparatus, and controlled every aspect of doing business.

VII.

Modern philosophy says that formal systems are bunk. The dream of reducing the complexity of reality to some mere set of rules is a childish desire reminiscent of the fascists and high modernists of the early 20th century. Enlightened thinkers realize that we need a Kegan 5 type fluid ability to transcend systematicity. So the people of Mirakoth don’t have laws. They’re just supposed to not do bad stuff.

If someone in Mirakoth thinks someone else did something bad, they can bring it before a council of seven judges. If a majority of the judges think it was bad, they can assign whatever seems to them like fair punishment. If the loser appeals, it goes to a larger council of forty-nine judges. If they think it was bad, it was bad. These judges are under no obligation to follow precedent or any particular philosophy. They’re just supposed to be in favor of good stuff and against bad stuff.

In order to prevent people from seeking out judges who agree with them, each case is assigned seven judges at random. All cases are tried by videoconference, to make sure the judge pool is unlimited by geographical mobility. If the judges think a case is frivolous, they can choose to punish the person who brought the case.

Doesn’t this create such paralyzing uncertainty that nobody knows if they can do anything at all? Not really. Controversial cases are more likely to go to the full 49 judge panel. If an opinion is only held by 20% of judges in the country, then there’s only about a 1 in a million chance that the panel will rule in favor. Even if the opinion is held by 40%, it’s still only an 8% chance of winning. So just don’t do things that more than 40% of people think are bad, and you’ll be fine!

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Open Thread 150.5

This is would usually be a hidden open thread, but I’m promoting it to front page to say a couple of things:

1. Future of Humanity Institute asks me to advertise their free pandemic modeling software for hospitals, policymakers, and anyone who just wants to play around with free pandemic modeling software.

2. People seem to be confused whether my face masks post last week was coming out against or in favor of face masks. Although it’s a complicated issue, I meant for it to conclude that (modulo the importance of reserving them for health care personnel), wearing face masks is probably helpful.

3. On Friday, I stated that people should stop smoking to reduce their risk of serious lung complications of coronavirus. Although that conclusion was supported by one Chinese study and by common sense, a few people have pointed out to me that more recent studies show the opposite. This study of Chinese patients finds that smoking and vaping are not dangerous in coronavirus and may have “a protective role”, possibly due to downregulation of ACE (but note that the lead author has a history of getting funding from e-cigarette companies). This study from China finds that although never-smokers have better survival rates than current-smokers, former-smokers do worse than either, which would argue against quitting right now. And this study confirms that quitting smoking can upregulate expression of coronavirus receptor genes (though it finds that smoking does as well).

I’m pretty suspicious of this research. It’s new, lots of it isn’t yet peer reviewed, and it contradicts itself in places. The former-smokers-do-worse effect is reminiscent of the teetotalers-do-worst effect in alcohol research, which is probably because very sick people get told to stop drinking, and so teetotalers are a disproportionately sickly population. Everything is working off a few heavily-biased mortality numbers in China. And also, even if quitting smoking increases your coronavirus mortality risk it will still be very good for you on net.

Still, the most recent research does apparently show that the advice I gave you yesterday was diametrically wrong and could kill you, so I figured I had better get that out there.

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Coronalinks 3/27/20: We’re Number One

The United States now has more coronavirus cases than any other country, including China, marking a new stage in the epidemic. As before, feel free to treat this as an open thread for all coronavirus-related issues. Everything here is speculative and not intended as medical advice.

Hammer and dance

Most of the smart people I’ve been reading have converged on something like the ideas expressed in The Hammer And The Dance – see this Less Wrong post for more.

Summary: Asian countries have managed to control the pandemic through mass testing, contact tracing, and travel bans, without economic shutdown. The West lost the chance for a clean win when it bungled its first month of response, but it can still recover its footing. We need a medium-term national shutdown to arrest the spread of the virus until authorities can get their act together – manufacture lots of tests and face masks, create a testing infrastructure, come up with policies for how to respond when people test positive, distribute the face masks to everyone, etc. With a lot of work, we can manage that in a month or so. After that, we can relax the national shutdown, start over with a clean slate, and pursue the Asian-style containment strategy we should have been doing since the beginning.

This is the only plan I’ve heard from anybody that doesn’t result in either hundreds of thousands of deaths, or the economy crashing so hard we’re all reduced to eating weeds and rocks.

I relayed some criticism of a previous Medium post, Flattening The Curve Is A Deadly Delusion, last links post. In retrospect, I was wrong, it was right (except for the minor math errors it admitted to), and it was trying to say something similar to this. There is no practical way to “flatten the curve” except by making it so flat that the virus is all-but-gone, like it is in South Korea right now. I think this was also the conclusion of the Imperial College London report that everyone has been talking about.

Thank you for not smoking

There isn’t a lot you can do to improve your chances if you get coronavirus, but one really important intervention you can take right now is to STOP SMOKING.

I try not to lecture my patients on their health failings. I am not a jerk to obese people or people who don’t get enough exercise. But I try to tell every smoker, at least once, to STOP SMOKING. Studies have shown that having a doctor or other authority figure say this actually helps a lot, and every person who STOPS SMOKING gains 5 – 10 years of life expectancy. There is nothing else you can do as a doctor or a human being that gives you a medium chance of saving ten life-years with a ten second speech. Everything that effective altruism has to offer pales in comparison. So even though I hate lecturing people – on this blog as much as in my medical practice – I suck it up and tell everyone STOP SMOKING.

If you need a reason to quit now instead of later, here it is: coronavirus is a lot worse for smokers. The virus kills by infecting your lungs. If your respiratory health is pretty good, you have lung capacity to spare and will probably be okay. If your respiratory health is already iffy, you will need ventilation and maybe die. From this article:

An article reporting disease outcomes in 1,099 laboratory confirmed cases of covid-19 reported that 12.4% (17/137) of current smokers died, required intensive care unit admission or mechanical ventilation compared with 4.7% (44/927) among never smokers. Smoking prevalence among men in China is approximately 48% but only 3% in women; this is coupled with findings from the WHO-China Joint Mission on Coronavirus Disease 2019, which reports a higher case fatality rate among males compared with females (4.7% vs. 2.8%).

[EDIT: In Sweden, men and women smoke equally but men still die more, so the gender argument may not be as strong as it sounded a few weeks ago]

I want to clarify that what I’m telling you right now is totally unprincipled propaganda, intended to take advantage of a moment of panic – realistically, on the list of ways smoking can kill you, coronavirus is somewhere near the bottom. Quick back-of-the-napkin math: assume you have a 30% chance of getting coronavirus this year, that smokers’ death rate is 4% compared to non-smokers’ 1%, so quitting smoking now will save you a 1% risk of coronavirus death this year. But about 10% of smokers get lung cancer eventually, compared to very few non-smokers, and lung cancer has about a 66% death rate, so it’ll save you a 6.6% chance of death by lung cancer. Honestly, coronavirus shouldn’t even figure into your calculations here.

But since you are panicking about coronavirus right now, you might as well use it as motivation to STOP SMOKING. Smokers’ lungs start to heal as soon as one month after quitting – so quit now, and if Trump makes good on his threats to stop self-isolation and restart the epidemic after Easter, you’ll be feeling better by the time things get bad again.

Some people have a lot of trouble quitting smoking. If you’ve been unsuccessful before and you don’t have good access to medical care, try e-cigarettes – whatever you’ve heard about them, they’re infinitely better than the real thing. If you do have good access to medical care, ask your doctor for bupropion (aka “Wellbutrin”, “Zyban”), a very effective stop-smoking medication. I have seen dozens of patients quit smoking on bupropion; my most recent success was yesterday. It’s a great medication, and the most common side effects are curing your depression, improving your sex life, and making you lose weight. If you’re worried about going outside to get it, remember that most US doctors and psychiatrists are seeing people by video now, and many pharmacies have started drive-thru and delivery services. Alternately, you could travel to your local pharmacy on a crowded bus, lick everyone who goes on or off, then stop in Wuhan on your way home for a tasty bowl of bat soup. It doesn’t matter, taking care of this now instead of putting it off would still increase your life expectancy on net.

Japan and other mysteries

Japan should be having a terrible time right now. They were one of the first countries to get coronavirus cases, around the same time as South Korea and Italy. And their response has been somewhere between terrible and nonexistent. A friend living in Japan says that “Japan has the worst coronavirus response in the world (the USA is second worst)”, and gets backup from commenters, including a photo of still-packed rush hour trains. Japan is super-dense and full of old people, so at this point the living should envy the dead.

But actually their case number has barely budged over the past month. It was 200 a month ago. Now it’s 1300. This is the most successful coronavirus containment by any major country’s, much better than even South Korea’s, and it was all done with zero effort.

The obvious conclusion is that Japan just isn’t testing anyone. This turns out to be true – they were hoping that if they made themselves look virus-free, the world would still let them hold the Tokyo Olympics this summer.

But at this point, it should be beyond their ability to cover up. We should be getting the same horrifying stories of overflowing hospitals and convoys of coffins that we hear out of Italy. Japanese cities should be defying the national government’s orders and going into total lockdowns. Since none of this is happening, it looks like Japan really is almost virus-free. The Japan Times is as confused about this as I am.

Some people have gestured at the Japanese being an unusually clean and law-abiding people. Maybe the government has just sort of subtly communicated “don’t do anything that will mess up our Olympics chances” and everyone has been really good at not touching their face. Maybe widespread use of face masks is much much more important than anyone has previously believed. I don’t know.

One way this should affect us Westerners is by making us worried that an Asian-style containment strategy wouldn’t work here. The evidence in favor of such a strategy is that it worked in a bunch of Asian countries like South Korea, Taiwan, Hong Kong, and Singapore. But if there’s something about wealthy orderly mask-wearing Asian societies that makes them mysteriously immune to the pandemic, maybe their containment strategies aren’t really that impressive. Maybe they just needed a little bit of containment to tip them over the edge. I don’t know, things sure seemed bad in South Korea a few weeks ago (and in Wuhan). I am so boggled by this that I don’t know what to think.

Also, what about Iran? The reports sounded basically apocalyptic a few weeks ago. They stubbornly refused to institute any lockdowns or stop kissing their sacred shrines. Now they have fewer cases than Spain, Germany, or the US. A quick look at the data confirms that their doubling time is now 11 days, compared to six days in Italy and four in the US. Again, I have no explanation.

Takeout

So far every US state and local self-isolation order has included exceptions for getting takeout or delivery food. I’m sure restaurants appreciate the business and consumers appreciate getting to keep that particular aspect of a normal lifestyle. But is it actually safe?

All the big organizations say yes. From Forbes:

“Takeout food seems to pose a very minimal risk of passing on coronavirus. Here, virology experts explain why….”There is no evidence that SARS-CoV-2 can be transmitted by eating food. I imagine that if this is possible, the risk is extremely low,” said Angela L. Rasmussen, PhD, a virologist in the faculty of the Center for Infection and Immunity at the Columbia Mailman School of Public Health, adding that she is not aware of any human coronaviruses that can be transmitted through food.

And the San Francisco Chronicle:

With dining in restaurants off the table, many Americans are wondering if take-out and delivery food options are still viable in the age of coronavirus. Luckily for people tired of their own home cooking, the answer is, by and large, yes.

According to the CDC, transmission of COVID-19 primarily happens person-to-person, so your largest risk is not in the food but in human interaction. Keep your distance as much as possible when picking up food, or request that delivery workers leave the food on your doorstep. As with other in-person interactions, remember to avoid touching your face and be sure to wash your hands thoroughly as soon as you can.

“It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads,” the CDC says.

On the other hand, all of my friends who are actually worried about getting the condition are avoiding delivery food like, well, the plague. Their argument is that we know the virus can survive on surfaces for a while, so all you need is one food worker to cough on your food after it’s been cooked (or on food that doesn’t get cooked at all), and you’re screwed. Restauarants are supposed to follow sanitary precautions, but people familiar with the industry say these precautions are not so strong to 100% (or even an especially high percent) ensure you get un-coughed-on food. The CDC telling food workers they don’t need face masks does not exactly inspire confidence here.

I am really craving something other than the three or four things I can cook myself, and I have a lot of mutually-quarantined housemates to convince, so if any of you have any clearer estimate of the risk situation, please share.

Ventilator numbers

Britain has 5,000, or one per 12,000 citizens. The US has 160,000, or about 1 per 2,000 citizens (why are these numbers so different?). The head of a small ventilator company says they usually “sell 50 in a good month”.

Elon Musk recently delivered 1,255 ventilators to California from some of Tesla’s Chinese contacts, and promised to make more. Dyson, the British vacuum manufacturer, says it will be able to make 10,000 ventilators in time to help with the crisis – remember, that’s twice what the whole UK has right now. The American Hospital Association says 960,000 Americans may require ventilators during the pandemic – hopefully not all at once.

Ventilators also require trained staff to operate. I never know how far to trust medical people when they say something requires training. You would think doing a lumbar puncture requires training, but the training I received for this in residency was watching one (1) guy do it one (1) time, and then them saying “Now you do it” – which by the way is exactly as scary as you would expect. This is an official thing in medical education, called see one, do one, teach one. So when people say some medical task requires training, I don’t know if they mean “ten years’ experience and a licensing exam”, “watch it once and then we throw you in the deep end” or “we’re going to make you go through the former, but the latter would have worked too”. Hopefully ventilators are more like the latter and someone can train new people really quickly.

If you’re confused about the difference between ventilators, oxygen concentrators, etc, or you have clever questions like “can we repurpose CPAP machines as ventilators?”, you might like Sarah Constantin’s Oxygen Supplementation 101.

The British reversal

A UK critical care doctor on Reddit wrote a great explanation of their recent about-face on coronavirus strategy.

They say that over the past few years, Britain developed a cutting-edge new strategy for dealing with pandemics by building herd immunity. It was actually really novel and exciting and they were anxious to try it out. When the coronavirus came along, the government plugged its spread rate, death rate, etc into the strategy and got the plan Johnson originally announced. This is why he kept talking about how evidence-based it was and how top scientists said this was the best way to do things.

But other pandemics don’t require ventilators nearly as often as coronavirus does. So the model, which was originally built around flu, didn’t include a term for ventilator shortages. Once someone added that in, the herd immunity strategy went from clever idea to total disaster, and the UK had to perform a disastrous about-face. Something something technocratic hubris vs. complexity of the real world.

Maybe we should have taken it easy with the huddled masses

China had Wuhan, Italy had Lombardy. Two weeks ago, everyone expected Seattle or the Bay would be the epicenter of the pandemic in the US. Well, right now both of those places combined have about 3,000 cases. New York City has 30,000. The New York/New Jersey area has about half the cases in the US, and is rising fast.

What changed? Partly the international epidemic shifted from Asia (which has immigrant communities and transportation links on the West Coast) to Italy and Europe (which have immigrant communities and transportation links on the East Coast). Partly the West Coast had some good policy whereas New York had terrible policy (while California was instituting shelter-in-place, Governor Cuomo was vetoing NYC’s shelter-in-place order and later griping about the term shelter-in-place’s etymology).

But the other major factor seems to be density. NYC is by far the densest city in America, almost twice as dense as second-placer San Francisco. Density forces people together and makes infections spread more easily.

At least that’s the story. So how come San Francisco – again, number two on the density list – has been almost completely spared? How come, despite its towering skyscrapers and close links to China, SF has only 178 diagnosed cases – fewer than such bustling metropolises as Indianapolis, Indiana, or Nashville, Tennessee? How come the virus is so well-behaved in very dense countries like Japan, and so deadly in relatively sparsely-populated places like Switzerland?

I’m not sure. Maybe density measures are really bad? Like if NYC annexed all of Long Island, it would drop to having one of the lowest densities in the nation on paper, but this purely political act wouldn’t affect its coronavirus susceptibility at all. Maybe there are enough problems like this that all existing density statistics average very dense areas with less dense areas and so don’t tell us what we want to know for disease spread.

Consider Spain. On paper, it’s one of the least densely-populated countries in Europe. In practice, it’s a lot of rolling countryside plus a few very dense cities – four of the ten densest cities in Europe are there. Maybe that’s why it’s got the fourth most cases in the world right now, behind only China, Italy, and the US?

The worst-affected US city per capita isn’t any of the ones I would have predicted – it’s New Orleans. Nathan Robinson lives there and takes some guesses about why things there are so bad. By the way, it’s going to reach 89 degrees in New Orleans tomorrow; keep that in mind whenever someone says the virus can’t spread in warm weather.

Irresponsible opinions on meds

Donald Trump tweeted excitedly about hydroxychloroquine/azithromycin, a drug combination which looked good in a single small preliminary trial against coronavirus but is otherwise unproven.

A few days later, an Arizona couple took a fish-tank cleaner including the closely-related drug chloroquine to try to protect themselves from the disease. The man died and the woman is in the ICU.

First things first – from a medical perspective, what went wrong here? Fish tank chloroquine is chloroquine phosphate, which is a perfectly acceptable form of chloroquine approved for human consumption as the antimalarial drug Aralen. Chloroquine has lots of nasty side effects, but none of them are bad enough to kill you instantly. My guess is that the guy either took orders of magnitude too high a dose – the news articles just say “a spoonful” – or that there were other things in the fish tank cleaner. Interested to hear from doctors who know more about chloroquine on this.

Okay, now let’s get to the controversial part: is Trump responsible? He seems causally responsible, in the sense that his endorsement led to the overdose. But is he morally responsible? I just got done telling all of you that stop-smoking-aid bupropion is an amazing drug that can save your life. If one if you is an idiot and responds by taking 100 times the safe dose of some industrial chemical with bupropion in it, does that make me responsible for your death? Is the difference that bupropion is known to work, but chloroquine is only speculative? Why should this change how we distribute responsibility?

Maybe responsibility is the wrong lens here? Maybe Presidents should be aware that they have such an immense platform that all of their statements can be interpreted in absurd ways, and perform a cost-benefit analysis before saying anything at all? Maybe (to go back to my example), the cost benefit analysis passes muster for bupropion, because the chance that one of you does something idiotic and kills yourself is counterbalanced by the chance that many of you use it correctly and stop smoking? But responsible scientists were going to investigate hydroxychloroquine responsibly before Trump said anything, so his statement had no benefit and he should have thought more about the costs.

I appreciate this line of reasoning, but I hate it. It means you stop being able to communicate your real thoughts in favor of communicating whatever information a utility calculation says it’s most beneficial to communicate – which is fine until people very reasonably choose to stop interpreting your mouth movements as words. On the other hand, the President of the US is not really supposed to be a clearinghouse for medical information, and is definitely somebody whose words have direct effects on the world, so maybe we should make an exception for him.

For a fun example of how complicated this way of thinking becomes, @WebDevMason condemns the media for over-reporting on fish-tank-man’s death. She points out that that hydroxychloroquine may yet prove effective and become an important part of our arsenal against coronavirus. And when doctors start trying to prescribe it, a big chunk of the US population is going to know it only as “that thing Trump irresponsibly recommended even though it’s an ingredient in fish tank cleaners that kills you if you take it”. And they’re going to freak out and refuse. Might this also cause deaths? Who knows!

So who deserves blame here? Trump, for irresponsibly praising the drug? The media, for irresponsibly condemning Trump for praising the drug? Mason, for irresponsibly condemning the media for condemning Trump for praising the drug? Me, for irresponsibly praising Mason for condemning the media for condemning Trump for praising the drug? Had gadya, had gadya.

The third world

…is in really deep trouble, isn’t it?

The numbers say it isn’t. Less developed countries are doing fine. Nigeria only has 65 cases. Ethiopia, 12 cases. Sudan only has three!

But they probably just aren’t testing enough. San Diego has 337 diagnosed cases right now. The equally-sized Mexican city of Tijuana, so close by that San Diegans and Tijuanans play volleyball over the border fence, has 10. If we assume that the real numbers are more similar (can we assume this?), then Mexico is undercounting by a factor of 30 relative to the US, which is itself undercounting by a factor of 10 or so. This would suggest Mexico has the same number of cases as eg Britain, which doesn’t seem so far off to me (Mexico has twice as many people).

The developing world doesn’t have many ventilators and doesn’t have enough state capacity to enforce self-isolation very effectively. It’s full of very densely packed slums. It has a lot of dictators who like to deny the existence of problems and shoot anyone who keeps insisting a problem exists. It could get really bad.

I worry that nobody has the spare energy to do anything about this. The First World is busy saving itself. Rich countries will probably corner the facemask and ventilator supply. The kind of doctors who go to Doctors Without Borders are probably at home busy saving their countrymen. Everyone else is going to have such a bad time, with few reasons for optimism.

I’m not even sure what concerned people can do. Charities’ usual MO is to divert resources from First World countries to Third World ones, but First World countries are using all their relevant resources and won’t sell for any price – can you imagine trying to export ventilators from the US right now? You’d probably get arrested. Maybe the highest-leverage interventions are figuring out how to repurpose cheap pre-existing material for medical care – face masks made out of paper/cloth/whatever, ventilators out of ???.

Nigeria and Mexico and so on make me confused in the same way as Japan – why aren’t they already so bad that they can’t hide it? If the very poorest countries in sub-Saharan Africa were suffering a full-scale coronavirus epidemic, would we definitely know? In Liberia, only 3% of people are aged above 65 (in the US, it’s 16%). It only has one doctor per 100,000 people (in the US, it’s one per 400) – what does “hospital overcrowding” even mean in a situation like that? I don’t think a full-scale epidemic could stay completely hidden forever, but maybe it could be harder to notice we would naively expect.

How can you help?

Sanjay on the Effective Altruism forum has a post about the best places to donate [to fight] COVID-19. Some of these are long-term work of questionable immediate relevance – the Johns Hopkins Center on Health Security does great work, but I wonder if a donation now just means that they hire some better researchers in six months and produce better policy recommendations next year. Also, I predict biosecurity think tanks won’t be funding-constrained for the immediate future.

Development Media International and Univursa Health are their recommendations for where to donate to help fight coronavirus in the Third World, but as far as I can tell neither organization is publicly doing that yet – they just seem like the kind of organizations that could and will eventually have to.

The writer is not entirely sure you should donate to coronavirus control at all – everyone’s doing it and the field probably has enough funding to pick most low-hanging fruits. Remember that malaria still kills 400,000 people per year (about 20% of the expected coronavirus death toll) but is probably getting a tiny fraction of the funding and attention right now.

Give Directly, previously known for giving cash directly to poor Africans, is now also working on giving cash directly to Americans who are affected by coronavirus. You can read about their program here, and donate here.

The Frontline Responders Fund is working with Silicon Valley logistics company Flexport to try to transport masks and other medical supplies from producers to people who need them. You can read about them here and donate here.

r/CoronavirusArmy is the subreddit for people trying to coordinate various useful virus response projects. There’s the expected massive variation in quality, but some of them could be really helpful.

Worth it

A lot of people are secretly wondering whether preventing the potential damage from coronavirus is really worth shutting down the entire economy for months. You shouldn’t feel ashamed for wondering that. Everyone, including the US government, agrees that it is sometimes worth putting a dollar cost on human life, and there are all sorts of paradoxes and ridiculous behaviors you get trapped in if you refuse to do so.

Some people on this thread on the subreddit have tried to calculate it out, using the government’s value-of-one-life-year figures. There are a lot of variables involved that we can only guess at, but given some reasonable predictions, even at a low value of $30,000 per life-year it’s worth spending trillions of dollars to slow down the epidemic.

I don’t want anyone to feel uncomfortable discussing this, so if you disagree or have different calculations please feel like the comments here are a safe place to talk about it.

But no, You sent us Congress

The Senate mercifully approved a stimulus bill earlier this week. I say “mercifully” because watching the negotiations was painful. I still have no idea which party was Boldly Trying To Provide The American People With Necessary Relief and which one was trying to hold the bill hostage in order to add a wish list of stupid partisan demands.

The narrative I’ve been hearing from Democrats was that they were Boldly Trying To Provide The American People With Necessary Relief by giving loans to nonprofits, and the Republicans held it hostage by hamhandedly adding rules intended to guarantee that none of the loans could go to Planned Parenthood in particular – hamhandedly because the particular fig leaf they used – “no loans to nonprofits receiving Medicaid funding” – also disqualifies anyone else who helps poor people get healthcare.

The narrative I’ve been hearing from Republicans was that they were Boldly Trying To Provide The American People With Necessary Relief by giving loans and money to a broad selection of the American people, and the Democrats held it hostage by trying to make it about all of their pet issues instead. So National Review makes fun of Democratic demands that the package include rules restricting carbon emissions and expanding the bargaining power of unions. (see conservative satire site Babylon Bee for the complete list, YES I KNOW THIS IS FAKE).

But apparently all that got cleared up, and now the bill is under threat from – libertarians! According to the Washington Post, the main holdout in the House of Representatives is a “constitutional libertarian” who’s trying to prevent the House from voting remotely because the Constitution says it shouldn’t.

I have a lot of respect for principled constitutionalists who believe that the nation’s government should occasionally follow the document that they take a solemn oath to protect. But insisting on that now, of all times, seems kind of like closing the barn door after the horse has left, caught a plane to Cape Canaveral, boarded an experimental rocketship, gotten halfway to the Oort Cloud, and also some kind of weird terrorist group is threatening to start a nuclear apocalypse if anyone closes any barn doors. Just let this one go and get back to your noble-yet-quixotic crusade sometime when we’re not all going to die.

Getting it Right

It took the mainstream media a while to realize the seriousness of the coronavirus. The right wing has its own parallel media system, and I’ve heard accusations that it failed even worse, and for longer. I can’t comment on whether this was true at the time, but it seems to have improved; as of me writing this, fox.com, breitbart.com, nationalreview.com, and townhall.com all have front pages full of the same kind of frantic coronavirus news I would expect to see anywhere else. Reddit’s big pro-Trump subreddit r/The_Donald has a sticky thread of “President Trump’s Coronavirus Guidelines For America – 15 Days To Stop The Spread – READ AND FOLLOW”. Even the front page of Infowars urges readers Don’t Be A Covidiot – their term for someone who ignores the danger of coronavirus and doesn’t practice good social distancing.

Still, that was the result of a long battle. Just like on the left, a few prescient right-wingers had to battle to make their friends and colleagues realize the danger. I’ve heard Tucker Carlson deserves special honor for fighting the good fight when the rest of FOX was trying to downplay everything. Steve Bannon and Lindsey Graham also took a hard line and helped their colleagues see reason.

I’m not sure what the role of liberals (here used as a general term encompassing everyone except the hard right) should be in this process. I can only beg us not to mess it up. Calling right-wingers dumb for not getting the point fast enough risks messing it up; it could just make them more stubborn and angry. Also, Trump is the acknowledged world expert at reaching Trump supporters. If he thinks that calling it “the Chinese virus” will convince his xenophobic fans to take it seriously, consider not messing with that.

Short Links

Iceland has finally done what everyone’s been waiting for and tested lots of people to see how many are asymptomatic. They conclude that about half of carriers don’t know they have the disease. If there had been very many more asymptomatic carriers than symptomatic patients, it would have been good news – most cases never show up in the statistics, and all of our estimates of hospitalization rate and mortality rate would be much too high. Although it’s nice to be able to divide all of those by two, a lot of people were hoping we could divide them by ten or a hundred and stop worrying completely. This study suggests we can’t. [EDIT: jgr79 points out a more optimistic interpretation: the testing happened around March 20, when Iceland had 300 reported cases, but detected that 1% of Icelanders were positive, ie 3,000 reported cases. This matches all the other evidence that real cases outnumber diagnosed cases by a factor of 10 or so, and probably does mean we can divide observed mortality rates by that amount. Is everyone already doing this in their models?]

In 1918, people got so tired of containment procedures for the Spanish Flu that concerned citizens started an Anti-Mask League Of San Francisco.

Future of Humanity Institute has put up a dashboard making advanced pandemic modelling software available to the public. They are also also offering pro bono forecasting services to under-resourced groups like hospitals and governments in developing nations). They’ve asked me to help spread the word on this, and I will, but I’d be more comfortable if someone who knows their stuff can confirm it’s net helpful, so please contact me if you consider yourself informed enough to have an opinion on this.

Robin Hanson makes the case for variolation – deliberately exposing people to virus particles at low doses through routes that make the infection less dangerous. This operates as kind of a poor man’s vaccine, giving a very mild case that prevents the person from getting sick in the future. Has worked with many past epidemics (like smallpox), still unknown how to predict how it would work for this one.

Hall of shame: Bangladesh (where 25,000 people have gathered for a mass prayer rally against the coronavirus – if only the New Atheists were still around to offer opinions on this kind of thing). Mississippi, as usual (see this comment by an MS Redditor). Russia, as usual. Donald Trump is a permanent lifetime member at this point. The FDA is also probably a permanent lifetime member.

Last links post I included tech company Triplebyte in the shame list for refusing to let employees switch to work-from-home, then firing them. A representative of Triplebyte contacted me and asked me to explain their perspective, which is that they took the pandemic seriously and went all-remote around the same time as everyone else. The reluctance to let employees switch to work-from-home applied only to a few employees in early March, before the scale of the crisis was widely appreciated, and they say that they would have tried to make accommodations if they had understood the seriousness of the requests. They had been planning the downsizing for a while, it was really unlucky that it ended up in the middle of a pandemic, and they tried to make it as painless as possible by offering good severance pay, etc. I’m relaying their statement because I’m realizing it was probably unfair of me to single them out in particular – my hearing a lot about this was downstream of my having a lot of friends who work(ed) for Triplebyte, and my having a lot of friends who work(ed) for Triplebyte was downstream of them being a great company doing important work which all my friends wanted to work for. I continue to generally respect them and their vision (see here for more), and you don’t need to give them any more grief over it than they’re already getting.

Hall of fame: Service Employees International Union (“found” 40 million face masks and is donating them to local hospitals; what does it even mean to “find” this many masks in this context?), and Amazon (now giving workers double pay for overtime). And Brazilian gangs, in the face of government inaction, declared a unilateral quarantine order in Rio de Janeiro, saying “If the government won’t do the right thing, organized crime will”. I deeply appreciate the commentator who described this as “state capacity anarcho-capitalism”.

Face Masks: Much More Than You Wanted To Know

There’s been recent controversy about the use of face masks for protection against coronavirus. Mainstream sources, including the CDC and most of the media say masks are likely useless and not recommended. They’ve recently been challenged, for example by Professor Zeynep Tufekci in the New York Times and by Jim and Elizabeth on Less Wrong. There was also some debate in the comment section here last week, so I promised I’d look into it in more depth.

As far as I can tell, both sides agree on some points.

They agree that N95 respirators, when properly used by trained professionals, help prevent the wearer from getting infected.

They agree that surgical masks help prevent sick people from infecting others. Since many sick people don’t know they are sick, in an ideal world with unlimited mask supplies everyone would wear surgical masks just to prevent themselves from spreading disease.

They also agree that there’s currently a shortage of both surgical masks and respirators, so for altruistic reasons people should avoid hoarding them and give healthcare workers first dibs.

But they disagree on whether surgical masks alone help prevent the wearer from becoming infected, which will be the focus of the rest of this piece.

1. What are the theoretical reasons why surgical masks might or might not work?

Epidemiologists used to sort disease transmission into three categories: contact, droplet, and airborne. Contact means you only get a disease by touching a victim. This could be literally touching them, or a euphemism for very explicit contact like kissing or sex. Droplet means you get a disease when a victim expels disease-laden particles into your face, usually through coughing, sneezing, or talking. Airborne means you get a disease because it floats in the air and you breathe it in. Transmission via “fomites”, objects like doorknobs and tables that a victim has touched and left their germs on, is a bonus transmission route that can accompany any of these other methods.

More recently, scientists have realized that droplet and airborne transmission exist along more of a spectrum. Droplets can stay in the air for more or less time, and spread through more or less volume of space before settling on the ground. The term for this new droplet-airborne spectrum idea is “aerosol transmission”. Diseases with aerosol transmission may be spread primarily through droplets, but can get inhaled along with the air too. This concept is controversial, with different authorities having different opinions over which viruses can be aerosolized. It looks like most people now believe aerosol transmission is real and applicable to conditions like influenza, SARS, and coronavirus.

Surgical masks are loose pieces of fabric placed in front of the mouth and nose. They offer very good protection against outgoing droplets (eg if you sneeze, you won’t infect other people), and offer some protection against incoming droplets (eg if someone else sneezes, it doesn’t go straight into your nose). They’re not airtight, so they offer no protection against airborne disease or the airborne component of aerosol diseases.

Respirators are tight pieces of fabric that form a seal around your mouth and nose. They have various “ratings”; N95 is the most common, and I’ll be using “N95 respirator” and “respirator” interchangably through most of this post even though that’s not quite correct. When used correctly, they theoretically offer protection against incoming and outgoing droplet and airborne diseases; since aerosol diseases are a combination of these, they offer generalized protection against those too. Hospitals hate the new “aerosol transmission” idea, because it means they probably have to switch from easy/cheap/comfortable surgical masks to hard/expensive/uncomfortable respirators for a lot more diseases.

Theory alone tells us surgical masks should not provide complete protection. Coronavirus has aerosol transmission, so it is partly airborne. Since surgical masks cannot prevent inhalation of airborne particles, they shouldn’t offer 100% safety against coronavirus. But theory doesn’t tell us whether they might not offer 99% safety against coronavirus, and that would still be pretty good.

2. Are people who wear surgical masks less likely to get infected during epidemics?

It’s unethical to randomize people to wear vs. not-wear masks during a pandemic, so nobody has done this. Instead we have case-control studies. After the pandemic is over, scientists look at the health care workers who did vs. didn’t get infected, and see whether the infected people were less likely to wear masks. If so, that suggests maybe the masks helped.

This is an especially bad study design, for two reasons. First, it usually suffers recall bias – if someone wore a mask inconsistently, then they’re more likely to summarize this as “didn’t wear masks” if they got infected, and more likely to summarize it as “did wear masks” if they stayed safe. Second, probably some nurses are responsible and do everything right, and other nurses are irresponsible and do everything wrong, and that means that if anything at all helps (eg washing your hands), then it will look like masks working, since the nurses who washed their hands are more likely to have worn masks. Still, these studies are the best we can do.

Gralton & McLaws, 2010 reviews several studies of this type, mostly from the SARS epidemic of the early 2000s. A few are underpowered and find that neither surgical masks nor respirators prevent infection (probably not true). A few others show respirators prevent infection, but do not investigate surgical masks (probably right, but useless for our purposes). Two seem relevant to the question of whether surgical masks work:

Rapid awareness and transmission of SARS in Hanoi French Hospital, Vietnam was conducted in a poor hospital that only had surgical masks, not respirators. In the latter stages of the epidemic, 4 workers got sick and 26 stayed healthy. It found that 3 of the 4 sick workers hadn’t been wearing masks, but only 1 of the 26 healthy workers hadn’t. This is a pretty dramatic result – subject to the above confounders, of course.

Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of SARS is larger and more prestigious, and looked at a cluster of five hospitals. Staff in these hospitals used a variety of mask types, including jury-rigged paper masks that no serious authority expects to work, surgical masks, and N95 respirators. It found that 7% of paper-mask-wearers got infected, compared to 0% of surgical-mask and respirator wearers. This seems to suggest that surgical masks are pretty good.

The meta-analysis itself avoided drawing any conclusions at all, and would not even admit that N95 respirators worked. It just said that more research was needed. Still, the two studies at least give us a little bit of evidence in surgical masks’ favor.

How concerned should we be that these studies looked at health care workers specifically? On the one hand, health care workers are ordinary humans, so what works for them should work for anyone else. On the other, health care workers may have more practice using these masks, or may face different kinds of situations than other people. Unlike respirators, surgical masks don’t seem particularly hard to use, so I’m not sure health care workers’ training really gives them an advantage here. Overall I think this provides some evidence that surgical masks are helpful.

I was able to find one study like this outside of the health care setting. Some people with swine flu travelled on a plane from New York to China, and many fellow passengers got infected. Some researchers looked at whether passengers who wore masks throughout the flight stayed healthier. The answer was very much yes. They were able to track down 9 people who got sick on the flight and 32 who didn’t. 0% of the sick passengers wore masks, compared to 47% of the healthy passengers. Another way to look at that is that 0% of mask-wearers got sick, but 35% of non-wearers did. This was a significant difference, and of obvious applicability to the current question.

3. Do surgical masks underperform respirators in randomized trials?

Usually it would be unethical to randomize health care workers to no protection, so several studies randomize them to face masks vs. respirators. But a few others were done in foreign hospitals where lack of protection was the norm, and these studies did include a no-protection control group.

MacIntyre & Chugtai 2015, Facemasks For The Prevention Of Infection In Healthcare And Community Settings, reviews four of these. Two of the four are unable to find any benefit of either masks or respirators. The third finds a benefit of respirators, but only if nobody tested the respirators to see if they fit, which doesn’t make sense and suggests it’s probably an artifact. The fourth finds a benefit of respirators, but not masks. It seems unlikely that respirators don’t help, so this suggests all these studies were underpowered. If we throw good statistical practice to the winds and just look at the trends, they look like this:

In other words, respirators are better than masks are better than nothing. It would be wrong to genuinely conclude this, because it’s not statistically significant. But it would also be wrong to conclude the studies show masks don’t work, because they mostly show respirators don’t work, and we (hopefully) know they do.

Overall these studies don’t seem very helpful and I’m reluctant to conclude anything from them. In section 6, I’ll talk more about why studies may not have shown any advantage for respirators.

4. Do surgical masks prevent ordinary people from getting infected outside the healthcare setting?

The same review lists nine randomized trials with a different design: when the doctor diagnoses you with flu, she either asks everyone in your family to wear masks (experimental group), or doesn’t do that (control group), and then checks how many family members in each group got the flu.

How did these go? That depends whether you use intention-to-treat or per-protocol analysis. Intention-to-treat means that you just compare number of infections in the assigned-to-wear-masks group vs. the control group. Per-protocol means that you only count someone in the study if they actually followed directions. So if someone in the assigned-to-wear mask group didn’t wear their mask, you remove them from the study; if someone in the control group went rogue and did wear a mask, you remove them too.

Both of these methods have their pros and cons. Per protocol is good because if you’re trying to determine the effect of wearing a mask, you would really prefer to only be looking at subjects who actually wore a mask. But it has a problem: adherence to protocol is nonrandom. The people who follow your instructions diligently are selected for being diligent people. Maybe they also diligently wash their hands, and diligently practice social distancing. So once you go per protocol, you’re no longer a perfect randomized controlled trial. Only intention-to-treat analyses carry the full weight of a gold standard RCT.

According to intention-to-treat, the studies unanimously found masks to be useless. But there were a lot of signs that intention-to-treat wasn’t the right choice here. Only about a fifth of people who were asked to wear masks did so with any level of consistency. The rest wore the mask for a few hours and then get bored and took it off. Honestly, it’s hard to blame them; these studies asked a lot from families. If a husband has flu, and sleeps in the same bed as his wife, are they both wearing masks all night?

Of the three studies that added per-protocol analyses, all three found masks to be useful (1, 2, 3) . Does this prove masks work? Not 100%; per-protocol analyses are inherently confounded. But it sure is suggestive.

The review author summarizes:

The routine use of facemasks is not recommended by WHO, the CDC, or the ECDC in the community setting. However, the use of facemasks is recommended in crowded settings (such as public transport) and for those at high risk (older people, pregnant women, and those with a medical condition) during an outbreak or pandemic. A modelling study suggests that the use of face-masks in the community may help delay and contain a pandemic, although efficacy estimates were not based on RCT data. Community masks were protective during the SARS outbreaks, and about 76% of the population used a facemask in Hong Kong.

There is evidence that masks have efficacy in the community setting, subject to compliance [13] and early use [12, 18, 19]. It has been shown that compliance in the household setting decreases with each day of mask use, however, which makes long term use over weeks or months a challenge […]

Community RCTs suggest that facemasks provide protection against infection in various community settings, subject to compliance and early use. For health-care workers, the evidence suggests that respirators offer superior protection to facemasks.

Parts of this summary are infuriating. If the big organizations recommend that especially vulnerable groups wear masks, aren’t they admitting masks work? But if they’re admitting masks work, why don’t they recommend them for ordinary people?

It looks like they’re saying masks work a little, they’re too annoying for it to be worth it for normal people, but they might be worth it for the especially vulnerable. But then why don’t they just say masks work, and let each person decide how much annoyance is worthwhile? I’m not sure. But it looks like the author basically ends up in favor of community use of surgical masks in a pandemic, mostly on the basis of per-protocol analyses of community RCTs.

5. How do surgical masks and respirators compare in hokey lab studies?

Our source here is Smith et al 2016, Effectiveness Of N95 Respirators Versus Surgical Masks In Protecting Health Care Workers From Acute Respiratory Infection: A Systematic Review And Meta-Analysis. They review some of the same studies we looked at earlier, but then investigate 23 “surrogate exposure studies”, ie throwing virus-shaped particles at different masks in a lab and seeing if they got through. You can find the results of each in their appendix. Typically, about 1 – 5% of particles make it through the respirator, and 10 – 50% make it through the surgical mask. They summarize this as:

In general, compared with surgical masks, N95 respirators showed less filter penetration, less face-seal leakage and less total inward leakage under the laboratory experimental conditions described.

I think in general the fewer virus particles get through your mask, the better, so I think this endorses surgical masks as better than nothing, since their failure rate was less than 100%.

Booth et al, 2013 examines surgical masks themselves more closely. They hook a surgical mask up to “a breathing simulator” and then squirt real influenza virus at it, finding that:

Live influenza virus was measurable from the air behind all surgical masks tested. The data indicate that a surgical mask will reduce exposure to aerosolised infectious influenza virus; reductions ranged from 1.1- to 55-fold (average 6-fold), depending on the design of the mask…the results demonstrated limitations of surgical masks in this context, although they are to some extent protective.

The paper doesn’t discuss how particle number maps to infection risk. Does letting a single influenza virus through mean you will get infected? If so, any reduction short of 100% is useless. I have a vague sense that this isn’t true; your immune system can fight off most viruses, and the fewer you get, the better the chance it will win. Also, even respirators don’t claim to reduce particle load by more than 99% or so, and those work, so it can’t be that literally a single virus will get you. Overall I think modest reductions in particle number are still pretty good, but I don’t have a study that proves it.

6. Is it true that the public won’t be able to use N95 respirators correctly?

Yes.

I remember my respirator training, the last time I worked in a hospital. They gave the standard two minute explanation, made you put the respirator on, and then made you go underneath a hood where they squirted some aerosolized sugar solution. If you could smell the sugar, your respirator was leaky and you failed. I tried so hard and I failed so many times. It was embarrassing and I hated it.

I’m naturally clumsy and always bad at that kind of thing. Some people were able to listen to the two minute explanation and then pass right away. Those kinds of people could probably also listen to a two minute YouTube explanation and be fine. So I don’t want to claim it’s impossible or requires lots of specialized background knowledge. It’s just a slightly difficult physical skill you have to get right.

Bunyan et al, 2013, Respiratory And Facial Protection: A Critical Review Of Recent Literature, discusses this in more depth. They review some of the same studies we reviewed earlier, showing no benefit of N95 respirators over surgical masks for health care workers in most situations. This doesn’t make much theoretical sense – the respirators should win hands down.

The most likely explanation is: doctors aren’t much better at using respirators than anyone else. In a California study of tuberculosis precautions, 65% of health care workers used their respirators incorrectly. That’s little better than the general public, who have a 76% failure rate. Bunyan et al note:

The fitting of N95 respirators has been the subject of many publications. The effective functioning of N95 respirators requires a seal between the mask and the face of the wearer. Variation in face size and shape and different respirator designs mean that a proper fit is only possible in a minority of health care workers for any particular mask. Winter et al. reported that, for any one of three widely used respirators, a satisfactory fit could be achieved by fewer than half of the healthcare workers tested, and for 28% of the participants none of the masks gave a satisfactory fit.

Fit-testing is a laborious task, taking around 30 min to do properly, and comprises qualitative fit-testing (testing whether the respirator-wearing healthcare worker can taste an intensely bitter or sweet substance sprayed into the ambient air around the outside of the mask) or quantitative fit testing (measuring the ratio of particles in the air inside and outside the breathing zone when wearing the respirator). Attempts have been made to circumvent the requirement for fit testing, and it has been suggested that self-testing for a seal by the respirator wearer (see http://youtu.be/pGXiUyAoEd8a for a video demonstration) is a sufficient substitute for fit-testing. However, self-checking for a seal has been demonstrated to be a highly unreliable technique in two separate studies so that full fit-testing remains a necessary preliminary requirement before respirators can be used in the healthcare setting.

Operationally, this presents significant challenges to organizations with many healthcare workers who require fit-testing. Chakladar et al. pointed out that, in addition to the routine need for repeat testing over time to ensure that changes in weight or facial hair have not compromised a good fit, movements of healthcare workers between organizations using different makes of respirators would necessitate additional repeat fit-testing. Fit-testing is likely to remain problematic to health-care organizations for the foreseeable future. In addition to the requirement for fit-testing, ‘fit-checking’ is also required each time the respirator is donned to ensure there are no air leaks.

Is a poorly-fitting N95 respirator better than nothing? The reviewed studies suggest that at that point it’s just a very fancy and expensive surgical mask.

7. Were the CDC recommendations intentionally deceptive?

No, and I owe them an apology here.

I think the evidence above suggests masks can be helpful. Masked health care workers were less likely to catch disease than unmasked ones. Masked travelers on planes were less likely to catch disease than unmasked ones. In per protocol analysis, masked family members are less likely to catch disease from an index patient than unmasked ones. Laboratory studies confirm that masks block most particles. All of this accords with a common-sense understanding of droplet and aerosol transmission of disease.

None of these, except maybe the plane study, tell us exactly what we want to know. The SARS studies were all done in a health care setting, so they don’t prove that regular people can benefit from masks. But health care workers are closely related to homo sapiens and ought to have similar anatomy and physiology. Surgical masks aren’t as complicated as respirators and we can assume most people get them right. And although health care workers are in unusually high-risk situations, that should just affect the magnitude of the benefit, not the sign; obviously the level of risk ordinary people encounter is sometimes relevant, considering they do often catch pandemic diseases. So our default assumption should be that these studies carry over, not that they don’t.

Likewise, most of the community studies were done on family members. Most guidelines already say to mask up if you have a sick family member, so talking about subways and crowds requires a little bit of extrapolation. But again, being in a family is just one form of close contact. It would take bizarre convolutions to even imagine a theory where you can catch diseases from your family members but not from people you sit next to on a train. Our default assumption should be in favor of these results generalizing, not against them.

But the CDC has recommended against mask use. I hypothesized that the CDC was intentionally lying to us, trying to trick us into not buying masks so there would be enough for health care workers.

But that can’t be true, because the CDC and other experts came up with their no-masks policy years ago, long before there was any supply shortage. For example, during the 2009 swine flu pandemic, their website offered the following table:

And during the 2015 MERS epidemic, NPR said South Koreans were wrong to wear masks:

Masks can be helpful for protecting health workers from a variety of infectious diseases, including MERS…

But either type of mask is less likely to do much good for the average person on the street…Wearing a mask might make people feel better. After all, MERS has killed about a third of the people known to be infected.

But there are no good studies looking at how well these masks prevent MERS transmission out in the community, says Geeta Sood, an infectious disease specialist at Johns Hopkins University. “On the street or the subway, for MERS specifically, they’re probably not effective,” she says. One problem is that the masks are loose fitting, and a lot of tiny airborne particles can get in around the sides of the masks.

So if studies generally suggest masks are effective, and the CDC wasn’t deliberately lying to us, why are they recommending against mask use?

I’m not sure. I haven’t been able to track down any documents where they discuss the reasons behind their policies. It’s possible they found different studies than I did, or interpreted the studies differently, or have some other superior knowledge.

But I think that more likely, they’re trying to do something different with medical communication. Consider legal communication. If a court declares a suspect is “not guilty”, that could mean that he is actually not guilty of the crime. Or it could mean that he did it but they can’t prove it. Or it could mean that he did it, they can prove it, but the police officer who found the proof didn’t have a warrant at the time so they had to throw it out. A legal communication like “this man is not guilty” is intended not just to convey information, but to formally reflect the output of a sacrosanct process.

Medicine has been traumatized by its century-long war with quackery, and ended up with its jargon also formally reflecting the output of a sancrosanct process. Remember, there are dozens of studies supposedly showing homeopathy works, not to mention even more studies proving telepathy exists. At some point you have to redesign all your institutions to operate in an environment of epistemic learned helplessness, and the result is very high standards of proof.

Masks haven’t quite reached these standards. The case-control trials look good, and the per-protocol RCTs look good, but there aren’t really the large-scale intention-to-treat RCTs that would be absolutely perfect. Even if these studies work, they only prove things about the health care setting and the family setting, not “the community setting” in general. So masks haven’t been proven to work beyond a reasonable doubt. Just like the legal term for “not proven guilty beyond a reasonable doubt” is “not guilty”, the medical communication term for “not proven effective beyond a reasonable doubt” is “not effective”. This already muddled communication gets even worse because doctors are constitutionally incapable of distinguishing “no evidence for” from “there is evidence against” – I have no explanation for this one.

There’s an even more complicated language-use issue. The CDC may be thinking of its recommendations not just as conveying an opinion but as taking an action – performing the medical intervention of recommending people wear masks. All of those RCTs listed above show that the medical intervention of recommending people wear masks is ineffective. Sure, that’s because people don’t listen. But the CDC doesn’t care about that. They’ve proven that giving the advice won’t help, why are you still asking them to give the advice?

I’m not sure this is really the CDC’s reasoning. It seems pretty weird from the point of view of an organization trying to manage a real-world pandemic with people dying if they get it wrong. But I’m having trouble figuring out other possibilities that make sense.

8. So should you wear a mask?

Please don’t buy up masks while there is a shortage and healthcare workers don’t have enough.

If the shortage ends, and wearing a mask is cost-free, I agree with the guidelines from China, Hong Kong, and Japan – consider wearing a mask in high-risk situations like subways or crowded buildings. Wearing masks will not make you invincible, and if you risk compensate even a little it might do more harm than good. Realistically you should be avoiding high-risk situations like subways and crowded buildings as much as you possibly can. But if you have to go in them, yes, most likely a mask will help.

In low-risk situations, like being at home or taking a walk, I mean sure, a mask might make you 0.0001% (or whatever) less likely to get infected. If that’s worth it to you, consider the possibility that you might be freaking out a little too much about this whole pandemic thing. If it’s still worth it, go for it.

You are unlikely to be able to figure out how to use an N95 respirator correctly. I’m not saying it’s impossible, if you try really hard, but assume you’re going to fail unless you have some reason to think otherwise. The most likely outcome is that you have an overpriced surgical mask that might make you incorrectly risk-compensate.

If you are a surgeon performing surgery, bad news. It turns out surgical masks are not very useful for you (1, 2)! You should avoid buying them, since doing so may deplete the number available for people who want to wear them on the subway.

Open Thread 150

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. Also:

1. Thanks to Jeremiah for his work on the SSC podcast. Going forward, the podcast will be run by Solenoid Entity.

2. All in-person SSC meetups are cancelled indefinitely, for obvious reasons. There will be a videochat meetup at 17:00 UTC on March 24, run by Joshua Fox and Less Wrong Israel. See here for more information and how to sign up.

3. There were some great comments on the Hoover book review, for example this thread comparing Hoover to Robert Moses.

And economist Scott Sumner, an expert on the Great Depression, wrote a great post explaining exactly how Hoover was vs. wasn’t to blame.

And a few people linked me to this review by Adam Cadre of a different Hoover biography. It’s generally great, but what really blew me away was this answer to one of the questions I asked on my post – why was Hoover so good at international relief, but so reluctant to relieve his own country?:

Many wondered why Hoover, who had made his name dealing with hunger crises overseas, did so little about the one that unfolded in his own country during his presidency.  One columnist growled that “the only mistake [the] starving unemployed of this country have made is that they did not march on Washington and under the windows of Mr. Hoover in the White House display banners reading, ‘We are Belgians!'”  A senator expressed disbelief that Hoover would happily feed “hungry Russians, hungry Bolsheviks, hungry men with long whiskers and wild ideas”, but not starving Americans. 

But Herbert Hoover believed in American exceptionalism.  It made sense to him that people in places like Belgium and Russia might find themselves starving and in desperate need of help, for they did not hold to the tenets of American individualism, and so it was only to be expected that their inferior philosophies would lead them into dire straits.  But that couldn’t happen in America. It just couldn’t.

The surest sign that I accomplished what I wanted with the book review was that a few days later, when some people on Twitter were comparing Trump’s coronavirus response to Herbert Hoover, more knowledgeable people pointed out that this was wrong: Hoover is exactly who we would want leading the response right now!

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Coronalinks 3/19/20

As before, feel free to treat this as an open thread for all coronavirus-related issues. Everything here is speculative and not intended as medical advice.

How many real cases?

As of today, the US has almost 10,000 official cases. How many real cases per official case?

One epidemiologist says 8x. In this US News article, scientists estimate 9000 true cases back when the official count was 600, suggesting 15x, and BBC estimates 10,000 real cases in the UK to 500 official ones, suggesting 20x. A study in Science (article, paper) estimates 86% are undetected, for about 7x. So it seems like most people are converging around 5 – 20.

Probably this number is different in every country, depending on their test rates. You’re probably all already following the map of cases per country, but you can supplement with this map of how many tests each country is running per million people (h/t curryeater259 from the subreddit)

What about the evidence from famous people? If only 100,000 Americans are infected, it’s pretty weird that it would hit both Tom Hanks and Idris Elba (also, Tormund from Game of Thrones). The Atlantic makes this case more formally. Given that Iran’s vice-president is affected, what are the chances that only 1/12,000 of Iranians had the virus? Some people calculated it out and found that hundreds of thousands of Iranians must be affected for the prevalence among politicians to make sense, suggesting ratios of 100x or even 1000x.

I’m skeptical. Famous people travel a lot and shake a lot of hands. And they mostly interact with other famous people, forming their own little “compartment” where the epidemic can be worse than in other societies. I think it’s more likely that Hollywood actors and Iranian politicians have 100x higher risk than their host population, than that epidemiologists are wrong about the size of the epidemic by orders of magnitude.

We still don’t have an endgame

A brief flurry of interest last week as the UK seemed to be trying a different strategy from everyone else – isolating their oldest and most vulnerable citizens, but letting everyone else get the virus to build herd immunity. They’ve since backtracked after people did the math and found that an epidemic even among healthy young people only would overwhelm their medical system. Here’s another critique of herd immunity, appropriately enough on UnHerd.com.

But the UK’s original point – that without herd immunity, all we can do is continue the lockdown until something happens – remains sound and worrying. Everyone is hoping for a quick vaccine or antiviral, but this is a field where “quick” sometimes means months or years instead of decades. If we don’t get a deus ex machina, eventually somebody will need to implement some long-term strategy.

Last week I predicted that this might look like titrating quarantine levels – locking everything down, then trying to unlock it just enough to use available medical capacity, then locking things down more again if it looked like the number of cases was starting to get out of hand. This would eventually develop herd immunity without overwhelming the medical system. A paper yesterday out of Imperial College London (discussed here) said the same thing, arguing for alternating periods of higher and lower quarantine levels based on how the medical system was doing:

The orange line is projected ICU cases. The blue line is government-mandated social distancing levels. Relax social distancing levels, then after ICU cases cross some threshold, reinstate them again. That way at least we can have a few weeks of normal economic activity and seeing friends in between each lockdown. Control systems are the solution to everything!

Problem: it would take forever to develop herd immunity under this system, and we might just have to keep turning quarantine on and off for a year or two until a vaccine gets developed. Does anyone have any better ideas?

The closest thing I’ve heard is “what China and South Korea are doing”, which seems to be having so many tests available, and such good health services, that it’s easy to detect cases, track down their contacts, and manage the epidemic even while life goes on mostly as usual. So maybe the end date isn’t “have a vaccine available”, it’s “have millions of test kits available”, which I think looks more like a few months than like years and years.

Flatten the curve

Is flattening the curve just another name for the “have a control system to titrate lockdown levels so that only the right number of people get it at a time” strategy? Maybe everyone just assumes that we’re never going to get the cases down to too low a level, so we should try to get them as low as possible and maybe hit the right amount? And overshooting and reducing it so far that you’re not using the medical capacity you have, and wasting an opportunity to have a normal life and/or build herd immunity, is just really unlikely without China-level resources?

An article called Flattening The Curve Is A Deadly Delusion has been going around this part of the Internet, saying that there’s basically no way to match a curve of any flatness with our current hospital capacity. Nostalgebraist says the math is wrong, mostly because it uses a normal distribution when it should use an exponential one. But I’ve seen some other people making this basic point now, so it could just a be a question of how bad things get, rather than whether they’ll be bad at all.

Do you just have the flu?

Courtesy of Popular Science:

Don’t use aspirin

Doctors in Germany and France are saying that a suspicious number of young coronavirus patients who end up in the ICU took aspirin or other anti-inflammatory drugs (Advil, Motrin, Aleve, ibuprofen, diclofenac, etc, yes I know several of these are the same drug, I’m trying to inform readers) before getting worse. There’s a plausible biological mechanism; anti-inflammatories dial down the immune system. BMJ agrees: Ibuprofen should not be used for managing symptoms, say doctors and scientists. Tylenol, acetaminophen, or paracetamol (YES, I KNOW) is still okay, so use that for coronavirus-induced fever.

[EDIT: WHO is skeptical, but French and German doctors stick to their guns. It seems like there’s a longstanding debate on this with the French and German medical establishment thinking it’s bad for lots of diseases, and most of the rest of the world not believing them. I have no strong beliefs about whether France/Germany or everyone else is better, but switching from Motrin to Tylenol in this case seems pretty low cost]

Ventilation

An anonymous reader writes:

Idea: for collective transport like buses and trains around the world, if they are still operating, then keep the windows open.

Actionable proposal: quickly evaluate whether this makes sense, then if it does organize somebody to communicate with relevant parts of governments and transport authorities in different countries and cities and urge them to implement, maybe first get an official looking letter that some prestigious sounding expert has signed to the effect that this seems like a good idea.

(Disclaimer: I haven’t done any due diligence or critical assessment of this idea, just firing from the hip. I heard of some study that showed somebody caught the virus on a bus from an infection person who left the bus 30 mins earlier and the two had not touched any of the same surfaces – this plus my intuitive model suggests that better ventilation could help significantly in these settings, and it would not cost anything and it would not impede any normal activities)

I’m also not sure how leaving windows open would interact with infections that spread by aerosol, but some places like Israel already seem to be trying this.

Ventilation, part 2

Right now the biggest bottleneck to treating coronavirus is likely shortage of ventilators and oxygen concentrators. Many people are trying to come up with ideas for solving the shortage. EndCoronavirus.Org is trying to get a team together, and is looking for doctors, engineers – and of course lawyers, to jump over the inevitable regulatory hurdles.

Meanwhile, at least according to Breitbart, existing ventilator manufacturers are just…not bothering to ramp up production yet? Does this make sense to anyone else? According to Forbes, ventilator manufacturers could quintuple capacity over the next few months, but…nobody has asked them to?…and they don’t want to take the initiative until somebody asks? Economists are begging the US government to ask, and maybe to ensure that every ventilator they make will get bought no matter what the circumstances are a few months from now – if they can’t, maybe private philanthropists should step in? Kudos to the UK government, which has just sent ventilator blueprints to a bunch of manufacturers and told them to get to work. But even if this comes through, how are we going to get enough skilled labor to ventilate this many people? [EDIT: As per WSJ, ventilator manufacturers are now ramping up production].

Also in medical supply news – when a hospital runs out of a critical $11,000 part and the manufacturer can’t supply more, a local guy with a 3D printer prints one up for $1. Now he’s being threatened with a lawsuit by the manufacturer. [EDIT: possibly not true or exaggerated, see here] This whole epidemic has been a fun adventure in “newspapers finally paying attention to what everything in health care is like all the time.”

Ventilation, part 3

When doctors need to ventilate someone in an emergency and don’t have time to hook them up to a real ventilator, they use manual ventilation, ie “bag and mask ventilation”, a really simple technique using a $30 piece of equipment which is literally just a bag attached to a face mask. Somebody squeezes the bag in a breathing-like rhythm, sending air into the person’s lungs until they’re able to get on a real ventilator. It’s not perfect but it saves lives.

In a New York Times article on the expected upcoming ventilator shortage, they say:

One doctor wondered if they could recruit enough volunteers to manually ventilate patients — which involves squeezing a small inflatable device by hand — indefinitely.

I know nothing about respiratory medicine, and I guess I always assumed that there were issues with bag-mask ventilation which made it unsuitable for longer than the few-minute-period it usually gets used for. If that’s not true, and the limiting factor is just getting enough people to keep squeezing the little bag, then surely our civilization can come up with some sort of automatic squeezing machine, right?

[EDIT: some discussion of why this may not work here and here.]

Come summer

The smart people seem to be going back and forth on whether the coronavirus might die down in summer like a seasonal flu. The good news is that this has sparked more interest in the absolutely fascinating field of disease seasonality:

Except in the equatorial regions, respiratory syncytial virus (RSV) is a winter disease, Martinez wrote, but chickenpox favors the spring. Rotavirus peaks in December or January in the U.S. Southwest, but in April and May in the Northeast. Genital herpes surges all over the country in the spring and summer, whereas tetanus favors midsummer; gonorrhea takes off in the summer and fall, and pertussis has a higher incidence from June through October. Syphilis does well in winter in China, but typhoid fever spikes there in July. Hepatitis C peaks in winter in India but in spring or summer in Egypt, China, and Mexico. Dry seasons are linked to Guinea worm disease and Lassa fever in Nigeria and hepatitis A in Brazil.

Their explanation for why we don’t know more about this:

“It’s an absolute swine of a field,” says Andrew Loudon, a chronobiologist at the University of Manchester. Investigating a hypothesis over several seasons can take 2 or 3 years. “Postdocs can only get one experiment done and it can be a career killer,”

As for the coronavirus itself? Unclear. The latest study says it might be seasonal, but a lot of comments on it point out continuing epidemics in tropical countries like Malaysia (currently 900 official cases). If your hometown isn’t going to get warmer this summer than Kuala Lumpur is right now (95 degrees at time of writing), you may not quite be off the hook.

John Ioannidis says we need better data

I mean, of course John Ioannidis would say that, he says that about everything. But his column in Stat News is actually pretty interesting. He points out that our mortality rate statistics use diagnosed cases as a denominator, and (as mentioned above) we barely have a clue what the real-case-to-diagnosed-case ratio is. Based on his calculations, the confidence intervals for the mortality rate are so wide that it could still be lower than the average seasonal flu (he’s not saying this is definitely true or even plausible, just a possibility). He calls for testing of a random sample of the population to help pin down better numbers.

Hail the Bay

I’m usually pretty harsh on Bay Area governments here. So I want to give credit where credit is due: they’ve reacted to the coronavirus epidemic with a level of swiftness and ferocity they usually reserve for attempts to build new housing. While New York and Seattle dither, the Bay Area (despite having fewer cases than either) has instituted a shelter-in-place order, essentially banning people from non-essential leaving the house. I think they’re the only people here who are going to come off looking really good in the history books (and hint to the 2024 DNC, SF Mayor London Breed looks pretty presidential right now). Most of the people I talk to (including patients from all slices of life) are cooperating enthusiastically and feel well-taken-care-of.

I’m even willing to give California state government a little credit. For the past week, most of the organizations that usually try to thwart me have instead been working to make my job easier. The state’s medical board usually puts onerous restrictions on telepsychiatry – for example, before you can prescribe a telepsych patient a controlled substance, you either have to meet them in person once or get a signed note from a doctor who has. Now they’ve lifted all of those and made video appointments a lot easier.

And the same is true of local businesses. I have never used the words “flexibility” and “insurance companies” in the same sentence before, but they have been positively pleasant to work with this past week as I try to navigate the difficulties of switching everybody to video appointments ASAP.

My contacts in tech mostly say the same thing about their own workplaces. Most of my rationalist friends self-isolated really early, before it was socially acceptable to do so, and their tech company employers kind of rolled their eyes but agreed to let them work from home. I know Google switched to work-from-home only long before the government mandated they do so, and I think the other big companies were also really on top of this.

Hall of shame goes to Triplebyte, which forced its employees to work from the office well into the epidemic, then fired a fifth of them without warning. The rumor is that it had planned the downsizing for a while, wanted the employees to be in the office to hear about it in person, and didn’t care how much risk it had to expose the soon-to-be-ex-employees to in order to make it happen. Not cool, and I’ve cancelled my Triplebyte affiliate link in protest. GameStop is also getting in trouble for staying open and requiring employees to bring their own sanitary wipes. And although Tesla originally got in trouble after Elon Musk dismissed concern as dumb, Musk has since claimed he will repurpose his factories to make ventilators if needed, so I will refrain from criticizing him until I’m sure we don’t all end up owing him our lives.

Short links

Chinese anti-coronavirus propaganda banners. “Visiting friends and relatives is mutual slaughter”, “Everyone you encounter on the street is a wild ghost seeking to take your life.” Thinking of getting a “Those who come visit you are enemies” banner for after the virus dies down, just so people know where I stand on social events.

It’s not a real global disaster until hordes of ravenous wild monkeys terrorize cities.

The current death toll of the coronavirus is negative fifty thousand, although the article is out of date and it may have risen to more like negative forty thousand by now.

In the last coronavirus links post, I suggested that the guidance against wearing masks seemed like more of a Noble Lie intended to prevent hoarding than good science. A Less Wrong post gave more information and expanded the case, and now it’s in The New York Times: Why Telling People They Don’t Need Masks Backfired. And notice the wording! It’s not newsworthy that the government deceived us, it’s newsworthy that the deception didn’t achieve its intended goal.

California governor Gavin Newsom responded to the coronavirus in a very California way: by shutting down all large gatherings of 250 people except Disneyland. A few days later, Disneyland closed anyway.

US: all nonessential public gatherings are banned. France: “More than 3,500 Smurf cosplayers gathered over the weekend in an attempt to break the Guinness World Record for the largest group of people dressed as Smurfs.” Also: “Mayor Patrick Leclerc defended the decision to hold the event, which he said was necessary to alleviate the “ambient gloom” around the country. “We must not stop living. It was the chance to say that we are alive,” he told AFP.

Police departments: criminals should do their part by not committing crimes during the coronavirus epidemic. ISIS: terrorists should avoid Europe for the duration of the epidemic.

More on how the FDA and CDC tried to thwart the Seattle study that finally discovered the coronavirus had been circulating uncaught in the city for weeks. And Pro Publica talks about how, in addition to thwarting more coronavirus tests, the FDA is forcing the CDC to waste its few tests by testing the same people twice.

Related: according to numbers I have not independently confirmed, a single billionaire is providing orders of magnitude more coronavirus tests to the US than the entire federal government so far. It’s a good time to be against against billionaire philanthropy!

Our World In Data has a predictably great piece on the coronavirus, including the opportunity to track how many cases in each country on each different day. Very useful for amateur research!

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Book Review: Hoover

You probably remember Herbert Hoover as the guy who bungled the Great Depression. Maybe you shouldn’t. Maybe you should remember him as a bold explorer looking for silver in the jungles of Burma. Or as the heroic defender of Tientsin during the Boxer Rebellion. Or as a dashing pirate-philanthropist, gallivanting around the world, saving millions of lives wherever he went. Or as the temporary dictator of Europe. Or as a geologist, or a bank tycoon, or author of the premier 1900s textbook on metallurgy.

How did a backwards orphan son of a blacksmith, dropped in the middle of a forgotten spot in the Midwest, grow up to be a captain of industry and a US President? How did he become such a towering figure in the history of philanthropy that biographer Kenneth Whyte claims “the number of lives Hoover saved through his various humanitarian campaigns might exceed 100 million, a record of benevolence unlike anything in human history”? To find out, I picked up Whyte’s Hoover: An Extraordinary Life In Extraordinary Times.

Herbert Hoover was born in 1874 to poor parents in the tiny Quaker farming community of West Branch, Iowa. His father was a blacksmith, his mother a schoolteacher. His childhood was strict. Magazines and novels were banned; acceptable reading material included the Bible and Prohibitionist pamphlets. His hobby was collecting oddly shaped sticks.

His father dies when he is 6, his mother when he is 10. The orphaned Hoover and his two siblings are shuttled from relative to relative. He spends one summer on the Osage Indian Reservation in Oklahoma, living with an uncle who worked for the Department of Indian Affairs. Another year passes on a pig farm with his Uncle Allen. In 1885, he is more permanently adopted by his Uncle John, a doctor and businessman helping found a Quaker colony in Oregon. Hoover’s various guardians are dutiful but distant; they never abuse or neglect him, but treat him more as an extra pair of hands around the house than as someone to be loved and cherished. Hoover reciprocates in kind, doing what is expected of him but excelling neither in school nor anywhere else.

In his early teens, Hoover gets his first job, as an office boy at a local real estate company. He loves it! He has spent his whole life doing chores for no pay, and working for pay is so much better! He has spent his whole life sullenly following orders, and now he’s expected to be proactive and figure things out for himself! Hoover the mediocre student and all-around unexceptional kid does a complete 180 and accepts Capitalism as the father he never had.

His first task is to write some newspaper ads for Oregon real estate. He writes brilliant ads, ads that draw people to Oregon from every corner of the country. But he learns some out-of-towners read his ads, come to town, stay at hotels, and are intercepted by competitors before they negotiate with his company. Of his own initiative, he rents several houses around town and turns them into boarding houses for out-of-towners coming to buy real estate, then doesn’t tell his competitors where they are. Then he marks up rent on the boarding houses and makes a tidy profit on the side. Everything he does is like this. When an especially acrimonious board meeting threatens to split the company, a quick-thinking Hoover sneaks out and turns off the gas to the building, plunging the meeting into darkness. Everyone else has to adjourn, the extra time gives cooler heads a change to prevail, and the company is saved. Everything he does is like this.

(on the other hand, he has zero friends and only one acquaintance his own age, who later describes him to biographers as “about as much excitement as a china egg”.)

Hoover meets all sorts of people passing through the Oregon frontier. One is a mining engineer. He regales young Herbert with his stories of traveling through the mountains, opening up new sources of minerals to feed the voracious appetite of Progress. This is the age of steamships, skyscrapers, and railroads, and to the young idealistic Hoover, engineering has an irresistible romance. He wants to leave home and go to college. But he worries a poor frontier boy like him would never fit in at Harvard or Yale. He gets a tip – a new, tuition-free university might be opening in Palo Alto, California. If he heads down right away, he might make it in time for the entrance exam. Hoover fails the entrance exam, but the new university is short on students and decides to take him anyway.

Herbert Hoover is the first student at Stanford. Not just a member of the first graduating class. Literally the first student. He arrives at the dorms two months early to get a head start on various money-making schemes, including distributing newspapers, delivering laundry, tending livestock, and helping other students register. He would later sell some of these businesses to other students and start more, operating a constant churn of enterprises throughout his college career. His academics remain mediocre, and he continues to have few friends – until he tries out for the football team in sophomore year. He has zero athletic talent and fails miserably, but the coach (whose eye for talent apparently transcends athletics) spots potential in Hoover and asks him to come on as team manager. In this role, Hoover is an unqualified success. He turns the team’s debt into a surplus, and starts the Big Game – a UC Berkeley vs. Stanford football match played on Thanksgiving which remains a beloved Stanford football tradition.

Other Stanford students notice his competence, and by his senior year he is running not just the football team but the baseball team, a lecture series, a set of concerts and plays, and much of the student government. For the first time, he makes many social contacts, which is sort of like having friends, although real emotional connection remains beyond him. Whyte describes an occasion when Will Irwin, the football team’s star player, suffers a career-ending injury:

[Irwin] was outfitted with a plaster cast and deposited in his dorm room. Hoover visited him to approve spending on the athlete’s medical supplies…Hoover carried his head to one side as he took in Irwin’s cast and obvious discomfort…To make conversation and keep up his courage, Irwin tried to make light of his situation and watched as Hoover tried to laugh. A ‘deep, rich, chuckle’ originated far down in his chest, Irwin recalled, yet it was strangled ‘before it came to the surface’. Hoover did not offer the patient a single word of consolation or reassurance during his time in the room. Irwin assumed hat Hoover’s sympathies, for he did appear to be affected, were garroted and buried in the same internal graveyard as the chuckle. After a few minutes, Hoover headed for the door and, at the last instant, turned and blurted ‘I’m sorry’. Irwin recognized that this minimal expression of emotion was as traumatic for Hoover as a broken ankle.

Hoover graduates Stanford in 1895 with a Geology degree. He plans to work for the US Geological Survey, but the Panic of 1895 devastates government finances and his job is cancelled. Hoover hikes up and down the Sierra Nevadas looking for work as a mining engineer. When none materializes, he takes a job an ordinary miner, hoping to work his way up from the bottom:

He signed on as a mucker at the Reward Mine, shoveling wet dirt and rock into an ore car on ten-hour shifts for two dollars a day, seven days a week. The Cornishmen mocked him for his schooling and taught him the basics of their mole-like existence: how to breathe while the dust cleared from a blast; how to nap in a steel wheelbarrow heated from underneath by candles. The ceaseless grind of filling his car and pushing it up the slick rails of the Reward’s dripping tunnels taxed Hoover’s stamina. He was tortured in his sleep by muscle pain and neuralgia.

After a few months, he finds a position as a clerk at a top Bay Area mining firm. One year later, he is a senior mining engineer. He is moving up rapidly – but not rapidly enough for his purposes. An opportunity arises: London company Berwick Moreing is looking for someone to supervise their mines in the Australian Outback. Their only requirement is that he be at least 35 years old, experienced, and an engineer. Hoover (22 years old, <1 year experience, geology degree only) travels to Britain, strides into their office, and declares himself their man. The executives “professed astonishment at Americans’ ability to maintain their youthful appearance” (Hoover had told them he was 36), but hire him and send him on an ocean liner to Australia.


22 year old Hoover trying his best to look like a respectable 36 year old capitalist
What does he think of his new home?

In numerous letters over the next two years, Hoover would refer to Western Australia as hell, and he meant it. The landscape was hell, a flat, monotonous, dust-choked desert, barren but for low tangles of mulga and wattle bush as far as the eye could see.

The climate was hell, a dry broil for the most part, one hundred degrees at midnight for days on end…

The insects were hell, scorpions, tarantulas, snakelike centipedes, and disease carrying airborne pests with an unerring aim for one’s eyes and dinner plate…

The settlements were hell, overnight ramshackled boomtowns with names like Kalgoorie and Coolgardie, box-shaped lodgings with walls of corrugated iron that roared in the wind, beds with unwashed sheets, meals of beans, biscuits, canned potatoes, and “tinned dog” (probably mutton or ham), entertainment consisting of out-of-date copies of American magazines, the odd horse race, and drunks dodging camels on Main Street.

“You cannot appreciate the real damnation of this country,” wrote Hoover.

Hoover soon manages to personally offend every single person in Australia:

The harshness of the environment and Hoover’s desire to prove himself drew an element of savagery from him. He fired rafts of employees for laziness and incompetence and dumped two of his own assistants for being “damn noodle heads”…uncompromising in pursuit of better margins, Hoover haggled with camel dealers to save a few dollars on freight costs He moved swiftly to shut losing properties…He lengthened shifts in the Coolgardie mines from 44 to 48 hours (his efforts to introduce labor-saving technology at another mine would result in a job action, which Hoover answered by firing the strikers and hiring more pliable Italian labor)…

Hoover drove himself relentlessly as well, sleeping as little as four hours a night. His eyes and stomach gave him trouble. Months of roasting on the Western Australia grill left him with a chronic inflammation of the bladder. Sometimes he was so ill he could not sit up, but he refused to slow down, traveling on his back on a mattress on the bottom of a horse-drawn cart.

After a year, Hoover is the most hated person in Australia, and also doing amazing. His mines are producing more ore at lower prices than ever before. He receives promotion after promotion.

Success goes to his head and makes him paranoid. He starts plotting against his immediate boss, Berwick Moreing’s Australia chief Ernest Williams. Thought Williams didn’t originally bear him any ill will, all the plotting eventually gets to him, and he arranges for Hoover to be transferred to China. Hoover is on board with this, since China is a lucrative market and the transfer feels like a promotion. He travels first back to Stanford – where he marries his college sweetheart Lou Henry – and then the two of them head to China.


Herbert Hoover’s college sweetheart
China is Australia 2.0. Hoover hates everyone in the country and they hate him back:

Hoover shared the prevailing European conviction of Chinese racial inferiority. He would write of the ‘simply appalling and universal dishonesty of the working classes, the racial slowness, and the low average of intelligence’…Hoover was baffled at their lack of enthusiasm for mechanization and orderly administration. Lou reported that ‘the utter apathy of the Chinese to everything, their unconquerable dilatoriness’ was almost heartbreaking to her energetic husband.

The same conflicts are playing themselves out on the world stage, as Chinese resentment at their would-be-colonizers boils over into the Boxer Rebellion. A cult with a great name – “Society Of Righteous And Harmonious Fists” – takes over the government and encourages angry mobs to go around killing Westerners. Thousands of Europeans, including Herbert and Lou, barricade themselves in the partly-Europeanized city of Tientsin to make a final last stand. Hoover

“…fought fires in the settlement and delivered food and medical supplies on his bicycle, hugging the brick walls along the street to avoid gunfire. Reporters on the scene observed that he seemed to be moving on the double quick, furiously jingling the change in his pockets and chewing nuts without shucking them. Lou, unwilling to join other women in the safety of the basement at city hall, ran bicycle errands of her own, a .38 Mauser strapped to her hip…

In between dodging artillery shells, Hoover furiously negotiates property deals with his fellow besiegees. He argues that if any of them survive, it will probably because Western powers invade China to save them. That means they will soon be operating under Western law, and people who had already sold their mines to Western companies would be ahead of the game and avoid involuntary confiscation. Somehow, everything comes up exactly how Hoover predicts. US Marines arrive in Tientsin to liberate the city (Hoover marches with them as their local guide) and he is ready to collect his winnings.

Problem: it turns out that “Whatever, sure, you can have my gold mine, we’re all going to die anyway” is not legally binding. Hoover, enraged as he watches apparently done deals slip through his fingers, reaches new levels of moral turpitude. He offers the Chinese great verbal deals, then gives them contracts with terrible deals, saying that this is some kind of quaint foreign custom and if they just sign the contract then the verbal deal will be the legally binding one (this is totally false). At one point, he literally holds up a property office with a gun to get the deed to a mine he wants. Somehow, after consecutively scamming half the population of Asia, he ends up with the rights to China’s most lucrative minefields. Berwick Moreing congratulates him and promotes him to managing director. He and Lou sail for London to live the lives of British corporate bigshots.

Predictably, Hoover makes an amazing corporate bigshot:

Hoover had a ‘gift of juggling corporate assets in such a manner that insiders almost always benefitted’, whatever happened to the capital of the original shareholders. He was masterful at wielding write-offs and preference shares with multiple voting power on the grounds that new capital was required to avert bankruptcy. His favorite deals were those so complicated no one else could figure out they worked.

On top of this, Hoover could keep mental maps of dozens of mines in his mind and, by one account, follow the progress of each shaft like a blindfolded chess master. He liked to receive telegrams from these properties and, without opening them, noting only the date and address, predict the level of the mine and the cost per ton of ore. He was usually correct.

His intellectual capacities and powerful will made Hoover a fearsome negotiator. Arriving at the table with shirtsleeves rolled up, abrupt and aggressive, he had a singular talent for stripping away nonessential information and getting directly to the root of things, and he knew how to close. He possessed what one businessman said was a curious dynamic force that could compel the most reluctant person to put signatures to paper.

Also predictably, Hoover manages to offend everyone in Britain. Soon he is signing off on a ‘mutually agreeable’, ‘amicable’ dismissal from Berwick Moreing. They agree to let him go on the condition that he does not compete with them – a promise he breaks basically instantly. He goes into banking, and his “bank” funds mining operations in a way indistinguishable from being a mining conglomerate. Eventually he abandons even this fig leaf, and just mines directly.

But in other ways, his tens of millions of dollars are mellowing him out. Over his years in London, he develops hobbies besides making money and crushing people. He starts a family; he and Lou have two sons, Herbert Jr and Allen. He even hosts dinner parties, very gradually working on the skill of getting through an entire meal without mortally offending any guests:

His fund of small talk was perpetually overdrawn, and if he interacted with the guests at his elbows, it was typically in a series of grunts or nods. If he wanted to make a point, he made it in a flat voice and then stopped abruptly, as one friend noted, someone had pulled his plug. If aroused, he would speak with force, sometimes veering into tactlessness, pursuing minor differences of opinion so harshly and indignantly that his victims nursed grudges for the rest of their natural lives. One acquaintance considered him the bluntest man in Europe, another ‘the rudest man in London’. He seldom took the time to enjoy his food, and was once clocked swallowing five courses in eleven minutes flat.

And he writes a book on metallurgy, which becomes the canonical text for a generation of engineering students. He can’t resist adding some of his own commentary. For example:

Among the book’s idiosyncratic touches is Hoover’s attempt to end discussion of the capacity of different races of workers, a common debating point in early 20th century mining, by quantifying a racial productivity gap. He deemed one white worker equal to two or three of the colored races in simple tasks like shoveling, and as high as one to eleven in the most complicated mechanical work.

But also:

To the engineer falls the work of creating from the dry bones of scientific fact the living body of industry. It is he whose intellect and direction bring to the world the comforts and necessities of daily need. Unlike the doctor, his is not the constant struggle to save the weak. Unlike the soldier, destruction is not his prime function. Unlike the lawyer, quarrels are not his daily bread. Engineering is the profession of creation and of construction, of stimulation of human effort and accomplishment.

Finally, having won respect in the financial, social, and intellectual worlds, he decides the natural next step is to become a public servant. Insofar as he has any political philosophy, he thinks of engineers as a sort of benevolent master race, destined to lead the world into an efficient technocracy. And he can think of no better standard-bearer than himself. He writes some Stanford friends, asking if they would support him for Governor of California. They suggest he start lower on the ladder, and offer him a position on the Stanford Board of Trustees, which he accepts (trustees are supposed to live in Palo Alto, but he lies and tells them he is moving back right away). He begins his public career by attacking tenure, “which he considered a protection racket for the weak and lazy and an outrage on the sanctity of higher education.”

Okay, fine. He hadn’t mellowed out that much. He manages to offend everyone in Stanford basically immediately, and that probably would have been the end of his career in politics. Luckily for him, World War I chooses that moment to break out, and little things like tenure are suddenly forgotten in the shadow of the greatest conflict the world has ever known.

II.

Count up the victims of World War I, and American tourists will be pretty far down the list. But victims they were. When the conflict broke out, thousands of Americans were overseas visiting the cathedrals of Florence or the museums of London. They woke up one morning to find the ships that were supposed to take them back had been conscripted into the war effort, or refused to sail for fear of enemy fire. The banks that were supposed to cash their travelers’ checks were panicking, or devoting all their funds to the war effort, or dealing with a million other things. The hotels that were supposed to house them were closed indefinitely, their employees rushing to enlist out of patriotic fervor. And so thousands of frantic Americans, stuck in a foreign continent with no money and nowhere to stay, showed up at the door of the US Embassy in London and said – help!

The US Consulate in London didn’t know how to solve these problems either. But Herbert Hoover, still high on his decision to pivot to philanthropy and public service, calls them up and asks if he can assist. They say yes, definitely. Hoover gets in touch with his rich friends, passes around the collection plate, and organizes a Committee For The Assistance Of American Travelers. Then he gets to work, the way only he can:

Within 24 hours, Hoover’s committee had its own stationery, and within forty-eight it was operating a booth in the ballroom of the Savoy Hotel as well as three other London locations. Through his business connections, Hoover managed to bypass restrictions on telegraph service and open a transatlantic line to allow Americans to wire money to stranded friends and relatives. In a city suddenly flooded with refugees, he reserved for American travelers some two thousand rooms in hotels or boardinghouses. He issued a press release proclaiming that his Residents’ Committee was assuming charge of all American relief work in the city, and that in doing so it had the blessings of its honorary chairman, Walter Hines Page, the US ambassador to London.

…which is totally false. Hoover is starting to display a pattern that will stick with him his whole life – that of crushing competing charities. He begins a lobbying effort to get the US Embassy to ban all non-Hoover relief work, focusing on the inefficiency of having multiple groups working on the same problem. When the US Assistant Secretary Of War arrives in London to coordinate a response, he is met on the dock by Hoover employees, who demand he consult with Hoover before interfering in the US tourist issue. Eventually the Embassy, equally exasperated by Hoover’s pestering and impressed with his results, agrees to give him official control of the relief effort.

After two months of work, Hoover and his Committee have repatriated all 120,000 US tourists, supporting them in style until it could find them boat tickets. All of its loans and operating costs have been repaid by grateful tourists, and its budget is in the black. The rescued travelers are universal in their praise for Hoover, albeit partly because Hoover has threatened to ruin any of them who get too critical:

Other complainants were received with less patience, including a hotheaded professor of history from the University of Michigan, who wrote to accuse the Residents’ Committee of mistreatment. Hoover refuted his charges indignantly and comprehensively, copying his response to the president of the university and its board of regents. After a meeting with his employer, the professor returned Hoover an abject retraction and apology.

Just as Hoover is preparing to rest on his laurels, he receives a cry for help. Germany has occupied and blockaded Belgium. The blockade prevents this tiny, heavily urban country from importing food, and the Belgians are starving. Germany needs its own food for its own armies, and is refusing to help. The Belgians order a thousand tons of grain from Britain, but when their representative comes to pick it up, Britain refuses to let them transport it, nervous at sending food into enemy-occupied territory. During tense negotiations, someone suggests using neutral power America as a go-between. But America is 5,000 miles away and busy with its own problems. So the US Ambassador to Britain asks his new best friend Herbert Hoover if he has any ideas.

Hoover invites Emile Francqui, a Belgian mining engineer he knows, to Britain. Together, they plan a Committee For The Relief of Belgium, intended not just to help transport the thousand tons of grain at issue, but to develop a long-term solution to the impending Belgian famine. Nothing like this has ever been tried before. Belgium has seven million people and almost no food. No government is offering to help, and they don’t have enough money to feed seven million people even for one day, let alone indefinitely. Hoover springs into action…

…by crushing all competing attempts to provide food for Belgium. He attacks the Rockefeller Foundation, which is trying to help, with a blitz of press coverage accusing it of various forms of insensitivity and interference, until it finally backs off. Then he gets to work on the government:

The letter bore several Hoover watermarks, beginning with its heavy load of facts and figures organized in point form. It noted that myriad relief committees were springing up both inside and outside of Belgium, and urged consolidation. “It is impossible to handle the situation except with the strongest centralization and effective monopoly, and therefore the two organizations [Hoover outside Belgium and Francqui inside it] will refuse to recognize any element except themselves alone.” The letter also contained Hoover’s usual autocratic and slightly paranoid demands for “absolute command” of his part of the enterprise.

Control attained, Hoover springs into action actually feeding Belgium. He launches one of the largest public relations campaigns the world has ever seen, sending letters to newspapers around the world asking for donations. He “urged reporters to investigate the famine conditions in Belgium and play up the ‘detailed personal horror stuff’. He personally arranged for a motion picture crew to capture footage of food lines in Brussels, and he hired famous authors, including Thomas Hardy and George Bernard Shaw, to plead for public support of the rescue effort.” He constantly telegrams his exasperated wife and children, now safely back in Palo Alto, demanding they raise more and more money from the West Coast elite.

He browbeats shipping conglomerates until they agree to ship his food for free, then browbeats railroads until they agree to carry it. By telegraph and letter he coordinates banks, docks, trains, ships, and relief workers on both sides of the Atlantic. But that’s just the prelude. His real problem is the governments. Britain doesn’t want food shipped to Belgium, because right now the starving Belgians are Germany’s problem, and they don’t want to solve an enemy’s problem for them. But Germany also doesn’t want food shipped to Belgium, because the Belgians are resisting the occupation, and they figure starvation will make them more compliant. Shuttling back and forth across the North Sea, Hoover tries to get them to switch theories: Germany needs to think starving Belgians are their problem which it would be helpful to solve, and Britain needs to think starvation would make Belgians more compliant with the German occupation. In the end, both countries allow the shipments.

He goes on a fact-finding mission to Belgium, and manages to somehow offend everyone in the country that he is, at that very moment, saving from mass starvation:

A third of Brussels’ population was receiving free food at more than a hundred canteens set up by the Comite Central and supplied by the CRB. Ration cards entitled the bearer to coffee, soup, and bread. On the cold, wet morning of December 1, Whitlock took Hoover to the street outside a theater that had been converted to a canteen in the Quarter des Marolles. They saw hundreds of Belgians shivering silently in the breadline…Whitlock kept his eyes on Hoover throughout the visit and saw him turn away and stare off down the street rather than share his feelings. Whitlock understood Hoover’s reaction as simple reticence. Others witnessing the same sort of behavior found it disturbing. They noticed how Hoover obsessed over the logistics of food distribution while avoiding interaction with recipients of relief and thought him a bloodless man. “He told of the work in Belgium as coldly as if he were giving statistics of production,” said US official. “From his words and his manner he seemed to regard human beings as so many numbers. Not once did he show the slightest feeling.”

Hoover’s reticence was chronic. He was the sort of man who could sit for three hours on a train with his closest colleagues and not utter a single word, or bid farewell to his wife, not expecting to see her again for several months, in a curt telegraph: “Goodbye, Love, Bert”. It was often difficult to know if his behavior was due to bad manners, callousness, anxiety, or an effort to manage powerful emotions, because he was capable of all these things. Indeed, a few days after he averted his eyes from the breadline, he wrote, “It is difficult to state the position of the civil population of Belgium without becoming hysterical.” The sight of ragged and hungry children especially bothered him, and he soon inaugurated a program of daily hot meals of bread and cocoa at Belgian schools.

By 1915, Hoover is, indeed, feeding millions of Belgians, indefinitely, using only private funding. He is also almost broke. Millions of Brits and Americans have given him contributions, from tycoons donating fortunes to ordinary people donating their wages, but it’s not enough. His expenses pass $5 million a month, which would be about $100 million today; all these bills are starting to catch up to him. In an act of supreme sacrifice, Hoover pledges his entire personal fortune as collateral for the Committee’s loans, then takes out more money. The grain shipments continue to flow, but his credit is at its end.

He continues beating on the doors of every government official he can find – British, German, American – demanding help. They all say their budgets are already occupied with the war effort. He begs them, lectures them, tells them that millions of people are doing to die. He goes all the way to the top, finagling an opportunity to meet with British Prime Minister David Lloyd George. Lloyd George later calls Hoover’s presentation “the clearest he had [ever] heard on any subject”, but he can offer only moral support.

What finally works is going to Germany and meeting with their top military brass. The brass are unimpressed; they still think that Belgium starving is as likely to help them as hinder. But the contact spooks top British officials, who agree to meet with Hoover again. Hoover feeds them carefully crafted lies, saying that the German brass have told him that British aid to Belgium would be a disaster to the Central Powers and so they, the Germans, are going to fund everything Hoover wants and more. “Oh no they don’t!” say the British, who promise to give Hoover even more funding than his imaginary German partners. The Committee for the Relief Of Belgium is finally back in the black. And what a black it is:

The scope and powers of the Committee For Relief of Belgium were mindboggling. Its shipping fleet flew its own flag. Its members carried special documents that served as CRB passports. Hoover himself was granted a form of diplomatic immunity by all belligerents, with the British permitting him to cross the Channel at will and the Germans providing him a document saying ‘this man is not to be stopped anywhere under any circumstances’. Hoover had privileged access to generals, diplomats, and ministers. He enjoyed personal contacts with the heads of warring governments. He negotiated treaties with the belligerents, advised them on policy, and delivered private messages among them. Great Britain, France, and Belgium would soon be turning over to him $150 million a year, enough to run a small country, and taking nothing for it beyond his receipt. As one British official observed, Hoover was running ‘a piratical state organized for benevolence.’

In 1917, America enters World War I. Hoover is no longer neutral and so has to resign from the CRB. He returns to the US a war hero. The New York Times proclaims Hoover’s CRB work “the greatest American achievement of the last two years.” There is talk that he should run for President. Instead, he goes to Washington and tells President Woodrow Wilson he is at his service.

Wilson is working on the greatest mobilization in American history. He realizes one of the US’ most important roles will be breadbasket for the Allied Powers, and names Hoover “food commissioner”, in charge of ensuring that there is enough food to support the troops, the home front, and the other Allies. His powers are absurdly vast – he can do anything at all related to the nation’s food supply, from fixing prices to confiscating shipments to telling families what to eat. The press affectionately dubs him “Food Dictator” (I assume today they would use “Food Czar”, but this is 1917 and it is Too Soon).

Hoover displays the same manic energy he showed in Belgium. His public relations blitz telling families to save food is so successful that the word “Hooverize” enters the language, meaning to ration or consume efficiently. But it turns out none of this is necessary. Hoover improves food production and distribution efficiency so much that no rationing is needed, America has lots of food to export to Europe, and his rationing agency makes an eight-digit profit selling all the extra food it has.

By 1918, Europe is in ruins. The warring powers have declared an Armistice, but their people are starving, and winter is coming on fast. Also, Herbert Hoover has so much food that he has to swim through amber waves of grain to get to work every morning. Mountains of uneaten pork bellies are starting to blot out the sky. Maybe one of these problems can solve the other? President Wilson dispatches Hoover to Europe as “special representative for relief and economic rehabilitation”. Hoover rises to the challenge:

Hoover accepted the assignment with the usual claim that he had no interest in the job, simultaneously seeking for himself the broadest possible mandate and absolute control. The broad mandate, he said, was essential, because he could not hope to deliver food without refurnishing Europe’s broken finance, trade, communications, and transportation systems…

Hoover had a hundred ships filled with food bound for neutral and newly liberated parts of the Continent before the peace conferences were even underway. He formalized his power in January 1919 by drafting for Wilson a post facto executive order authorizing the creation of the American Relief Administration (ARA), with Hoover as its executive director, authorized to feed Europe by practically any means he deemed necessary. He addressed the order to himself and passed it to the president for his signature…

The actual delivery of relief was ingeniously improvised. Only Hoover, with his keep grasp of the mechanics of civilization, could have made the logistics of rehabilitating a war-ravaged continent look easy. He arranged to extend the tours of thousands of US army officers already on the scene and deployed them as ARA agents in 32 different countries. Finding Europe’s telegraph and telephone services a shambles, he used US Navy vessels and Army Signal Corps employees to devise the best-functioning and most secure wireless system on the continent. Needing transportation, Hoover took charge of ports and canals and rebuilt railroads in Central and Eastern Europe. The ARA was for a time the only agency that could reliably arrange shipping between nations…

The New York Times said it was only apparent in retrospect how much power Hoover wielded during the peace talks. “He has been the nearest approach Europe has had to a dictator since Napoleon.”

Once again, Hoover faces not only the inherent challenge of feeding millions, but opposition from the national governments he is trying to serve. Britain and France plan to let Germany starve, hoping this will decrease its bargaining power at Versailles. They ban Hoover from transporting any food to the defeated Central Powers. Hoover, “in a series of transactions so byzantine it was impossible for outsiders to see exactly what he was up to”, causes some kind of absurd logistics chain that results in 42% of the food getting to Germany in untraceable ways.

He is less able to stop the European powers’ controlled implosion at Versailles. He believes 100% in Woodrow Wilson’s vision of a fair peace treaty with no reparations for Germany and a League Of Nations powerful enough to prevent any future wars. But Wilson and Hoover famously fail. Hoover predicts a second World War in five years (later he lowers his estimate to “thirty days”), but takes comfort in what he has been able to accomplish thus far.

He returns to the US as some sort of super-double-war-hero. He is credited with saving tens of millions of lives, keeping Europe from fraying apart, and preventing the spread of Communism. He is not just a saint but a magician, accomplishing feats of logistics that everyone believed impossible. John Maynard Keynes:

Never was a nobler work of disinterested goodwill carried through with more tenacy and sincerity and skill, and with less thanks either asked or given. The ungrateful Governments of Europe owe much more to the statesmanship and insight of Mr. Hoover and his band of American workers than they have yet appreciated or will ever acknowledge. It was their efforts…often acting in the teeth of European obstruction, which not only saved an immense amount of human suffering, but averted a widespread breakdown of the European system.

III.

Hoover wants to be president. It fits his self-image as a benevolent engineer-king destined to save the populace from the vagaries of politics. The people want Hoover to be president; he’s a super-double-war-hero during a time when most other leaders have embarrassed themselves. Even politicians are up for Hoover being president; Woodrow Wilson is incapacitated by stroke, leaving both Democrats and Republicans leaderless. The situation seems perfect.

Hoover bungles it. He plays hard-to-get by pretending he doesn’t want the Presidency, but potential supporters interpret this as him just literally not wanting the Presidency. He refuses to identify as either a Democrat or Republican, intending to make a gesture of above-the-fray non-partisanship, but this prevents either party from rallying around him. Also, he might be the worst public speaker in the history of politics.

Warren G. Harding, a nondescript Senator from Ohio, wins the Republican nomination and the Presidency. Hoover follows his usual strategy of playing hard-to-get by proclaiming he doesn’t want any Cabinet positions. This time it works, but not well: Harding offers him Secretary of Commerce, widely considered a powerless “dud” position. Hoover accepts.

Harding is famous for promising “return to normalcy”, in particular a winding down of the massive expansion of government that marked WWI and the Wilson Administration. Hoover had a better idea – use the newly-muscular government to centralize and rationalize America. In his first few years in Commerce – hitherto a meaningless portfolio for people who wanted to say vaguely pro-prosperity things and then go off and play golf – Hoover instituted/invented housing standards, traffic safety standards, industrial standards, zoning standards, standardized electrical sockets, standardized screws, standardized bricks, standardized boards, and standardized hundreds of other things. He founded the FAA to standardize air traffic, and the FCC to standardize communications. In order to learn how his standards were affecting the economy, he founded the NBER to standardize government statistics.

But that isn’t enough! He mediates an inter-state conflict over water rights to the Colorado River, even though that would normally be a Department of the Interior job. He solves railroad strikes, over the protests of the Department of Labor. “Much to the annoyance of the State Department, Hoover fielded his own foreign service”. He proposes to transfer 16 agencies from other Cabinet departments to the Department of Commerce, and when other Secretaries shoot him down, he does all their jobs anyway. The press dub him “Secretary of Commerce and Undersecretary Of Everything Else”.

Hoover’s greatest political test comes when the market crashes in the Panic of 1921. The federal government has previously ignored these financial panics. Pre-Wilson, it was small and limited to its constitutional duties – plus nobody knew how to solve a financial panic anyway. Hoover jumps into action, calling a conference of top economists and moving forward large spending projects. More important, he is one of the first government officials to realize that financial panics have a psychological aspect, so he immediately puts out lots of press releases saying that economists agree everything is fine and the panic is definitely over. He takes the opportunity to write letters saying that Herbert Hoover has solved the financial panic and is a great guy, then sign President Harding’s name to them. Whether or not Hoover deserves credit, the panic is short and mild, and his reputation grows.

While everyone else obsesses over his recession-busting, Hoover’s own pet project is saving the Soviet Union. Several years of civil war, communism, and crop failure have produced mass famine. Most of the world refuses to help, angry that the USSR is refusing to pay Czarist Russia’s debts and also pretty peeved over the whole Communism thing. Hoover finds $20 million to spend on food aid for Russia, over everyone else’s objection:

Russian relief would prove less popular than the Belgian variety, with the left accusing Hoover of seeking to undermine communism with capitalist aid…and the right charging him with rescuing and legitimating the shaky Soviet regime. Hoover gave the same answer to all critics: ‘Twenty million people are starving. Whatever their politics, they shall be fed.’

Maxim Gorky, in Italy nursing his tuberculosis, wrote Hoover personally: ‘In the past year you have saved from death three and one-half million children, five and one-half million adults. In the history of practical humanitarianism I know of no accomplishment which in…magnitude and generosity can be compared to the relief you have actually accomplished.

So passed the early 1920s. Warren Harding died of a stroke, and was succeeded by Vice-President “Silent Cal” Coolidge. Coolidge won re-election easily in 1924. Hoover continued shepherding the economy (average incomes will rise 30% over his eight years in Commerce), but also works on promoting Hooverism, his political philosophy. It has grown from just “benevolent engineers oversee everything” to something kind of like a precursor of modern neoliberalism:

Hoover’s plan amounted to a complete refit of America’s single gigantic plant, and a radical shift in Washington’s economic priorities. Newsmen were fascinated by is talk of a ‘third alternative’ between ‘the unrestrained capitalism of Adam Smith’ and the new strain of socialism rooting in Europe. Laissez-faire was finished, Hoover declared, pointing to antitrust laws and the growth of public utilities as evidence. Socialism, on the other hand, was a dead end, providing no stimulus to individual initiative, the engine of progress. The new Commerce Department was seeking what one reporter summarized as a balance between fairly intelligent business and intelligently fair government. If that were achieved, said Hoover, ‘we should have given a priceless gift to the twentieth century.’

Finally, it is 1928. Hoover feels like he has accomplished his goal of becoming the sort of knowledgeable political insider who can run for President successfully. Silent Cal decides not to run for a second term (in typical Coolidge style, he hands a piece of paper to a reporter saying “I do not choose to run for President in 1928” and then disappears and refuses to answer further questions). The Democrats nominate Al Smith, an Irish-Italian Catholic with a funny accent; it’s too early for the country to really be ready for this. Historians still debate whether Hoover and/or his campaign deserves blame for being racist or credit for being surprisingly non-racist-under-the-circumstances.

The main issue is Prohibition. Smith, true to his roots, is against. Hoover, true to his own roots (his mother was a temperance activist) is in favor. The country is starting to realize Prohibition isn’t going too well, but they’re not ready to abandon it entirely, and Hoover promises to close loopholes and fix it up. Advantage: Hoover.

The second issue is tariffs. Everyone wants some. Hoover promises that if he wins, he will call a special session of Congress to debate the tariff question. Advantage: Hoover.

The last issue is personality. Republican strategists decide the best way for their candidate to handle his respective strengths and weaknesses is not to campaign at all, or be anywhere near the public, or expose himself to the electorate in any way. Instead, they are “selling a conception. Hoover was the omnicompetent engineer, humanitarian, and public servant, the ‘most useful American citizen now alive.’ He was an almost supernatural figure, whose wisdom encompasses all branches, whose judgment was never at fault, who knew the answers to all questions.” Al Smith is supremely charismatic, but “boasted of never having read a book”. Advantage: unclear, but Hoover’s strategy does seem to work pretty well for him. He racks up most of the media endorsements. TIME Magazine offers a rare dissent, saying that “In a society of temperate, industrious, unspectacular beavers, such a beaver-man would make an ideal King-beaver. But humans are different.”

Apparently not that different. Hoover wins 444 votes to 87, one of the greatest electoral landslides in American history.


You may not like it, but this is what peak presidentialness looks like
Anne McCormick of the New York Times describes the inauguration:

We were in a mood for magic…and the whole country was a vast, expectant gallery, its eyes focused on Washington. We had summoned a great engineer to solve our problems for us; now we sat back comfortable and confidently to watch our problems being solved. The modern technical mind was for the first time at the head of a government. Relieved and gratified, we turned over to that mind all of the complications and difficulties no other had been able to settle. Almost with the air of giving genius its chance, we waited for the performance to begin.

IV.

Herbert Hoover spent his entire presidency miserable.

First, he has no doubt that the economy is going to crash. It’s been too good for too long. He frantically tries to cool down the market, begs moneylenders to stop lending and bankers to stop banking. It doesn’t work, and the Federal Reserve is less concerned than he is. So he sits back and waits glumly for the other shoe to drop.

Second, he hates politics. Somehow he had thought that if he was the President, he would be above politics and everyone would have to listen to him. The exact opposite proves true. His special session of Congress comes up with the worst, most politically venal tariff bill imaginable. Each representative declares there should be low tariffs on everything except the products produced in his own district, then compromises by agreeing to high tariffs on everything with good lobbyists. The Senate declares that the House of Representatives is corrupt nincompoops and sends the bill back in disgust. Hoover has no idea how to solve this problem except to ask the House to do some kind of rational economically-correct calculation about optimal tariffs, which the House finds hilarious. “Opposed to the House bill and divided against itself, the Senate ran out the remaining seven weeks [of the special session] in a debauch of taunts, accusations, recriminations, and procedural argument.” The public blames Hoover, pretty fairly – a more experienced president would have known how to shepherd his party to a palatable compromise.

Also, there are crime waves, prison riots, bootlegging, and a heat wave during which Washington DC is basically uninhabitable. Also, at one point the White House is literally on fire.

…and then the market finally crashes. Hoover is among the first to call it a Depression instead of a Panic – he thinks the new term might make people panic less. But in fact, people aren’t panicking. They assume Hoover has everything in hand.

At first he does. He gathers the heads of Ford, Du Pont, Standard Oil, General Electric, General Motors, and Sears Roebuck and pressures them to say publicly they won’t fire people. He gathers the AFL and all the union heads and pressures them to say publicly they won’t strike. He enacts sweeping tax cuts, and the Fed enacts sweeping rate cuts. Everyone is bedazzled:

The sweep and speed of Washington’s response to the crash, which gave the impression that Hoover had ‘thoroughly anticipated the debacle and mapped out the shortest road to recovery’, was hailed in the press as an entirely new approach to management of the nation’s economic affairs.” Herald-Tribune: “President Hoover’s prompt action to prevent the depression extending to business and industry saved the situation. The panic was checked in a few days. Wages were left unaffected, stabilization was insured; production was encouraged to continue as usual. This leadership was all the more notable, since it was practically the first of the sort ever to originate in the White House.

And:

Economic joined journalists in congratulating Hoover on what was easily the most sophisticated response to a major economic event by any administration. ‘For the first time in our history,’ wrote Keynesian forerunners William Foster and Waddill Catchings, ‘a president is taking aggressive leadership in guiding private business through a crisis.

Six months later, employment is back to its usual levels, the stock market is approaching its 1929 level, and Democrats are fuming because they expect Hoover’s popularity to make him unbeatable in the midterms. I got confused at this point in the book – did I accidentally get a biography from an alternate timeline with a shorter, milder Great Depression? No. I do think I accidentally got a biography by someone obsessed with defending Hoover at any cost and willing to stray into revisionist history to do it. As per Whyte, Hoover would take some brilliant and decisive action. Economists would praise him. The economy would start to look better. Everyone would declare the problem solved – especially Hoover, sensitive both to his own reputation and to the importance of keeping economic optimism high. Then for reasons totally outside the President’s control, the recovery would stall, or reverse, or something else would go wrong.

People are still debating what made the Great Depression so long and hard. Whyte’s theory, insofar as he has one at all, is “one thing after another”. Every time the economy started to go up (thanks to Hoover), there was another shock. Most of them involved Europe – Germany threatening to default on its debts, Britain going off the gold standard. A few involved the US – the Federal Reserve made some really bad calls. The one thing Whyte is really sure about is that his idol Herbert Hoover was totally blameless.

He argues that Hoover’s bank relief plan could have stopped the Depression in its tracks – but that Congressional Democrats intent on sabotaging Hoover forced the plan to publicize the names of the banks applying. The Democrats hoped to catch Hoover propping up his plutocrat friends – but the change actually had the effect of making banks scared to apply for funding and panicking the customers of banks that were known to have applied. He argues that the “Hoover Holiday” – a plan to grant debt relief to Germany, taking some pressure off the clusterf**k that was Europe – was a masterstroke, but that France sabotaged it in the interests of bleeding a few more pennies from its arch-rival. International trade might have sparked a recovery – except that Congress finally passed the Hawley-Smoot Tariff, the end result of the corruption-plagued tariff negotiations, just in time to choke it off.

Whyte saves his barbs for the real villain: FDR. If the book is to be believed, Hoover actually had things pretty much under control by 1932. Employment was rising, the stock market was heading back up. FDR and his fellow Democrats worked to tear everything back down so he could win the election and take complete credit for the recovery. The wrecking campaign entered high gear after FDR won in 1932; he was terrified that the economy might get better before he took office, and used his President-Elect status to hint that he was going to do all sorts of awful things. The economy got skittish again and obediently declined, allowing him to get inaugurated at the precise lowest point and gain the credit for recovery he so ardently desired.

For example: November 1932. Hoover has just lost the election, but is a lame duck until March. The European debt crisis flashes up again. Hoover knows how to solve it. But:

He had already met with congressional leaders and learned, as he had suspected, that they would not change their stance without Roosevelt’s support. Seized with the urgency of the moment, he continued to bombard his opponents with proposals for cooperation toward solutions, going so far as to suggest that Democratic nominees, not Republicans, be sent to Europe to engage in negotiations, all to no avail. Notwithstanding what editorialists called his “personal and moral responsibility” to engage with the outgoing administration, Roosevelt had instructed Democratic leaders in Congress not to let Hoover “tinker” with the debts. He had also let it be known that any solution to the problem would occur on his watch – “Roosevelt holds he and not Hoover will fix debt policy”, read the headlines. Thus ended what the New York Times called Hoover’s magnanimous proposal for “unity and constructive action”, not to mention his 12-year effort to convince America of its obligation and self-interest in fostering European political and financial stability…

During the debt discussions and to some extent as a result of them, the economy turned south again. Several other factors contributed. Investors were exchanging US dollars for gold as doubt spread about Roosevelt’s intentions to remain on the gold standard. Gold stocks in the Federal Reserve thus declined, threatening the stability of the financial sector…what’s more, the effectiveness of [Hoover’s bank support plan], which had succeeded in stabilizing the banking system, was severely compromised by [Democrats’] insistence on publicizing its loans, as the administration had warned. For these reasons, Hoover would forever blame Roosevelt and the Democratic Congress for spoiling his hard-earned recovery, an argument that has only recently gained currency among economists.

And:

Alarmed at these threats to recovery, Hoover pushed Democratic congressional leaders and the incoming administration for action. He wanted to cut federal spending, reorganize the executive branch to save money, reestablish the confidentiality of RFC loans, introduce bankruptcy legislation to protect foreclosures, grant new powers to the Federal Reserve, and pass new banking regulation, including measures to protect depositors…He was frustrated at every turn by Democratic leadership taking cues from the President-Elect…On February 5, Congress took the obstructionism a degree further by closing shop with 23 days left in its session.

In mid-February, there is another run on the banks, worse than all the other runs on the banks thus far. Hoover asks Congress to do something – Congress says they will only listen to President-Elect Roosevelt. Hoover writes a letter to Roosevelt begging him to give Congress permission to act, saying it is a national emergency and he has to act right now. Roosevelt refuses to respond to the letter for eleven days, by which time the banks have all failed.

Then, a month later, he stands up before the American people and says they have nothing to fear but fear itself – a line he stole from Hoover – and accepts their adulation as Destined Savior. He keeps this Destined Savior status throughout his administration. In 1939, Roosevelt still had everyone convinced that Hoover was totally discredited by his failure to solve the Great Depression in three years – whereas Roosevelt had failed to solve it for six but that was totally okay and he deserved credit for being a bold leader who tried really hard.

So how come Hoover bears so much of the blame in public consciousness? Whyte points to three factors.

First, Hoover just the bad luck of being in office when an international depression struck. Its beginning wasn’t his fault, its persistence wasn’t his fault, but it happened on his watch and he got blamed.

Second, in 1928 the Democratic National Committee took the unprecedented step of continuing to exist even after a presidential election. It dedicated itself to the sort of PR we now take for granted: critical responses to major speeches, coordinated messaging among Democratic politicians, working alongside friendly media to create a narrative. The Republicans had nothing like it; the RNC forgot to exist for the 1930 midterms, and Hoover was forced to personally coordinate Republican campaigns from his White House office. Although Hoover was good (some would say obsessed) at reacting to specific threats on his personal reputation, the idea of coordinating a media narrative felt too much like the kind of politics he felt was beneath him. So he didn’t try. When the Democrats launched a massive public blitz to get everyone to call homeless encampments “Hoovervilles”, he privately fumed but publicly held his tongue. FDR and the Democrats stayed relentlessly on message and the accusation stuck.

And third, Hoover was dead-set against welfare. However admirable his attempts to reverse the Depression, stabilize banking, etc, he drew the line at a national dole for the Depression’s victims. This was one of FDR’s chief accusations against him, and it was entirely correct. Hoover suspected that going down that route would lead pretty much where it led Roosevelt – to a dectupling of the size of government and the abandonment of the Constitutional vision of a small federal government presiding over substantially autonomous states. He decided it wasn’t worth it. So Herbert Hoover, history’s greatest philanthropist and ender-of-famines, would go down in history as the guy who refused to feed starving people. And they hated him for it.

V.

Some people might call Herbert Hoover a sore loser. But he argues that no, it’s totally reasonable for him to spend the rest of his life attacking FDR and trying to destroy his legacy.

His theory, explained in the countless books, pamphlets, and speeches that he spends his post-presidential life writing, is that FDR came from the same cloth as Hitler and Stalin. The miseries of the Great Depression, the centralizing tendencies of the age, the rise of mass media, and the collapse of republican virtue were combining all around the world in a monstrous reaction against the cause of liberty. “Daily,” wrote Hoover, “the world goes back to the regimentation of the Middle Ages, whether it be Bolshevism, Hitlerism, Fascism, or the New Deal.”

He has more! “[The New Deal] has no philosophy. It is sheer opportunism, a muddle of a spoils system, of reckless adventure, of unctuous claims to a monopoly of human sympathy, of greed for power, of a desire for popular acclaim and an aspiration to make the front pages of the newspapers.” He has more! “The New Deal has contributed to sapping our stamina and making us soft…the road to regeneration is burdensome and hard. It is straight and simple. It is a road paved with work and with sacrifice and consecration to the indefinable spirit that is America.”

He has more! He just keeps going like this, again and again. FDR, for his part, seems slightly befuddled. He tried offering Hoover a position coordinating the US effort to help war refugees – which Hoover turned down, assuming anything from FDR was a trick. Hoover just keeps shouting and fulminating and writing more and more books and pamphlets until FDR dies – which enrages Hoover, who wanted him to “live long enough to reap what he had sown”.

Whyte’s theory is that this period of Hoover’s life sowed the seeds for the modern conservative movement: “Modern American conservatism, conceived as an antidote to the New Deal, was born on December 16, 1937, with Hoover as its prophet and philosopher.” He doesn’t do much to back this theory up, and Hoover gets all of a paragraph in Wikipedia’s long History of conservativism in the United States. We are left to piece it together from a few mentions here and there – Hoover befriending and helping a young William F. Buckley, Hoover giving a key endorsement to Barry Goldwater, and of course the namesake Hoover Institution that he founded, funded, and guided until his death.

I have to admit this is a hole in my understanding. Smart people definitely say that modern American conservativism began with Buckley and Goldwater and their friends, but what does this mean? Hasn’t about half of America been conservative since the 1700s? Hasn’t a philosophy of small government, individual freedom, and capitalist economics been pretty fundamental to America since its beginning? I’m not sure, and without this knowledge I don’t feel qualified to judge Hoover’s role.

Hoover passes in 1964, ninety years old. He lived long enough to become a hero to a new brand of conservative who considered him an intellectual forebear, and through various acts of public service to win back the love of his country. He had not quite finished his magnum opus, Freedom Betrayed. In 2012, historians finally dug it up, revised it, and released it to the world. It turned out to be 957 pages of him attacking Franklin Roosevelt. Give Herbert Hoover credit: he died as he lived.

VI.

I’m sorry this review was so long. I couldn’t bear to make it any shorter. I find the whole story so fascinating, and I just regret I couldn’t include more. I didn’t even get a chance to mention the time Hoover rescued the US South from the Great Mississippi Flood, or the time he discovered ancient ruins in the jungles of Burma, the time a 71-year-old Hoover was called back into service by President Truman to solve another post-World-War famine, or the time he invented the new sport of Hooverball (now part of the popular CrossFit exercise program).


Herbert Hoover on a famine relief tour of Poland, along with some of the children he is helping.
Hoover was a man who did everything wrong. He was the quintessential High Modernist. He was arrogant, he was authoritarian, he didn’t listen to anyone, he put no effort into pleasing people or making his ideas more palatable. He never solicited stakeholders’ opinions. He lied like a rug, constantly and egregiously. He lived his life like a caricature of exactly the sort of person who should fail at philanthropy and become a horror story to warn future generations.

But he won anyway. He started from a measly few million dollars and beat out Rockefellers and Carnegies to become the most successful philanthropist in early 20th century history. Whyte’s estimate of 100 million lives saved seems much too high; there were only 100 million people in Europe total during the relevant period. But even during his own time, people universally credited him with saving millions. And he did it again and again and again. I didn’t even have space to talk about the time he saved the Southern United States from a giant flood, or half a dozen other impressive accomplishments. Maybe the rules are wrong. Maybe all of this stuff about how authoritarian approaches never work, and you need to let the people you are helping lead the way, is all just modern prejudices, and putting a brilliant and very rich engineer in charge of a hypercentralized organization is just as good as any other way of doing things.

But even this I find less interesting than his psychology. He combined a personal callousness with a love for all humanity. When he was inspecting mines in Australia, he fired the worst-performing X% of workers. One worker begged him to reconsider – he had a family to support. Hoover raised $300 for the man’s family – a lot of money at the time! Probably more than Hoover made in a month! – but fired him anyway. In 1932, when the Bonus Army marched on Washington, Hoover was adamant that he would not give these men – poor, starving veterans – a single cent more than they were entitled to by their existing benefits. But he also instructed his staff to go around to their encampments and give them food and supplies in secret.

Sometimes his stubbornness calls to mind the fictional Inspector Javert, who refuses to bend the law for any reason. In this model, Hoover sympathizes with everybody, but his honor forbids him to bend the rules in favor of underperforming employees or protesters who want more than their contracts entitle them to. But this picture of a hyper-honorable Hoover crashes into his constant willingness to lie, cheat, and bend the rules in his own favor. Sometimes his lies are for the greater good, like when he tells Britain that Germany is preparing to feed Belgium. Other times they seem entirely selfish, like his various Chinese mining scams. The best that can be said about Hoover is that if he decides a principle is involved, he sticks to it.

And this is actually really good! Again and again through the book, Hoover feels like the only person with a moral compass. When it is in everyone’s strategic interest to let Belgium starve, Hoover is the only one who is able to keep fixated on the potential human toll. When it is in everyone’s interest to let the USSR starve, only Hoover – despite his fanatical anti-communism – is able to stick to the frame where the Russians are human beings and politics is beside the point. When Americans are starving during the Great Depression…

…okay, Hoover totally dropped the ball on that one. In fact, one of his Democratic opponents wrote something about how maybe if unemployed American workers pretended to be Belgians, they could get Hoover’s sympathy. I don’t have a great explanation for this. But Hoover’s weak and inconsistent sympathies are often enough to let him outdo everyone else. Or at least, he is uncorrelated with everyone else and succeeds when they fail. Again and again Hoover is accused of treating people like numbers on a piece of paper. But if this is true, it seems to be linked to the reverse talent – the ability to remember that numbers on a piece of paper represent people, even when other people would rather forget.

I’m equally confused about Hoover’s politics, although it’s not really his fault. The whole era confuses me. The Progressives, Hoover’s own faction, seem clearly related to modern progressives. But they also give me more of a technophile, rationalist feel than their modern counterparts. Am I imagining things? If not, where did this go?

And how did Hoover so deftly merge his centralizing technocratic engineer side with his small-government individual-freedom pro-capitalism side? Maybe it wasn’t that deft? Maybe he started his life as a centralizing technocrat, then made a 180 after becoming a small-government individualist helped him dunk on FDR more effectively? But it didn’t feel that way. It felt like all of it was coming from some central set of core beliefs throughout his life.

My confusion here feels similar to my confusion about Tyler Cowen’s “state capacity libertarianism”. Creating a strong and effective state is certainly…a goal you can have. But I don’t understand the argument for calling this a libertarian project. At best, it’s a project not entirely opposed to libertarianism. Still, perhaps this is my ignorance. Cowen thinks that strengthening the state and instituting effective technocratic government can be allied to a small-government individualistic market-based philosophy. Whatever he’s smoking, maybe Herbert Hoover was smoking the same thing.

I get the impression that Kenneth Whyte is a bit of a revisionist historian, too sympathetic to his subject to tell his story the way everyone else does. But at least in Whyte’s telling, the Hoover presidency was a great missed opportunity, or at least a fulcrum of history. If a few key economic events had been a few months off in one direction or the other, FDR might have been a footnote to history, and a four-term President Hoover might have left an indelible mark on America. Instead of a New Deal, we might have gotten a optimistic small-government technocratic meritocracy that was able to merge the best aspects of a dying frontier America with the best aspects of the industrial age.

In one of the most poignant passages in the book, Commerce Secretary Hoover fires back at his socialist critics. He points out that of the top dozen US officials – the President, VP, and ten Cabinet Secretaries – eight, including himself, had begun as manual laborers and worked their way up. That was the America Hoover was working to defend. He lost, and now we have this shitshow. But it’s hard to begrudge him the attempt.

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For, Then Against, High-Saturated-Fat Diets

I.

In the 1800s, the average US man weighed about 155 lbs. Today, he weighs about 195. The change is even starker at the extremes. Someone at the 90th percentile of weight back then weighed about 185 lbs; today, he would weigh 320 lbs. Back then, about 1% of men were obese. Today, about 25% are.

This puts a lot of modern dietary advice into perspective. For example, lots of people think low-carb is the solution to everything. But people in the 1800s ate almost 50% more bread than we do today, and still had almost no obesity. Other people think paleo is the solution to everything, but Americans in the 1800s ate a diet heavy in bread, milk, potatoes, and vegetables, and relatively low in red meat and other more caveman-recognizable foods. Intermittent fasting – again, cool idea, but your great-grandfather wasn’t doing that, and he had a 1% obesity risk.

This isn’t to say those diets can’t work. Just that if they work, they’re hacks. They treat the symptoms, not the underlying problem. Something went terribly wrong in US nutrition between 1900 and today, and all this talk about low-carb and intermittent fasting and so on are skew to that thing. Given that 1800s Americans seem to have effortlessly maintained near-zero obesity rates while eating foods a lot like the ones we eat today, maybe we should stop trying to figure out what cavemen were doing, and start trying to figure out what Great-Grandpa was doing, which sounds a lot easier.

We get similarly confusing evidence from other countries. Until recently, Chinese people ate mostly white rice. This is exactly the sort of high-glycemic-index carb that low-carbers say should be terrible for you. But the Chinese stayed thin even when they ate a lot. It was only when they started eating processed Western-style food that their obesity rate started to rise.

Or what about France? The French diet is about what you would expect; baguettes, pastries, cheese, meat. Lots of sugar, white flour, and fat – the opposite of all reasonable dietary advice. But 1970s France had the same kind of low obesity rates as 1800s America or China. This is related to the nutritional conundrum famously called the French paradox – why aren’t the French fatter and sicker than they are?

The answer to all these questions seems to be something like “the body is pretty good at regulating its own weight under any diet except modern American processed food.” But what aspect of processed food makes it bad?

A new section of the online nutrition-sphere claims the answer has to do with the way mitochondria process fat. I’ve been trying to read these people and get a feel for their opinions. Most of what I’ve absorbed has come from Brad Marshall of Fire In A Bottle and his posts on The Croissant Diet. I’ve been told that another blog called Hyperlipid has a deeper investigation, but I’ve only scratched the surface of them. The r/SaturatedFat subreddit has some good stuff too. I don’t claim to fully understand these people and I apologize for any misrepresentations I might be making. But the short version is: they all agree that everything went wrong when we switched from saturated to unsaturated fat.

Wait, isn’t unsaturated fat the good kind of fat? Well, yes, this is what everyone else thinks. This is definitely one of those “good things are bad and bad things are good” diets. But let’s take a look at the argument.

In the 1950s, heart disease rates were rising in the US. Realistically, this was mostly because lots of people had started smoking a few decades before, and now all that tobacco was catching up with them. But people didn’t know that at the time, so they did some studies into nutrition, and the studies suggested maybe saturated fat caused heart attacks. So the government told people to replace saturated fat with unsaturated fat, and this was back when the government was competent, so saturated fat consumption plummeted and unsaturated fat consumption shot up.

This paragraph is an extreme oversimplification: saturated fat is mostly found in things like milk, butter, and meat. Unsaturated fat comes in two types: monounsaturated and polyunsaturated. Monounsaturated fat is found in olive oil. Polyunsaturated fat comes in two types: omega-3 and omega-6. Omega-3 is mostly found in fish (“fish oil”). Omega-6 is mostly found in vegetables (“vegetable oil”). If you’ve ever looked at your food and seen ingredients like soybean oil, safflower oil, canola oil, corn oil, et cetera oil, these are omega-6 polyunsaturated fats.

When the government recommended a switch from saturated fats to unsaturated fats around the 1950s, it was omega-6 polyunsaturated fats – vegetable oils – that picked up the slack. Here are some helpful charts:

I cannot for the life of me find original sources for either of these graphs, but they seem consistent with everything else I’ve heard so I am going to trust them. Sorry!

[source]

This dramatic change in consumption of fat was reflected in a dramatic change in the composition of the human body. Studies of human fat cells and breast milk found that they went from being overwhelmingly saturated fat (like the fat cells and breast milk of animals) to being partly polyunsaturated fat:

[source, source, source, source]

The only common villain everyone agrees on in the obesity story is “processed food”. I’ve previously found this frustrating – it reeks of a sort of unreflective technophobia. What part of processing makes food bad? How does mere contact with a machine turn food from healthy to unhealthy? What food counts as “processed” or “not processed”? Is ground beef processed, since you grind it? Are scrambled eggs processed, since you scramble them? Is bread processed, since wheat doesn’t grow in loaves? Is water processed, since it goes through water processing facilities? Is the Eucharist processed, even though the processing only changes its metaphysical essence and not its physical properties? Everybody I ask acts like the answers to these questions are obvious, but everyone has different answers, and nobody can tell me their decision procedure.

Omega-6 polyunsaturated fats provide a tempting answer. Processing is bad at the point where it involves adding vegetable oil to stuff.

Here is a not-so-fun experiment you can try. Go to your local grocery store, check the ingredients of everything, and see what is the most ridiculous place you can find added vegetable oil – soybean oil will be the most common, though you can spot others. I thought I had reached a low when I found soybean oil listed in the ingredients of what was, to all appearances, just a bag of rice. But then I checked the bread section and found that about 90% of the loaves of bread had soybean oil added to them too (and some of the remainder had safflower oil). It really is the closest thing to a ubiquitous omni-ingredient in every processed food, and in some foods that you wouldn’t have thought were processed at all.

So this is the circumstantial evidence linking polyunsaturated fat to obesity. Although polyunsaturated fat itself is natural (found in eg nuts and seeds), modern Americans consume it at levels that would have been equally foreign to cavemen and your great-grandfather. The vegetable oil craze started around the same time as the obesity epidemic, and the two have been following the same pattern ever since. And it’s concentrated in the same processed foods that most people think are most responsible for obesity. Also, the body fat of obese people is more polyunsaturated than the body fat of healthy people.

But is there a biologically plausible reason why polyunsaturated fat would cause obesity?

Actually, there are several. The one I’d heard a few years ago blames an omega-6 to omega-3 imbalance. Before 1950, most people ate a reasonable amount of fish and a reasonable amount of nuts, and got about 4x as much omega-6 as omega-3. After 1950, people started eating lots of high-omega-6 vegetable oil, but only the same amount of high-omega-3 fish, and the ratio shot up: now it’s about 10x-50x as much omega-6 as omega-3. Both omega-6 and omega-3 are involved in cell membranes and signaling chemicals, and there’s some evidence that omega-6s may be pro-inflammatory and omega-3s anti-inflammatory. Although the studies haven’t really been done, you can tell a story where the natural ratio of 6s to 3s creates a natural level of inflammation, and the current extreme level of 6s to 3s creates an extreme level of inflammation. Inflammation in the parts of the brain that regulate diet are one proposed mechanism for obesity, so there’s the skeleton of an explanation here, although lots of work would need to be done to prove it.

But the new one, the one that Marshall and Hyperlipid are pushing, is a little different. They think unsaturated fats in general are bad, including monounsaturated fats and omega-3s (though realistically omega-6 vegetable oils so overwhelm these in the average American diet that we can forget everything else.). The exact mechanism is complicated, but focuses on the Krebs cycle, bane of medical students everywhere. The Krebs cycle is the set of chemical reactions that your cells use to convert high-energy food chemicals into ATP, a form of energy your body can use to power its own biological processes. Both saturated and unsaturated fats feed into the Krebs cycle. But the Krebs cycle produces reactive oxygen species (aka free radicals, eg hydrogen peroxide) when it metabolizes saturated fats, and not when it metabolizes unsaturated fats. Reactive oxygen species seem to be one of the signals the body uses to detect satiety, which makes sense – if they’re a byproduct of metabolizing food, and you have a lot of them, that probably means you just metabolized a lot of food, and so you should be full. There’s a lot of biochemistry here, and I haven’t gone through all of it. But the basic idea is – burning saturated fat makes you full, but for decades we’ve been replacing saturated fat with polyunsaturated fat, which doesn’t make you full. So we’ve been eating more. Hence, obesity.

If this were true, it suggests a diet high in saturated fat and low in unsaturated fat, especially polyunsaturated fat. Marshall calculated out the right macronutrient ratio and found that the food that most closely matched it was butter croissants – hence the name “the croissant diet”. Yes, you can live off croissants if you want. But it also allows lots of other things with high saturated and low unsaturated fat. Red meat (but not chicken or pork; most chickens and pigs are fed high-PUFA feed that gives them high-PUFA meat). Milk, cheese, and butter (but not margarine, which is mostly PUFAs). Pasta, rice, and other carbs (but if you’re putting sauces on them, make sure they’re high saturated fat). Fried things, as long as you fry them in coconut oil, palm oil, or butter (mostly saturated fat) instead of vegetable oils or olive oils (mostly unsaturated fat). You can read the full specification here.

This diet is kind of the opposite of the one most nutritionists recommend. But it would taste a lot better. And following nutritionists’ advice hasn’t worked out so well for Americans circa 1970 through 2020. So what could go wrong?

II.

I find this to be a really elegant and provocative theory, with impressive circumstantial evidence. Unfortunately, as far as I can tell all of the direct evidence is against it. I’m not a nutritionist and have not studied these nearly as intently as the nutrition bloggers who support it, so low confidence in this part. But I’m putting my objections out there in the spirit of seeing whether other people will be able to reply to them and shoot them down.

First, let’s start with the diet itself. Lots of people have tried it, and the most common result is nothing. The r/SaturatedFat subreddit is full of people talking about how the diet didn’t work for them, with only a few contrary opinions. I tried it for about a month, and lost about 4 pounds the first two weeks, followed by no more weight loss no matter how hard I tried. This is my usual pattern every time I try a new diet, and I interpret it as placebo or just the effect of restricting some foods. The high-saturated-fat croissant diet did no better.

(Marshall argues it gets better results in waistline shrinkage than weight loss alone, and my own results sort of seem to confirm this, but I’m not confident in the accuracy of my waistline measurements. Also, why should this be true?)

Second, mouse studies. You can feed mice whatever you want, then see how much weight they gain. There are a lot of these, they’re all conducted with different mice, different macronutrient sources, and different methodologies, and they all get different results. After looking at many of them, all I can say is that there is definitely no strong trend for lower saturated and higher polyunsaturated fat diets to result in more weight gain. For example, in this study, mice who ate palm oil (a high saturated-fat oil) gained more weight than those who ate safflower oil (a high polyunsaturated fat oil), although mice who ate cocoa butter (a different high saturated fat oil) gained less than either. In this study, mice who ate lard (high in saturated fat) gained more weight than those who ate olive oil (monounsaturated) or fish oil (polyunsaturated). Again, I’m less interested in these particular studies or their particular results than in the vast amount of literature that has investigated these questions and very rarely found a strong unambiguous tendency for saturated fat to be good and unsaturated fat to be bad. Stephan Guyenet, who used to support the omega-3:omega-6 ratio theory, agrees with this and now considers it unlikely based on mouse study results. It’s possible that I’m missing different results for different kinds of saturated fat – stearic acid (a specific kind of saturated fat) seems to do pretty well, and the croissant diet to some degree centers around it. But as far as I can tell, an inferiority of any kinds of saturated fat to any kinds of polyunsaturated fat doesn’t seem compatible with the basic theory.

And third, people have studied the effect of saturated vs. unsaturated fat so much. This is maybe the biggest controversy in nutrition right now. Some people think (in accordance with the 1950s and 1960s findings) that saturated fat contributes to cardiovascular disease. Other people think those findings were wrong and it doesn’t. There have been a bunch of studies and big meta-analyses trying to find out who’s right with only limited agreement. While some studies have found that saturated fat is bad and others that it’s harmless, as far as I know none of them have found that it has a strong protective effect against weight gain. If this was really the difference between the 1800s when nobody was obese and today when a bunch of people are, it ought to be a blindingly bright signal. But I don’t see anything of the sort.

Just to give examples: Lin investigated the relationship between saturated fat and weight loss, and found that the higher a diet was in saturated fat, the more likely people were to gain back weight they had lost. Phillips investigated the same question in relation to a probably irrelevant candidate gene, and found the same thing. Utzscheinder investigated high- vs. low- saturated fat diets and found no difference in weight loss, but the high saturated fat diet contributed to unhealthy liver fat deposition. Khaw et al investigated the effect of butter and coconut oil(saturated) vs. olive oil (monounsaturated) on obesity, and found nothing. Schwingshackl et al investigated the effect of 10 food groups on metabolic parameters and found that nuts were the healthiest, even though they are the highest in omega-6 fats.

(also, the whole point of this diet was supposed to be that croissants should be an unusually satiety-producing food, but somebody studied how much satiety every food produces, and croissants are literally the lowest on the list.)

I haven’t looked closely at any of these studies and don’t especially trust them. I’m more gesturing toward the general idea of how unlikely it is that people have studied saturated fat in depth for a long time, gotten a bunch of small negative effects that might or might not be real, and failed to notice that the real effect is gigantic and positive.

For that matter, where are the random Redditors? Saturated fat is one of the major macronutrients, it’s not exactly some weird exotic chemical nobody ever thought to test. If high-saturated-fat or low-polyunsaturated-fat diets help you stay thin as easily as 1800s Americans stayed thin, how come people didn’t figure this out in ten minutes? There have been so many random diet crazes like low-carb and paleo, all linked to some people squinting and thinking they might have seen a signal among all the noise. If there were a diet that was pretty basic and actually worked in an obvious way, don’t you think people would have found it?

III.

There’s an awkward tension between the first part of this post and that last counterargument.

The first part of the post said that there is some dramatic and hard-to-explain difference in obesity between the modern West and every other civilization, whether that’s the historical West or other modern countries that haven’t yet adopted our diet. I haven’t given evidence here, but the obesity goes hand in hand with higher cancer rates, higher cardiovascular disease rates, and just generally worse health. Presumably we’re doing something very wrong.

The last counterargument said that if we were doing something very wrong, one of the thousands of biohackers who has tried every ridiculous fad diet and long-shot idea would have reversed the one wrong thing we were doing and gotten incredible results. Then, by the efficient market hypothesis, somebody would have noticed the incredible results, and the smart paying-attention people would switch to that diet, and then we’d have a world that looks a lot different than the past decade or two of people chasing various exciting ideas with no results. As far as I know, nobody has yet met Ampersand’s challenge of finding a peer-reviewed study demonstrating that some diet can consistently help people lose lots of weight and keep it off.

But how could that be? If people used to be thin and healthy, we should just be able to do what they were doing! And then that would be the diet that can consistently lose weight and keep it off!

I can only see three ways out of this paradox.

First, conventional wisdom is right about everything. People are fatter today than in the 1800s because they eat too much and exercise too little. They eat too much because they are rich, food is cheap, and food tastes really good. They exercise too little because they’re office workers now instead of farmers. In this model, the reason the efficient market hasn’t found the secret to weight loss is because there’s no secret and weight loss is really hard. It wasn’t hard for your great-grandfather because he had fewer options and so he didn’t need to exercise willpower to avoid the bad ones. The most sophisticated version of this model, so sophisticated that maybe I shouldn’t call it this model at all, is the food reward theory ably defended by Stephan Guyenet.

This has a lot going for it, but can’t be quite right. Exercise seems like a red herring; studies of how much people eat, exercise, and gain weight have shown that dietary changes explain more than 100% of weight gain over the past 30-40 years – probably we are exercising a little more. And there was really tasty food in 1800s America and 1970s France, so how come people didn’t overindulge in that? How does it explain all the weird results like lab animals, pets, and feral rats gaining weight? This probably part of it, but it still feels like something’s missing.

Second, diet is barely related to the obesity epidemic, and it’s being caused by plastics or antibiotics affecting the microbiome or something like that. This is another thing where I would have expected people to notice, but I definitely don’t want to dismiss it prematurely.

Third, it’s a ratchet. Departing from the ways of our ancestors (or great-grandparents) can make you obese, but returning to their ways cannot make you thin again. A bad diet (whatever that is) shifts your weight set point up, but a good diet does not shift it back down, at least not in a reasonable amount of time. It just prevents further damage.

This contradicts the evidence from some people who do manage to lose weight, including some people who manage to lose a lot of weight and keep it off. I think the theory would have to be that different people’s set points are differently malleable, and that some people are obese because their set point is set to obese, and other people barely have a set point and are mostly operating on calories-in-calories-out. If this seems a little too convenient an assumption, keep in mind this is how lots of other set points work – some people will gain tolerance to certain drugs almost instantly, and other people will never get it at all.

Overall I am ending this research more confused than when I started it. I think the most likely dietary change I make is to try to avoid foods with soybean, corn, or safflower oil, since this is probably a good stand-in for “foods processed enough that they count as processed foods and you should avoid them”. I don’t think the evidence is good for avoiding fish oil and olive oil, and there’s enough evidence from elsewhere that these foods are healthy that I’m going to keep trying to eat them. I don’t think the evidence is good for saturated fats being especially good, and there seems to be at least equally strong evidence that they’re bad, so although I’m not going to work too hard to avoid them I’m definitely not going to optimize my diet for getting as many of them as possible.

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