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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Open Thread 149

This is the bi-weekly visible open thread (there are also hidden open threads twice a week you can reach through the Open Thread tab on the top of the page). Post about anything you want, but please try to avoid hot-button political and social topics. You can also talk at the SSC subreddit – and also check out the SSC Podcast. Also:

1. Comment of the week is knzhou on using zinc to treat colds and coronavirus. Also check out PhilH’s Less Wrong post on zinc for the common cold.

2. On the last links post, I linked an article by researcher Mark Ledwich describing a study he did debunking YouTube “algorithmic radicalization”, but expressed some concerns about the way he communicated it. He’s responded to those concerns in a comment here.

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Socratic Grilling

Imagine an kid in school first hearing about germ theory. The conversation might go something like this:

Teacher: Many diseases like the common cold are spread by germs, when one infected person contacts another.

Student: But I got a cold a few weeks ago, and I never touch anyone except my family members. And none of them were sick.

Teacher: You don’t need to actually touch someone. Sometimes it can spread through mucus droplets in the air.

Student: And one time I was camping in the woods for a month, and then I got a cold, even though I hadn’t been around anybody.

Teacher: If it was spring, you might have gotten allergies. Allergies can feel a lot like a cold, but they aren’t spread by germs.

Student: It was fall.

Teacher: Then maybe it was an unusual allergy, or some other condition.

Student: Hey, wait. If germs are spread from person to person on touch, why doesn’t the government just mandate one week when nobody is allowed to touch anyone else? Then all the germs will die and we’ll never have to worry about germs again.

Teacher: That’s a good question. A lot of germs have what’s called reservoirs in the environment, where they live when they’re not infecting humans. Even if the government tried your plan, probably most sicknesses would come back from their reservoirs.

Student: I’ve never seen a germ reservoir. Where are they?

Teacher: They’re not literal reservoirs like a water reservoir, that’s just what we call it when germs live in bats or raccoons or something.

Notice a few things about this conversation.

First, it’s really good that it happened. The student was clearly confused at many points. First, he had direct evidence that seemed to contradict the teacher’s claims that germs only spread by touch. Second, he had a sort of efficient-market-style confusion: germ theory seems to imply an easy way to eliminate all sicknesses forever, so why hasn’t someone picked this low-hanging fruit? Third, he was confused by an awkward term – he thought germ reservoirs were lakes full of germs in the hills somewhere.

All of these confusions are totally understandable. In fact, they’re a really good sign he’s paying attention – that he’s trying to figure out what germ theory really means and how it interacts with the rest of his worldview. They’re the direct opposite of guessing the teacher’s password. One day this kid is going to be an amazing scientist.

Second, to a hostile observer, it would sound like the student was challenging the teacher. Every time the teacher tried to explain germ theory, the student “pounced” on a supposed inconsistency. When the teacher tried to explain the inconsistency, the student challenged her explanations. At times he almost seems to be mocking the teacher. Without contextual clues – and without an appreciation for how confused young kids can be sometimes – it could sound like this kid is an arrogant know-it-all who thinks he’s checkmated biologists and proven that germ theory can’t possibly be true. Or that he thinks that he, a mere schoolchild, can come up with a novel way to end all sickness forever that nobody else ever thought of.

And the thesis of this post is that you must never, ever say that. Saying that is so bad. Smack down that student once, say “I think I know more about germ theory than you do”, make him feel like he challenged your authority and that’s bad – and the best case scenario is he will never ask questions to resolve his confusion again. The worst case scenario is that he stops feeling the confusion entirely, or stops thinking of forcing things to fit together and make sense as a desirable goal to have.

One of the most important rationalist skills is “noticing your confusion”. But that depends on an even more important proto-skill of wanting things to make sense. If you lose that skill – if it stops bothering you and seeming like a problem when things don’t make sense to you – you will never notice your confusion and you will never become a good scientist or a good anything-else-that-requires-independent-thought. And interpreting an attempt to explore dissonance as a status grab that needs to be knocked down is absolutely fatal for that skill. Instead, you need to think of it as Socratic grilling – like Socratic questioning, but a little harsher and more confrontational in order to get to the point more quickly.

Tolerating this is harder than it sounds. Most people can stay helpful for one or two iterations. But most people are bad at explaining things, so one or two iterations isn’t always enough I’ve had times when I need five or ten question-answer rounds with a teacher in order to understand what they’re telling me. The process sounds a lot like “The thing you just said is obviously wrong”…”no, that explanation you gave doesn’t make sense, you’re still obviously wrong”…”you keep saying the same thing over and over again, and it keeps being obviously wrong”…”no, that’s irrelevant to the point that’s bothering me”…”no, that’s also irrelevant, you keep saying an obviously wrong thing”…”Oh! That word means something totally different from what I thought it meant, now your statement makes total sense.”

But it’s harder even than that. Sometimes there is a vast inferential distance between you and the place where your teacher’s model makes sense, and you need to go through a process as laborious as converting a religious person to a materialist worldview (or vice versa) before the gap gets closed. The process of learning to really appreciate communism, or libertarianism, or whatever, coming from a diametrically opposed philosophy, looks a lot like dozens of questions about “but isn’t that an atrocity?” “wouldn’t this inevitably lead to dystopia?” and hearing what your interlocutor has to answer. It’s so, so tempting to round this off to them trying to gotcha you (as indeed sometimes it will be) and assume they’re not really committed to trying to understand.

With a good teacher, you can add enough disclaimers to your statements that they won’t get mad at you during this process: “I know I am but a mere student, and nowhere near smart enough to actually challenge you, so I’m sure I’m just misunderstanding this, but the thing you just said seems really confusing to me, and I’m not saying it’s not true, but I can’t figure out how it possibly could be true, which is my fault and not yours, but could you please try to explain it differently?” With a great teacher, all of this is assumed, and you don’t need the disclaimers, and you can just say “What? That makes no sense,” and expect the teacher to try again.

I think actual teachers get this right more often than not. What I’m concerned about is the self-appointed Internet anti-autodidact brigade. I occasionally get these people as commenters on my blog, but they’re more common in Reddit and places like that. Someone goes “that’s weird” or “if X was really true, wouldn’t that imply Y?” and gets hit with “You really think you’re smarter than everyone else? You really think a random person on the Internet has discovered a hole in X?” No, sometimes they’re just using Socratic grilling to expose the contradictions in their model and get somebody to resolve them.

I find this to be one of the most frustrating parts of writing this blog: how do I signal the things I still need to learn without the Arrogance Police descending on me? This is different from the case with a specific teacher – here there’s just me projecting my confusions out into the void to see if anyone answers. And every so often I do flatter myself that I’ve discovered a flaw in my betters’ reasoning, so it’s less obvious when I mean to imply that and when I don’t. Next time this happens I’m going to try just linking this post and seeing how it goes.

I think I strike a good balance, at the cost of endless annoying disclaimers that 95% of you don’t need. From now on, maybe I’ll just link this post.

Coronavirus: Links, Speculation, Open Thread

[Epistemic status: Very weak – I’m still trying to figure all of this out. Some things in here will almost certainly be wrong. Please don’t let this overrule what government agencies or your common sense are telling you. For a more careful guide to the coronavirus and what to do about it, see here.]

Prepping

For a description of why you might want to prep, see Putanumonit: Seeing The Smoke. For a description of how to prep, see this article by Kelsey. For a really intense guide by a professional prepper, see here.

But there’s such a thing as being too intense. You probably won’t need to store water – the water kept running in Wuhan. You probably won’t need a generator – Wuhan has electricity. The most important thing seems to be food (and toiletries, and other necessities). If the epidemic gets bad, you’ll want food so you can avoid going out to coronavirus-filled supermarkets. And if you get the coronavirus and are feeling sick, you’ll want food at home so you don’t have to get too far out of bed.

What about Amazon? Getting fresh groceries delivered whenever you want seems like a pretty good alternative to stocking up on canned beans. You’d need faith that it won’t get so bad that Amazon’s logistics break down. I think that faith is mostly justified – The Chinese version of Amazon seems to still be making deliveries in Wuhan. And it’s hard to imagine anything – pandemic, nuclear war, demon apocalypse – getting between Jeff Bezos and his next billion dollars. Three cheers for capitalism!

Coronavirus can remain on objects for a few days, and Amazon warehouse workers may come into work with the condition, so if you’re using Amazon as part of a self-quarantine strategy, you should probably open packages away from your main living space, using gloves, and disinfect anything inside that doesn’t have its own packaging from the manufacturer.

How bad will it be?

From the Chinese numbers, people have estimated these death rates:

The good news is that it’s pretty unlikely to kill young people. The bad news is that even young people seem to have severe cases that can land them in the hospital. This comes from former FDA commissioner Scott Gottleib – the rate of hospitalizations for flu vs. COVID-19 by age group:

This page says that the Chinese population is 70% under 49, 20% 50-65, and 10% 65+. So the graph above implies that every demographic has approximately equal hospitalization rates, which other sources suggest are 15% to 20%.

This is a weird pattern – why are so many young people getting hospitalized if almost none of them die? Either the medical system is serving these people really well (ie they would die if they didn’t go the hospital, but everyone does make it to the hospital, and the hospital saves everyone who goes there), they are being hospitalized unnecessarily (ie they would live even if they didn’t go the hospital, but they do anyway), or it’s statistical shenanigans (eg most statistics are collected at the hospital, so it looks like everybody goes to the hospital).

Are these an overestimate? Maybe most cases never come to the government’s attention? There’s some evidence for this. In South Korea, coronavirus started spreading through a tightly knit cult, so the government had to test the whole cult, including the people with no symptoms. 70% of asymptomatic members tested positive for the virus, suggesting that many cases may not come to medical attention (although some of those people might have just been in the incubation period). So hopefully the 20% hospitalization rate will prove to be a worst case scenario, and the real number will be less.

[EDIT: several people are saying that in other countries the hospitalization rate is closer to 5%; let me know if any of you find a source for this]

Self-quarantine starting now vs. later?

Rough Fermi estimate: there are 10 reported cases in the Bay Area. Optimistic scenario, we’re only missing another 20. Median scenario, most haven’t been detected and there are really 100. Pessimistic scenario, 1000.

(in a draft, I used the term “worst-case scenario”, but it turns out some people can think of some really bad scenarios. Let’s stick with “pessimistic”.)

The number of infected people doubles every 2-7 days. Let’s say optimistically 7, median 3.5, pessimistically 2.

So over the next week, we can expect there to be 20 (optimistic), 300 (median), or 10,000 (pessimistic) new cases in the Bay Area.

The Bay Area has a population of 8 million. So we can expect that 1/400,000 (optimistic), 1/30,000 (median), or 1/800 (pessimistic) of the population will be infected in the next week.

Suppose you’re trying to decide whether to quarantine your 5-person household. Worst-case scenario you multiply the number by 5. But realistically your infection risk will be correlated – you’ll be in the same areas, hanging out with the same social circle. If the epidemic spreads solely among Chinese-American schoolchildren in San Mateo, and none of you are in that demographic, then you’re all safe. So for the median and optimistic scenarios, we’ll say risk varies with square root of the number of people in your house, and for the pessimistic we’ll keep it linear. So per house risk is 1/200,000 (optimistic), 1/15,000 (middle), or 1/160 (pessimistic).

So even in a pretty pessimistic scenario, Bay Arean households have a less than 1% chance of getting the virus this week (people from elsewhere will have to redo the math with their local numbers). Next week you can check how many cases there are (and how many hidden cases you suspect there to be) and reassess.

Ways this model might fail: there are more than 1000 cases in the Bay Area, you live with more than 5 people, some of the people you live with have an unusually high risk profile (are health workers? travel a lot?), unknown unknowns.

EDIT: Daniel Filan on Less Wrong has made a more complete risk assessment model.

What’s the endgame?

The theory is: you quarantine yourself for a few weeks or months while the epidemic is going on, eventually there aren’t enough virus-naive hosts to sustain transmission, and we’re all safe until the next time some moron in China eats a bat.

This theory might not be true. CDC director Robert Redfield says:

This virus is probably with us beyond this season, beyond this year, and I think eventually the virus will find a foothold and we will get community-based transmission…The containment phase is really to give us more time.

I don’t know exactly what this means, but it sounds like he’s saying it will become something like the cold, flu, or chicken pox – a virus that’s just ambient all the time, and you’re always at risk of getting it. You can’t outlast it because it doesn’t go away.

If that’s true, the goal of quarantine would change to outlasting the crisis. There will probably be a peak of the epidemic when hospitals are overcrowded and there are no spare ventilators and you really don’t want to need medical care. If you can get past that, and catch it a year or two from now, there will be spare doctors and nurses to care for you and spare ventilators to support you if you need it.

But if that’s true, maybe it would also be acceptable to catch it early and beat the rush. If you catch it literally today, you’re near-certain to get a hospital bed; if you catch it a month from now, who knows? This is another argument against premature quarantine, although not a strong one if you expect your quarantine to work.

(This part is especially speculative, even more than the rest of this post. Please don’t go out and try to catch the coronavirus on purpose.)

No, really, what’s the endgame?

Some sources argue that recovered patients can get reinfected with coronavirus, ie people don’t build immunity after surviving it once. This would really suck. I don’t know exactly how to model this – surely it wouldn’t mean a perma-epidemic all the time – but at the very least it would mean it was around permanently and even good quarantines wouldn’t be very valuable.

Microbiologist Florian Krammer (link) thinks these are probably false positives. Some other people have said they might be very elderly or sick people with abnormally poor immune responses. Let’s hope.

Home health care

Some people in the rationalist community have put together a document with some useful suggestions. Among them:

– Most coronavirus infections will be generally mild and probably treated at home. Make sure your home has oral rehydration solutions like Gatorade or Pedialyte available to deal with dehydration from vomiting, diarrhea, or other causes, and Tylenol available to help with fever.
– If you think you’ll fret a lot about whether you need to go the hospital, get a pulse oximeter ($20 on Amazon). Readings consistently below 90-94% are pretty bad and mean you should seek immediate treatment.
– Everything that makes you feel better and healthier in general helps your immune system too, so get good sleep, eat healthy, and take Vitamin D if you’re deficient.
– The best way to avoid infection is still to wash your hands frequently and avoid touching your face. Less good but cooler ways to avoid infection include putting copper tape over everything in your house (copper kills viruses on touch). For best results, use a combination of copper, iron, and silver tape to be protected from coronavirus, fae, and werewolves simultaneously.

Don’t visit Grandma

Seen on Tumblr: the coronavirus death rate is 0.2% for people in their 30s and 15% for people in their 80s. The vast majority of our concern should be for our elderly and for what happens to the 2020 election after we lose every presidential candidate except Pete Buttigieg.

You might want to call your elderly parents and grandparents and ask them to store enough food and water to stay in the house for a long time. You might want to talk to them about how bad things would have to get before they should stop visiting large gatherings, and how bad things would have to get before they stop leaving the house. You might want to explain to them how to use Amazon if they don’t already know how to do it, or coordinate with them so you can Amazon them things if they need it later on. You might want to make sure they have enough of their prescription meds stored up in case going to the doctor suddenly becomes harder. You might want to talk about whether they should come stay with you assuming you aren’t more exposed to the outside world than they are; if you have kids who go to school every day, your elderly relatives might be better off at their retirement home.

But have these conversations by phone! Don’t visit them! The last thing we need is everyone suddenly going and visiting the elderly much more often than usual!

(Grandma, if you’re reading this, the reason I haven’t called you about this yet is that Dad is investigating options and he will be contacting you soon).

Also, although the original post was titled “Don’t visit Grandma”, technically it’s Grandpa you should be most concerned about – elderly men seem to have twice the death rate of elderly women. [EDIT: Michael Keenan points out this might just be because elderly men in China smoke a lot and have bad lungs]

The view from China

A Chinese-speaker on the subreddit sums up what they’ve gleaned from Chinese social media. For example:

People are talking less about Wuhan and more about the rest of the world in recent days. The worst of the overload in Wuhan is over, and the quarantine in the rest of the country is keeping spread more or less manageable. People are talking more about the usual scandals and fandom stuff. Meanwhile, people are horrified at, say, Japan’s mismanagement of its earlier cases. I’ve seen the attitude “we sacrificed Wuhan to slow the spread and you guys are just wasting your window of opportunity?” And comments that maybe the CCP isn’t that incompetent in comparison after all.

The framing of sacrificing Wuhan to save the rest of the world is pretty poignant, and partly true; they did buy a lot of time. And cruachanmor describes the ways the Chinese quarantine can basically be called a success:

The fact is that the Chinese efforts at containment do seem to have worked – cases have been dropping consistently now for nearly a couple of weeks. Back in the first week of February the Chinese were diagnosing between 3,000 and 4,000 cases a day (and that was lab diagnosis only) on an alarmingly upward trend, yesterday there were just 415 (lab+clinical), all but 17 in Hubei, with 600 or so suspected (which follows a similar pattern). That’s really quite remarkable – and despite the common internet belief that China is lying through it’s teeth that’s unlikely because more open societies like Singapore and Thailand have followed similar patterns. If there were a more widespread infection then this wouldn’t be the pattern. Indeed at this point the stats would suggest there’s now significantly less people in China with an active infection than there was two weeks ago – this is not “dubious efficacy and inherent harms of China’s historically unprecedented crackdown.” – well that is unless the only thing you care about is the amount of product coming out of Chinese factories.

Whilst the virus may now be in more countries, epidemiologicaly there’s little difference between spreading around the world and spreading in China – which does after all contain 20% of the world population.

Of course that’s not to say we won’t see a pandemic, but The Atlantic is way off on this. In the UK for instance a 40% infection rate with a 2% death rate would be half a million dead. If any democratic government threw up it’s hands and took the ‘fuck it, we’ll let it burn through’ approach suggested by the Atlantic whilst at the same time China does manage to contain it then said elected government is not going to be elected long.

No country that has to respond to the concerns of its citizens (and that includes China where the CCP needs to retain legitimacy) is going to let this go. Even Iran, as there’s a lot of pent up discontent by the younger generation there who are not going to look kindly on their government after a major epidemic.

The story I’m hearing from most smart people is that China has done amazing work and mostly halted their epidemic. This is very impressive, but it’s unclear what it will achieve long-term; they’ve basically turned off their whole country, and they’re going to have to turn it on again sometime. Once that happens, the coronavirus can just pick up where it left off, either from a few people in Wuhan who they missed, or from foreign travelers. I guess they’re gambling they can put out every fire as soon as it starts using the logistical capacity they built for Wuhan, and maybe they’re even right. Nobody’s too optimistic that democratic countries can follow their lead, though.

No problem so bad overregulation can’t make it worse

So far the government has bungled its coronavirus response pretty egregiously.

Most hospitals have the equipment in house to detect coronavirus. But the FDA banned them from using it. They said all coronavirus tests needed FDA approval, and refused to approve anything except the official test made by the CDC.

Unfortunately, the official CDC test was defective. The test itself worked, but one component in the test kit was broken. Most hospitals had their own supply of this component and could have substituted it in, but the way the FDA approved the CDC test banned them from doing this.

The CDC tried as hard as it could to fix their broken tests quickly, but they weren’t able to do it fast enough to satisfy demand. In order to ration the scarce tests, they mandated that hospitals only test people who had recently been to China, or been in close contact with someone who had.

This was a disaster. For example, here’s a story from a person who traveled to Japan, where the coronavirus is active. He came back to the US, started developing symptoms, and went to a hospital. The hospital said since he hadn’t been to China, they couldn’t test him, and sent him home (he voluntarily quarantined after discharge, so thanks).

But even worse, the policy ruled out by fiat ever being able to detect when the epidemic spread to the US. So in mid-February, when a patient with no history of travel to China came to a hospital in California with coronavirus symptoms, the doctors had to ask the CDC for special permission to test. The CDC dithered for four days before granting the permission, during which nobody put any work into containing the disease. Finally the test came back positive – after some health workers had already been infected.

There were many points where this could have been avoided. A better CDC could have made tests that worked from the beginning, or ramped up production of working tests faster, or come up with smarter criteria for rationing tests. But it would have been even better to have a system where things don’t have to go perfectly, and where a few mistakes don’t choke up the entire response to an epidemic for weeks. If we hadn’t let our culture reach the point where governments ban things by default and review at leisure, and where individual iniative is frowned upon in favor of waiting for official permission to do the right thing, we could have recovered from all of these mistakes. Hospitals would have used their existing tests which they already have more than enough of, doctors would have had permission to test suspicious cases at their discretion, and we would have had a chance to catch infections early before they could spread. If the government didn’t already regulate adrenaline, buspirone, insulin, and genetic testing to the point of near-unavailability, maybe people would have thought it was weirder, or raised more of a fuss, when they started doing it for coronavirus tests.

If you don’t trust me, trust former FDA director Scott Gottleib, who explains the situation here in an unusually candid communication from an ex-government official talking about his former agency. His Twitter feed is a great source of information in general.

And here’s a more careful analysis of some of the laws around diagnostic testing and how they contributed to the current crisis. And by more careful, I mean it ends with “Bottom line: the FDA is going to kill us all”.

The efficient market hypothesis is the real victim

I know a bunch of people who sold or shorted stocks when the virus started hitting China hard, based on the assumption that a pandemic sounded bad for business and business hadn’t priced this in yet. Jacob of Putanumonit and Wei Dai on Less Wrong both mention doing this and making healthy amounts of money. Good work on their part – though given the recent market crash, trying to replicate their success now seems suspiciously like a buy high, sell low strategy.

Masks and respirators

People are coming down really hard against face masks for coronavirus. Wirecutter: You Don’t Need A Face Mask For Coronavirus> Marketwatch: US Health Officials Say Americans Shouldn’t Wear Face Masks To Prevent Coronavirus – Here Are Three Other Reasons Not To Wear One. Fastcompany: Five Reasons Not To Wear A Surgical Mask To Stop Coronavirus (number five is “Just don’t.”) The CDC and Department of Health and Human Services have both officially recommended against mask-wearing.

Some of the reasons given are idiotic: the virus is not common in the US yet, so you are wrong to worry. This reminds me of all the people saying that AIs are not currently superintelligent, so any discussion that AIs might become superintelligent is just fearmongering. Who are these people? How are they still alive? How do they avoid driving off cliffs? They’re heading towards the cliff face, and their passengers scream at them: “YOU’RE DRIVING TOWARDS A CLIFF!”. And they calmly respond with “We are not falling off the cliff yet, we’re on perfectly level ground, there’s no reason to panic.”

Other reasons are superficially better, but collapse under scrutiny. Masks, the articles say, only help people who are sick avoid transmitting the disease, so healthy people don’t need to wear them. But the coronavirus can be asymptomatic for weeks, so if you want contagious people to wear them, part of your target demographic will think they’re healthy. Also, if you become sick, you don’t want to have to go out to the store to buy a mask or wait for it to arrive from Amazon, you want to have it immediately.

Other reasons make more sense. Standard-issue surgical masks may not help much, especially if you aren’t trained in their use. The coronavirus isn’t airborne; wearing a mask while walking outside is unnecessary – it’s when you’re kissing your spouse or chatting around the water cooler or touching a doorknob that you really want to worry. Any mask weak enough to stay comfortable while wearing for long periods, or even weak enough to talk through, is probably too weak to work. There’s a good NYT article about some of these issues here. If people with masks risk compensate even a few percent, that’s enough to make them a net negative.

And other reasons are really truly excellent: if random people buy up all the masks, there won’t be enough left for health care workers or the very sick. I agree this one is a good point.

But the thing is, I already own a P100 respirator. I bought it during fire season last year, aka the-air-is-unbreathable season. Living in California is full of excitement, and after a couple of years you end up prepared for lots of stuff. And the other day, I wore it on the BART – a densely-packed subway full of people who are constantly breathing in your face. And my friends told me – haven’t you heard that the government says masks don’t work?

An N, P, or R rated respirator, worn properly, in specific high risk situations, can be an appropriate part of a safety strategy. I think an accurate treatment of the topic would admit this, while also stressing the reasons most masks might not appropriate for most people in most situations. The statements and articles I’ve read don’t seem up to this level of subtlety. Instead, they seem focused on getting people to do what they consider the right thing (not hoard masks and panic) at the cost of oversimplifying the situation, sometimes up to the point of mistruth.

Their goal is understandable, and maybe this kind of simple messaging is the right choice during a pandemic. But the thing is, I doubt any government preparedness czar called up the major media companies and started their pitch with “I’m going to ask you to make an unprecedented sacrifice today”. I doubt there were hours of soul-searching in newrooms and government PR departments as people considered whether to take this step. I think this happened instantly and seamlessly because it’s what everybody has been doing all the time for years.

So no, don’t use masks or respirators unless you know what you’re doing and are sure it isn’t inconveniencing anyone else. But also, try to pay attention to the forces shaping your informational environment.

(update: South Korea is going full speed in the other direction and making it a top priority to give everybody masks. See the Reddit thread about it here. I hope someone compares results once this is all over).

Zinc

There are a couple of compounds that probably help a little against the common cold. Some cold viruses are coronaviruses, and lots of respiratory infections share common mechanisms. Could these be helpful against coronavirus too?

For example, most studies suggest that zinc probably shortens the duration of cold symptoms by 25 – 50%. The studies didn’t really look at severity, but plausibly it affects that too. It’s unclear exactly how it works, but some people think it inhibits viral replication. It also might be involved in immune system function, and there’s some growing evidence that adequate zinc levels prevent pneumonia.

None of this evidence is great. And even if it were, there’s no guarantee it would transfer to coronavirus. Taking zinc to help coronavirus is a really long shot.

Still, it’s weird how explicitly anti-zinc a lot of sources are. Consumer Reports gives 6 reasons (why are these things always six?) that you shouldn’t use zinc for a cold – number one is because, although it will shorten the cold, it won’t prevent it entirely. That’s some galaxy-brain-level reasoning there. Wall Street Journal just warns people that zinc is not known to prevent coronavirus and so you should wash your hands instead, and the Telegraph warns about zinc in the context of scam coronavirus cures we should watch out for.

Again, I understand the impetus. Maybe people are morons, and if you say there’s a chance zinc might be helpful, they’ll go out, down a whole bottle of zinc pills, and then fly to Wuhan and gorge on batburgers because they think they’re invincible. Then when they get it anyway they’ll blame it on you. And there are so many scammers selling so many dumb supplements that it feels irresponsible to do anything which might aid or abet them. There’s no good way of saying “maybe there’s a 10%-20% chance, with lots of Knightian uncertainty, that zinc could make your coronavirus case a little less severe, but zinc pills are cheap and safe, so you might want to try it as long as you stick to safe levels”.

But again, I can’t help feeling like my information environment is being optimized to prevent stupid people from panicking, and not to help me make good decisions. I would love if the average news site I went to had an interview with an immunologist who gave their honest probability estimate for whether zinc would be helpful or not. In the real world, all we can do is make dumb guesses on our own.

Edit: knzhou has better information on this, including a microbiologist’s opinion.

Metaculus is optimistic

Metaculus is a prediction engine run by some cool people at UC Santa Cruz. It crowdsources predictions made in different ways, then studies various algorithms for aggregating them together. Unlike PredictIt, which is almost useless for anything outside the presidential primaries and Trump’s tweeting habits, Metaculus is doing a great job covering the coronavirus epidemic and the questions that are important to me (sometimes too good – I wasn’t expecting them to tell me how likely is is that the Effective Altruism Global conference next month gets cancelled).

As of me writing this they’re estimating that coronavirus kills 140,000 people worldwide in 2020 (25th percentile estimate is 33,000, 75th percentile estimate is 1,100,000). This confuses me – the flu kills a few hundred thouasnd people yearly, so the site seems to think COVID-19 will be less bad than an average flu season. Maybe they expect that people will demand higher standards of evidence in attributing a death to the coronavirus than people have making wild guesses about how many people die of the flu? Or maybe they predict a very high chance it stays contained?

Updates

The best source for continuing information about the progress of the epidemic is the Johns Hopkins coronavirus dashboard. And feel free to use the comments here to share any other information or questions you might have.

Book Review: The Seven Principles For Making Marriage Work

I.

John Gottman is a legendary figure, and the legend is told best by John Gottman. He describes wading into the field of marital counseling as a young psychology postdoc, only to find it was a total mess:

When we began our research, the wide range of marital therapies based on conflict resolution shared a very high level of relapse. In fact, the best of this type of marital therapy, conducted by Neil Jacobson, had only a 35 to 50 percent success rate. In other words, his own studies showed that only 35 to 50 percent of couples saw a meaningful improvement in their marriages as a result of the therapy. A year later, less than half of that group — or just 18 to 25 percent of all couples who entered therapy — retained these benefits. A while ago, Consumer Reports surveyed a large sample of its members on their experience with all kinds of psychotherapists. Most therapists got very high customer-satisfaction marks—except for the marital ones, who received very poor ratings. Though this survey did not qualify as rigorous scientific research, it confirmed what most professionals in the field already knew: in the long run, marital therapy did not benefit the majority of couples.

Gottman decided the field needed statistical rigor, and that he – a former MIT math major – was exactly the guy to enforce it. He set up a model apartment in his University of Washington research center – affectionately called “the Love Lab”, and invited hundreds of couples to spend a few days there – observed, videotaped, and attached to electrodes collecting information on every detail of their physiology. While at the lab, the couples went through their ordinary lives. They experienced love, hatred, romantic dinners, screaming matches, and occasionally self-transformation. Then Gottman monitored them for years, seeing who made things work and who got divorced. Did you know that if a husband fails to acknowledge his wife’s feelings during an argument, there is an 81% chance it will damage the marriage? Or that 69% of marital conflicts are about long-term problems rather than specific situations? John Gottman knows all of this and much, much more.

Using his mountain of data (the legend continues) Gottman became a Divorce Prophet:

After years of research…I am now able to predict whether a couple will stay happily together or lose their way. I can make this prediction after listening to the couple interact in our Love Lab for as little as five minutes! My accuracy rate in these predictions averages 91 percent over three separate studies. In other words, in 91 percent of the cases where I have predicted that a couple’s marriage would eventually fail or succeed, time has proven me right. These predictions are not based on my intuition or preconceived notions of what marriage “should” be, but on the data I’ve accumulated over years of study.

…which is pretty interesting. But predicting destiny is only an intermediate step – as another legend once said, “the point is to change it”. So, science in hand, John Gottman resolved to fix marital counseling. And apparently succeeded:

We found that at the beginning of our workshops, 27 percent of couples were at very high risk for divorce. At our three-month followup that proportion was 6.7 percent and at nine months it was 0 percent. But even couples who were not at high risk for divorce were significantly helped by the workshops.

Twenty years later, the legend has spread to every corner of the world. He has received glowing praise from The New York Times, The Atlantic, BBC, CNN, Washington Post, The New York Times again, Harvard Business Review, Scientific American, Time, and The New York Times a third time. He has published over two hundred scientific papers, some of which have been cited thousands of times. He has been voted one of the top 10 most influential therapists of the past quarter-century. His Gottman Relationship Institute, founded together with his wife Julie Gottman, has become a marriage counseling empire, trained hundreds of therapists in the Gottman method, and operates a referral network that can find you Certified Gottman Level 3 Therapists from Australia to Uruguay. After a long life of helping save countless marriages, his one regret is that he is so great he can no longer find an adequate control group for his studies:

When we sat down to write the first edition of this book, we were excited to share the results of laboratory research into relationships but we knew we’d face some skepticism. Could scientific study of something as intangible, idiosyncratic, and personal as romantic love deliver useful advice to couples in the real world? Well, more than fifteen years and millions of readers later we are happy to report that The Seven Principles for Making Marriage Work has done just that. Countless readers across the globe tell us that the book’s strategies have enhanced, shielded, or saved their relationship. We have received thank-yous from every imaginable type of couple, including newlyweds, traditional spouses, two-career partners, devoutly religious spouses, military couples, cohabitants, same-sex partners, not-yet-marrieds, divorced people looking toward the future, and counselors who work with all of the above.

It is a great source of satisfaction and pride that we have been able to help so many people. We’re also gratified that research continues to confirm what these readers consistently tell us: The Seven Principles can have a powerfully positive effect on your relationship. In fact, a randomized clinical study by John and his coresearchers (Julia Babcock, Kim Ryan, and Julie Gottman) found that married couples who simply read The Seven Principles and worked through the quizzes and exercises on their own (but received no additional professional aid) were significantly happier in their relationship, and these effects lasted when assessed a year later. Simply reading this book proved so successful that it actually bollixed the research: the original experiment had been designed to use these “book-only” couples as a control group to test marital therapy techniques!

Sounds like some book! And God knows we need good marriage therapy. The world needs it. And I need it in particular. I am a psychiatrist. I am trained to treat depression and schizophrenia and nice simple things like that. But somehow, I keep getting patients who need help with relationship problems. I am totally unprepared for this. In the past, my advice has been “go find someone trained by John Gottman, I hear he is some kind of living legend”. But at some point, I figured I should finally read his book, The Seven Principles For Making Marriage Work: A Practical Guide From The Country’s Foremost Relationship Expert, so that I could have an informed opinion on this and maybe try helping people directly.

This is a review of that book. It starts with a summary of Gottman’s marital counseling techniques, continues to a discussion of the evidence for and against them, and ends with some random thoughts about marriage.

II.

The secret to a happy marriage is that you should like your spouse.

Maybe this doesn’t sound especially secret, when put that way. But part of the Gottman legend is that the old school of marriage therapists kind of missed that part. They were really into solving conflicts and having good communication skills and things like that. But over his years of monitoring hundreds of couples in real-world situations, Gottman found that this was overrated. Plenty of couples had atrocious communication skills and got in conflicts all the time, but loved each other very much and had no real marital problems. Plenty of other couples had finely-polished communication skills and always used “I statements” and things like that, and still ended up divorced. Communication skills are good, and you should definitely try to have them, but you’re putting the cart before the horse unless you focus on liking your spouse.

I totally believe this. I remember my grandparents used to fight all the time. Any time my grandmother said something, my grandfather would disagree with her, and vice versa, and the ensuing argument would (to my young ears) sound absolutely vicious, and then they would laugh it off and forget about it and continue being wonderfully and obviously in love. So fine, focus on liking your spouse. But how do you make that happen?

Seven Principles excels in its selection of worksheets, activities, and games. There is a seven-week program of talking about one nice thing with your spouse every day, a “Building Your Love Maps” game, and a list of questions you and your spouse should answer together one by one. The underlying principle seems to be that to know somebody is to love them. If you get a really good mental model of where your spouse is in their life, their hopes, their dreams, their fears, their daily toil, then it’s hard to not have at least some fondness for them. One activity is a quiz, with questions like:

1. I can name my partner’s best friends.
2. I can tell you what stresses my partner is currently facing.
3. I know the names of some of the people who have been irritating
my partner lately.
4. I can tell you some of my partner’s life dreams.
5. I am very familiar with my partner’s religious beliefs and ideas.
6. I can tell you about my partner’s basic philosophy of life.
7. I can list the relatives my partner likes the least.
8. I know my partner’s favorite music.
9. I can list my partner’s three favorite movies.

The more you know, the more likely your marriage is to make it.

Along with knowing the big things, you should also know what they’re doing on a day-to-day basis. You should conspicuously make sure to know it. Apart from whatever other exercise you’re doing each day, Gottman recommends a ritual of checking in after work and exchanging stories about your days. This time is a Designated Support Zone, no criticism allowed. You take your spouse’s side whether you secretly disagree with them or not. If your spouse gets angry that a police officer gave them a ticket for driving 110 mph through a 25 mph school zone, you are obligated by the terms of your marriage contract to shake your head and say “I know, cops these days have no respect.”

Gottman is slightly less strict in other situations, but he still thinks it’s very important that you take your spouse’s side in conflicts. He especially highlights a common dynamic where your parents are always trying to cause trouble between you and your spouse, and your marriage will be in danger until you commit to side with your spouse whenever this kind of thing comes up:

At the core of the tension is a turf battle between [the wife and the mother] for the husband’s love. The wife is watching to see whether her husband backs her or his mother. She is wondering, “Which family are you really in?” Often the mother is asking the same question. The man, for his part, just wishes the two women could get along better. He loves them both and does not want to have to choose. The whole idea is ridiculous to him. After all, he has loyalties to each, and he must honor and respect both. Unfortunately, this attitude often throws him into the role of peacemaker or mediator, which invariably makes the situation worse.

The only way out of this dilemma is for the husband to side with his wife against his mother. Although this may sound harsh, remember that one of the basic tasks of a marriage is to establish a sense of “we-ness” between husband and wife. So the husband must let his mother know that his wife does indeed come first. His house is his and his wife’s house, not his mother’s. He is a husband first, then a son. This is not a pleasant position to take. His mother’s feelings may be hurt. But eventually she will probably adjust to the reality that her son’s family unit, where he is the husband, takes precedence to him over all others. It is absolutely critical for the marriage that the husband be firm about this, even if he feels unfairly put upon and even if his mother cannot accept the new reality.

This is not to suggest that a man do anything that he feels demeans and dishonors his parents or goes against his basic values. He should not compromise who he is. But he has to stand with his wife and not in the middle

A final method of making yourself like your spouse: just explicitly and consciously focus on their good qualities. One of the worksheets lists a bunch of good qualities and asks you to pick some you appreciate in your spouse and explain why. Another asks you to reminisce about the old days, on the theory that presumably you liked your spouse back when you decided to marry them. This isn’t always true – Gottman finds that couples who are really far gone will export their present hostility back into the past and talk about how they always knew it was a bad idea. With typical statistical precision, he notes that “94 percent of the time that couples who put a positive spin on their marriage’s history are likely to have a happy future as well. When happy memories are distorted, it’s a sign that the marriage needs help.” But it’s usually true enough to get both partners warming up to each other a little.

But okay. You’ve done all this stuff and you like your spouse at least a little. Now what?

Now you can start learning communication skills.

Gottman’s communication skills work focuses on what he calls “The Four Horsemen Of The Apocalypse”: criticism, contempt, defensiveness, and stonewalling. These may seem obvious, though Gottman takes some of them in non-obvious directions – “couples who are contemptuous of each other are more likely to suffer from infectious illnesses (colds, flu, and so on) than other people”. Avoiding the four horsemen is vital, especially in the crucial “startup” phase of a conversation. How do you do it?

Some tips are very small in scale. Use I-Statements like “I have trouble dealing with how messy things are sometimes” instead of You-Statements like “You never clean up around here”. Be polite. Try to make “repair attempts” – conflict-ending attempts that can be anywhere from “Hey, you’re yelling at me” to “You are right and I am wrong and I am sorry” to “Oh my god, listen to us, let’s get a drink and never speak of this matter again”. Accept your spouse’s repair attempts when offered.

Others are more general. Don’t have a fight when you’re physiologically aroused. Don’t have a fight when you’re physiologically aroused. Monitor your physiological arousal, and if you start to notice the signs – fast heartbeat, tense muscles, shallow breathing – call a time-out, go somewhere else, and use meditation or deep breathing or whatever to calm down.

This is especially important for men. Gottman has strong opinions on gender. He uncritically accepts the feminist view that men feel entitled because of patriarchy and that if they feel angry or upset it’s probably just their entitlement flaring up again. He flirts with saying that men should generally yield to their wife in a conflict (presumably because, thanks to patriarchy, everything will always be biased in favor of the man and so the wife is usually right). In the end, he softens this to a statement that men should “accept influence from” their wives, but also heavily implying that a man who doesn’t give in to his wife must not be accepting her influence – for example, an exercise on page 118 asks men to describe how they would accept their wife’s influence in various situations, and includes an answer key where the right answer is always to say she is right and do what she wants. You might object to this, but sorry, it is Evidence Based According To Science. Gottman tells us that only 35% of husbands are emotionally intelligent, and that “when a man is not willing to share influence with his partner, there is an 81% chance that his marriage will self-destruct”.

But Gottman’s most controversial views on gender involve physiology. He proposes an evo psych explanation for why men can’t handle talking about problems:

This is not because of some lack on the man’s part. The reason lies in our evolutionary heritage. Anthropological evidence suggests that we evolved from hominids whose lives were circumscribed by very rigid gender roles, since these were advantageous to survival in a harsh environment. The females specialized in nurturing children while the males specialized in cooperative hunting.

As any nursing mother can tell you, the amount of milk you produce is affected by how relaxed you feel, which is related to the release of the hormone oxytocin in the brain. So natural selection would favor a female who could quickly soothe herself and calm down after feeling stressed. Her ability to remain composed could enhance her children’s chances of survival by optimizing the amount of nutrition they received. But in the male natural selection would reward the opposite response. For these early cooperative hunters, maintaining vigilance was a key survival skill. So males whose adrenaline kicked in quite readily and who did not calm down so easily were more likely to survive and procreate. To this day, the male cardiovascular system remains more reactive than the female and slower to recover from stress […]

This gender difference in how physiologically reactive our bodies are also influences what men and women tend to think about when they experience marital stress. As part of some experiments, we ask couples to watch themselves arguing on tape and then tell us what they were thinking when our sensors detected they were flooded. Their answers suggest that men have a greater tendency to have negative thoughts that maintain their distress, while women are more likely to think soothing thoughts that help them calm down and be conciliatory. Men, generally, either think about how righteous and indignant they feel (“I’m going to get even,” “I don’t have to take this”), which tends to lead to contempt or belligerence. Or they think about themselves as an innocent victim of their wife’s wrath or complaint (“Why is she always blaming me?”), which leads to defensiveness.

Obviously these rules don’t hold for every male and every female. But after twenty-five years of research, I have noted that the majority of couples do follow these gender differences in physiological and psychological reactions to stress. Because of these dissimilarities, most marriages (including healthy, happy ones) follow a comparable pattern of conflict in which the wife, who is constitutionally better able to handle the stress, brings up sensitive issues. The husband, who is not as able to cope with it, will attempt to avoid getting into the subject. He may become defensive and stonewall. Or he may even become belligerent or contemptuous in an attempt to silence her.

The problem is, men are just too flighty and emotional! They need a rational, hard-headed woman to take care of them and keep them grounded!

Sorry. To be more serious, he thinks that because women are emotionally stable and men aren’t, women tend to bring up long-standing problems that need to be solved, and because men can’t handle this level of stress they panic or shut down or blow up or otherwise start a conflict in order to avoid having to deal with it. “More than 80 percent of the time it’s the wife who brings up sticky marital issues, while the husband tries to avoid discussing them.” The solution is for men to learn calming techniques so they don’t stop the conversation as quickly.

Okay, so now you like your spouse and you know how to communicate. Now you can prepare to actually solve some conflicts.

But not all of them. Gottman divides conflicts into two types: solvable and unsolvable. Solvable conflicts are simple, specific, and about the thing they seem to be about – for example, the husband is supposed to take the trash out after work, but work has gotten really stressful lately and he keeps forgetting, and now the trash is overflowing and the wife is annoyed. The solution here is to use normal problem-solving techniques. Put a sign in the bedroom saying “DID YOU REMEMBER TO TAKE THE TRASH OUT?” or something. Whatever.

Unsolvable conflicts are temporary manifestations of deep psychological issues. The particular thing that sparked the fight this time is irrelevant, but both spouses will fight to the death because it represents something important. For example, the husband is late to dinner one night because he went out to the bar. The wife yells at him and says he doesn’t care about her. He yells back that she’s a control freak. Here the problem will not be solved by coming up with a compromise where he can go to the bar half of nights. The problem is that she secretly worries his drinking buddies have a closer connection to him than she ever will, that he doesn’t love her anymore, that he goes to the bar to escape her. He worries that he’s lost his freedom, that he’s become emasculated, that he’s become some boring old person who is never allowed to have fun. If the bar burnt down tomorrow, they would find some other excuse to fight over this dynamic.

There’s no hard line between solvable and unsolvable conflicts. One couple’s solvable problem might be another’s unsolvable one. Forgetting to take the trash out becomes an unsolvable problem if it represents how the husband is irresponsible or the wife is too controlling. Staying out too late at the bar is a solveable problem if it’s just that dinner is getting cold and neither of them has any problem with the husband eating leftovers. But usually couples can figure out whether their particular issue taps into deeper roots.

Gottman suggests dealing with unsolvable conflicts by making the underlying “dreams” explicit. He recommends both partners talk about what the dream driving their side of the conflict means to them. So for example, the husband who stays late at the bar might say “When I was young, my dad was so poor he had to work twelve hour days. Then he would come home, do some chores, go to sleep, and start all over again. I told myself that if I ever ended up like that, I might as well just die, because it seemed like such a crappy and joyless life. To me, getting to go have fun with people means that I’m successful enough that I don’t have to end up like my dad.” While one spouse (the “dreamer”) is describing this, the other spouse has to be completely supportive and try to understand them, without pointing out ways they’re wrong.

Once both partners feel like they’ve been heard and that they understand each other, they discuss the absolute minimum they would need in order to feel like their dreams were being respected, versus the beyond-minimum things that they’re willing to be flexible on. Then they both agree to a compromise that gives both of them their bare minimum and splits the difference on the flexible parts. What if the two bare minima are mutually exclusive? The book doesn’t say. Probably you got a defective dream, and you should go to the dream factory and ask if they take returns.

The last part of the book is maybe the least actionable, but also my favorite. It discusses couples as almost miniature cultures, with their own rituals, in-jokes, ideologies, and systems of meaning. Partly it’s about how to create these things, partly it’s about how to acknowledge these things, and partly it’s just John Gottman’s love letter to the concept of couplehood. It’s really heart-warming. Don’t make the same mistake I did and read it when you’re feeling lonely.

III.

Okay, but can John Gottman really predict divorce with 91% success rate and do all the other things he says he can do? Haha, no. All of that stuff is totally false.

Richard Heyman published the definitive paper on this in 2001, The Hazards Of Predicting Divorce Without Crossvalidation (kudos to Laurie Abraham of Slate, the only one of the journalists covering Gottman to find and mention this, and my source for some of the following). Heyman notes that Gottman doesn’t predict divorce at all. He postdicts it. He gets 100 (or however many) couples, sees how many divorced, and then finds a set of factors that explain what happened.

Confused about the difference between prediction and postdiction? It’s a confusing concept, but let me give an example, loosely based on this Wikipedia article. The following rule accurately matches the results of every US presidential election since 1932: the incumbent party will win the election if and only if the Washington Redskins won their last home game before the election – unless the incumbent is black or the challenger attended a Central European boarding school, in which case it will lose.

In common language, we might say that this rule “predicts” the last 22 presidential elections, in the sense that knowing the rule and the Redskins’ record, we can generate the presidential winners. But really it doesn’t predict anything – there’s no reason to think any future presidential elections will follow the rule. It’s just somebody looking to see what things coincidentally matched information that we already have. This is properly called postdiction – finding rules that describe things we already know.

Postdictive ability often implies predictive ability. If I read over hospital records and find that only immunodeficient people caught a certain virus, I might conclude I’ve found a natural law – the virus only infects immunodeficient people – and predict that the pattern will continue in the future.

But this isn’t always true. Sometimes, especially when you’re using small datasets with lots of variables, you get predictive rules that work very well, not because they describe natural laws, but just by coincidence. It’s coincidence that the Redskins’ win-loss record matches presidential elections, and with n = 22 datapoints, you’re almost certain to get some coincidences like that.

Even an honest attempt to use plausible variables to postdict a large dataset will give you a prediction rule that’s a combination of real natural law and spurious coincidence. So you’re not allowed to claim a certain specific level of predictive ability until you’ve used your rule to predict out-of-training-data events. Gottman didn’t do this.

In his paper, Heyman creates a divorce prediction algorithm out of basic demographic data: husband and wife’s education level, employment status, etc. He is able to achieve 90% predictive success on the training data – nearly identical to Gottman’s 91% – without any of Gottman’s hard work. No making the couples spend days in a laboratory and counting up how many times they use I-statements. No monitoring their blood pressure as they gaze into each other’s eyes. Heyman never met any of his couples at all, let along analyzed their interaction patterns. And he did just as well as Gottman did at predicting divorce (technically he predicted low scores on a measure of marital stability; his dataset did not include divorce outcomes).

Then he applied his prediction rule to out-of-sample couples. Accuracy dropped to 70%. We have no reason not to think Gottman’s accuracy would drop at the same rate. But 70% is around the accuracy you get if you predict nobody will divorce. It’s little better than chance, and all of Gottman’s claims to be a master divorce predictor are totally baseless.

The first question on Gottman’s FAQ is whether he is doing this. He says he did this once, but that 6 of his 7 studies have been properly predictive. But Wikipedia notes that this claim uses “a non-standard definition of prediction in which all that is required is that predictive variables, but not their specific relationship to the outcome, were selected in advance”. Heyman and Abraham specifically criticize the 6 studies that Gottman calls genuinely predictive as being postdictive. I cannot find all the relevant studies, as many of them are in books, but contra the FAQ it looks as if he is still postdicting.

It’s hard for me to dismiss this as an honest mistake. Gottman constantly plays up his credentials as a mathematician and statistician, saying that:

In the beginning, Dr. John Gottman’s research was devoted to the discovery of reliable patterns in observational data. He wanted to see if there were indeed patterns of behavior, or sequences of interactions, that could discriminate happy from unhappy couples. It was not at all clear that these patterns existed. Dr. Gottman and his colleagues began developing the math for sequential analysis, which now is a well-developed methodology.

Anyone smart enough to invent new mathematical methodologies should also be smart enough to know you can’t validate your predictor on its training data, so he must know exactly what he’s doing. And it would be so easy to fix if he wanted to! All he needs to do is take one of his predictors, apply it to data that wasn’t its training data, and tell us how it does! How could this be an innocent mistake‽

And speaking of things that an MIT mathematician should know better than to do, what’s up with claims like “when a man is unwilling to share power with his partner, there is an 81% chance his marriage will self-destruct”. Obviously you can replace 81% with any number you want by operationalizing “unwilling to share power with his partner” differently. This sentence as written is totally meaningless. It could potentially be part of a good study, where Gottman investigated different forms of power-sharing and how they affected marital stability – but only because the study would carefully explain its methods so that the end number meant something. Outside the context of that number, it communicates nothing. Yet Gottman put it in a book and expects us to be impressed by it. It feels like he’s just trying to dazzle us with mathematical precision, and hoping we don’t think about it long enough to realize that it doesn’t make sense.

But the most important statistical question is – does Gottman marriage counseling work? Gottman cites a bunch of different studies proving that it does, but he conducted or oversaw all of them. I randomly chose Shapiro and Gottman (2005) for further analysis. It is typical of this genre: it takes couples who have just had a baby (a particularly perilous time in a marriage), gives half of them a Gottman workshop, and the other half get nothing (no placebo or alternate method here!). The study evaluates husbands and wives separately (was this a preregistered decision?) on several established marital tests and subscales of marital tests (was the choice to keep some tests whole and take subscales of others preregistered?) and finds a significant quadratic effect of their program on marital quality.

I had to look up what a quadratic effect is. It means that the effect approximates a parabola. That is, things start by getting worse, then get better again, in a parabolic pattern. If I’m understanding the study correctly, then if you just do normal linear tests (did the couples’ marriage get better or worse, overall?) there was no significant effect. Gottman writes that:

Our best guess as to why the quadratic pattern occurs is the following. With intervention, things get worse at first because the immediate effects of the interventions are to increase the amount of conflict that the couple experiences. Our interventions encourage couples to honestly face and discuss their conflicts, particularly potential or actual inequities in housework and childcare, conflicts that they would naturally avoid and which they do avoid in the control group. This early increase in the amount of conflict in our intervention group probably causes temporary discomfort, which is reflected in lowered marital quality and increased postpartum depression. However, because the couples in the intervention group learn the communicative skills to cope with these issues, the conflicts get dealt with to some degree, and thereafter marital quality and postpartum depression both improve, whereas in the control group, because these conflicts have not been dealt with, things get worse over time.

This is fine, but the abstract just sums it up as “results showed that, in general, the preventive intervention using a psycho-communicative-educational format was effective”. No! If you didn’t preregister that you expected a quadratic effect, you are lost in the Garden of Forking Paths and you should give up and start over. Also, I feel like probably Gottman advertises to his clients that their marital happiness will improve. But even if we accept his argument here, the only thing he can say with confidence is that their marital happiness will increasingly approximate a parabola over time, which is not really what I think most people go to therapists looking for.

I might be misinterpreting this, and maybe I’m being overly harsh. But I am predisposed to be overly harsh because the whole “predicting divorce” thing makes me think Gottman is out to get me, and so I am less forgiving of unusual polynomials than I might be otherwise. Also, if you’re running the study of your own method, you ought to be on extra good behavior, and this does not really seem all that extra.

What happens when people who aren’t Gottman evaluate the Gottman method? A large government-funded multicenter study testing a Gottman curriculum as well as several others found no effect of any on marital outcomes; control couples actually stayed together slightly more than ones who got marriage counseling. The Gottman curriculum seemed to do worst of the three curricula studied, although there were no statistical tests performed to prove it. I have no explanation for this. Maybe the parabola is just really big, and the divorce is the low point of the parabola, and later on they’ll end up super-double-married. But I am not optimistic.

I don’t want to be too harsh on Gottman here. Rigorous psychology studies are murderous. Things that we know basically have to work, like Alcoholics Anonymous and SSRIs and psychotherapy in general, end up showing no or minimal effects. Heck, zoom out a little bit and we have twin studies showing that parenting itself, in full generality, has no or minimal effect. I find all of this very suspicious, and it would not surprise me if there’s something really wrong here that makes studies biased towards false negatives. All of this stuff about learning to respect and appreciate your spouse and negotiate conflicts in a calm loving way seems like the sort of thing that should work, and for all we know it might work in some population or situation other than the ones being studied.

But for the guy whose whole legend centers around how he’s evidence-based, it’s not a good look.

IV.

I really wanted Gottman Marital Counseling to work.

I wear a psychiatrist hat and a therapist hat. I love the psychiatrist hat. It is blue and pointy and has little glowing stars and moons on it. When I wear it, then with sufficient knowledge and understanding I can give people substances that release obsessions, calm fears, and brighten sorrows. Sometimes I can help people solve their unbearable hopeless problems, and it’s the best feeling in the world.

I hate wearing the therapist hat. I put it on as rarely as possible. I don’t advertise myself as a therapist, and if people ask me to therapy them, I try to refer them to someone else. But if someone wants to talk about their problems in a session, you can’t just say no. And so they tell me about being trapped in an abusive relationship, or haunted by guilt, or trapped in a dead end job with no prospects for improvement. And then they expect me to be able to say something that makes it all better. I know that the textbook response is something about how therapy does not solve problems per se, but by sharing them with someone else it makes them more bearable and adds perspective. Unfortunately, my patients didn’t read that textbook, and they put hope in me, and as often as not I betray it.

I think every therapist feels this way. I once talked to an important professor of therapy, who admitted to me something like “even at my stage, I feel like in the end we only have five or so techniques”, and I got really excited and blurted out “wait, what are the other two?!”

Desperation breeds gullibility. Patients with terminal diseases, however smart they used to be, turn to homeopaths and charlatans rather than face the dismal truth. Therapists are desperate – being confronted with some of the most sympathetic people in the world, day in and day out, having the burden of helping them placed on your shoulders, and knowing that your armamentarium isn’t up to the task will do that to you. And so they become marks. Gullible, gullible marks. Realistically it’s going to be really hard for me to stop recommending Gottman marital counseling to people, because they need something so much. And this is something. And it sounds so good. And I can’t just let their marriage keep falling apart. And surely there’s still a chance it might work, right?

(don’t worry, eventually I’m going to look into some of those forms of counseling that outperformed it in that study)

Bad marriages are so, so bad. They’re so bad it’s shocking. The first time I saw one, I didn’t know what to do. I wanted to figure out some of the root issues, so I asked my patient something about his wife, and he immediately launched into a tirade about all the things his wife had done recently, and why she was in the wrong and he was in the right. I tried to redirect him, and briefly succeeded, but after a second or two the new line of conversation shifted to how unfair his wife was and how she was in the wrong about everything. I wanted to grab him by the shoulders and shake him and say “for the love of God, just put this aside and move to the meta-level and let’s talk about some of the places we can go from here!” but he was just incapable of this mental action. I wish I could say this was an isolated case. It isn’t.

My ex-girlfriend Ozy writes a relationship advice column. Probably taking relationship advice from an ex-girlfriend is some kind of classic mistake, but I read it anyway. They describe five kinds of relationship problems – stupid problems, basic incompatibilities, problems that are actually a different kind of problem, terrible people, and horrifying soul-sucking messes. For some reason, this taxonomy has stuck with me when all the supposedly evidence-based taxonomies I hear the social workers talk about have failed. And the horrifying soul-sucking mess category sticks with me most of all:

A problem of one of the previous three types was badly managed, perhaps for years. Now, every time you have a minor argument, you bring in everything wrong that happened for your entire relationship. You don’t feel like you can trust your partner. All the quirks you used to find charming drive you up the wall. You hate even your partner’s most innocuous actions. You avoid every topic that leads to a fight, and rapidly find that you can’t discuss anything except Marvel movies and the weather. You’re defensive whenever your partner says anything that sounds like even a minor criticism. You’re sarcastic and you call them names. Somehow, when you remember good things about the past– the time you saw Hamilton together or your birthday present or being the best man at their wedding– all you can remember is the long lines at intermission, the poor wrapping job, and their incredibly rude drunk aunt. If asked to name a good trait of theirs, you draw a blank, but you can go on for hours about their flaws.

I guess it might be in theory possible to fix a horrifying soul-sucking mess with a lot of hard work, but to be honest every time I’ve seen a person in one of those relationships they were a lot better and happier and stronger as people as soon as they ended it.

A lot of my patients are horrifying soul-sucking messes. I wish there was something I could do about it, but instead I just sit and listen as they spend forty-five minutes describing every way their spouse has wronged them.

I’m terrified of this. How did it happen? At some point these people must have loved each other. How does any human relationship get this bad? Could it happen to me? Could I marry a great person who I love a lot, and then five years later sign up for therapy just so I can start talking about all my grievances without letting the therapist get a word in edgewise?

Unlike my ex, I don’t write a relationship advice blog. I write a blog about other things. One of them is politics. And whenever I hear people talk about relationships, I hear weird echoes of political problems. People who hate their spouse have an outgroup of one. A unified polity has devolved into partisanship. Social trust has been broken; a defect-defect equilibrium is in place. Gottman thinks of couples as a two-person culture, and some of those cultures are decadent and fractious.

Theodore Adorno’s right-wing authoritarianism scale asked a lot of questions about marriage and child-rearing; his thesis was that people who want top-down government will control their families the same way. Certainly there are authoritarian marriages. But it also seems like there are marriages that are nationalist in a more positive sense – one where the couple has built itself a strong mutual culture and identity, subsumed both individuals into it, and come out stronger on the other side. There are liberal marriages, where both spouses do their own thing, occasionally come together for mutually beneficial exchange of affection, and then go back to doing their own thing. There are even social justice marriages, where both partners are obsessed with how they are being oppressed by the other, interpret all discussion of compromise as hostile attempts to excuse the oppression, and have no strategy beyond proclaiming their victimization louder and louder in the hopes that their grievances are recognized.

…I’m making fun of that last one, but maybe they have a good point. Gottman’s marital counseling – and every other kind of marital counseling I’ve read – is basically mistake theoretic. It assumes that two decent people who both want to live with each other are unable to because they don’t have communication skills or problem-solving skills or some other skill that lets them fulfill their mutual aims. That model seems to accurately describe most of my patients. But Ozy’s taxonomy is more thorough, including a category for terrible people:

One or both of you just sucks. This category includes abuse, but it certainly isn’t limited to it. This is the category from which advice columnists get all their pageviews: we love viewing a train wreck. Your partner has had a suicidal crisis every night at 3am for the last month, and you’re up all night comforting them, and they refuse to find anyone else to talk to or ride out their suicidal crisis on their own. Your partner cheats on you constantly. Your baby is eighteen months old and your partner has never changed a single diaper. Your partner has demanded that you keep your relationship secret from everyone. You asked your partner to clean up dog poo from the floor, and it is three days later, and the dog poo is still there. If you have found yourself in a committed relationship with a terrible person, you should DUMP THEM.

In marriage, as in other forms of politics, sometimes exit > voice. Which is probably not something marriage counselors want to think about very much.

I’m a liberal, and my advice usually follows liberal principles. Have meetings involving all stakeholders, agree on general rules based on deep principles, and then follow the rules even when it’s hard, since that ensures a minimum of conflict on specific issues. I tell patients to have a consistent weekly meeting with their spouse, maybe a Saturday date night. During the meeting, each of them has to say one nice thing about the other, and then one problem that they want to work on. The other person thanks them for the nice thing and then they brainstorm a solution to the problem. If they both agree to the solution, they have to stick with it at least until the next relationship meeting. A lot of my patients have said this really helps them, have continued the meetings long after the immediate crisis passes, and probably expect the technique was invented by some clever person like John Gottman. I will never tell them that actually I picked it up from a different ex-girlfriend, not even the one who writes relationship advice columns.

In conclusion, I have no idea what makes marriages work, and I am not convinced John Gottman does either. Sometimes marriages are horrible in ways I never could have imagined, and other times they are amazing and I am infinitely jealous of them. Also, the very existence of a next generation of the human race is dependent on people having them and making them work for nonzero periods of time, which is a pretty terrifying prospect. Honestly I’m surprised we’ve lasted this long.

Book Review: Just Giving

I.

Traditional book reviews tend to focus on a single book, such as Just Giving by Rob Reich. We ought, however, to be reviewing a broader question: what is the role of books in a liberal democratic society? And what role should they play?

Books were first invented during the early Bronze Age. Plato states people fiercely opposed the first books; in his dialogue Phaedrus, he recalls the Egyptian priests’ objection to early writing:

[Writing] will create forgetfulness in the learners’ souls, because they will not use their memories; they will trust to the external written characters and not remember of themselves. The specific which you have discovered is an aid not to memory, but to reminiscence, and you give your disciples not truth, but only the semblance of truth; they will be hearers of many things and will have learned nothing; they will appear to be omniscient and will generally know nothing; they will be tiresome company, having the show of wisdom without the reality.

Contrast the Egyptian scribes’ reception with the ceaseless praise given to the authors of our age. Rather than asking about the purposes of writing and the power of authors, we tend instead to celebrate writers, large and small, for their brilliance. But in our age, these are questions we should pose with greater urgency. Scholarly literature like Just Giving is an unaccountable, nontransparent, and perpetual exercise of power. It deserves more criticism than it has received.

There’s a conventional story to tell about book-writing and its relation to liberty. The story is this. Book-writing is thought to be tightly connected to liberty. This is so for two reasons. First, writing or reading a book is voluntary. Second, the exercise of liberty involves freedom of speech. This story is an attractive one, and it contains some truth. But it ignores that book-writing is inherently embedded in state institutions, like intellectual property laws. It should not be understood in the simplistic manner of an activity that takes place within a framework of nonintervention by the state, or as nothing more than private individual decisions to express thoughts. Instead, it must be understood as embedded in political institutions, laws, and public policy. Books may not be an invention of the state, but they are an artifact of it.

Most importantly, book-writing is heavily subsidized by the government. Authors receive a “pass-through” tax deduction of up to 20%. In addition, they can deduct most of the expenses they incur in writing a book, from freelance editing to literary agents to promotional events. In extending these tax incentives, federal and state treasuries forego tax revenue. Or to put it differently, tax incentives for writing books constitute a a kind of spending program. In fact, the fiscal effects of a direct spending program and a tax expenditure are exactly the same. In Suzanne Mettler’s apt phrase, federal policy driven by tax expenditures rather than direct spending constitutes the “submerged state”, obscured from public view and accountability, but with powerful distributional consequences. These tax breaks amount to massive federal and state subsidies for the creation and dissemination of written texts. They are supplemented by millions spent on libraries, literacy programs, and in some cases direct subsidies to book publishers.

A respect for the liberty of individuals to promote their views is one thing; subsidizing its exercise is another. The state does not merely permit and set guidelines within which writing takes place – offering the state’s imprimatur to every book and pamphlet and magazine and journal article – but is in a fiscally meaningful way actively participating in what authors do. If the state is actively funding, through a tax expenditure, some bad book, it makes the state partially complicit in the harm that the book causes. It is no exaggeration to say that as book-writing is currently structured, when authors do harm, so does the state. It is incorrect to say that mediocre books merely waste the time of the author and reader. Rather, writing a mediocre book squanders assets that are partially the public’s.

With this description of the relationship between book-writing and liberty in place, let us now consider whether the ideal of equality is playing any role in the institutional design of the policies. The median annual wage of authors is $62,000, twice the average US income of $31,000. Authors are most likely to be college-educated, upper class, and be the sorts of people who can take months off of their jobs to write a book. Scholarly books are often written by professors, a member of a tiny and unelected intellectual elite. This makes their immense ability to exercise power by writing a book and getting it published deeply troubling. Or consider a famous author like Jeffrey Sachs, whose successful books permit him to stride upon the world stage as if he were a head of state.

Perhaps books could play important roles in democratic societies, despite being an exercise of power and expression of plutocratic voice, if they were subject to different legal arrangements. But it is no coincidence that the wealthy dominate book-writing. The tax code is set up to unfairly privilege books by the well-off over the poor in two ways. First, the pass-through deduction and freelance editor deduction are available only to those individuals who itemize their deductions – people who opt not to take the so-called standard deduction on their income tax. This effectively penalizes, or fails to reward and provide an incentive for, all people who do not itemize their deductions, a group that constitutes roughly 70% of taxpayers. Thus the low-income renter who does not itemize her deductions but pays $500 to get their book edited receives no tax concession, while the high-income house owner who pays the same $500 fee can claim a deduction. Second, the tax subsidy given to those who do receive the deduction possesses what is known as an “upside-down effect”. The deduction functions as an increasingly greater subsidy with every higher step in the income tax bracket. Both of these features of the tax code are arbitrary and unfairly benefit the well-off. The choice of the the pass-through and business expenses tax deductions as the preferred tax policy for book-writing introduces a potent plutocratic bias.

Proponents of books might suggest that they nevertheless serve a compelling public interest in the form of spreading knowledge. But when we move away from individual works and consider the total distribution of literature, we find a pattern of writing that is hard to reconcile with expectations of educational outcomes. For anyone who believes that books imply something about knowledge or truth or education, the sunny picture of American book publishing here becomes decidedly cloudy.

Figure 1 demonstrates that the most popular type of book in the US is “mystery, thriller, or true crime”. Second and third place are held by history and biographies, which may perhaps be edifying to some people. But after that we get romance, cookbooks, science fiction, and fantasy. Literary classics and books on important current affairs are far down the list, only a fraction of total books read. What can we conclude from these data? The lesson is obvious: if we believe the purpose of reading and writing to be predominantly educational, an important mechanism to provide for our enlightenment and edification, the actually existing distribution of reading in the United States does not meet the test. Not by a long shot.

Finally, we must address the question of intergenerational justice. Books are designed to enshrine author intent and express their opinions in perpetuity. Thus does the dead hand of the author potentially extend from beyond the grave to strangle future generations. John Stuart Mill famously wrote that “There is no fact in history which posterity will find it more difficult to understand, than the idea of perpetuity, and that any of the contrivances of man, should have been coupled together in any sane mind.” Yet authors deliberately “write for the ages”, producing works that can be studied for hundreds or even thousands of years.

We might ask whether books would be a welcome institutional arrangement if we were designing a democratic society from scratch. The catalogue of the oddities of the book suggests a strong case against. Books appear at odds with democracy, for they represent, by definition and by law, the expression of plutocratic voices directed to public education. But why, in a democracy, should the size of one’s wallet give one a greater say in public policy? Why should this plutocratic voice be subsidized by the public? And why should democracy allow this voice to extend across generations in the form of intellectual property laws? It would seem that books are a misplaced plutocratic and powerful element in a democratic society. And we can trace, in the evolution of books, the emergence of a particular kind of high-profile author such as Dan Brown, Stephen King, and J.K. Rowling, whose activity supplants the state, subverts public education processes, and in so doing diminishes democracy.

I find many points of agreement, especially when considering the actual content of books today. Yet despite all this, I think a role for books can be defended. First, books can help overcome problems in the marketplace of ideas by diminishing government orthodoxy and decentralizing the production of knowledge. Second, because of their size and longevity, books can operate on a different and longer timeline than government propaganda broadcasts, taking risks in the expression of ideas we should not routinely expect to see in press releases by government agencies.

This argument is not intended to justify the full range of legal permissions currently afforded to books, but it provides hints as to what a just literary world might look like. I worry, for instance, about the massive boom in short books. Books with fewer than 150 pages primarily serve the author’s vanity. What loss to public benefit would there be with a minimum page length to publish a book, say 250 or 300 pages? I think very little, and quite possibly there would be some gain, for people with less exciting ideas who could not reach the page threshold might be convinced to help other people with their books rather than writing their own. But even if books of all lengths do partly decentralize the definition and provision of knowledge, the resulting pluralism of literary voices will have a plutocratic, not fully democratic, cast. The experimental or heterodox opinions in books will represent the preferences of the wealthy, not of the wider citizenry. Indeed, there is empirical evidence to suggest that at least in the United States, the very wealthy have significantly more politically conservative preferences than average citizens. Thus, the activity of books, even when it decentralizes the production of knowledge, retains a plutocratic character. Does this mean that we should eliminate books? I do not think so. Perhaps a plutocratic tempering of government orthodoxy is better than no tempering at all. I conclude that the decentralization argument provides a plausibly but not definitive case for books as a democracy-supporting institutional design in our society.

In conclusion, how can we make books more compatible with a democratic society? I propose that instead of giving authors tax deductions, they might receive a certain percent of their expenses paid back to them by the government, capped at $100, and that books with fewer than 150 pages should be banned. Are books democratically required? I am not prepared to answer this question affirmatively, for a democratic government has multiple mechanisms to cultivate pluralism and foster discovery. But I have shown that books are certainly democratically permissible.

II.

Yeah, okay, that was weird.

But I put the blame squarely on the hands of Rob Reich, author of Just Giving. The structure, arguments, and most of the individual sentences are his, not mine. I just changed the word “charity” to “books”, and replaced all the charity-related examples with book-related examples. A few parts were edited slightly to make them flow together better, and a few sentences are entirely my own, summarizing parts of the argument that wouldn’t fit into a short blog post.

I wrote this weird edited pastiche/summary because I couldn’t figure out how else to express my frustration at Just Giving. The book does not conclude that philanthropy is bad. In the end, it comes out saying that philanthropy is potentially okay and can serve a useful purpose, although the tax incentives around it are weird and should be structured better. But along the way it manages to darkly hint that philanthropy is bad about two hundred times on every page. Nothing in the book is wrong. But a lot of the right things in it are fully general counterarguments that demand charity display a level of rigor that nothing else has. And the author’s interviews and summaries mostly keep the dark hinting while watering down the “actually it is okay” part so much it becomes almost invisible. The resulting style could be used to condemn not just charity but any productive human activity, including the writing of Just Giving itself.

For example: charity is not just an activity that takes place in a void. It takes place in a human society. So far, so good – nothing takes place in a void, except maybe space travel. But the book manages to darkly hint that because this is true, any regulation on it is justified. It never says this. In the end it doesn’t even want to regulate charity. But if you started feeling creeped out by sentences above like “books should not be understood in the simplistic manner of an activity that takes place within a framework of nonintervention by the state, or as nothing more than private individual decisions to express thoughts” or “writing a mediocre book squanders assets that are partially the public’s” – if you started thinking “Wait, is he pushing totalitarianism?” – well, both of those are pretty direct quotes from Just Giving, and the originals gave me the same level of unease about charity.

Or: it’s true that there’s a sense in which if the state gives someone a tax deduction for something, it is subsidizing their activity. And it’s true that authors can deduct some of their book-writing expenses from their tax bill. But it seems troubling to go from there to calling book-writing “part of the submerged state, obscured from public view and accountability”, or to say that now “the state is partially complicit in the harm caused by bad books”. Yet both of these are real Just Giving sentences too. I find myself much less attached to the tax deduction for authors’ business expenses (which may or may not be useful, no strong opinions) than to the project of preventing people from saying things like “Making sure books are good is kind of the responsibility of the state, isn’t it?”

Or: it’s true that authors just write whatever they want. You could describe this as making them “unaccountable and nontransparent”, and “at odds with democracy”. But at some point you might think things like “Wait a second, isn’t democracy perfectly compatible with private individuals doing their own thing? Are you sure you’re not thinking of totalitarianism?” Normally I would add something like “…and these considerations become immediately apparently when we’re talking about writing books, which makes this a classic case of proving too much“, except that to me they also become immediately apparent when we’re talking about philanthropy, so there must just be some fundamental disconnect going on here.

In a few sections, I “cheated” by using Just Giving‘s sentences or paragraphs about charitable foundations, rather than philanthropy in general. Reich is not necessarily worried about every charitable donation making “the dead hand of the donor potentially [extend] from beyond the grave to strangle future generations” (yes, this is a real quotation from the book), only about donations from foundations doing that. Still, might this be a little dramatic? Reich treats it as self-evident that permanent foundations are bizarre, maybe literally the most bizarre thing, quoting John Stuart Mill’s opinion that charitable foundations are “among the grossest and most conspicuous abuses of the time” and that the necessity of banning foundations that outlast their founder’s lifetime is “so obvious that he can scarcely conceive how any earnest inquirer could think otherwise”. Unfortunately for Mill, this is not at all obvious to me, and I was left baffled on this point which the book kind of assumed to be a natural human instinct. Why should my ability to control my donations be limited by something as random as my lifespan? If Bill Gates happens to get hit by a truck tomorrow, does this coincidence have some sort of important moral bearing on how the Gates Foundation’s money should be spent? If we decree it does, this leads to odd conclusions, like that the most important effective altruist cause in the world is encasing Bill Gates in an impenetrable steel shell so that nothing can possibly harm him – do we endorse this use of resources? If we oppose foundations, is Bill Gates still allowed to leave all his money to the single person in the world most aligned with his values, and then hope really hard that this person doesn’t betray him? Isn’t part of the point of law to abstract out things like “people might betray you” and replace them with comfortable ironclad contracts?

(a confession: my point about books being a perpetual exercise of the author’s power in the same way foundations are a perpetual exercise of the founder’s power is unfair, and addressed by Reich in the book. He states that most permanent things wield power only as long as the living choose to humor them – eg a dead author only matters if living people choose to read them and take their advice to heart – but foundations do not need the support of the living as long as the contracts that create them remain enforced).

There is much to like about Just Giving. Its breakdown of where charitable dollars actually go (mostly to religious institutions if you’re poor, mostly to colleges and museums if you’re rich) contains data I’ve been looking for a long time, and rightly points out that we should do better. Its discussion of the way tax deductions interact with wealth is interesting, although not obviously more applicable to charity than to book-writing or anything else. Its conclusion – that charity and philanthropic foundations have an important role in diversifying the range of represented interests and experimenting with new social policy – seems dead right, and matches my own thoughts on the subject (and see also this article by Kelsey Piper). I really can’t disagree with this book too much on the object level.

And yet if my review sounds scathing, I hope this is a sort of justice. Rob Reich has limited disagreements with charity on the object level, but still manages to write what sounds like a scathing review of it. I think this is bad.

In conclusion, Just Giving is a government-subsidized exercise of plutocratic power and plutocratic voice repugnant to the very idea of a democratic society of equals. I hope this gets corrected in any future editions.

[EDIT: Professor Reich responds in the comments. Please be polite if you try to discuss this with him. Also, please stop mistaking him for former Labor Secretary Robert Reich, they are two different people.]