Quick hits (part I)

1) The fact that here we are in 2021 with all the technological sophistication we have and HBO cannot make an app for Roku that’s not extremely glitchy strikes me as nuts.  I mean, I use a bunch of different apps on Roku and HBO Max is the only one that consistently has problems.  And, yet, here we are.  It clearly cannot be that difficult a technological problem if you just care enough, thus HBO apparently, does not.  Damn them and all their good programming I want to watch despite their glitchy app!  Appreciated very much this Bloomberg article as I now know it’s not remotely just me:

Hershberger is not the only irritated customer. For months, subscribers have been complaining about HBO Max’s technical shortcomings, particularly on Roku — one of the most popular streaming devices, with 54 million active accounts. A post in December on Roku’s community forum about how HBO Max freezes and crashes now stretches 37 pages long and is filled with more than 360 replies. Similar angry comments from HBO Max subscribers have flooded Twitter and Reddit

Andi Agardy, 46, who lives in Tennessee, decided to wait a few months to sign up for HBO Max to give the service time to work out the bugs on Roku’s platform. But she said the app still frequently freezes and crashes, forcing her Roku to restart.

She also subscribes to Netflix, Hulu and YouTube TV. But HBO Max, she said, “is the one I have the most problems with.” …

Annoyed HBO Max subscribers say they’re torn between a desire to see the acclaimed shows and the headaches of constantly restarting the app.

2) Very good stuff on the evolution of Covid:

This progression of variants demonstrates the virus’s drive for heightened fitness, the natural selection of mutations and strains that make it more likely to find hosts and are further facilitated by sidestepping the immune response, even allowing repeat infections of people who previously had COVID-19. We emphasize, however, that enhanced transmissibility, rather than immunoevasion or greater lethality, would be considered the most potent path for the virus to become more fit and viable.

Indeed, more-fit variants can be expected to emerge over time (the occurrence of which will need to be monitored meticulously, as these pose a potential public health threat), but we believe that these will not continue to emerge indefinitely: nothing is infinite in nature, and eventually the virus will reach its form of ‘maximum transmission’. After then, new variants will provide no further advantage in infectivity. The virus will thus stabilize and this ‘final’ variant will prevail and become the dominant strain, experiencing only occasional, minimal variations.

By homology, we can imagine that the same took place when some very contagious RNA viruses (e.g., measles virus) spilled over in humans: in the early stages of the epidemic, the virus was probably unstable and less transmissible than it is now; then—once the most contagious phenotype was reached—the measles virus stabilized. We note that the inevitable outcome of this strategy for all RNA viruses that have developed high contagiousness (beyond measles virus, we could name, for instance, the viral agents that cause hepatitis A, poliomyelitis, mumps and rubella) is the lack of molecular structures that allow the virus to ‘dodge’ the immune response of the recovered host. Why is that? To make a long story short, by the time these viruses are attacked by the adaptive immunity of their new host, they have no immediate advantage in evading it, because they have probably already spread to another susceptible host, where replication and survival are ensured4.

3) I was having a hard time figuring out how I felt about the Simone Biles thing until I read this.  I had actually come to the conclusion that what was going on seemed a lot like the yips in golf or baseball and then I read this.  It’s the twisties! I love validation. I absolutely feel for Biles and this makes it clear she was right to pull out.  But, also, it really is stunning and I think unprecedented for such a superlative athlete to be felled by a psychological malady in a circumstance like this.

TOKYO — Imagine flying through the air, springing off a piece of equipment as you prepare to flip on one axis while twisting on another. It all happens fast, so there’s little time to adjust. You rely on muscle memory, trusting that it’ll work out, because with so much practice, it usually does.

But then suddenly, you’re upside down in midair and your brain feels disconnected from your body. Your limbs that usually control how much you spin have stopped listening, and you feel lost. You hope all the years you’ve spent in this sport will guide your body to a safe landing position.

When Simone Biles pushed off the vaulting table Tuesday, she entered that terrifying world of uncertainty. In the Olympic team final, Biles planned to perform a 2½-twisting vault, but her mind chose to stall after just 1½ twists instead.

Biles, who subsequently withdrew from the team competition and then the all-around final a day later, described what went wrong during that vault as “having a little bit of the twisties.”

The cute-sounding term, well-known in the gymnastics community, describes a frightening predicament. When gymnasts have the “twisties,” they lose control of their bodies as they spin through the air. Sometimes they twist when they hadn’t planned to. Other times they stop midway through, as Biles did. And after experiencing the twisties once, it’s very difficult to forget. Instinct gets replaced by thought. Thought quickly leads to worry. Worry is difficult to escape.

“Simply, your life is in danger when you’re doing gymnastics,” said Sean Melton, a former elite gymnast who dealt with the twisties through his entire career. “And then, when you add this unknown of not being able to control your body while doing these extremely dangerous skills, it adds an extreme level of stress. And it’s terrifying, honestly, because you have no idea what is going to happen.”
The twisties are essentially like the yips in other sports. But in gymnastics, the phenomenon affects the athletes when they’re in the air, so the mind-body disconnect can be dangerous, even for someone of Biles’s caliber.

4) Really, really enjoyed this profile of Matt Damon.  Especially the parts about the changing business of hollywood and how there’s no good mid-range movies anymore.

But you only have to look a bit closer at Damon’s career, at the notion of Matt Damon, Movie Star we have in our heads, to see that nice might be an ingenious sleight-of-hand, an illusion of sorts. Because that darkness is there. Damon doesn’t just play nice guys. Far from it. There’s Jason Bourne, whom he has played in four hit films and who is a miserable, self-loathing killing machine; the sociopathic social climber Tom Ripley in Anthony Minghella’s “The Talented Mr. Ripley”; the crooked Colin Sullivan in “The Departed.” Or the prep-school anti-Semite in “School Ties,” an early hint at the lurking appeal of Bad Matt. Damon’s most deftly portrayed cretin may be Mark Whitacre, the self-dealing, weaselly-mustached corporate whistle-blower in Steven Soderbergh’s “The Informant!” His most unexpected heel turn: a cameo as a cowardly astronaut (Mark Watney turned inside out) in Christopher Nolan’s “Interstellar.” “He has a willingness to rip apart his boyish, all-American exterior,” says Soderbergh, who has directed Damon in nine films. “He’s self-aware enough, and secure enough, to riff on that.” Whether another actor could have similar riffing opportunities anymore is doubtful. Over the course of his career, Damon has seen the films like the ones that sustained him — that is, the $20-million-to-$70 million drama, what he calls his “bread and butter” — mostly disappear. “You need those roles to develop as an actor and build your career, and those are gone,” Damon said, nodding. “Courtroom dramas, all that stuff, they can’t get made.” Those sorts of movies have been replaced by more easily exportable, higher-budget but paradoxically lower-risk ones. “You’re looking for a home run that can play in all these different territories to all these different ages,” Damon said. “You want the most accessible thing you can make, in terms of language and culture. And what is that? A superhero movie.” …

William Goldman’s old saw about how in Hollywood nobody knows anything could probably now be amended to this: Everyone knows only one thing, and it’s that superhero movies sell. The reorientation of the studios toward those films and other pre-existing intellectual property means the power of actors, even proven stars like Damon, has diminished. It’s the recognizable characters and cinematic universes that can be counted on financially, not the people inhabiting them. Fewer attractive parts adds extra pressure on stars to pick those parts wisely — a big, undervalued aspect of Hollywood acting. In hindsight, when you look over a successful actor’s IMDB page, it’s a list of hits and near misses and duds, but originally, they were all the same: a script. Nothing is preordained. Anyone who has a 25-year career as firmly A-list as Damon is good at picking, at telling not just whether a movie will be good but also whether he can be good in it, and whether it can be good for him. “Sometimes the right choice for an actor isn’t the biggest film, but what is the right choice for that moment in an actor’s career,” says George Clooney, who directed Damon in “The Monuments Men” and “Suburbicon.” “Matt has bounced back and forth between big studio pictures and independent, interesting films. Because he doesn’t keep doing the same thing, audiences don’t get bored of him.”

5) Drum has his list of rules for the pandemic. I endorse:

YES, kids should go back to school in person next month, with temporary exceptions during serious outbreaks. The risks of infection are far lower than the risk of yet another year of remote “learning.”

YES, kids should wear masks in school. Some extra caution is a good idea.

YES, vaccinations should be mandated for all health professionals who work with the public. This is really a no-brainer.

YES, we should accept help from wherever we can get it. If Alex Jones is willing to hype vaccinations by inventing a story that liberals have been secretly promoting vaccine fear in order to kill off conservatives, that’s fine. Whatever.

YES, vaccination mandates should be as widespread as possible. Corporations should put them in place for their own workers; businesses should put them in place for customers; and states should put them in place for everyone. They are legal, constitutional, and sensible. Enforce them via tax credits available only to those who have been vaccinated.

NO, mask mandates shouldn’t include most outdoor areas. The point here is not to put in place the maximum possible regime. It’s to put in place a regime that truly provides the most bang for the buck.

6) What’s interesting to me is the pathetically transparent rationalizations/justifications of the journalists who think this is a remotely reasonable way to practice journalism, “A Catholic newsletter promised investigative journalism. Then it outed a priest using Grindr data.”

In January, when Ed Condon and JD Flynn broke off from their jobs at a long-standing Catholic news agency, they promised readers of their new newsletter that they would deliver reporting without an agenda, or a foregone conclusion. “We aim to do serious, responsible, sober journalism about the Church, from the Church and for the Church. . . . We want The Pillar to be a different kind of journalism.”

Six months later the Pillar broke the kind of story mainstream news organizations would be unlikely to touch: They said they had obtained commercially available data that included location history from the hookup app Grindr, and used it to track a high-ranking priest from his offices and family lake house to gay nightclubs.

Now Condon and Flynn, two 38-year-old canon lawyers-turned-muckrakers, are at the center of both a global surveillance-ethics story as well as a mud fight among their fellow Catholics over whether last week they served or disgraced the church. One Catholic writer described it as “a witch hunt aimed at gay Catholic priests.”…

Flynn and Condon initially said they were not interested in participating in an interview for this article, then agreed to consider questions by email, and later said they didn’t have sufficient time and declined. But in comments they’ve tweeted since Tuesday and a podcast they posted Friday, they explained a bit of their thinking.

“There’s nothing to recommend the indiscriminate naming and shaming of people for moral failures just because you can. That is unethical. And that is not something I believe we’ve done,”Condon said on the podcast.

“People are entitled to moral failures and repentance and reconciliation and to a legitimate good reputation. There’s a difference between that and serial and consistent, immoral behavior on the part of a public figure charged with addressing public morality, isn’t there?” Flynn said.

7) Great stuff from Jeremy Faust (I highly recommend his newsletter) on the Olympics.  “Don’t cancel the Tokyo Olympics. Emulate them.”

In the lead up to the Opening Ceremonies, many in Japan and around the world called for the Tokyo Olympics to again be postponed or scrapped entirely. But one week into the Games, it appears that the 108-acre Olympic Village may actually be one of the safest populated areas on the planet.

Yes, there have been coronavirus cases among athletes and staff, and more will occur. That was inevitable. But a close analysis reveals that the International Olympic and Paralympic Committee “playbook” seems to be working as hoped. Cases have been identified rapidly. Those with positive tests have been quickly isolated and contact tracing has been completed. As a result, the situation has never spiraled out of control. The realistic goal was never to find zero cases. The idea was to rapidly find any and all cases, act decisively, and keep everyone else safe.

The system is working. While the plan has many elements, it is rooted in one crucial idea: a testing tsunami.

Check out the data visualization that we created for Inside Medicine below‡. It demonstrates that if the Olympic Village were a country, it would be the 4th most vaccinated nation in the world, behind Gibralter (population 34,000), Pitcairn (population 67), and Malta (population 502,000), and it would lead the world in daily coronavirus testing per person by a colossal margin. In fact, if coronavirus testing were an Olympic sport, the Olympic Village would tower over the world in Gold Medal position at over 250 tests per 1,000 people each day, with Cyprus in a distant Silver Medal position at just 84 tests per 1,000 people per day. Only 9 countries on Earth are currently conducting more than 10 tests per 1,000 people daily.

One week into the Games, it appears that the 108-acre Olympic Village may actually be one of the safest populated areas on the planet.
There is no populated region anywhere on the globe currently combining such high rates of vaccination and anything close to the testing protocols being implemented at the Olympic Games. So far, around 1 in 5,000 coronavirus tests performed in the Olympic Village have come back positive, giving it the lowest “positivity” rate in the world by a factor of 5 over its four closest competitors (Austria, Singapore, Australia, and Taiwan), and a literal order of magnitude or better than the rest of the nations of the world. As of this writing, more Olympic athletes have tested positive for banned drugs leading up to and during the Games than have tested positive for SARS-CoV-2 while living in the actual Olympic Village in Tokyo.

8) The Washington Post takes a deep dive behind the scenes of UNC and NHJ.

9) For those of you at all epidemiologically inclined, this was really, really good, “How the coronavirus infects cells — and why Delta is so dangerous.”  Lots of really cool visualizations, e.g., 

Life cycle of the pandemic coronavirus: Infographic showing how the virus enters, adapts and exits from host cells.

10) Good Covid stuff from Katherine Xue, “COVID-19 is likely to become an endemic disease. How will our immune systems resist it?”

Still, it is likely that the virus itself is here to stay. “I personally think that there’s essentially zero chance that sars-CoV-2 will be eradicated,” Jesse Bloom, a virologist at the Fred Hutchinson Cancer Research Center, told me. (Bloom advised my Ph.D. research on influenza evolution.) Most viruses, including the four seasonal coronaviruses, other common-cold viruses, and the flu, haven’t been eradicated; scientists describe them as “endemic,” a term derived from the Greek word éndēmos, meaning “in the people.” Endemic viruses circulate constantly, typically at low levels, but with occasional, more severe outbreaks. We don’t shut out these endemic viruses with quarantines and stay-at-home orders; we live with them.

What will it be like to live with endemic sars-CoV-2? That depends on the strength of our immune memories. How vividly will our bodies remember the virus or vaccine? How will waning immunity and the rise of variants—such as Delta, which is currently driving a spike in covid cases around the world—affect our vulnerability to reinfection? We’re beginning to learn the answers to some of these questions, and to get a sense of the years to come…

The immune system’s overlapping layers work together to strengthen its memory. But viruses aren’t static. As they accumulate mutations, their shapes shift, and they gradually become more difficult for the system to recognize. Survivors of the 1918 flu pandemic maintained strong antibody responses against that virus for almost ninety years. And yet adults still get the flu approximately once every five years, because the influenza virus’s rapid evolution insures that each year brings new variants. On average, flu viruses acquire half a dozen mutations each year; many of these alter the proteins that allow the viruses to enter and exit host cells. Antibodies that once bound tightly to a virus may have a weaker grip on its evolved form; the virus might escape the notice of certain T cells that used to recognize it.

“You can also ask the question for coronaviruses,” Bloom said. “How much of the ability to reinfect people might be driven by the virus changing?” Growing evidence suggests how much viral evolution might make us vulnerable to coronavirus reinfection. Recently, researchers in Bloom’s lab analyzed blood samples collected from people in the nineteen-eighties and nineties; the samples contained antibodies for the version of seasonal coronavirus 229E that circulated back then. Those same antibodies failed to recognize the descendants of the virus that had evolved in the intervening years. Coronaviruses mutate more slowly than viruses like influenza and H.I.V., but, over the course of a decade or two, they can still change enough to evade our immune memory.

11) This was fascinating, “Doctors Might Have Been Focusing on the Wrong Asthma Triggers: The pandemic was a big social experiment that sent asthma attacks plummeting.”

All around the country, doctors have spent the pandemic wondering why their patients with asthma were suddenly doing so well. Asthma attacks have plummeted. Pediatric ICUs have sat strangely empty. “We braced ourselves for significant problems for the millions of people living with asthma,” says David Stukus, Scarlett’s doctor at Nationwide Children’s Hospital. “It was the complete opposite. It’s amazing.” (Fears about people with asthma getting more severe COVID-19 infections haven’t been borne out either.) Studies in other countries, including England, Scotland, and South Korea, also found big drops in hospital and doctor’s-office visits for asthma attacks.

The massive global experiment that is the pandemic is now leading doctors to rethink some long-held assumptions about the disease. Asthma is a chronic condition that occasionally flares up, leading to 3,500 deaths and 1.6 million emergency-room visits a year in the United States. These acute attacks can be triggered by a number of environmental factors: viruses, pollen, mold, dust mites, rodents, cockroaches, pet dander, smoke, air pollution, etc. Doctors have often scrutinized allergens that patients can control at home, such as pests and secondhand smoke. But patients have stayed at home for a year and suffered dramatically fewer asthma attacks—suggesting bigger roles for other triggers, especially routine cold and flu viruses, which nearly vanished this year with social distancing and masks.

With life in the U.S. snapping back to normal, asthma doctors and patients are facing another new reality. Masks are going away; schools will be reopening in the fall. The pandemic unexpectedly reduced asthma attacks, and now doctors and patients have to navigate between what they know is possible in extraordinary conditions and what is practical in more ordinary ones.

12) Good stuff from the How Democracies Die team, “The Biggest Threat to Democracy Is the GOP Stealing the Next Election: Unless and until the Republican Party recommits itself to playing by democratic rules of the game, American democracy will remain at risk.”

13) What I find particularly interesting about this study is the ideological backlash to its conclusions.  Maybe it’s wrong and could have been conducted better; always a reasonable critique.  But I really don’t like critiques based on not liking the implications of the findings.  “Is opening more strip clubs one way to reduce sex crimes?”

In theory, adult entertainment businesses — including strip clubs and escort services — could either increase or decrease sex crimes. By teaching men to treat women as sex objects, they could foster the kinds of attitudes that lead men to commit rape and sexual assault. On the other hand, such establishments might provide substitutions for sex crimes: Men otherwise inclined to commit assaults might instead spend more time in strip clubs or hiring escorts.

In a forthcoming study in the Economic Journal, we found evidence for the second theory: In New York City, over the period from Jan. 1, 2004, to June 30, 2012, the opening of an adult entertainment business in a police precinct decreased sex crimes by 13 percent in that precinct.

This did not seem to be because police presence increased in those precincts when strip clubs appeared: Other crime rates — involving drugs and theft, for example — were not affected, something we’d be unlikely to see if more police were patrolling these neighborhoods. Nor was it because women (including street prostitutes, who are often the victims of sex crimes) avoided the areas around such businesses: If that were true, we’d expect to find sex crimes increase in neighboring precincts; the crimes might simply be relocated.

All of that suggests that the substitution explanation may be true: People inclined to commit sex crimes may be less likely to do so if they have an outlet for sexually explicit entertainment (which may include, at some clubs, illegal prostitution). Strengthening the case for this conclusion is the fact that the effect we found was more powerful at night, when these establishments do most of their business.

14) Pretty damn happy with the heat pump that’s been keeping me warm in winter for almost 20 years here in NC, “Are ‘Heat Pumps’ the Answer to Heat Waves? Some Cities Think So.”

15) Michael Pollan, “The invisible addiction: is it time to give up caffeine?” Ummm, no, it’s not time.  But I do try to avoid it after mid-afternoon most all days.  In my case, I’m definitely not using caffeine to compensate for poor sleep as, I never use caffeine before noon (that’s when I go on my Diet Dr Pepper binge for the day).

An English neuroscientist on the faculty at University of California, Berkeley, Walker, author of Why We Sleep, is single-minded in his mission: to alert the world to an invisible public-health crisis, which is that we are not getting nearly enough sleep, the sleep we are getting is of poor quality, and a principal culprit in this crime against body and mind is caffeine. Caffeine itself might not be bad for you, but the sleep it’s stealing from you may have a price. According to Walker, research suggests that insufficient sleep may be a key factor in the development of Alzheimer’s disease, arteriosclerosis, stroke, heart failure, depression, anxiety, suicide and obesity. “The shorter you sleep,” he bluntly concludes, “the shorter your lifespan.”

Walker grew up in England drinking copious amounts of black tea, morning, noon and night. He no longer consumes caffeine, save for the small amounts in his occasional cup of decaf. In fact, none of the sleep researchers or experts on circadian rhythms I interviewed for this story use caffeine.

I thought of myself as a pretty good sleeper before I met Walker. At lunch he probed me about my sleep habits. I told him I usually get a solid seven hours, fall asleep easily, dream most nights.

“How many times a night do you wake up?” he asked. I’m up three or four times a night (usually to pee), but I almost always fall right back to sleep.

He nodded gravely. “That’s really not good, all those interruptions. Sleep quality is just as important as sleep quantity.” The interruptions were undermining the amount of “deep” or “slow wave” sleep I was getting, something above and beyond the REM sleep I had always thought was the measure of a good night’s rest. But it seems that deep sleep is just as important to our health, and the amount we get tends to decline with age.

Caffeine is not the sole cause of our sleep crisis; screens, alcohol (which is as hard on REM sleep as caffeine is on deep sleep), pharmaceuticals, work schedules, noise and light pollution, and anxiety can all play a role in undermining both the duration and quality of our sleep. But here’s what’s uniquely insidious about caffeine: the drug is not only a leading cause of our sleep deprivation; it is also the principal tool we rely on to remedy the problem. Most of the caffeine consumed today is being used to compensate for the lousy sleep that caffeine causes – which means that caffeine is helping to hide from our awareness the very problem that caffeine creates.

16) I cannot imagine writing a book without Laurel Elder’s help.  Meanwhile, Laurel just churns out books on her own:

From Kamala Harris and Elizabeth Warren to Stacey Abrams and Alexandria Ocasio-Cortez, women around the country are running in—and winning—elections at an unprecedented rate. It appears that women are on a steady march toward equal representation across state legislatures and the US Congress, but there is a sharp divide in this representation along party lines. Most of the women in office are Democrats, and the number of elected Republican women has been plunging for decades.

In The Partisan Gap, Elder examines why this disparity in women’s representation exists, and why it’s only going to get worse. Drawing on interviews with female office-holders, candidates, and committee members, she takes a look at what it is like to be a woman in each party. From party culture and ideology, to candidate recruitment and the makeup of regional biases, Elder shows the factors contributing to this harmful partisan gap, and what can be done to address it in the future. The Partisan Gap explores the factors that help, and hinder, women’s political representation.


Damn, the latest on Delta is not great.  Some of the coverage may be overblown, but it seems reasonably clear that Delta is much better at spreading among the vaccinated than all the previous versions of Covid.  This Post story has been getting a lot of coverage:

The delta variant of the coronavirus appears to cause more severe illness than earlier variants and spreads as easily as chickenpox, according to an internal federal health document that argues officials must “acknowledge the war has changed.”

The document is an internal Centers for Disease Control and Prevention slide presentation, shared within the CDC and obtained by The Washington Post. It captures the struggle of the nation’s top public health agency to persuade the public to embrace vaccination and prevention measures, including mask-wearing, as cases surge across the United States and new research suggests vaccinated people can spread the virus.

The document strikes an urgent note, revealing the agency knows it must revamp its public messaging to emphasize vaccination as the best defense against a variant so contagious that it acts almost like a different novel virus, leaping from target to target more swiftly than Ebola or the common cold. [emphasis mine]

It cites a combination of recently obtained, still-unpublished data from outbreak investigations and outside studies showing that vaccinated individuals infected with delta may be able to transmit the virus as easily as those who are unvaccinated. Vaccinated people infected with delta have measurable viral loads similar to those who are unvaccinated and infected with the variant.

“I finished reading it significantly more concerned than when I began,” Robert Wachter, chairman of the Department of Medicine at the University of California at San Francisco, wrote in an email.

CDC scientists were so alarmed by the new research that the agency earlier this week significantly changed guidance for vaccinated people even before making new data public.

The data and studies cited in the document played a key role in revamped recommendations that call for everyone — vaccinated or not — to wear masks indoors in public settings in certain circumstances, a federal health official said. That official told The Post that the data will be published in full on Friday. CDC Director Rochelle Walensky privately briefed members of Congress on Thursday, drawing on much of the material in the document.

That’s all… not good.  But, I’ve got to call out the fearmongering on Ebola.  I mean seriously?  Original Covid was probably more transmissible than Ebola.  Ebola is scary because of a ridiculously high fatality rate (and disease course).  But, come on.  And, they’ve all been more contagious than the common cold. 

Delta is up there with chicken pox and seriously contagious airborne viruses and that’s a big deal and bad enough.  Delta is the reality of what we wrongly feared original Covid was (fomites aside).  But don’t scare people with Ebola.  

Anyway, some good tweets on this:


Anyway, Delta really kind of sucks.  Yes, selection pressure and evolution are things, but there’s certainly an element of chance and, yeah, I’m bummed that Covid didn’t top out at Alpha. This late summer and Fall and going to be a lot worse than it looked like they were going to be.  But, still so, so, so much better due to vaccines.  Don’t forget that.  And, yes, we need FDA approval and we need mandates.  

FDA versus cost/benefit analysis

As you hopefully know, I’m a huge fan of applying cost/benefit (and especially efficiciency) to not just public policy problems, but life in general.  But, yeah, especially public policy problems.  Like, whether the FDA should act in due haste in in a rapid approval of the Covid vaccines.  Gives those priors of mine (and you know how I feel about the FDA), I really loved this Yglesias post on the FDA having a huge problem in not taking a cost/benefit approach where it should (and this is the rare free post, so I strongly encourage you to read all of it):

The two critiques of the FDA

The way the FDA thinks about this is that there are certain scientific criteria a drug has to meet in order to qualify as approved, and then there is a factual question as to whether or not a drug has in fact met that standard. The FDA then takes two forms of criticism.

One, which is popular in the lefty nonprofit space and the public interest community, is that the FDA is too captured by industry and too eager to give drugs the thumbs up. These critics tend to point to things like the approval of Aducanumab, excessive enthusiasm for prescription opioids, and a tendency to go soft on copycat drugs that provide on-patent alternatives to cheaper medicines without necessarily offering commensurate benefits. The other critique, which is popular among libertarians, is that the FDA is too slow and too hesitant to approve drugs.

If you dive into the guts of these criticisms, the critics are in many ways actually saying the same thing, which is that the FDA is not applying a cost-benefit lens to these decisions. And in their defense, as best as I can tell, that’s not their statutory mandate. So in the sense that the FDA is a bunch of human beings with jobs to do, I am not sure they are actually doing anything wrong at all. And I want to be clear about that — I’m not here to insult people or impugn their work… [emphasis mine]

I’m dwelling on the benefits because to me, that is the issue — we should give the vaccines the regulatory treatment that is most likely to be beneficial to society.

But trust me, it’s not that I “don’t understand” that this isn’t how the process works. I am saying the process is bad…

Officials in Canada and the UK are, I think, more accustomed to thinking of healthcare as a resource-optimization problem because they have single-payer systems. So they looked at the data and saw that a single mRNA shot clearly does provide a meaningful degree of protection and opted for a “first shots first” strategy, prioritizing getting as many people as possible a single shot before looping back to get boosters. Canada does not have a vaccine manufacturing industry, and the United States initially banned vaccine exports, so we started with a large vaccination lead. But then you can see how first shots first worked by looking at how they caught up to and then surpassed us.

This, to me, is the kind of flexible decision-making that we need from our public health authorities. It is absolutely reasonable to ask drug companies to preregister their dosing designs and to have some skepticism of proposals to deviate from that. But a public health agency does not have to act like it’s populated by robots who only know how to follow the established procedure. A holistic look at the data supported a deviation, so Canada deviated…

Superficially, the left’s critique that the FDA approves too many drugs is the opposite of the right’s critique that it approves too few. But we are really talking in both cases about a failure of cost-benefit analysis.

Suppose I created an All-Purpose Miracle Pill that, regardless of patient health status, extended life by somewhere between four and eight months in all cases. Unfortunately, the Miracle Pill costs $10 million and also often causes headaches and nausea. The questions of “should this pill be illegal?” and “should Medicare pay $10 million for this pill?” are really totally distinct.

But because we created the FDA, then created Medicare, then created the Medicare prescription drug purchasing program with a stipulation that Medicare won’t “bargain” with drug companies, we have a situation where the FDA is both a consumer safety regulator and also a de facto price regulator. So a common sense category of “look, we’re not telling you it’s so dangerous that it should be illegal, but we don’t really think we should pay for it” doesn’t exist…

Lots of the public sector in the United States is conducted by institutions that are not particularly technocratic in their design or their operation. But the Fed and the FDA are. These are institutions that employ a lot of technical specialists and that have a tradition of independence from the White House. In the long run, I think the way technocratic institutions safeguard their independence and build their legitimacy is by doing a good job. You want people to think “these guys seem like they know what they are doing.”

And to me, the pattern of ignoring first-order cost-benefit considerations and then appealing to public confidence as the explanation of why that’s okay does the opposite. It suggests that the large-ish minority of people who are quantitatively competent need to all be doing their own analyses of issues like supplementing an initial J&J dose with a booster, and that basically every policy decision needs to be litigated and re-litigated in the public square. That’s not going to foster long-term confidence. If you want that, you need to make decisions that are justifiable on the merits.

So, to really TL;DR Yglesias central point, which I strongly agree with… The FDA does not do cost/benefit analysis, but it really should.  And the current situation with the slow approval is making that case manifest.  (Also, more good stuff very much worth reading in the full post)

And while we’re at it, the newly-energized TNR (the excellent Michael Tomasky is editor now) with a good piece, “What the $%&! Is Going On at the FDA? Experts want to know why the agency approved a questionable Alzheimer’s drug but has withheld full approval from Covid vaccines.”  And here’s an area where I think Biden deserves some serious criticism:

Six months into Biden’s presidency, the FDA is in turmoil; the administration still hasn’t even named a commissioner to lead the agency. The hasty Aduhelm approval shocked observers, in part because the agency has yet to offer full approval to Covid-19 vaccines despite millions of successful and safe vaccinations. With Pfizer expected to file within weeks for another emergency use authorization for a third Covid booster shot, and the highly contagious delta variant spreading, fully approving the Covid vaccines could offer the country a much-needed vaccination boost. “The FDA is close to hitting rock bottom,” Gonsalves said.

The lack of a nominated commissioner, during one of the most turbulent times in recent history, could have long-term implications for the agency. Without a confirmed commissioner, it’s difficult for the agency to form and execute policy. “We have leaders for a reason. And the FDA right now has no leader,” one longtime representative for pharmaceutical companies and other FDA-regulated industries, who asked not to be identified by name, told me. “I don’t think the FDA is going to get out of this mess until they get a confirmed commissioner.”…

But now that there’s ample evidence the vaccines are both safe and effective, the agency’s failure to offer full approval for the Pfizer-BioNTech, Moderna, and other vaccines also puzzles experts. “Why they haven’t issued the approval, I simply don’t understand it,” the observer said. “I can’t imagine anything that’s a higher priority.”…

Dr. Eric Topol, director and founder of the Scripps Research Translational Institute, has argued for the vaccines’ approval, in large part to improve vaccination rates in the United States. “I do think that’s the biggest thing we can do right now to get the United States on track,” he told me. Once the vaccines are approved, employers and organizations—from hospitals to schools—can require either vaccination or masking with frequent testing, he said. “The day that happens, with full FDA licensure—which should’ve happened by now—we will see a big jolt. Tens of millions of people who get vaccinated because they realize there’s no way out, because they don’t really want to wear a mask and get a swab up their nose frequently.” As the highly contagious delta variant spreads, the country desperately needs the vaccination jump that full approval would offer.

“There’s just no excuse anymore, just no excuse,” Topol said. (He has said he was approached as a potential candidate for the commissioner job, but he declined.) “And here they approve the Alzheimer’s drug, which had no data yet, and they approved that based on 3,000 people—and here we have hundreds of millions of people where the proof is there of the safety and effectiveness” of vaccines, he said. “I’m extremely frustrated. Every day I get more frustrated, because that is the singular thing that could change this thing around.”…

In the long term, good regulations help the pharmaceutical industry enormously. Undermining regulations, or pushing out drugs that don’t actually work, could undermine the credibility of the entire industry. And approving drugs in the hope that they might work could do more harm than good.

“Patients need more than hope,” Gonsalves told me. “Patients need drugs that keep them alive.”What troubles him about the FDA’s seemingly arbitrary approval pattern in the past year is that it frequently seems to serve pharmaceutical companies rather than patients. AIDS activists, he recalled, quickly abandoned the push for FDA authorization in favor of demanding more funding and better research from the National Institutes of Health. But drug companies had already latched onto the idea of a fast track: “We got hijacked by the pharmaceutical industry and its allies to use our early, most naïve moment as their own rallying cry today in the most cynical way,” he said….

The irony is that Covid vaccines really do seem to be one such blockbuster. (They, too, took time: almost a decade of research since the first SARS outbreak, as well as years of work on platform vaccines.) Why the FDA has withheld approval from them while offering it to Aduhelm is a question people will be puzzling over for a long time to come. At this critical moment in FDA history, the choices the agency makes—and the Biden administration, in nominating a leader—could reverberate for decades.

My take?  Oh, you know that.  Approve the damn things already. If they get approved tomorrow, Fox may say, “oh, no, a politicized process!” but let’s be honest, they’d say that in a year.  So, just get them approved.

Republicans versus science

Pretty interesting Gallup report last week with this headline, “Democratic, Republican Confidence in Science Diverges”

And here’s a key chart:


Whoa!  Come on Republicans!  That Covid vaccine, all our amazing technology and various medical miracles?  Science!  

But, if you’re like me, you might have thought, “yeah, well, the college educated have shifted dramatically away from Republicans and towards Democrats.”  And, quite often, Gallup does not take potential confounding variables into account.  But, hooray for Gallup, this time they did and I was actually somewhat surprised by the results:

Party Differences Exceed Those by Education

College graduates (72%) and college nongraduates (60%) differ modestly in the degree of confidence they have in science. Notably, these education differences appear to be confined mostly to Democrats, as 91% of Democrats with a bachelor’s degree are confident in science compared with 70% of Democrats without a four-year degree. Among independents and Republicans, college graduates and non-graduates have similar levels of confidence in science. Thus, it does not appear that education has much of a mediating effect on confidence in science among Republicans or independents.

And damn, if Gallup doesn’t also call it pretty accurately with their “bottom line”

Republican mistrust may stem from conservative thought leaders’ allegations of liberal bias in the scientific community, perhaps because colleges and universities employ many scientists. Republicans also mistrust colleges and universities and cite a liberal political agenda as the reason for that lack of trust. A specific recent example of Republican allegations of bias concerned the theory that the COVID-19 virus leaked from a Chinese lab. Many scientists, including Dr. Anthony Fauci, initially favored other theories, but the lab-leak theory has gotten more serious consideration in recent months.

Still, Republicans’ lack of trust in science opens up the possibility of their being more vulnerable to influence by ideas that lack scientific support, especially if those ideas are advanced by political conservatives they implicitly trust.

One real-world manifestation of Republicans’ lack of faith in science is the greater reluctance among Republicans than Democrats to get COVID-19 vaccines.

At first it may be fun to dunk on Republicans as troglodytic science deniers.  But, actually it just sucks.  We are sharing this country.  We are sharing this (increasingly Covid-infested) air.  We are sharing this government.  It would be a lot better if we could figure out what’s going on here and if there’s anything we can do about it.  My quasi-naïve hypothesis, there is huge profit to be made by right-wing media by playing to populist/anti-science fears and there’s always incentive for people to do what’s profitable.  We need a better electoral system and better institutional design, but, damn, if we could solve the “right-wing media is genuinely destroying American democracy” problem, that would be good.  

A great explanation of structural racism

Not sure what to call David French.  Reality-based conservative?  Open-minded conservative?  Anyway, the sort of person whom I generally disagree with, but am happy to do so as he operates in good faith and recognizes the deep pathologies of the Republican Party.  

This post is largely written about dealing with CRT and wokeness within the conservative Christian community, but, what I really love is that this is about the best explanation of structural racism (and the difficulties of honestly facing it) as anything I’ve seen. 

Let’s apply this more concretely, to the United States of America. Enforcing the Constitution’s Equal Protection Clause and passing the Civil Rights Act was (and is) necessary to end overt, legal discrimination, but it was hardly sufficient to ameliorate the effects of slavery and Jim Crow. These effects are so embedded in our system that powerful people often perpetuate those structures even when they lack any racist intent at all.

To illustrate this reality, I’ll turn to perhaps the most commonly cited example (because it’s so significant) of how racism can be truly “structural” or “systemic” and thus linger for years even when the surrounding society over time loses much of its malign intent. 

Residential segregation, through redlining and other means—especially when combined with profound employment discrimination and educational disparities—resulted in the creation of large communities of dramatically disadvantaged Americans. Because of centuries of systematic, de jure (by law) oppression, they possessed fewer resources and less education than those who didn’t suffer equivalent discrimination.

While the passing of the Civil Rights Act meant that black Americans had the right to live elsewhere, they often lacked the resources to purchase homes or rent apartments in wealthier neighborhoods with better schools. Indeed, to this day, the median net worth of a black family ($17,150) is roughly one-tenth the median net worth of a white family ($171,000). That means less money for down payments, less money for security deposits, and overall fewer resources that enable social mobility.

One of the solutions to this problem is permitting more multi-family housing in wealthier communities. But that’s exactly when NIMBYism rears its head. Even if every member of a local zoning and planning commission isn’t racist, there are multiple non-racist reasons for them to resist greater population density. There’s traffic congestion. There’s school overcrowding. There’s the potential consequence to property values. There are environmental objections. There are a host of related infrastructure concerns.

These non-racist reasons to block multi-family development are a reason why even the most deep-blue, race-conscious progressive neighborhoods so often bitterly resist new development, school zoning changes, and other concrete reforms that would grant individuals in historically segregated neighborhoods greater access to the educational and economic opportunities of historically white communities. 

Time and again, there are non-racist reasons for wanting to maintain the structures racists created. Thus, you can begin to understand the cultural and political divide. A person who harbors absolutely no racial animus gets angry when they’re told they’re perpetuating systemic racism, or that racism can exist without malign intent. To be told you’re perpetuating racism when, in your heart of hearts, you know you’re making choices based on road safety, your child’s education, or the beauty of your environment can feel deeply offensive.

Conversely, a person who lives in the midst of the economic and educational deprivation originally created by racists are understandably angered when they’re told there is no racism present when powerful people repeatedly block reforms that would change the status quo. Justice fails when the same unjust outcomes are perpetuated, even though the newest generation of elites may possess different intent…

But even in the midst of all this complexity, some things are still clearly true. We still live with the legacy of the discriminatory structures our forefathers created. Our obligation to seek justice does not depend on a finding of personal fault. Christians must be open to truth from any source. And there is nothing—absolutely nothing—“conservative” about denying the reality of the consequences of centuries of intentional, racist harm. 


Time to change course on Covid?

Sadly,  the answer is “yes.”  Having so many vaccinated people, especially elderly, is great.  We’re simply never going to be nearly as bad off as before vaccines.  But Delta sucks.  Delta is as bad as many mistakenly believed the original Covid was, in terms of transmissibility.  

Some good stuff from Leana Wen:

With coronavirus infections climbing throughout the country and the pandemic worsening once more, the Biden administration needs to strongly urge a return of covid-19 restrictions.

The United States is on a very different trajectory now than it was back in May, when the Centers for Disease Control and Prevention issued guidance that fully vaccinated people no longer needed to wear masks. Even then, when cases were trending downward, many of us in public health were alarmed that the CDC’s recommendations would herald the precipitous and premature end of indoor mask mandates.

We were right. The CDC’s honor system didn’t work. The unvaccinated took off their masks, too; not enough people were vaccinated to be a backstop against further surges; and infections began to soar.

Compared with two weeks ago, daily coronavirus infections in the United States have climbed 145 percent. The most contagious form of SARS-CoV-2 yet, the delta variant, accounts for the majority of new infections. Vaccinated people are still well-protected from becoming severely ill, but reports abound of breakthrough infections. Because the CDC has inexplicably stopped tracking mild infections among the vaccinated, however, we don’t know how frequently these occur. In addition, because those infected with the delta variant appear to have a viral load that’s 1,000 times higher than that of those infected with the original strains, it’s an open question as to whether vaccinated people who contract the variant can infect their unvaccinated close contacts.

It’s time for the CDC to issue new guidance that takes into account these emerging concerns. It can reiterate that vaccination is safe and effective by stating that the vaccinated are safe around others who are also fully vaccinated. In settings where everyone is known to have immunity, no additional restrictions are needed.

However, if vaccinated individuals are around those who remain unvaccinated, the unvaccinated could pose a risk to the vaccinated, particularly those who live at home with young children or immunocompromised family members. So the CDC needs to state, as it should have in May, that unless there is a way to distinguish between the vaccinated and unvaccinated, indoor mask requirements should be reinstated. Los Angeles County has issued such a mandate. The federal government should urge other jurisdictions to follow suit.

I also liked this in a Josh Marshall post:

In late Spring it seemed like COVID was basically about over. Critically, it seemed like the non-vaccinated might be able to hitch a ride on the rest of the country’s vaccinated immunity. Everyone could drop their masks and get back into restaurants and theaters and it would all be fine. Clearly that didn’t pan out. 

Exactly.  Prior to Delta, the unvaccinated could seemingly free ride on the vaccinated, but no more. 

Of course, what’s especially frustrating about this is the fact that not only are the unvaccinated not getting vaccinated, they are also dishonestly refusing to wear masks indoors where they should be.  Among other things, there’d simply be a lot less spread if they were.  If we actually lived in a world where unvaxxed  could be counted upon to wear masks (which are especially effective at blocking transmission from the source), it really wouldn’t make sense to call for the vaccinated to start wearing masks again.  Alas, we are not in that world, but one marked by far too much vaccine hesitancy and far too much dishonesty.  

Quick hits (part II)

1) This is so good.  Amanda Knox— famous for being wrongfully convicted in Italy– with a great piece on the many, many cognitive biases that led to her awful situation.  

2) I’m an unapologetic Olympics lover.  Matt Grossman has been tweeting links to Olympics research.  Love this regresssion model of gold medals by country:

3) This from Melinda Wenner Moyer sounds right to me, “American Parents Are Way Too Focused on Their Kids’ Self-Esteem: Our over-the-top efforts to ensure that kids feel valued and adored can actually make them feel inept.”  I’ve requested and plan to read her new book, How to Raise Kids Who Aren’t Assholes.  But, seriously, she couldn’t give it a title that’s not going to be super awkward when I have it on the coffee table where I leave the books I’m reading?  I’m 95% positive this title will ultimately hurt her sales and readership.  Anyway…

But as I dug into the research, I learned that many American parents have been woefully overvaluing and misunderstanding the concept. Having healthy self-esteem does not ensure that kids will fare well or stay out of trouble. And although self-esteem is a tricky concept to study, research suggests that the steps parents take to foster self-esteem in their kids often have the paradoxical effect of undermining it. Our over-the-top efforts to ensure that kids feel valued and adored can actually make them feel inept—whereas intentionally exposing our kids to disappointment and failure, which so many parents are loath to do, can give children a satisfying sense of self-efficacy.

For decades, Americans have been a little obsessed with the concept of self-esteema measure of how much confidence and value people feel they have. In 1986, the governor of California, George Deukmejian, signed legislation that created the Task Force to Promote Self-Esteem and Personal and Social Responsibility, which concluded that boosting Californians’ collective levels of self-esteem would lower rates of crime, teen pregnancy, drug abuse, welfare dependency, and school underachievement. The task force’s final report referred to self-esteem as a “social vaccine” that is “central to most of the personal and social problems that plague human life in today’s world.”

That’s a bold statement, based on a bold assumption that the U.S. is suffering from an ongoing epidemic of low self-esteem, and that this deficiency is dangerous. You’ve probably heard that teens with low self-esteem are more likely than other kids to be depressed, to be anxious, to drink, to do drugs, and to commit crimes. This is all true. But what might come as a surprise is that the inverse of this statement is not also true. High self-esteem is not a panacea against all things bad, and kids with high self-esteem often make bad choices too.

“It’s unclear, actually, just how important self-esteem may be in terms of predicting healthy outcomes,” says Grace Cho, a developmental psychologist at St. Olaf College, in Minnesota, and the co-author of Self-Esteem in Time and Place: How American Families Imagine, Enact, and Personalize a Cultural Ideal. “The literature is actually really kind of messy and mixed.” In an exhaustive review of the research literature, the Florida State University social psychologist Roy F. Baumeister and his colleagues concluded that “raising self-esteem will not by itself make young people perform better in school, obey the law, stay out of trouble, get along better with their fellows, or respect the rights of others.”

4) Monica Gandhi, “We are testing too many vaccinated people who lack covid symptoms”

Early in the pandemic, the United States had an undertesting problem. Now we are overtesting those who are immune and asymptomatic. A person with immunity to the coronavirus will fight off an infection. But during and after the person’s exposure to the virus, it’s common for a low number of virus particles to be detectable in the nose. In medicine, we call this virus a “colonizer” — a pathogen that does not cause illness or spread the illness. It’s an incidental finding. But in today’s world of routine coronavirus testing of vaccinated people, these positive tests are inflating the number of positive cases in a misleading way.

It is true that the delta variant has led to an increase in cases in parts of the country where vaccination rates are low, and these surges need to be taken seriously; these cases correlate with increases in serious illnesses and hospitalizations mainly among the unvaccinated. What we’re concerned about is the overtesting of the fully vaccinated, who now make up roughly 60 percent of U.S. adults. The Centers for Disease Control and Prevention has officially decreed that fully vaccinated people should not be tested for the coronavirus in the absence of symptoms. That’s because immunity works. Mounting evidence has demonstrated an extremely low risk of asymptomatic transmission by vaccinated people.

But despite this guideline, testing vaccinated people with no symptoms is a bandwagon that cannot seem to be stopped. Employers, entertainment venuesschoolsairlines, local governments and even hospitals are adopting universal testing policies regardless of vaccination status. This results in asymptomatic immune people testing positive even though they pose no substantive public health threat. This practice was evident even at the White House’s outdoor Fourth of July party, where each of the more than 1,000 attendees was tested for the coronavirus. We can assume that many of Biden’s staff and friends who attended were vaccinated. So unless they had symptoms (which would preclude them from attending, anyway) this testing was not consistent with CDC guidelines.

Testing people who have been vaccinated and have no symptoms could extend this pandemic forever. That’s because a PCR test, which still remains the gold standard of testing (over antigen-based testing), can detect just a few virus particles — or even just one. Those small amounts of the virus are not enough to cause transmission, according to studies in the Journal of Infectious Diseases and the Lancet. Indeed, such small amounts of exposure can boost immunity in the vaccinated while causing no ill effects.

In this new phase of battling the pandemic, we should change the way we talk about covid-19 infections: Rather than discussing “cases” — meaning instances when a PCR test delivers a positive result — we should describe the viral load a person is carrying. Measuring the load size is done by determining the number of cycles required for the PCR machine to detect the virus. The more cycles used to find a virus, the lower the viral load. A positive test with a high cycle threshold, say, more than 25 cycles) — signaling a noninfectious virus — should be treated as far less worrisome than a positive test with a low-cycle threshold.

5) We don’t hear a lot about the J&J vaccine these days.  This is good, “Johnson & Johnson’s vaccine produced fewer antibodies against Delta compared with other shots in an experiment. Experts say we shouldn’t worry about the results.”

Dr. Ned Landau, who led the experiment, told CNBC that the findings suggested people who got the J&J vaccine “should at least consider” a second dose of the same vaccine or one from Pfizer or Moderna. 

But other experts aren’t convinced about the findings of a small lab study, which hasn’t yet been scrutinized by other experts in a peer review. They say Johnson & Johnson’s vaccine could still work against Delta in real life.

Insider’s Hilary Brueck reported Tuesday that fully vaccinated people could get COVID-19 — but if they do, they usually get mild symptoms, or none at all.


8) As someone who discovered oral allergy syndrome and my allergies to apples as an adult, I found this really interesting:

My grandson Tomas first noticed a distressing reaction to hazelnuts at age 8. Whenever he ate Nutella, his mouth and throat felt tingly and swollen, and so this sweet spread was then banned from his diet and the household.

A few years later, Tomas had the same reaction when he ate raw carrots. In researching this column, I learned that hazelnuts and carrots, although botanically unrelated foods, share a protein with birch pollen, to which Tomas is allergic. However, he can eat cooked carrots safely because cooking denatures the allergenic protein.

Now 21, he has not yet reacted to other foods that also contain the birch pollen protein, namely celery, potato, apple and peach, although he could eventually become sensitive to one or more of them. His father said that as an adult he’s developed similar mouth and throat symptoms when he eats apples and peaches, especially during pollen season.

I also learned of another common link between pollen and food sensitivities. People allergic to ragweed may also react to bananas and melons. Again, a shared protein is responsible. This type of allergy is believed to start with sensitization to inhalation of the offending pollen that later results in an allergic reaction when the food protein is consumed.

9) I had the amazing opportunity when I was in 9th grade to spend a week in the Dominican Republic with my high school band so I’ve always tried to pay a little extra attention to the country.  Really interesting piece from Noah Smith examining all the hypotheses for why it has been so much more successful than its island neighbor, Haiti.  Short version– lots of good ideas, but no clear answer.  

10) I love this approach from Drum on how to make American politics so, so much better:

If you’ve been watching Fox News since last November, you believe that:

  1. Democratic voter fraud was rampant in the 2020 presidential election, which Donald Trump probably won.
  2. The 1/6 insurrection was a false flag operation of some kind that was planned and carried out by liberals, the FBI, and other parts of the Deep State who then tried to blame it on Trump supporters.
  3. There is no reason to get vaccinated against COVID-19.
  4. Our nation’s public schools have been taken over by left-wing teachers who tell white kids that they should all be ashamed of being white.

If I were a multi-billionaire, what would I do with my money? Unfortunately, the really big problems—climate change, national healthcare, racism, etc.—are too big even for a billionaire. Only national governments can really address them.

Instead I would dedicate my fortune to destroying Fox News. I would do it any way I could. Marketing. Lawsuits. Boycotts. Talent poaching. Cable access. Making Rupert Murdoch’s life miserable. You name it. Nor would I have any qualms about playing fair. You have a plan for a space-based laser that interferes with Fox News broadcasts and makes them unwatchable? Great! Here’s a hundred million to give it a go.

Fox News may have started out with narrower goals, but today it’s explicitly aimed at undermining American politics and getting us to hate each other. Why? Because it adds to the fortune of an Australian plutocrat who thinks that plundering the American public is a great way of becoming ever richer. Ditto for the on-air “talent,” which has become rich by figuring out ever bigger and better ways of scaring the poor schmoes who trust them.

American politics is unlikely to recover until Fox News is reduced to rubble. Anyone know a billionaire who agrees?

11) What Texas is trying to do with its abortion law may have far-reaching consequences.  Really good stuff here from Laurence Tribe and Stephen Vladeck:

Efforts in red states to pass increasingly restrictive limits on abortions have ramped up in the past few years as the composition of the Supreme Court has made it more likely that those laws will be upheld. But a new law in Texas that’s set to go into effect on Sept. 1 is especially worrisome.

Not only has Texas banned virtually all abortions after the sixth week of pregnancy, a point at which many women do not even know they’re pregnant, it has also provided for enforcement of that ban by private citizens. If you suspect that a Texan is seeking to obtain an abortion after the sixth week of pregnancy, not only will you be able to sue the provider to try to stop it, but if you succeed, you’ll also be entitled to compensation. (And what’s known as the litigation privilege would likely protect you from a defamation claim even if you’re wrong.) The law, known as S.B. 8, effectively enlists the citizenry to act as an anti-abortion Stasi.

All of that would be problematic enough, but enlisting private citizens to enforce the restriction makes it very difficult, procedurally, to challenge the bill’s constitutionality in court. A lawsuit filed in federal court in Austin last week tries to get around those roadblocks. We believe that it should succeed. But if it fails, not only would that leave the most restrictive anti-abortion law in the country impervious to constitutional challenge, it would also encourage other states to follow Texas’ lead on abortion, as well as on every other contested question of social policy.

California could shift to private enforcement of its gun control regulations, never mind the Second Amendment implications of such restrictions. Vermont could shift to private enforcement of its environmental regulations, never mind the federal pre-emption implications. And the list goes on.

In the abstract, allowing citizens to help enforce the law is nothing new. Many states have so-called citizen suit or private attorney general provisions that allow people to help enforce a range of laws and rules governing consumer and environmental protection, government transparency and more. The federal government authorizes citizens to help bring certain fraud claims on behalf of the United States — and allows those citizens to share in any damages that the government receives. The critical point in both of those contexts is that citizens are supplementing government enforcement.

The Texas law, by contrast, leaves private enforcement as the only mechanism for enforcing the broad restrictions on abortions after the sixth week of pregnancy. It specifically precludes the state’s attorney general or any other state official from initiating enforcement. Under this new law, private enforcement supplants government enforcement rather than supplements it. If this seems like a strange move, it is. And it appears to be a deeply cynical one, serving no purpose other than to make the abortion ban difficult to challenge in court.

12) This was really interesting, especially for a Jeopardy fan, “What Ever Happened to IBM’s Watson? IBM’s artificial intelligence was supposed to transform industries and generate riches for the company. Neither has panned out. Now, IBM has settled on a humbler vision for Watson.”


Is it time for the vaccinated to mask up again?

Man, I’ve really enjoyed largely mask-free living for the past bit.  But, damnit, I’m really starting to think that Delta and dramatically-rising case counts should probably put an end to that.  Why?  Because I still really don’t want to get Covid and it seems that pretty soon here, there’s going to be a non-trivial amount of Covid circulating around here and the vaccines, awesome as they are, are certainly not perfect.  Delta’s transmissibility seems to be so high because people are shedding just ridiculous amounts of virus.  Again, usually, the vaccines still work great, but I think I’d rather not count on usually when there’s still so many infected, unvaccinated people running around spreading disease.  There was a really good Slate article on these breakthrough cases:

The most important thing to realize is that breakthrough cases are going to continue to surface in our lives. “The goal was never to eradicate COVID from being annoying—it was to eradicate it from being a killer,” said Dara Kass, an emergency medicine physician in New York. (She emphasized, again, that the vaccines are very good at doing the latter.) And so even while you have likely heard that breakthrough cases are “rare,” that’s a subjective assessment that is probably worth adjusting upward. There hasn’t been a firm percentage available beyond these vague characterizations—and the CDC is only tracking breakthrough cases that result in hospitalization or death, a decision a Harvard doctor called “disappointing” on the medical school’s blog. But medical professionals are starting to think about this more and more, and the suspicion is that they will happen with increasing frequency—and we shouldn’t be surprised when we do…

Another disconnect is what we think of as “severe illness” and what is actually severe illness. My colleague said he could not imagine describing the illness he had experienced as anything other than “severe”—he was unable to do anything for 36 hours and said it was on par with having debilitating food poisoning. But when I asked a couple doctors about this, they disagreed with his ranking. “Technically, it sounds like he had a mild bout of COVID-19, by strict case definitions,” emergency physician and sometime Slate contributor Jeremy Samuel Faust wrote to me. “Mild does not mean pleasant. In fact, you can have fever, chills, body aches, and feel downright terrible for a week or more and still be categorized as ‘mild.’ ”

To approach even a moderate (or severe) case of COVID, “there must be significant lung involvement as evidenced by low oxygen levels, for example,” Faust said. “It really can be miserable. But you’re at home, not in the ICU.”

Hanage told me that a vaccinated friend of his had just had a mild case that lasted fourdays. And that still means the vaccines are doing what scientists like him believed they would. “Vaccination effectively removes the threat of nationally overburdened healthcare—even though locally serious outbreaks remain not only possible but likely,” he said.

Yeah, so, on a population level, the vaccines are doing great and saving lives, but I still don’t want to be laid up with a nasty disease circulating around if avoiding it can be much more likely just by wearing a mask when around potentially unvaccinated people.  Katherine Wu had a really, really good piece on this, “4 Reasons I’m Wearing a Mask Again
Our vaccines are extraordinary, but right now they need all the help they can get.”

Most post-vaccination infections, or breakthroughs, appear to be asymptomatic or mild, a sign that the vaccines are doing their job. But mild illness still isn’t desirable illness, especially given the threat of long COVID, which reportedly can happen in vaccinated people, though researchers aren’t yet sure how widely.

Masks slash the risks of all these outcomes. Breakthroughs are more common when the immune system faces a ton of inbound virus—when there’s an ongoing outbreak, or when the people around me aren’t immune. A mask reduces my exposure every time I wear one. Some variants, including Delta, might be more transmissible, but they’re still thwarted by physical barriers such as cloth…

3. I trust the vaccines, but I understand their limits.

My pivot back to masks says nothing about my continued confidence in the vaccines and what they’re capable of. But although vaccines are an excellent tool, they are also an imperfect one, and they’ll perform differently depending on the context in which they’re used.

Consider, for example, the effectiveness of sunscreen, another stellar yet flawed preventive. Certain brands, including those with higher SPF, will be better than others at blocking burns and cancer. Mileage may vary even with the same tube of sunscreen, depending on who’s using it (how much melanin is in their skin?), how they’re behaving (are they dipping in and out of the shade, or spending all day soaking up rays?), and local conditions (is it a cloudy day in a wooded park, or a sunny day on a snow-speckled hill?). Vaccines are similar. Breakthroughs are more likely in people with a weakened immune system and those who mingle frequently with the virus; they may happen more often with certain variants.

Asking a vaccine to shoulder the entire burden of protection felt all right a month ago, when case rates were plunging. Now they’re ticking back up. The vaccines don’t feel different, but the conditions they’re working in do. Maybe now’s not the best time to rely on them alone. “That’s putting a lot of pressure on the vaccines,” Jason Kindrachuk, a virologist at the University of Manitoba, told me. The virus has upped the ante, and I feel the urge to match it. When it’s extra sunny out, I’m probably going to reach for sunscreen and a hat…

4. Wearing an accessory on my head doesn’t feel like a huge cost to me.

Don’t get me wrong. I don’t enjoy wearing a mask, and all else equal, I’d still prefer to keep it off. But for me, it’s not a big sacrifice to make for a bit more security: I’ll mainly be using one indoors when I’m around strangers, a situation in which the risk of spread is high. And I’ll keep checking pandemic conditions like I would a weather forecast—hospitalizations, variants, immunization rates, and the behaviors of people around me—and adjust as needed. The idea is that this state of affairs will be short-lived, until vaccinations climb and the virus retreats again.

That all strikes me as a very well-reasoned and sensible take.  Here’s in NC, we’ve got from a 2% positive test rate to around 7% in just 4 weeks.  That’s not great.  Wake County is still at 3%, so I’m not exactly freaked out here, but I do agree with Wu that it’s probably time to adjust mask-wearing to the Covid conditions around. 

Yes, even more blogging about why the FDA needs to approve ASAP

Of course, I’m always happy to see when I’m in accord with David Leonhardt.  Here’s his latest on the FDA:

Why, then, hasn’t the F.D.A. taken the final step of formal approval?

It is following a version of its traditional, cautious process for vaccine approval. That process has historically had some big advantages, reducing the chances that Americans end up taking a faulty drug. To move much more quickly would risk undermining the public’s confidence in the F.D.A. and, by extension, the medicines it approves, Dr. Peter Marks, who oversees the process, has argued.

But I think the F.D.A.’s leaders have failed to understand how most Americans really think about the vaccines. It is different from the way that scientists and epidemiologists do. It’s less technical and based more on an accumulation of the publicly known facts.

It reminds me of another example of expert miscommunication, early in the pandemic. Back then, public health officials made highly technical statements about masks that many people interpreted as discouragement from wearing them. These statements ignored the many reasons to believe that masks could make a difference (like their longtime popularity in Asia to prevent the spread of viruses) and focused instead on the absence of studies showing that masks specifically prevented the spread of Covid.

Later, officials insisted that they were merely “following the data.” In truth, though, they were basing their advice on a narrow reading of the data — and not understanding how most people would interpret their comments.

The long wait to approve the vaccines is similar. F.D.A. officials are acting as if most Americans are experts in the nuances of their approval process and will be shocked if the agency expedites it. In reality, many Americans know almost nothing about that process. But some are understandably confused by the mixed messages that the F.D.A. is sending.

Hundreds of millions of people around the world have been vaccinated. Tens of thousands of them were followed for months in clinical trials. And F.D.A. officials have repeatedly urged other Americans to get vaccinated. “In the history of medicine, few if any biologics (vaccines, antibodies, molecules) have had their safety and efficacy scrutinized to this degree,” Dr. Eric Topol of Scripps Research wrote in The Times.

Yet the agency still has not given formal approval to those same vaccines.

What I really love, though, is that he looks at this through a cost/benefit lens:

Big costs, few benefits

Think of it this way: In the highly unlikely event that the evidence were to change radically — if, say, the vaccines began causing serious side effects about 18 months after people had received a shot — Americans would not react by feeling confident in the F.D.A. and grateful for its caution. They would be outraged that Woodcock and other top officials had urged people to get vaccinated.

The combination means that the F.D.A.’s lack of formal approval has few benefits and large costs: The agency has neither protected its reputation for extreme caution nor maximized the number of Americans who have been protected from Covid. “In my mind, it’s the No. 1 issue in American public health,” Topol told me. “If we got F.D.A. approval, we could get another 20 million vaccinated,” he estimated.

What gives me pause?  For one, a lengthy discussion with BB who is far less gung-ho than I am.  He very much echoed the sentiments of Brendan Nyhan a political scientist I greatly respect who honestly knows a lot more about vaccines and public opinion than me.

And, yet, I’m still with the non political scientists here.  I just don’t see that the FDA moving with extreme alacrity, not “rushed” mind you, just everything they always do on a timetable as fast as humanly possible (I guarantee you they are not doing that) will actually undermine their credibility.  We are drowning in good data on the safety and efficacy of these vaccines.  There’s probably enough good data here to give full approval to 100 different drugs.  Make it happen!  Are people really going to doubt the credibiliby of the FDA if it happens next week instead of next month?

Also, I might as well share one of the few times I disagree with Drum:

I’m not going to pretend to any special expertise either, but I can at least point out a few things:

  • Despite what the Twitterati seem to believe, the folks at the FDA are not idiots. They might be wrong, but they aren’t idiots and they’re well aware of the benefits of granting full approval.
  • There is a documented process for granting full approval. Pfizer and others submitted the data for that approval in May and asked for expedited review. This was granted, of course, which means review will take about six months instead of two years.
  • Like it or not, approval is based on actual scientific studies (RCTs), not just the observation that lots of people have already gotten the vaccine and seem to be OK. This is the only reliable way to do things, and that doesn’t change just because we’d really, really like it to.
  • The FDA, of course, could change the approval process midstream and simply issue a full approval. However, skeptics would rightfully assume that this means the approval is political, not based on science. It would pretty much destroy the FDA’s credibility.

It’s true that the FDA approval process takes a long time. That’s why we also have an emergency use approval process that allows drugs to be prescribed in an emergency if they look promising but haven’t gotten through the full approval process yet. This makes perfect sense, and it’s what we’ve done.


Good points.  And yet… again, we are awash in good data about the safety and efficacy of these vaccines.  The FDA probably has more good data in just this time period about these vaccines than 99% of drugs that they take years to review.  This is not remotely normal and, under these not remotely normal circumstances, taking the normal amount of time is proving a huge disservice to the health and safety of Americans.  No, don’t “change the approval process midstream,” just do everything you always do a hell of a lot faster.  No, they are not idiot.  Rather, they are deeply entrenched bureaucrats within an organization and culture that is excessively (pathologically, in this case) conservative. They can do this. They have the data.  They have the information on manufacturing.  Make it happen!

And, here’s my humility…  Maybe I’m wrong.  People I deeply respect feel otherwise, but this is my read of the situation and I feel pretty strongly about it (as you can tell).  

The health care prices villain– it’s the hospitals

I know I’ve made this point before, but it’s an important one.  Everybody likes to blame the insurance companies for our over-priced and inefficient health care system, but, really, they are just the hapless middlemen.  The greedy capitalists sucking us all dry?  The hospitals.  But, nobody wants to blame the hospitals because we think of the dedicated doctors saving lives, not the over-priced administrators figuring out if they can get away with charging $50 instead of $40 for each dose of ibuprofen.  It was also thanks to hospitals that i learned what it really means to be a non-profit.  (It means the top employees profit handsomely, but there’s no shareholder profits).  Anyway, this is all laid out nicely in a terrific Planet Money newsletter, so here you go:

Hospitals are a really important part of the American economy. Not just in terms of health and wellbeing, but in terms of dollars and cents. The largest chunk of America’s healthcare spending goes to hospitals. And the hospital sector is one of the largest sectors in the overall American economy, accounting for about 6 percent of America’s GDP. Hospitals do a lot of good things. They save lives. They create good jobs. But because of growing monopolization of them, Zack Cooper, an economist at Yale School of Public Health, worries that they’re becoming like a “dracula” that “sucks some of the vibrancy out of a lot of towns across the country.” 

Cooper and his colleague, Martin Gaynor, have crunched the numbers on hospitals using the government’s preferred way of measuring market concentration, and they’ve found that about 80% of America’s hospital markets are now “highly concentrated.” [emphases mine] “The average hospital market in the U.S. is just way over what the FTC and the DOJ would consider a healthy level of concentration,” Cooper says. Many of these markets, he says, are dominated by just one or two hospitals, giving them market power to suck extra money from communities for health procedures and emergencies. 

In addition to decades of mergers and acquisitions with hospitals gobbling up other hospitals, hospitals have also been increasingly buying up physician practices. Economists refer to this as “vertical integration.” Think steel manufacturers buying the railroad lines. Like with mergers and acquisitions, Cooper says, many of these deals have not received adequate scrutiny from federal regulators. 

The research clearly shows, Cooper says, that growing monopolization has raised prices for patients. Less competition means hospitals can charge higher prices and get away with it. They can pay lower wages and get away with it. And they can provide worse care and get away with it. “We want firms to compete and be incentivized to raise their quality to attract more consumers, and the more that hospitals merge, the less sharp those incentives become,” Cooper says. “We have evidence that death rates are literally higher in markets where hospitals face less competition.” 

The bizarre part of all this is that many of these monopolizing hospitals are technically considered “nonprofits.” There are, apparently, “a lot of nonprofits to be made in the healthcare industry,” Cooper jokes. He doesn’t take their “nonprofit” status very seriously. He sees it more like a game where instead of making profits that are distributed to shareholders, nonprofit hospitals take the extra money they make and use it for executive compensation and buying shiny stuff. Cooper says nonprofit hospitals tend to “overinvest in technology. And the irony of that is that you get even more expensive gizmos that are probably not necessary in the first place — and they suck more money into the healthcare system.”

Being a non-profit offers hospitals some quirky benefits. They don’t have to pay taxes like for-profit businesses do. And while the FTC can block anti-competitive mergers between non-profit hospitals, they are hamstrung in investigating non-profit hospitals for anti-competitive conduct under current law. “It’s sort of crazy,” Cooper says. 

Anyway, the larger point of the piece is that the Biden administration is actually trying to do stuff about this.  Hooray for them!  Tiny steps, to be sure, but if we are every going to substantially improve American health care, we’ve got to take on the hospitals and this is a start.  

Yglesias vs the FDA

I really like how Yglesias constructs this argument without getting at all into how exactly the FDA approves things, but, rather looking at the big picture of what the FDA looks to accomplish by approving drugs/medicines.  And, here, it’s clearly failing in taking so long.  Since this is actually a public Yglesias post, you should just go read it and I won’t quote as extensively as I would if it were paywalled.  But, still:

The FDA should approve the vaccines

To me, the most striking, glaring, and obvious problem with the current state of the U.S. vaccine rollout is that the Food and Drug Administration has not given official approval to any of the vaccines that we are using. Instead, they have been given Emergency Use Authorization.

Any time you criticize any element of the American public health bureaucracy these days you get assailed by swarms of pro-system tweets, in this case usually accusing me of “not understanding the process.” But I actually think it’s the process-trusters here who don’t understand the process, and if you do you’ll see it’s a process that’s a poor fit for the situation.

After all, when you step back and think about it, the FDA approach to medications is at least a little bit odd. In many cases it’s perfectly legal to sell things that have no scientifically demonstrated medical benefits — that’s the whole world of unregulated supplements. And of course you can sell people things like beer, M&Ms, and cigars that everyone knows are harmful and have no offsetting medical benefits. Selling medicine is subject to a special, unusually high bar because we are trying to safeguard the public interest from a particular class of scam.

For example, a company might come along with a $56,000 Alzheimer’s pill that doesn’t have any clear evidence of efficacy. If you want to try to sell a $56,000 dietary supplement, then that’s between you and your sucker customers. But there is a general presumption that programs like Medicare, Medicaid, and subsidized private insurance plans will cover authorized prescription medications. So there is a real opportunity to damage the public interest with scammy products here. And we need the FDA to protect us. Now as it happens in the case of this drug, the FDA isn’t protecting us. But that’s its function; that’s why we need a fussy scientific agency with a high bar for approval.

But then in a crisis, you maybe want to be less fussy. Hence the FDA, rightly, was handing out EUAs like candy for various Covid treatments all throughout 2020.

In the crisis, we don’t really worry that we might be wasting money on convalescent plasma. We don’t have rigorous evidence that it works, but there are some general medical science reasons to think that it might work. And if a patient and his doctor want to try it, it seems counterproductive to block them. If nothing else, letting the treatment move forward is a good way to gather more data. But the FDA rightly emphasizes that it is not actually endorsing convalescent plasma, just as the FDA does not endorse dietary supplements. They are saying that in light of the emergency, and given that there’s no widely available and clearly superior treatment, they’re not going to stop you from trying the experimental therapy.

But that is not what doctors, scientists, and public officials say or believe about the vaccine.

Everyone wants people to get the vaccine

If you just listen to what anyone is saying about the Covid vaccines, they are endorsing them.

The acting director of the FDA and her Trump-era predecessor are encouraging people to get vaccinated. The director of the CDC and her Trump-era predecessor are encouraging people to get vaccinated. The President of the United States is loudly encouraging people to get vaccinated, and his predecessor is quietly doing so. The Surgeon General says you should get vaccinated. Dr. Fauci says you should get vaccinated. It’s possible these people are all lying and full of shit or something, but as a journalist, I am simply conveying what’s clearly true — all the people in positions of authority are endorsing the Covid vaccines and encouraging you to take them.

In other words, they are acting about the Covid vaccines the same way they’d act about a long-approved antibiotic or the measles vaccine, not the way they’d act about a dietary supplement. They are not saying you are allowed to get vaccinated, they are saying you should get vaccinated. Indeed, that’s not just their medical advice to you — it’s their stated belief (and I agree) that getting vaccinated is a pro-social means of safeguarding your entire community.

So I am saying, with a full understanding of the process, that the FDA ought to bring the official regulatory status of mRNA Covid vaccines into line with the scientific community’s actual understanding and attitude toward the vaccines. [emphases mine]

The government is not worried that Pfizer and Moderna might be running a scam on us. They are charging $20 a dose, not $56,000. We are begging people to take these shots. So we should act like it…

Low-hanging mandate fruit

Another issue about the lack of authorization is that many institutions, including the U.S. military, believe they legally cannot or should not mandate a vaccine that is available exclusively under EUA. There turns out, inconveniently, to not really be any case law on this. But I think it’s understandable that most major institutions want to tread cautiously here in the absence of a clear FDA thumbs up…

But this brings up another example of the utility of full authorization. American media is full of commercial advertising campaigns aimed at getting people to “ask your doctor” about various kinds of prescription drugs.

You can’t market off an EUA, and the vaccine makers have been persuaded to accept low margins for these products. Give a full authorization, bump up the payment rate, and watch the Pfizer and Moderna marketing campaigns explode. Give Donald Trump a bunch of money to be a Moderna pitchman and give LeBron James or whoever a bunch more to do it for Pfizer…

And right now if someone says to you “look, the mayor and the president don’t want to mention this, but these are experimental vaccines that the FDA hasn’t even approved,” that’s not misinformation — that’s true.

Now if I went around tweeting all day “don’t take the vaccines unless you’re highly vulnerable, they’re experimental treatments the FDA hasn’t approved because they say they don’t have enough safety data yet” people would (rightly) get very mad at me. Spreading that message would (rightly) be considered an anti-social and chaotic thing to be doing. But the message is true, and a good way to cut down on its spread would be to make it not be true, rather than trying to informally stigmatize saying it…

Start with the easy stuff

My big point about this is that the elite discussion of vaccine resistance seems a little bit perversely focused on the hardest problems. How do you persuade distrustful people who live in communities where trust and vaccination levels are so low that you need to be obsessed with avoiding political backlash? I’m not sure.

So we should start with the easy stuff.

Get the FDA to stop fueling vaccine resistance. Let institutions that don’t need to worry about backlash roll out mandates.

Calories in. Period.

Okay, to be fair, not exactly.  But, when it comes to diet and losing weight, pretty much.  So, I did a whole post on this just a few months ago referencing Herman Pontzer’s book, Burn.  And, I also mentioned some of this research in a recent quick hit (#3), but I actually read Burn last week and it was so, so good.  

First of all, Pontzer is a professor who writes like a science journalist.  So readable and engaging.  Also, he’s an evolutionary anthropologist, so the evolutionary lens through which he approaches all of this is fascinating.  I also loved little tidbits like how many calories are expended in each heartbeat (1/300th a calorie) and how humans lacking modern sanitation burn way more calories on their immune system.  And, yeah, I posted before about how little control you have over the calories out, but it really got through to me in reading this book.  Like the fact that the hunter/gatherer Hadza who walk miles and miles every day actually burn no more calories than your average American coach potato! Really.  

So, yes, of course calories out matters.  It’s just that you have almost no control over those.  And, of course, a ton of control over calories in.  The part about diet and nutrition was not necessarily all that new to me, but a great synthesis of knowledge on this subject.  Like, whatever diet allows you to consume a level of calories in consistent with your typical calories out where you are getting the nutrients you need and not feeling hungry is a good diet.  And I really loved the rule of thumb that, basically, the fat you ingest should come with protein and the carbs you ingest should come with fiber.  

Anyway, if you find this stuff interesting at all, you really should check out the book.  And here’s some good stuff from a Q&A:

Q: What’s the biggest misunderstanding about human metabolism?

A: We’re told — through fitness magazines, diet fads, online calorie counters — that the energy we burn each day is under our control: if we exercise more, we’ll burn more calories and burn off fat. It’s not that simple! Your body is a clever, dynamic product of evolution, shifting and adapting to changes in our lifestyle.

Q: In your book you say we’re driven to magical thinking when it comes to calories. What do you mean by that?

A: Because our body is so clever and dynamic, and because humans are just bad at keeping track of what we eat, it’s awfully hard to keep track of the calories we consume and burn each day. That, along with the proliferation of fad diets and get-thin-quick schemes, has led to this idea that “calories don’t matter.” That’s magical thinking. Every ounce of your body — including every calorie of fat you carry — is food you consumed and didn’t burn off. If we want to lose weight, we must eat fewer calories than we burn. It really comes down to that.

Q: Some people say that if the cavemen didn’t eat it, we shouldn’t either. What does research show about what foods are “natural” for humans to eat?

A: There’s no singular, natural human diet. Hunter-gatherers like the Hadza eat a diverse mix of plant and animal foods that varies day to day, month to month, and year to year. There’s even more dietary diversity when we look across populations. Humans are built to thrive on a wide variety of diets — just about everything is on the menu.

That said, the ultra-processed foods we’re inundated with in our modern industrialized world really are unnatural. There are no Twinkies to forage in the wild. Those foods are literally engineered to be overconsumed, with a mix of flavors that overwhelm our brain’s ability to regulate our appetites. Now, it is still possible to lose weight on a Twinkie diet (I’m not recommending it!), if you’re very strict about the calories eaten per day. But we need to be really careful about how we incorporate ultra-processed foods into our daily diets, because they are calorie bombs that drive us to overconsume.

Q: If we could time travel, what would our hunter-gatherer ancestors make of our industrialized diet today?

A: We don’t even need to imagine — We are those hunter-gatherers! Biologically, genetically, we are the same species that we were a hundred thousand years ago, when hunting and gathering were the only game in town. When we’re confronted with modern ultra-processed foods, we struggle. They are engineered to be delicious, and we tend to overconsume.

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