[Link] Forty Days

GLaDOS

A post from Gregory Cochran's and Henry Harpending's excellent blog West Hunter.

One of the many interesting aspects of how the US dealt with the AIDS epidemic is what we didn’t do – in particular, quarantine. Probably you need a decent test before quarantine is practical, but we had ELISA by 1985 and a better Western Blot test by 1987.

There was popular support for a quarantine.

But the public health experts generally opined that such a quarantine would not work.

Of course, they were wrong. Cuba institute a rigorous quarantine. They mandated antiviral treatment for pregnant women and mandated C-sections for those that were HIV-positive. People positive for any venereal disease were tested for HIV as well. HIV-infected people must provide the names of all sexual partners for the past sic months.

Compulsory quarantining was relaxed in 1994, but all those testing positive have to go to a sanatorium for 8 weeks of thorough education on the disease. People who leave after 8 weeks and engage in unsafe sex undergo permanent quarantine.

Cuba did pretty well: the per-capita death toll was 35 times lower than in the US.

Cuba had some advantages: the epidemic hit them at least five years later than it did the US (first observed Cuban case in 1986, first noticed cases in the US in 1981). That meant they were readier when they encountered the virus. You’d think that because of the epidemic’s late start in Cuba, there would have been a shorter interval without the effective protease inhibitors (which arrived in 1995 in the US) – but they don’t seem to have arrived in Cuba until 2001, so the interval was about the same.

If we had adopted the same strategy as Cuba, it would not have been as effective, largely because of that time lag. However, it surely would have prevented at least half of the ~600,000 AIDS deaths in the US. Probably well over half.

I still see people stating that of course quarantine would not have worked: fairly often from dimwitted people with a Masters in Public Health.

My favorite comment was from a libertarian friend who said that although quarantine certainly would have worked, better to sacrifice a few hundred thousand than validate the idea that the Feds can sometimes tell you what to do with good effect.

The commenter Ron Pavellas adds:

I was working as the CEO of a large hospital in California during the 1980s (I have MPH as my degree, by the way). I was outraged when the Public Health officials decided to not treat the HI-Virus as an STD for the purposes of case-finding, as is routinely and effectively done with syphilis, gonorrhea, etc. In other words, they decided to NOT perform classic epidemiology, thus sullying the whole field of Public Health. It was not politically correct to potentially ‘out’ individuals engaging in the kind of behavior which spreads the disease. No one has recently been concerned with the potential ‘outing’ of those who contract other STDs, due in large part to the confidential methods used and maintained over many decades. (Remember the Wassermann Test that was required before you got married?) As is pointed out in this article, lives were needlessly lost and untold suffering needlessly ensued.

The Wasserman Test.

A post from Gregory Cochran's and Henry Harpending's excellent blog West Hunter.

One of the many interesting aspects of how the US dealt with the AIDS epidemic is what we didn’t do – in particular, quarantine. Probably you need a decent test before quarantine is practical, but we had ELISA by 1985 and a better Western Blot test by 1987.

There was popular support for a quarantine.

But the public health experts generally opined that such a quarantine would not work.

Of course, they were wrong. Cuba institute a rigorous quarantine. They mandated antiviral treatment for pregnant women and mandated C-sections for those that were HIV-positive. People positive for any venereal disease were tested for HIV as well. HIV-infected people must provide the names of all sexual partners for the past sic months.

Compulsory quarantining was relaxed in 1994, but all those testing positive have to go to a sanatorium for 8 weeks of thorough education on the disease. People who leave after 8 weeks and engage in unsafe sex undergo permanent quarantine.

Cuba did pretty well: the per-capita death toll was 35 times lower than in the US.

Cuba had some advantages: the epidemic hit them at least five years later than it did the US (first observed Cuban case in 1986, first noticed cases in the US in 1981). That meant they were readier when they encountered the virus. You’d think that because of the epidemic’s late start in Cuba, there would have been a shorter interval without the effective protease inhibitors (which arrived in 1995 in the US) – but they don’t seem to have arrived in Cuba until 2001, so the interval was about the same.

If we had adopted the same strategy as Cuba, it would not have been as effective, largely because of that time lag. However, it surely would have prevented at least half of the ~600,000 AIDS deaths in the US. Probably well over half.

I still see people stating that of course quarantine would not have worked: fairly often from dimwitted people with a Masters in Public Health.

My favorite comment was from a libertarian friend who said that although quarantine certainly would have worked, better to sacrifice a few hundred thousand than validate the idea that the Feds can sometimes tell you what to do with good effect.

The commenter Ron Pavellas adds:

I was working as the CEO of a large hospital in California during the 1980s (I have MPH as my degree, by the way). I was outraged when the Public Health officials decided to not treat the HI-Virus as an STD for the purposes of case-finding, as is routinely and effectively done with syphilis, gonorrhea, etc. In other words, they decided to NOT perform classic epidemiology, thus sullying the whole field of Public Health. It was not politically correct to potentially ‘out’ individuals engaging in the kind of behavior which spreads the disease. No one has recently been concerned with the potential ‘outing’ of those who contract other STDs, due in large part to the confidential methods used and maintained over many decades. (Remember the Wassermann Test that was required before you got married?) As is pointed out in this article, lives were needlessly lost and untold suffering needlessly ensued.

The Wasserman Test.

[edit]Huge portions of this comment were missing originally; it's been edited but the context for descendent comments may have changed.

eg mass imprisonment of people who've committed no crime

I will point out that the current legal practice is to basically consider 'being suspected of having an infectious pandemic disease' as a 'crime,' in that the CDC can detain people at its discretion. If you subscribe to the 'non-agression principle,' I think this is consistent with that, since carrying an infectious disease is threatening or initiating violence (even if it's unintentional).

Moreover, if you need my consent for your plan, that's a great way of making sure that you really are acting in my interests.

Consider something like fluoridating municipal water supplies, or adding lithium to them, or filtering out arsenic from them. I don't see a serious difference between filtering out arsenic and adding fluoride- they're both adjusting the chemical properties of drinking water to improve health. (There is perhaps a status quo bias which sees removing something already there as safer than adding something not already there, but I don't think that's particularly relevant.) Adding fluoride or lithium to the water supply is something you either do or don't do- a house by house opt-in system would be tremendously more expensive and there's not a way to opt out besides filtering your water.

Suppose a city is voting on whether or not to add lithium to their water supply. A strict consent rule would require that every person vote for adding lithium in order for it to not be violating consent to add lithium. But it seems to me that we're better served by a Hansonian system of voting on values ("I am willing spend up to $X a year to reduce the number of deaths per year by 1 per 100,000 people") and then betting on beliefs ("If we increase the lithium supply from 1 microgram per liter to 40 micrograms per liter, we would expect suicides to decrease by 20 people per 100,000 per year"), so that the people price their various values and then experts evaluate how likely various approaches are to achieve those values, rather than requiring every voter to be an expert on all possible approaches. ("Fluoride? Doesn't that sap my precious bodily fluids?")

An agile approach based on feedback and iteration is an equally good description.

Sure, but we're back to the issue of what "feedback" means in the context of a pandemic. "Hmm, we let too many carriers of the disease out of isolation, and now 3% of the global population is dead. Oops!" This is perhaps a textbook example of a time-sensitive issue where it matters a lot to get it right the first time. (The current xkcd seems relevant.)

The failure of the "half-measure" should make you doubt the project a bit.

Suppose I'm designing a bridge, and calculate that in order to support a load of ten thousand kilograms, we'd need ten pylons. For budgetary reasons, we only use six pylons, and then the bridge breaks when a load of ten thousand kilograms is driven across it. Should we doubt my abilities as an engineer?

Once again, the question is: who should pay the costs of this risk adjustment? It looks to me very much like you want society as a whole (and HIV sufferers in particular) to subsidise your favourite recreational activity. You should pay.

Are you referring to other people being alive as 'my favorite recreational activity'? I don't think I've looked at it that way before, but that actually seems like it might be a fair description.

But to answer the question, I think that it's reasonable for public governments to pay for and enforce public health projects. I think that it is not objectionable for the broader population to subsidize narrower segments of the population- my tax dollars fund research into treatment of genetic conditions that neither I nor my hypothetical children will have, for example- but agree that when costs can be localized, they should. When you look at compulsory testing combined with 'soft quarantines' like tattooing, it seems to me that the cost for the test is born by society as a whole but the costs of having the disease are born (mostly) by those with the disease. (And my impression is that if we decided it was a social priority to be able to test everyone for HIV, then the scaling would allow the costs of testing to drop significantly.)

I think that smaller scale versions of this are feasible- say, a bathhouse that required all members to take a HIV test every n months, and only allowed entry to people with negative results- but as with most things in public health, larger scales have larger benefits.

Of course you would.

As a general comment, I find it more helpful to ask people questions about their positions, rather than making predictions about their positions. I have found that being right about a prediction is rarely helpful, and being wrong typically disastrous when it comes to having a productive conversation. For example, one of the hypothetical models I had of you earlier in this conversation was be that you might be a principled opponent to government coercion of individuals, and that model would object to the imprisonment of Typhoid Mary because it goes against the principle. Other models, though, wouldn't object to the imprisonment of Typhoid Mary, because they used cost/benefit analysis to make their decisions and that particular example passed. To reduce my uncertainty in a relatively costless way, I asked.

just as I do not believe for one second that you'd be in favour of a quarantine if it applied to you

If I suspect myself of being infectious, I wear gloves and a mask to protect other people (and avoid leaving the house if I can help it). If I were suspected of having a pandemic disease, I would submit to a quarantine. This feels to me like basic "being polite and kind to others," and so I'm moderately surprised you don't think I would behave that way.

And why you are no doubt gung-ho for gun control.

Actually, the evidence seems convincing that arming the populace reduces the amount of and damage done by crime; Kennesaw-style laws requiring heads of household to maintain a firearm with ammunition (with exceptions for conscientious objectors) seem better than the opposite.

And why you will no doubt be gung-ho against every civil liberty in turn.

One of the three charities I regularly donate to, along with CFAR and SENS, is the Institute for Justice, which is a public interest law firm that litigates economic liberty cases. It's up to you whether or not you class 'right to own property' or 'right to earn a living without interference from your competitors' as 'civil liberties' or different kinds of liberties, but I care about the project of advancing liberty comparably to how much I care about advancing rationality and defeating aging.

I, like Hayek, base my libertarianism on arguments from information costs: typically this leads to decentralization, but sometimes it leads to centralization- it makes much more sense to have one CDC with coercive powers than it does to decentralize and voluntarize the problem of preventing epidemics.

I think that smaller scale versions of this are feasible- say, a bathhouse that required all members to take a HIV test every n months, and only allowed entry to people with negative results- but as with most things in public health, larger scales have larger benefits.

This kind of thing is standard practice among porn studios...

2Lumifer12y

Nope -- it's called fluoridated toothpaste or fluoridated mouthwash. In general, the cost-benefit analysis for centralized interventions is difficult. Even besides the issues of properly estimating them, the costs and the benefits rarely align neatly -- there are winners and there are losers. The problems are exacerbated by the fact that the powerful usually make sure they end up among the winners and the powerless often enough find themselves among the losers. I tend to be wary of "it benefits everyone!" handwaving.

4Jiro12y

It is particularly relevant, because the regulators are running on corrupted hardware, and the consequence of bias and/or abuse by regulators is much greater for adding things than for taking them out. Adding substances to the water to sterilize everyone, and taking substances out so that water-without-substances sterilizes everyone would be similar--except that the second is not possible and the first is.

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