[Link] Forty Days

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17 [Link] Forty Days

by GLaDOS

29th Sep 2014

2 min read

17

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.

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[-]Salemicus10y580

Some points:

This is classic costless analysis. A quarantine would have prevented some transmissions of the disease, but would have severely limited the life quality of those quarantined. It would also have made it more difficult to detect HIV (if having HIV means compulsory quarantine, then if I suspect I have the disease I am less likely to get tested). Any proposal looks good under a benefit analysis; you are supposed to weigh those against the costs.
This kind of costless analysis is especially beloved by medicine and health professionals, whose only measure of value is health (e.g. their "quality of life" measure is essentially just health integrated over lifespan). I would have hoped rationalists would better recognise the complexity of human value.
The fact that the quarantine is compulsory ought to give the game away that it's not in the interests of the HIV sufferers. Let's call indefinite compulsory quarantine what it is - prison. It might well be in the interest of the rest of the population for HIV sufferers to be indefinitely imprisoned to stop the spread of the disease, but depending on your ethical theory, it is not obvious that the majority should have th

... (read more)

[-]Vaniver10y120

This is classic costless analysis. A quarantine would have prevented some transmissions of the disease, but would have severely limited the life quality of those quarantined.

Agreed that there are costs, but 35 to 1. If you're not categorically opposed to quarantine, that probably makes it on cost-benefit terms.

It would also have made it more difficult to detect HIV (if having HIV means compulsory quarantine, then if I suspect I have the disease I am less likely to get tested).

This is solved by compulsory testing.

"What gives the government the moral right to imprison people on grounds of public health?"

I think this has been seen as solidly the right move for centuries, and I think the fact that this is in question is a sign of how rare epidemics are, not of moral progress.

How about instead of quarantine, we had instead tattooed all HIV sufferers across the forehead?

The actual suggestion at the time was to tattoo them somewhere private- so that only potential sexual partners would be communicated of the risk.

[-]gattsuru10y100

Agreed that there are costs, but 35 to 1. If you're not categorically opposed to quarantine, that probably makes it on cost-benefit terms.

Is that 35-1 difference because of the quarantine, though? I thought we were supposed to know better than to conflate correlation and causation? The former might wink and nudge, but that doesn't actually make it correct -- especially when we're talking vastly different sets.

Cuba's first known cases of HIV didn't show up until 1985, the majority of the island's population was socially and politically isolated, the island's blood transfusion system was very easily isolated, and the place at least claims to have vastly lower illegal IV drug use. Contrast the United States, which has confirmed cases at least as far back as 1968 (West Hunter's estimate of first noticed cases in 1981 is highly off : GRID was proposed as a name that year), had and continues to have serious abuse of IV heroin, and by the invention of the ELISA blood test already had people receiving infected blood transfusions.

These are not similar groups. The low rate of infection in Cuba tells us that one or more of these matters probably explains the large difference, but as the number of differences increase the certainty that the quarantine was responsible or even helped decreases. If you look to other countries with similarly low infection rates -- Finland as one high-profile example -- you don't see such heavy-handed quarantines. This doesn't tell us anything for certain, but it's a pretty strong hint.

6Salemicus10y

35 what to one what? You're not exactly laying my fears to rest about the excessively coercive nature of your project. You are quite wrong that this has been seen as the right move for centuries. In the past, quarantines were normally carried out informally, sometimes by the church. The question I raised is not "should there be quarantines", it is "who decides." And whoever decides needs to take into account costs and benefits, not some random "35 to one." One normal way to look at that would be the burden of the disease vs the burden of the quarantine. In this case, AIDS is a not very infectious disease, that the mass of the population can easily avoid by not having unprotected casual sex (and, in particular, anal sex) and by not sharing needles. In addition, (even in the 80s) it was normally many years between diagnosis with HIV and death from AIDS, so the quarantine is especially burdensome. So this seems like a clear case where quarantine is a bad idea. Contrast with e.g. Bubonic plague, which is highly infectious, there are no easy steps to prevent transmission if sufferers are allowed to mingle with the rest of the population, and is over quickly, so the burden of quarantine is low. I am indeed old enough to remember those proposals, and they were roundly mocked at the time. I brought them up as a reductio, not as a serious suggestion. One thing I find strange about this discussion is that it's all in the past tense. To those so gung-ho about quarantine - why not quarantine now? HIV is just as infectious as ever.

[-]Vaniver10y130

35 what to one what?

Deaths in the US without quarantine to deaths in Cuba with quarantine. The two countries aren't directly comparable- Cochran is only confident estimating the number of AIDS deaths prevented as 'at least half'- but that's still 300k people. (If we had tested everyone in the US in 1987, that would be 300 deaths prevented for every person falsely quarantined.)

You're not exactly laying my fears to rest about the excessively coercive nature of your project.

The project is obviously coercive: otherwise it won't work. We're asking whether or not it's excessive, but I think in order to draw a line we need to have cases that clearly fall on each side of the line. Do you think it was excessive to, say, imprison Typoid Mary for three decades?

You are quite wrong that this has been seen as the right move for centuries. In the past, quarantines were normally carried out informally, sometimes by the church.

The US has federal laws on the books regarding quarantine since 1799. That's not because government quarantine is only 200 years old; that's because the US is only 200 years old. When churches have carried out quarantines, I would suspect it's because they are the ... (read more)

9pianoforte61110y

Did my quantified risks post make you more or less concerned?

6falenas10810y

Something you can do: Ask when they were most recently tested, and if you don't trust them then ask to see the STI report. In many circles that's not too unusual a request.

3CronoDAS10y

Incidentally, how hard is it to forge an STI report?

2falenas10810y

Probably not that difficult, if someone really wanted to. I don't think there's a standard everyone uses.

1Lumifer10y

Probably not harder than to forge an ID -- something a great number of teenagers manage to do successfully :-/

4Salemicus10y

How is this the relevant metric? I'm sure that if we banned scuba-diving, we could reduce the deaths from scuba-diving in this country by at least a factor of 35. That doesn't come close to an argument that scuba-diving should be banned. As long as you don't take seriously the hardship you are inflicting, you'll never be persuasive. Did Ronald Coase die in vain? Voluntary quarantine is the obvious starting point. Pay or persuade sufferers to undergo quarantine. If you make a good-faith effort at that, and then think further efforts are needed, I might be sympathetic. And the same goes for testing. Instead, you leap immediately to massively coercive projects, now aimed not just at a small number of sufferers but the whole population. This seems like a clear case of the cure worse than the disease. I already gave cases on either side of the line; HIV and plague. Typhoid Mary was a case where the disease was highly contagious, and there were no reasonable steps for the rest of the population to avoid getting the disease. On the other hand, quarantine was lengthy. On balance, quarantine seems to have been the right thing there, although it would have been much better if they had taken her into voluntary quarantine. Right, now we're talking - what is the burden of the quarantine vs what is the burden of not having a quarantine. The burden of the quarantine is lifetime imprisonment for sufferers, the burden of not-quarantine is that you don't get to have consequence-free casual sex (or share needles). It's not a close call.

2Azathoth12310y

The problem is that in the generality you want to apply it the Coase theorem is false.

7Salemicus10y

But we do have working tort law in this area. It is a tort to imprison someone, and it is a tort to deliberately or negligently infect someone with HIV. So the Coase theorem does apply.

1Vaniver10y

I do take it seriously, but there are three points I think should be made here. First is that, yes, policy debates shouldn't appear one-sided. Policies of forcible quarantine, voluntary quarantine, tattooing, and so on do have costs, and those costs require a conversion factor to be compared to the benefits of the various policies, and people can differ on what they think those conversion factors should be. Second is that I think that those conversion factors imply moral positions, and that it makes sense to condemn moral positions you disagree with strongly enough. If someone thinks that, to give an extreme example, we shouldn't imprison one person even if that prevents an epidemic that will murder a million people, I do not want them making public health decisions. Third, the response to AIDS seems especially tragic to me because it put feelings above people, and is strong evidence against civilizational competence. Again, Typhoid Mary. She refused to believe that she was infecting others, or to seek work as anything besides a cook. The tool of 'pay her to do something other than cook' has similar local incentives as 'punish her for cooking', but it has very different global incentives. "Hey, all I need to do is contract typhus and then I can collect money for not working!" The local incentives aren't quite the same, either: "I think I get... one million dollars worth of satisfaction for cooking a meal!" It seems to me that one of the secondary uses of government is to prevent people from capturing the majority of the consumer surplus from trade, and you don't need to stretch epidemics too far to make them fit that mold. By 'clearly' I meant that everyone involved in the discussion agreed they were clear. From my perspective, HIV and plague look fairly difficult to distinguish in terms of impact, though I agree they're different in terms of transmission vector. Recall that we are discussing about a third of a million preventable deaths, here. The primary bur

[-]Salemicus10y130

I think that those conversion factors imply moral positions, and that it makes sense to condemn moral positions you disagree with strongly enough... I do not want [people I disagree with] making public health decisions.

Agreed 100%. There has been an undertone in my posts of moral condemnation; and it's intentional. I do not want someone like Cochran making decisions about individual liberty.

[T]he response to AIDS seems especially tragic to me because it put feelings above people, and is strong evidence against civilizational competence.

I don't know what this means. Could you explain? It seems to me that the AIDS response put people's liberty before people's lifespan. This is not an uncontroversial choice, but it doesn't seem an obviously wrong one; both are about people, neither about 'feelings,' - except to the extent that 'feelings' reside within people. As for civilizational competence, it strikes me that civilisation is rolling along just fine; if anything, the AIDS epidemic appears to have played a major role in the major shift from homosexuals whining about "heteronormativity" to campaigning for gay marriage.

Incentives.

Of course there would be problems wi... (read more)

7Lumifer10y

Let me dial that up to 11 X-) So, the suggested remedy is to forcibly separate the society into the clean and the unclean, and to brand the unclean with an indelible mark. What could possibly go wrong? And let's talk practicalities. By the time AIDS was recognized as a serious threat and there were reliable tests for HIV status, how many HIV-positive people were there in the US already? Quarantines work well when you need to quarantine a few or a few dozens of people, not well-dispersed thousands and tens of thousands. How would compulsory testing work given that people know that failing the test leads to being branded unclean? Troops isolating city block by city block and dragging all inhabitants to a field testing station? How about costs of that?

6NancyLebovitz10y

Casual unprotected sex wasn't the only sexual risk-- the others were rape and having unprotected sex with an untrustworthy long term partner.

1Azathoth12310y

Also blood transfusions. It took the red cross a disgracefully long amount of time to start screening donors. Some people objecting to the screening compared it to the WWII-era separation of blood into black plasma and white plasma.

4Vaniver10y

Sure. I think people's first instinct whenever they encounter a policy question is to ask who they identify with. Is it the carrier of AIDS whose freedom or bodily autonomy would be violated by a quarantine or a tattoo, or is it the person at risk for AIDS? Actually considering the positions of both people is difficult but doable, and I think generally inconsistent with a rights-based view of morality. If we just say "liberty first!" then we make crazy trades where we give up many years of life for a bit of liberty; if we just say "lives first!" then we make crazy trades where we give up significant amounts of life satisfaction for a few lives; if we say "this is the tradeoff between life and liberty that we think it reasonable" then we have an actually quantitative discussion (which is less likely to be crazy). It seems to me (with the disclaimer that I'm not a historian) that most LGBT activists decided they identified with the people who had HIV, and so they advocated voluntary testing, and voluntary disclosure, and against policies that might possibly 'out' people, because they felt it more important to maintain the option to keep sex lives private than to prevent the spread of the disease. It's also claimed that Reagan mostly brushed the issue off because he identified with neither the carriers nor those at risk (until famous actors that he knew started dying), but, again, I'm not a historian. The time to close the stable door is before the horse escapes. As mentioned earlier, I think the cost/benefit has shifted on HIV to the point where quarantine isn't a good idea anymore (but compulsory testing and tattooing might still make sense). Trying half measures and then doubling down if they fail doesn't seem like a strong strategy relative to starting with the full approach in the presence of exponentially growing risks. (This is especially true if the failure of the half measure leads to discrediting the project, rather than to support for trying it harder.) A

1Lumifer10y

Um, why do you think so? The "rights-based" view is not that "he has a right so no one can do anything". Instead, it is "he has a right, so he can decide whether to insist on it or not, or maybe to trade it for some benefit". The core issue is who has the power, who decides. You are thinking of an impersonal entity above all whose freedom to choose the "optimal" solution is unnecessarily constrained by individual rights. The alternative is devolve the power downwards and let different people come to different views and conclusions. Sure, it's going to be messy and in many ways (especially at the micro level) non-optimal. However it avoids the pitfalls of trying to impose seeming optimality from above which, as history abundantly demonstrates, has some pretty horrible failure modes.

1Vaniver10y

Sure. And we have technical tools that help us solve this problem, rather than just reasoning from moral principles. We can look at the structure of the problem and determine the optimal level of centralization for a particular variety of intervention, because problems are caused by mismatch of optimizer centralization and information centralization, and this can be both that the optimizer is too far up and that the optimizer is too far down.

1Lumifer10y

I don't see how you can get to the single "optimal level" without assuming a single underlying system of values. Optimality is a function of your evaluation of outcomes and your evaluation of outcomes is a function of your value system. Who will determine that "optimal level" and what happens when there is significant disagreement about optimality?

-1Salemicus10y

No. The point is that people's rights are a key part of their position, and it's impossible to evaluate people's interests or "expected value" without considering their rights. That's not to say that you can never override people's rights, but it needs to take a lot, particularly if the violation is very serious (eg mass imprisonment of people who've committed no crime). 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. There is no end to my suspicion of people who view breaching rights without consent as a minor hiccup in their plan, rather than a key reason to abandon it. This is just rhetoric. An agile approach based on feedback and iteration is an equally good description. The failure of the "half-measure" should make you doubt the project a bit. It looks very much like you've got a hammer and are determined to wield it. Hang on now. I think the pharmaceutical companies who came up with the various tests and anti-retrovirals etc did something worthwhile. I think the people who campaigned for condom use did something worthwhile. But I'm not excited about compulsory testing and mass imprisonment of the innocent. 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. Of course you would. And you'd place practically no weight on people's freedom to drink (or sell) what they want, and you'd place practically no weight on people's enjoyment of alcohol, but massive weight on the health drawbacks and drunk driving statistics and the occasional alcoholic. And then you'd add in the subconscious bias that you don't drink, so screw those guys (just as I do not believe for one second that you'd be in favour of a quarantine if it applied to you). Which is why people like you were gung-ho for prohibition, and shocked wh

8Vaniver10y

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

4Jiro10y

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.

1Vaniver10y

I agree for "things" as a general class, but once we've conditioned on a particular thing ("what's the optimal level of chemical Q?") it seems to me that we should have symmetric levels of knowledge about moving the level of that thing up and down when it's possible to move both directions. (Fluoride and lithium groundwater levels already vary significantly between areas--that's how we discovered their effects in the first place--and so saying "let's artificially make our groundwater like their groundwater" doesn't seem that prone to bias or abuse.) It may be worth explicitly mentioning that if we're introducing something completely novel, when we shrink) the state of the evidence towards the reference class, the level of danger for "completely novel thing" is higher than the level of danger for "abundant common thing." I expect this will be minor, though, and many completely novel things are actually much better studied than abundant common things, because the abundant common things were grandfathered in rather than receiving serious scrutiny. (Here I'm thinking of particular artificial sweeteners, which were proven safe at levels where sugar would be toxic because they had to go to dramatically higher levels of the artificial sweetener to find any toxicity.) I suppose we should also mention the argument that if we create the ability to add molecules to the water supply, that ability could be corrupted to nefarious ends- but I think that's a fully general argument against any infrastructure development, and should be responded to by investing in security (and secure design) rather than not investing in infrastructure.

[-]Jiro10y130

but once we've conditioned on a particular thing ("what's the optimal level of chemical Q?") it seems to me that we should have symmetric levels of knowledge about moving the level of that thing up and down when it's possible to move both directions.

Moving the level of that thing down is limited at 0, and thus the effect of bias and abuse is also limited. Moving the level up is not so limited.
Deciding that you'll condition on a particular thing is itself subject to the same bias and abuse that deciding to add something is. Imagine regulators saying "we've already decided that we're going add sterility drugs to the water, we just need to decide how much". It's also solved the same way; just like you say "without satisfying very high standards, you may only filter stuff out and not add stuff", you say "without satisfying very high standards, you may only condition on things that are already present in significant amounts".

I think that's a fully general argument against any infrastructure development, and should be responded to by investing in security (and secure design) rather than not investing in infrastructure.

It is possible ... (read more)

2CronoDAS10y

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

2Lumifer10y

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.

3Vaniver10y

Which is only ten times more expensive. It's also more effective than just drinking fluoridated water, as you might expect, so the comparison isn't that clean.

6Lumifer10y

Hopefully you're buying toothpaste anyway, so the relevant number is the difference in price between fluoridated toothpaste and non-fluoridated. I think it's more or less zero. In fact, non-fluoridated toothpaste is likely to be some all-natural all-organic fancy expensive thing :-)

0Lumifer10y

This is a good discussion, but let's not get silly. Typhoid Mary was a very unusual case in that she was a carrier but didn't have any symptoms. I really don't think there would have been a problem with people intentionally contracting typhus in order to get benefits and forgetting about the dying part.

3Prismattic10y

I agree with this, but just wanted to note that typhoid fever and typhus are distinct diseases (with typhoid being misleadingly named).

0Lumifer10y

Yes, thank you.

2Vaniver10y

Agreed that the example is silly, but the general trend is basic economics. A tax and a subsidy have the same effect on behavior in the short term, but one of them makes the industry less profitable (and thus it shrinks) whereas the other makes the industry more profitable (and thus it grows). I really don't want to make the industry of "endangering public health" more profitable.

1Lumifer10y

Well, first of all, if there are two industries and their size is a zero-sum game (all population is divided between classes A and B and everyone must belong to either A or B) then the effect of a tax and a subsidy is exactly the same. What grows one part, shrinks the other part and vice versa. Second, this is a general-purpose argument against helping anyone in trouble. And, certainly, sometimes it is a valid argument (e.g. see the flood insurance for shore properties in the US). But sometimes its validity is more doubtful: for example, following this logic the SSI system for disability benefits should be dismantled immediately.

5Vaniver10y

Yes? If we, say, use subsidies to reward coal plants for reducing their emissions, then coal plants will have lower costs relative to nuclear, and we'll see more coal plants and less nuclear plants than we would have otherwise, and this goes against our stated goal of reducing emissions. If we taxed emissions, then we would get the same short-term behavior but in the long run there would be less coal plants and more nuclear plants, which would aid our stated goal of reducing emissions. Agreed. I think this is a concern that should be taken into account whenever considering whether or not to help someone in trouble, but think that it will only be decisive in marginal cases (or cases where trouble is easy to cause or fake). It seems obvious to me that a significant amount of 'disability' today actually is fraudulent, and the SSI system exists as it does because we haven't accepted on the social level that a growing percentage of the population is not able to contribute productive work in the modern economy. Given that SSI fulfils an actual social need that is different from its stated social need (as well as filling that need), dismantling it without fixing the problem it's been co-opted to fix seems like a mistake. If we had a guaranteed income (or negative income tax or however you want to call that solution), then it's not obvious to me that we would need SSI.

1Lumifer10y

I don't understand. It seems to me that we HAVE accepted that on the social level and so are paying that growing percentage of the population so that it doesn't starve (or turn to crime, etc.). Basic Income solves a somewhat different problem -- that of people not willing to work.

2Vaniver10y

I think we're disagreeing about the use of 'accepted' rather than the facts: I mean that the media consensus is not that we have 'surplus population' who should be paid to not starve or cause too much trouble, but that we have a growing number of people with disabilities, and that the labeling as 'disabled' is a significant portion of why the voting public is willing to spend taxpayer money on them. I understand you to use 'accepted' to mean that SSI is still funded and protected by public opinion against significant cuts.

4Lumifer10y

I think there is some definition fuzziness here. We started with "percentage of the population ... not able to contribute productive work", this mutated into "surplus population" which is not the same as "people with disabilities"? A resonable (economic) definition of "disabled" is "not able to contribute productive work"... Do you have in mind what Tyler Cowen calls ZMP (zero marginal productivity) workers?

6Vaniver10y

Agreed, but my impression is that SSI is targeted at medical disabilities- "I used to be a manual laborer but I now have persistent back pain" instead of "I used to be a manual laborer but now I'm structurally unemployed." The system as is encourages the medicalization of economic issues- and in particular of exaggerating the medical impact of issues rather than ameliorating them.

2Lumifer10y

Right, because the former means unable to work, while the latter usually means "can't find a job that I like enough". I agree. I have no particular wish to defend SSI or the way it's run -- my point was basically that "we should not subsidize failure" cannot be taken as an overriding principle. It is one of many considerations: sometimes it governs and sometimes it steps back.

0CronoDAS10y

It still (mostly) follows the principle that we should not subsidize deliberately choosing to fail, as medical disabilities are generally assumed not to be voluntarily self-inflicted.

0ESRogs10y

This example does not seem that silly to me, given that this is a thing.

4Lumifer10y

We're talking about broad-effect incentives for the society as a whole, not about what some fringe thrill-seekers might or might not do. The bugchasers are very much NOT motivated by the potential for some monetary/material benefits. However we can make this an empirical question. In the US if you get certified as medically disabled, the SSI will pay you money for the rest of your life. There are probably some statistics on the prevalence of self-harm with the goal of getting SSI benefits...

1pragmatist10y

Actually, that's not what you were talking about in this part of the discussion. You were talking about the burden of tattooing people non-consensually vs. the burden of not doing that. Being forced to get a tattoo is much less burdensome than being quarantined for most people, I imagine. That makes it at least a closer call. Also it's a bit disingenuous to characterize the burden of non-quarantine as not being able to have "consequence-free casual sex", when the consequences we're talking about are the deaths of hundreds of thousands of people. Probably you disagree that this was a necessary consequence of non-quarantine (and I'm with you on that), but that's a separate issue.

0DanArmak10y

Scuba-diving is dangerous to the diver only. HIV has a risk of transmission to others.

1CronoDAS10y

False positive rate, anyone?

[-]Vaniver10y120

False positive rate, anyone?

If you tested literally every person in the US, you would end up with about a thousand false positives. (This assumes that this is 1987, and we have the second, independent test, rather than just 1985 when we have only the one test.) If you restrict your sample to, say, New York City and San Francisco and so on, then you dramatically lower the number of false positives while still covering a large part of the at-risk population.

[-]Azathoth12310y120

This kind of costless analysis is especially beloved by medicine and health professionals, whose only measure of value is health (e.g. their "quality of life" measure is essentially just health integrated over lifespan). I would have hoped rationalists would better recognise the complexity of human value.

Yes, and the people who already have HIV don't have a long expected lifespan. Note that the suggestion was based on existing procedures for other STDs and those were anywhere near as lethal.

The fact that the quarantine is compulsory ought to give the game away that it's not in the interests of the HIV sufferers.

It's not in the interest of the people who already have HIV, it is in the interest of the people who might get it.

6pragmatist10y

This was the case in the 80s and 90s, but it is no longer true. In the United States, if you are diagnosed early and consistently receive antiretroviral therapy, your expected lifespan is the same as the population average.

4pianoforte61110y

There is a related phenomenon - acting like an extremist on one direction if you believe that too many people are wrong in the opposite direction. Eg. Arguing like a libertarian if you think people aren't libertarian enough, or arguing against libertarianism among crowds that you think are too libertarian. Or rating something 0 stars to drag down its rating even if you thought it was okay. The goal is not to be "correct" but to shift people towards the position you think is correct. (I don't know whether this strategy works) Presumably Cochran thinks people dismiss quarantines too much so he is arguing way in the opposite extreme.

4A1987dM10y

http://slatestarcodex.com/2013/06/09/all-debates-are-bravery-debates/

2pianoforte61110y

I don't think this is the same phenomenon. Bravery debater: "We live in an era in which suggestions of quarantines are vigorously opposed despite their benefits but I am not afraid to defend them despite the oppressive status quo" Person acting as an extremist: "Quarantines are really beneficial, and we should do more of them for X,Y and Z reasons" (conveniently not mentioning the negative effects)

3Azathoth12310y

Except people normally don't dismiss quarantines. They just did it for this particular disease. As Ron Pavellas commented even the things routinely done for other STDs weren't done with AIDS.

6gattsuru10y

Is that the case? We're happy to quarantine highly-transmittable diseases, but HIV isn't -- it takes significantly more than shaking a hand or coughing to transmit. Indeed, even with easily transmitted conditions like tuberculosis, we go for involuntary quarantine only during emergencies or as a last resort. Most carriers are only required to wear masks and avoid certain types of work.

2[anonymous]10y

Indeed, ebola is even less transmittable than HIV, so we shouldn't coercively quarantine it either.

4Stabilizer10y

I wish I could give you another upvote for introducing me to the concept of déformation professionnelle.

4skeptical_lurker10y

You could attach an unremovable (without the key) leg tag with a warning on it. This would be reversible and not on display during the normal course of daily life, diminishing the stigma.

7sixes_and_sevens10y

I only have hazy memories of the 1980s, but I'm pretty sure the fashions of the day still allowed you to have sex without taking any clothes off. You'd need a very different piece of equipment to enforce this. (I was going to improve a link to the Wikipedia article for chastity cages here, but it includes NSFW images. Investigate them at your own peril.)

5skeptical_lurker10y

I guess if there were std warning leg bracelets then most people would want to check their partner's ankles, even if they kept most of their clothes on. But government mandated chastity belts wins for comedy value.

1A1987dM10y

But quarantines are not intended to be for the benefit of people already infected, not even ostensibly; they are intended to curb externalities to people not yet infected. (But I'm not sure the concept of externality actually applies to non-airborne diseases. Unless I have sex (or share needles) with people without their consent, in which case I'd say I should be jailed even if I don't have AIDS.)

0[anonymous]10y

The problem is that they are utterly dominant.

0[anonymous]10y

Cuba basically disproves this doesn't it?

3Salemicus10y

How so? Perhaps their much lower incidence of HIV was caused in part by people never getting tested. Eventually, they are classified as dead of pneumonia, rather than dead of pneumonia caused by AIDS.

3Error10y

That seems like a testable hypothesis. If statistics on deaths by pneumonia and similar illnesses are recorded, and aren't so high as to dwarf HIV deaths, then there should be a noticeable spike in those deaths during the HIV years. One could compare that spike to the U.S. to see if Cuba's HIV deaths were underreported relative to the U.S. I think, anyway. I'm not a statistician, but it feels like it should work.

5A1987dM10y

I'd guess that in poor non-African countries that's a very big if.

[-]IlyaShpitser10y310

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.

I think my favorite example is food rationing in the UK in WW2. It's a great example because it shows both sides are right:

(a) Rationing resulted in people eating healthier (much more veggies, much less processed sugar and fats), and as a result many public health measures actually went up during the war, even as the public perception was that food quality was poor.

and yet at the same time

(b) Once the infrastructure for rationing was set up the temptation was irresistible to continue with it past immediate need (rationing in the UK continued for decades after WW2) for reasons that basically amounted to bureaucratic convenience.

So it's both true that government paternalism works (the 'leftist view'), and that giving the government tools to coordinate better simply results in the government using those tools for its ends, not yours (the 'libertarian view.')

[-]TheAncientGeek10y210

Not decades , about nine years.

[-]TsviBT10y260

Interesting post.

But:

HIV-infected people must provide the names of all sexual partners for the past sic months.

You missed a golden opportunity:

...all sexual partners for the past sic [sic] months.

0[anonymous]10y

Damn, I was all fired up to make that joke. Great minds think alike, I suppose...

[-]James_Miller10y250

I liked this comment from Rudolf Winestock

The plague that will wipe out most of humanity won’t be some super pathogen that’s immune to modern pharmacology, it’ll be an easy-to-treat pathogen so situated in the vector/target space that dealing with it rationally would make politically powerful groups howl.

[-]Lumifer10y190

undergo permanent quarantine.

Is that an euphemism for "imprisoned for life"?

7[anonymous]10y

Yes it is imprisonment, however the term is misleading because it implies the quality of life isn't better than US prisons. And this is why no it isn't an euphemism, but the correct term. It is literally how a bunch of diseases where dealt with, pretty effectively, historically. How they still are occasionally dealt with, what do you think happens to people who have some strains of drug resistant tuberculosis?

6Lumifer10y

"Imprisonment" is about lack of freedom, not about quality of life. A luxurious prison is still a prison. Um, nothing? These people are mostly homeless and have developed MDR TB precisely because they do not stay at a medical facility (and take the prescribed antibiotics) long enough to actually kill the TB. I am sure that in some cases they are quarantined, but I don't know if that happens in the majority of cases. It's also a different case because TB resolves quickly (compared to HIV) -- you either die or you respond to the last-line antibiotics.

4Azathoth12310y

During the time period under discussion AIDS also resolved quickly.

6Lumifer10y

Not really. AIDS resolved quickly, HIV-positive status did not.

0[anonymous]10y

Hence the dangers of conflating the two.

[-]GLaDOS10y90

Frito Bandito writes:

So what you’re saying is, sometimes people are too stupid to know what’s good for them and others, and you need a quasi-dictatorial regime to get them into doing it?

Cochran replies:

Most people won’t wear seatbelts. You don’t need a dictatorship: just a government that isn’t crazy. In 1940, the government would have imposed quarantine without much agonizing. Of course, you couldn’t have had a big AIDS epidemic back then.

A government that isn't crazy huh? (u_u)

That problem seems insolvable except it somehow has been solved from time to time.

[-][anonymous]10y80

People should consider the Trolley problem. Except this time the fat person isn't one that is killed, but is sent off to live in the equivalent of a Leper Colony.

0ChristianKl10y

I'm not sure turning whole countries into Leper Colonies is a good strategic choice given the amount of harm that Ebola causes.

[-]sixes_and_sevens10y70

For context to the following question, the West Hunter blog is on my feed reader, so I'm familiar with its content.

In your opinion, on what basis is the blog "excellent"?

[-]MrMind10y60

Let the mind-killing begin!

Besides, it would be interesting to know why the difference existed in the first place. Assuming no basic difference between Cuban and American epidemiologists' education, why the (supposedly) poorer choice was made in the US?
Was it political, bureaucratic, molochian... what?

2VAuroch10y

Well, Cuba was already working on a centrally-planned economy at that point. So the infrastructure for a quarantine was easily available, and the political costs were negligible.

0drethelin10y

For one thing, Cuba is an island.

[-]falenas10810y60

A big difference about outing someone with syphillis vs with AIDS is back then it was thought by a lot of folks that AIDS was only transferrable by anal sex, i.e. you would also be outing them as probably gay/bi.

Which was also much more dangerous to be outed as back then.

-8Azathoth12310y