What should we do about equity?
When social systems systematically deny some people access to goods, the net badness of that is more than would be expected just by summing over how bad it is for each person not to get the thing. If we both have a dollar, it is a better world overall than one where I have two dollars and you have one cent. Fairness is valuable, and systemic racism is icky.
It also has a way of falling down that "memory hole". People who can like to forget it still isn't a solved problem.
It seems like there was the appearance of an attempt to apply a constraint, to prevent people with systemic power from getting the scarce good unless people without that power had gotten it. That constraint seems to have been both costly to try to impose (because, for example, it resulted in a lot of wasted doses), and also not very effective (because, for example, it involved residency requirement hoops that everyone should have known would have the opposite effect). It's entirely possible that the whole project was actually a scam, and not a genuine attempt to apply an effective equity constraint at a manageable cost.
But the correct alternative is not to just not apply any equity constraints. If you apply a constraint that is a net benefit to the people it is supposed to help, and a larger net cost to the people it is constraining, it is justified if it evens out a large enough systemic difference in well-being.
We should look at why California's equity constraints seem to have failed to produce any equity, why they were so costly, and why they were able to masquerade as a real attempt to produce equity if they were not.
We should not abandon the notion that equity is a good thing that is worth paying a net cost to get.
The correct alternative was absolutely to not apply such constraints, but that's because supply should have been a non-issue. Paying $500/shot, for a course of vaccination begun in the first month, would have cost much less than 0.3 taken off of the 1.9 trillion dollar COVID relief bill of early 2021. This should have been literally free.
Zvi spends a lot of time talking about the problems of choosing scarcity - and dishonestly ignoring the evidence that African-Americans were more likely to die if they got infected - but the actual question should be why this wasn't trivially solved in the run-up to January 20, 2021, aside from that spot of bother concerning the changeover.
I had the privilege of getting an advance draft of Patrick McKenzie’s very long story founding and running VaccinateCA, an organization dedicated to providing Americans information on where and how to get vaccinated against Covid-19.
It is an amazing document. Despite its length, I am going to flat out say to Read the Whole Thing if you have the capability of doing that. It is full of things worth knowing and understanding. I benefited from reading it twice, once as a draft and again as a finished document.
Since the VaccinateCA post remains very long and difficult to navigate or draw reference from, this post is an attempt to pull out the most long-term-important passages and facts and give an outline of the events and insights that reflect the world outside VaccinateCA, to keep this bounded. I have a short bullet point section on the inside lessons as well, but to keep this bounded am focusing elsewhere.
A central theme is the author, Patrick McKenzie, being surprised and confused by how dysfunctional were government operations, and how deprioritized was the cause of having less citizens get sick and die. As you read, notice these repeated surprises and confuses, and notice that the correct model would not be so reliably surprised in the same directions.
Similarly, he notes that he believes some of his statements present the situation as so dysfunctional that they sound crazy. The statements do not sound crazy to me at all. They sound accurate, and like the type of thing one would expect. It seems important, if we want things to improve, to realize that such statements are accurate, normal and expected.
Again, seriously, read the original if you can, at least the parts about how government systems (largely didn’t) track the vaccine and ensure it was distributed to citizens.
The Logistical Problems With Distribution Were Unnecessary
For some reason we decided that our standardized cold chain, sufficient to keep the vaccines good for ten weeks, was not good enough, despite that obviously being good enough. So for no real physical reason, we didn’t use our existing infrastructure.
The Hyperlocal Information Problem
The core problem that VaccinateCA was created to solve was that our vaccine distribution system:
Patrick McKenzie posted a Tweet suggesting building a website and offering to pay server costs, Karl Yang took up the gauntlet and set up a discord server, and a group of ten worked through the night, forming the nucleus of the working group. Things went from there, the full post has lots of details.
The core plan was…
It was still a ton of work and this leaves out a ton of detail – see the full post.
The government was initially skeptical, but offered increasing levels of support once it was clear that VaccinateCA was getting the job done where others didn’t. At first this was informal. They got a Bat-Phone to California and volunteers started getting pointed in the project’s direction.
As opposed to the official California website My Turn, which had limited functionality and accuracy, and which failed to efficiently get shots into arms. The official system failed to understand, for example, that when it gave shots to the University of California at San Diego hospital system they then gave those shots to various different locations. The government posted where their records said their department’s share of the shipped doses should in theory be, as opposed to VaccinateCA which asked those on the ground where the doses were. Only one of these methods remotely matched reality. My Turn was, of course, deemed a huge success.
Or the official Federal attempt, VaccineFinder. This was supposed to aggregate data from the pharmacies. The problems included having a severe deficit of engineers, state politicians having zero interest in letting Biden take credit for anything they’d managed to put together, the pharmacies only getting half the doses to begin with, and the Federal Government having previously agreed to not write a huge percentage of the inventory information down or scrub it of information vital to things like knowing who had how many doses were where.
Oh, and this:
Also as opposed to much better resourced public health teams and others at major tech companies. Those people had the skills and resources needed to handle our needs, and did not do so. Patrick explains that this was because government was unwilling to work with Big Tech, and made it abundantly clear especially after January 6 that Big Tech Will Pay, so everyone involved was told they must keep their heads down and not do things like go around asking people for medical information.
It is often said that such effects – the ‘if politicians treat an industry or class as unfavored and threaten to treat that group badly in various ways, including not letting them keep their profits or potentially going after them, they will largely cease the Doing of Things, including and especially exactly that you would like them to do’ – are not something worth worrying about. This is a good example of why to worry.
The Low Tech Way versus The High Tech Way
Recently I asked around about why voice assistants so often fail to respond appropriately to scarily common requests – for example if you say ‘cancel my 5pm timer’ while having a 5pm reminder or 5pm alarm instead, it won’t notice. A majority of failed requests could be solved by a modest engineering team looking at failed requests and hardcoding if-then statements, and this does not happen, with the explanation being in part that no one wants to be on that team rather than figure out how to use fancy scalable machine learning techniques.
Here we have the opposite. The tech people are trying to get a physical result and notice that they have a workable solution. The government despairs of or dislikes such solutions and wants magical IT integration instead, while the tech people make it all work in a matter of hours or days.
We have essentially zero fast-moving state capacity in such a spot. If the state tried to do things that way, it would require endless approvals and bids and specifications and other steps and take quite a long time, even in the best case scenario.
On Being Legally Forbidden To Administer Lifesaving Healthcare
This section is brutal. I am going to quote a large portion of it and the following two.
If anything I think the situation is slightly worse than that in the general case. Saving a life even with a medical license is not so much legal by default as legal if you are engaging in standard pre-approved medical lifesaving practices using standard pre-approved medicines and devices, and illegal otherwise. But I digress.
This is about the prioritization system that determined who got access to lifesaving medicine first, since we decided to allocate via power. The elderly are at vastly more risk for Covid than everyone else, enough to overwhelm any and all other risk factors. Speed was of the essence. So what did we do?
And in the following section:
I do not think this sounds unhinged at all. Complexifying systems will by default favor power and the types of people who specialize in navigating complex systems. Allocating resources on the basis of power and patronage and expecting the resources to advance ‘equity’ is a category error. That is not how any of this usually works.
This happened. This really happened. This really resulted in a majority of doses sitting idling in a freezer, some of which expired and were thrown out. Those who gave out those doses faced threats and retaliation for doing so.
From the post, here’s Governor Newsome at a press conference on 28 December 2020.
This was meant to apply to those giving out such shots, even to random people to prevent them from being thrown out unused.
Focus only on what matters… to you.
This is from a later section:
Do not let this get memory holed.
People Were Made To Feel Bad About Getting Vaccinated ‘Too Early’
This was a constant problem. I dealt with it constantly with my own family, and also with lots of readers, concerned that they were ‘jumping the line’ or otherwise doing something unfair to get vaccinated when they were first able to do so. There was also vague FUD spread about potential retaliation for ‘skipping the line’ or getting wrong what phase things or someone was in.
So let me add to the chorus of people who can verify that this was a substantial practical barrier.
Noticing Confusion
Why did this happen? Patrick cared about and wanted it to be one way. Those with power, and the systems with power, cared about and wanted it to be the other.
An important confusion is what people who are interested in ‘equity’ care about.
This is exactly backwards. Equity concerns stand directly in opposition to productivity concerns or to combined utility concerns. Caring about equity is to say that you care about (the appearance of caring about) the relationships between the outcomes for favored groups versus unfavored groups rather than caring about getting better outcomes in general.
Patrick notices repeatedly that the system chose these equity concerns, of stopping the wrong people from not getting sick and dying, over the concern of less people getting sick and dying. He also noticed that this failed to achieve equity on its own terms, because it created complexity and awarded the ‘not dying’ prize to those with and favored by power and those with the ability to navigate opaque and complex official systems.
In terms of modeling logistics, fully accurate. Can confirm.
In terms of what these people care about: Again, no. This is backwards and I want to ensure that this fact is text. Note this, about some potential funders:
Such folks do not much care about getting the less privileged people checked out sooner. They mostly care about the system not doing things that get the more privileged people checked out faster, and they care about not giving those people additional privileges, such as the unique ability to switch lanes. Oh no.
This generalizes.
The Chains Lied About Vaccine Availability Because We Didn’t Pay Them
To be clear, when you pay so little to those providing a vital lifesaving service that they do their best to avoid providing it, such folks are not exactly covering themselves in glory, but this is on you, the person who is not paying them enough money. The amounts required would have been trivial.
An information source that made the whole process less time-consuming would also have helped a lot. You lie in a recording or on a website and say you don’t have information in order to not have to answer the same question over and over again, in addition to all the other reasons you might do that, and because you do not want a lot of people getting the idea that they should call you and then getting mad when told no.
The chains also intentionally had broken websites, as rationing mechanisms, to avoid having customers come to them to try and get vaccines and get mad when told no.
Whereas the mid-tier pharmacies had the opposite problem, where not enough people would seek them out and they wouldn’t be able to use all their doses. Nor would they be able, of course, to transfer the doses across the street, Patrick doesn’t even mention that possibility it is so absurd on its face, I mean come on.
Not all broken systems, of course, were broken on purpose. One advantage of being broken by accident is that when people notice, they can fix it.
America Still Pretty Great, All Things Considered
VaccinateCA ended up expanding across the country, vouching for data, connecting their map into places like Google and greatly enhancing our ability to get shots into arms.
The thing that VaccinateCA didn’t end up doing was going international.
The effort wasn’t designed to be sustained long enough to do that, and going international took away many comparative advantages.
More than that, America still has one very large advantage.
On Vaccine Hesitancy
At the same time that everyone was making maximalist claims about the vaccine with impunity, they didn’t do this where it would matter most, which was affirming that the vaccine was free.
Safe? Sure. Effective? Absolutely. Free? Well, let’s be careful about that one. WTF?
I knew the vaccine was all three of these things, so I wasn’t automatically tracking how often reminders included each of them, and I don’t have a good memory here.
Quick Notes on How To Actually Do a Thing
A lot of this seems highly relevant to my current tasks at Balsa. I have already been reminded of some of these lessons, including that for-profit companies have a vastly easier job acquiring funding. Even in explicitly EA spaces that are supposed to be non-profits, compare investment in OpenAI, Anthropic and Conjecture (or only Anthropic!) to the amounts spent on, well, everything else.
The sense of urgency and energy and long hours hits hard, both in its presence and its absence. As Balsa is in its current form a long term project without any hard deadlines, there is no ‘could this be done on Day 6 instead of Day 8?’ attached to everything, and I am pacing myself in a sustainable way rather than doing everything possible because every minute counts. I don’t have the ability to focus in totally on a thing for long periods the way I used to, as I am no longer as young. There is a huge difference.
On the flip side, the volunteer enthusiasm hits hard. When Balsa was announced, there was a giant outpouring of people eager to spend their time making things work. For several weeks I filled my calendar with phone calls, thereby getting lots of new info some of which was learning exactly how many phone calls with new people on a variety of topics I could handle before my brain stopped working right, and that I need to not be the person doing lots of volunteer coordination.
Overall Impressions and Takeaways
There are two central stories, the internal and the external. This post focused on the external.
The internal story is at heart a simple story of the power of Doing Thing. When people come together with the intention of working hard to damn well Doing the Thing without regard to credit or compensation or how it looks, they can do quite a lot. When they have experience in such matters, they can do even more.
The external story of America’s vaccination efforts is damning. A lot of this information is in danger of falling into a memory hole.
In particular: America chose to care about the appearance of favoring approved groups over disapproved groups, rather than to care about saving lives, getting shots into arms, people not getting sick and being able to resume their lives and other neat stuff like that. We retaliated against doctors who gave to ‘the wrong people’ doses that would otherwise expire. In doing all this, we created a complex web that favored only and exactly the same managerial class that was signaling their concern for ‘equity’ at the expense of saving lives, while those the policy claimed to benefit lacked the skills or resources to navigate the systems and were left behind even more. Funny that.
Remember how this prioritization process worked. Expect it to happen again.
Various other political concerns were also allowed to override the ability to do a variety of things that would have allowed shots to go into arms. Thanks to ridiculous government-imposed requirements, our existing vast logistical infrastructure that commonly delivers vaccines with exactly the same shelf-life conditions was not used, and instead doses were left untracked. Tech companies were shunned rather than embraced and felt the need to not be visible. Pharmacies were paid so little that some actively sought to avoid giving out doses and intentionally crippled their own websites. The government preferred not sharing vaccine info anywhere to giving the impression that some states were served better than other states. Local and state politicians did not want to share their information with the federal government lest they lose the credit.
That is only some of the things in this summary, let alone the original post.
It is vital that we not let any or all of this fall into a memory hole.
I will conclude with a question and answer from Patrick’s AMA on the Progress Forum. A lot of lowering of status, not much raising, the real government heroes are people whose names we never hear. Be sure to note the contrast between pharmacies and pharmacists, which reflects sharp contrasts throughout the OP where pharmacies consider vaccines an annoyance and pharmacists want to prevent people from dying.