Alex Tabarrok and Robert Tucker Omberg have published a new paper which confirms a thought that's been rattling around in my head for a while. The thought is this: aside from vaccines, pretty much nothing has much effect on the spread of COVID-19.
As usual, I'll lead with a couple of charts. The first one measures excess deaths as a function of the quality of a country's health care system:
There should be a downward slope to the regression line, showing that better health care systems lead to fewer deaths. However, there isn't even a modest downward slope. There's a tiny upward slope. Richer, more competent countries had more excess deaths than poorer countries.
(Note that excess deaths is used here rather than reported COVID-19 deaths. This is because reported deaths are unreliable, especially in poorer countries. Excess deaths are easier to measure and more reliable.)
And now here's another chart:
These charts divide countries into four buckets by their level of preparedness for a pandemic, with the red line indicating the most prepared countries. Among all countries, the red line shows nothing special. When you zoom in on just rich countries, those represented by the red line did do better than the others—but not by an awful lot and mostly in the vaccine distribution year of 2021.
Nor did anything else studied by the authors make much difference:
Our primary finding is that almost no form of pandemic preparedness helped to ameliorate or shorten the pandemic. Compared to other countries, the United States did not perform poorly because of cultural values such as individualism, collectivism, selfishness, or lack of trust. General state capacity, as opposed to specific pandemic investments, is one of the few factors which appears to improve pandemic performance.
In other words, what's important is not so much preparedness as the willingness to take quick action. That willingness is found mostly in countries that have experienced a recent pandemic and are therefore on alert for a new one.
The authors draw two lessons from all this. First, instead of producing massive planning documents, which mostly fail, we should increase our use of everyday procedures such as routine genomic sequencing and monitoring of sewage discharge. These can give us early warning of a new virus. Second, we should focus our energies on anything that might speed up the development and deployment of vaccines. This is, by a long margin, the most effective way to fight a new pandemic virus.
My take on this is that it by no means tells us to give up and do nothing except develop vaccines. The world didn't respond well to COVID-19, but that doesn't mean we can never respond well to a pandemic. I have a dim view of human nature, but not that dim.
That said, the reason this has all been rolling around in my head is because of a single observation: Although some countries initially did better than others, eventually everyone had to relax. When that happens, you get your turn in the barrel. Here are death rates through the middle of 2021, before vaccines started to overwhelm other factors:
Southeast Asian countries did well because they were still paranoid from the SARS epidemic of a few years ago. Nordic countries did well for some mysterious reason that I don't think we yet understand.
Among other rich countries, there's a (very) rough division between large and small: Large countries generally had higher death rates than small countries. I can think of lots of reasons this could be true, and you should feel free to take a crack at it too. However, as far as I know there's no evidence for anything in particular.
POSTSCRIPT: This is a preliminary study and shouldn't be taken as the final word on anything. Also, like me, the authors might be biased in favor of the results they found. Take this as an opening salvo, but nothing more for now.
The idea that you can take one pandemic and project lessons fromt it on all pandemics in the future is not that clever.
There are various issues to think about, but to say "it didn't work with Covid therefore it will never work" is frankly idiotic.
Again, haven't read the paper, but I'm wondering who, exactly, they point to as an example of countries that did prepare for the pandemic. China, I'd imagine (because of SARS) probably had some preparations in place, though I recall their early warning system crapped out badly. The US no doubt went through the motions prior to 2020. Some people at the CDC probably wrote up "plans." Perhaps the problem isn't the futility of planning in advance but the futility of relying on plans that are sketchy, not-well thought-out, and prepared without very much effort or seriousness. IOW shitty advanced planning isn't much better than no plans at all.
The thought is this: aside from vaccines, pretty much nothing has much effect on the spread of COVID-19.
I haven't read the paper, but this seems somewhat overstated. IIRC Japan, Taiwan and South Korea at this point have managed death tolls something like 20% of the level of the US. And at least part of this flows from much NPI adherence (whether voluntary, or mandated by the government). I think Australia and New Zealand are similar, no?
I don't know that I disagree much with the main point—the futility of preparation in advance—I'd need to ponder that some more (which is to say, I don't know that I agree with it, either).
But non-pharmaceutical interventions save lives, I believe. That's not to say there's not a legitimate cost/benefit analysis debate about NPIs (how many lives saved, and at what cost?).
I don't necessarily disagree, but I wouldn't put too much faith into any theory right now. Thailand and Vietnam and they did as well or better than Japan. I've been to all three and they are in no way comparable. Japan has an aging population that is declining, with a lot of professionals and desk workers that could work from home. Thailand and Vietnam are crowded countries with people jammed together and a very small percentage who were able to work from home. The fact that they all fared very well by world standards makes me think there must be something else going on. If I had to guess, I would say that some previous virus that came through Asia gave partial immunity, but that really is just a guess.
Thailand and Vietnam and they did as well or better than Japan. I've been to all three and they are in no way comparable.
I've been to all three also, and, while I agree they don't have all that much in common (though Saigon reminds me a lot of Bangkok), is it possible they do have some things in common with respect to dealing with the pandemic? I'm thinking mainly of, well, stricter adherence to NPIs (especially masking and avoiding crowds) to achieve social distancing. Maybe a whole slew of Asian countries are just more culturally amenable to collective action, masking, and adhering to the advice of governments?
I've wondered about the "Asia virus" thing myself. AFAIK one or two of the several dozen cold viruses endemic to our species are coronaviruses. Could it be that coronavirus infections have long been more common in East Asia than some regions? But I've never been able to find anything online, and I'd imagine researchers would have looked into this by now.
The other virus theory is neat and attractive but afaik has zero evidence. The communal willingness to mask up looks an obvious prime suspect. There are multiple reasons for this, but social compliance is greater on just about everything. In poorer countries, the absence of a strong health system may actual help with compliance.
I was in Tokyo a month ago. EVERYBODY is still wearing masks indoors, with better than 90% compliance based on my spot-checking. Their cities are crowded and the population is elderly, but they absolutely follow the recommendations of health care experts.
So I'm not at all surprised that Japan's COVID death toll is a fraction of the USA's.
Exactly. Beijing's outbreak peaked about a month ago, and the city has largely gotten back to normal: I went to the mall yesterday and it was full of pre-New Year's crowds. Ditto the supermarket today. And yet virtually no let up in masking whatsoever in the spaces we're required to mask in (subways, malls, supermarkets, taxis, buses).
Need some charts comparing rural and non-mobile countries vs. highly urbanized and very mobile wealthier countries. Yes, eventually it spreads but if you live in some poor rural area that nobody visits it will take a long time to get there, and hopefully by then there will be vaccines and treatments. That might even out the results with the wealthy countries that have better healthcare to start with.
Yes, people in wealthy countries travel more, domestically and internationally, so facilitating earlier, more rapid spread of the virus. Also, people in wealthier countries live longer, and Covid deaths skewed toward the oldest. Proportionately more people in wealthy countries were at high risk. In poorer countries, a greater proportion of the high-risk group was already dead of something else.
In other words, what's important is not so much preparedness as the willingness to take quick action.
How much difference is there, really, between "willingness" to take quick action and "ability" to take quick action (something that's difficult if, uh, you haven't planned effectively)?
A big difference! This has been another in the series of Easy Answers to Dumb Questions.
A big difference! This has been another in the series of Easy Answers...
If it's so easy to answer why didn't you provide one? Are you stingy that way?
I believe there's often very little distinction between the two, for the rather obvious reason that a state is effectively unable to take successful action in the wake of a pandemic if its citizenry won't play ball on anti-pandemic measures. There are several elements that go into "state capacity," but surely one of those is something along the lines of "public attitudes."
(In)Famously, the World Health organization conducted a study a few years before the arrival of covid—an assessment of the pandemic preparedness of different nations. The USA and UK were ranked #1 and #2, respectively. A real laugher in retrospect, right? But at the time it probably didn't seem crazy. To cite the US example, it would have been easy to spot many advantages: everything from few land borders (US has two: China has 14) to enormous wealth; a huge array of powerful and well-resourced subnational governments; a large number of world-leading medical research facilities; the world's biggest and most advanced biopharma sector; highly experienced officials and government scientists (the CDC is who other countries used to call when they had a problem to sort out); and so on.
But what WHO didn't count on was the fact that half the damn population in the US would be at war with science and reality by 2020 (in other words no willingness to take actual, science-based steps to fight a pandemic). And if a nation's people are unwilling to get their act together, said nation lacks the ability to successfully respond. Again, a distinction without a difference (at least not a very meaningful difference).
Nordic countries did well for some mysterious reason that I don't think we yet understand.
Affluence tends to be good for health outcomes. Both because wealthier people tend to be healthier to begin with, but also because wealth enables a more effective healthcare sector. We see this even in the US: a number of affluent states were hard-hit in the beginning due to dumb luck, but they've all tended to do better since those dark days, and, last time I looked, covid mortality in the US is now mostly dominated by the poorest states.
Nordic affluence in particular isn't only characterized by highish incomes, productivity, etc, but also by the absence of low incomes and poverty (post tax-transfer). Poor people are more vulnerable, all things equal, to a host of health problems. So having fewer of them in your population seems likely to show up in the pandemic statistics.
There is a noticeable missing country in the Nordic discussion and chart, and that is Sweden. Looking at WHO data, the cumulative COVID death rate by the end of April, 2021 was 1,264 or well above their Nordic peers. I believe Sweden, at least initially, took a hands-off approach to preventing COVID spread and that might account for why their death rate was 5 times neighboring Norway and Finland.
In the end, though, Sweden and Norway arrived at close to the same place. Sweden got hit hard and fast, although not enough so it overwhelmed their infrastructure, and then slowed down dramatically. Norway had a slower, steadier accumulation. I think they ended up at something like 15.5/100K while Sweden ended up at 17.
I don't know where you're getting your numbers. At the NY Times,
deaths per 100k for the entire pandemic:
Sweden 220
Finland 153
Denmark 136
Norway 93
Looks to me like Sweden did poorly compared to its Nordic neighbors.
Mysterious reasons?!
From a song...
The ordinary will ignore
Whatever they cannot explain
As if - nothing ever happened
And everything remained the same again
It's about community and its importance in the heart of the individual.
During the epidemic my son traveled a few times to Japan. He needed negative tests before leaving (within 72 hrs of departure) for a while a negative test was also done at the airport on arrival. For a while he was also required to stay for a week or two at a hotel near the airport under the supervision of Japan’s health authority, in isolation before being allowed entry after yet another negative test. Another time he was allowed to go to accommodation in Tokyo after negative test on arrival but had to largely avoid public spaced (monitored by daily call and web-app locator). And all the time in Japan he and everyone else wore masks. On his return to the U.S., aside from the test before leaving there were no precautions or enforced isolations.
Yes they took it seriously. Not sure whether SARS had anything to do with it. And yes their economy was largely open for the entire period of the epidemic.
Do the poor people in wealthy countries do as badly as the people in poor countries, such that they should be separated in statistics like this as a separate country?
Its hard to separate preparedness from intervention. You can have the best preparations imaginable, but if you dont carry them out well or in a timely manner then that preparedness doesnt matter. We actually had OK preparedness to make the vaccines but there was little effort on distribution. Anyway, I think they mostly ended up looking at effects of interventions or no interventions.
I have some issues with the GHS, but I think this is a good first attempt. There is clearly, I think, a lot fo preparation that is obvious that could have been done, but overall I dont think we know what we should most value for preparation. Unfortunately it may come down to having the best possible people in position to respond.
Steve
Amplifying the signal of dodgy personages seems to be a thing with Kevin, especially those contrarian types who have the bestest reasons for why Libertarianism plus Capitalism is the bestest social arrangement evah! I'll believe there is something to this analysis when somebody other than Alex Tabarrok comes up with the same conclusions as this 'study'. Not before.
P. S. - Yes, of course that means I didn't bother to read the paper cited before dismissing it out of hand and no that's not unfair. I don't take much account of Tabarrok for the same reason I dismiss the likes of Cowen, DeLong et. al. as lightweights who put out far too much garbage to make it worth trawling through for real but extremely infrequent insites.
Economics department at George Mason University. 😐
Yeah, there's that of course. But I come by my disdain honestly; I thought these guys were stumblebums at best, transparent, dishonest hacks at worst long before I knew their affiliation. For some reason, there were -- and still are -- plenty of people like Kevin who I generally have a good opinion of, but will nevertheless regularly promote the output of ever-so 'contrarian' dunderheads.
To be honest, I've never had much patience with The Earth is Flat type of contrarianism. I remember one time when an NPR celebrant (Could have been James Surowieki himself) was giving a wisdom of the crowds type of explanation to the interviewer and yelling at the radio "That's not the way it works, Dumbass!" At which point my partner looked up and suggested that be the title of my new book 🙂
The economics department at George Mason University has gotten tons of funding from the Kochs. No wonder they lean toward libertarian economic theory.
I was gobsmacked when I recently read this article about the obscure but very influential right wing economist James Buchanan. George Mason now houses the Center for Public Choice which is based on Buchanan’s extremist ideas. For example Buchanan and his acolytes really believe that “ people who “failed to foresee and save money for their future needs” are to be treated, as Buchanan put it, “as subordinate members of the species, akin to…animals who are dependent.’”
https://www.ineteconomics.org/perspectives/blog/meet-the-economist-behind-the-one-percents-stealth-takeover-of-america
Are these numbers age-adjusted? If not that's a big problem. Rich countries are generally older, and age is so large a COVID risk factor it's basically the only factor that matters. You'll mistakenly think rich countries did worse than they did if you don't age-adjust.
Good question, but China and especially Japan are "old" countries.
But both were off the charts in terms of lock down response compared to most of the rest of the developed world. Japanese wear masks and sanitize everything even when there isn't a pandemic happening.
And now China has out-of-control spread of Covid. I wonder if Xi actually wants to reduce the number of older citizens given his reluctance to promote the use of effective vaccines.
Great point.
Imagine the paper concluding that prevention measures at preschools were far superior to those taken at assisted living facilities. Just look at the death counts!
Age is probably the single biggest reason why a rich country like Italy had a higher death rate than say Kenya.
Yeah - mortality rates seem to be a function of age and obesity, largely. Measures of "preparedness" or "healthcare spending" or "John-Wayne-ness"? Idk.
As I have been saying, the Southeast Asian countries, including Australia and New Zealand (not shown on Kevin's graph), have had much lower death rates, presumably because they either isolated geographically or with strict in-country isolation and tracing, until the majority of the population was vaccinated. After these countries opened up, they had very high infection rates, but comparatively low death rates. It is possible that China will also be like this, although it remains to be seen how effective their vaccinations were and whether they really got everybody vaccinated (the reported numbers claim they did).
So if this interpretation is correct, the proper preparation is in getting vaccination and isolation and tracing set up beforehand, not so much in having treatment facilities for the severely ill. Those countries apparently avoided the waves of really bad infections that most other countries had, including the US. In the US getting ready would also involve convincing millions of yahoos that they should mask and get vaccinated, which is apparently impossible.
The Nordic countries are still a mystery.
The US has the obesity problem worse than most too. That seems to be a "huge" factor. My guess is that a combination of less obesity, more mask wearing, better diet, more activity, and warmer climates makes a lot of difference. In warmer places that are poor people leave windows open, so better ventilation.
The claim about Nordic countries doing well is achieved solely by pretending sweden doesn't exist. So yes, if you leave out 1/4 of the nordic countries you can make preposterous claims look reasonable. And note how the graph claims germany is a small rich country. And mexico is a large rich country. Mexico is certainly large, but rich? Not so much.
The claim about Nordic countries doing well is achieved solely by pretending sweden doesn't exist
Not sure what your point is. Just an issue with the semantics?
If we change the statement to "four of the five Nordic nations did much better than the USA" it seems valid (or five of six if you include Greenland).
I think it's widely concluded that these countries have some advantages over the US that helped them deal with the pandemic (higher trust in government; more social cohesion; less economic inequality; effective public health services backed up by universal coverage; etc), and, critically, they generally weren't run by lunatics the way the US was in 2020.
As for the example of Sweden, well, they went for a "bend the curve" approach that squandered their advantages to a certain extent, and therefore got the worst results in the region. But results that are still (at this point) quite a bit better than the USA's in terms of covid morality.
(Our friend the Swedish troll used to insist Sweden's underperformance was something to do with the timing of school vacations and Swedes' love of Alpine ski resorts, and, while that doesn't seem to be the main explicator he would insist, this factor likely does have some effect, too.)
I guess the bottom line is: the Nordic region did well wrt to the pandemic compared to many rich countries—and a lot better than the US—but Sweden's the regional laggard. Fair?
Sweden has had the lowest excess deaths in Europe the past three years and that is a much better measure of success than Covid deaths per million since Sweden started out with more weak elderly due to a mild flu season in 2019.
The Norwegian health department concluded in May 2020 that its lockdown failed to slow the spread of Covid so other factors must have played a role in its Covid death rate being lower than Sweden. The top two are Norwegians weren't skiing in Italy nearly as much as Swedes because they had different school holiday weeks. Also important, Norwegian longterm care homes are much smaller and better run than those in Sweden.
Japan and South Korea have much fewer Covid deaths because 1) they have 4% obese and almost no one morbidly obese. being a bit obese rarely killed, but hugely obese could.
Masks did nothing in Japan and South Korea.
All Asian countries have had much narrower definitions of what constitutes a Covid death than the West.
As somebody else pointed out, is this age-adjusted?
What about vaccine-rate-adjusted? I can't help but look at that first graph and see two large countries highlighted (Russia and Brazil) which recently or still have far-right governments. Brazil has a good vaccination rate, but Russia doesn't. What are the other countries in that cluster of outliers? Without those, that regression line is going to be slightly downward-sloping.
I'd also question including every country that's included there. There's a reason OECD/non-OECD countries (or other categorizations) are typically used for a comparison among groups. Yes, it's measuring healthcare system capacity, but it's not measuring quality of capacity whatsoever.
Like ScentOfViolets, I'm dismissing this as contrarian bullshit.
Oh FFS, READ THE STUDY.
No.
How in the world does the USA rate in the first chart as having the greatest "ability of the health sector to treat the sick"? Is this based on spending per capita? If so, the author needs to consider that the US healthcare system is the world's least efficient.
Maybe the axis is misnamed. Is there an explanation buried in the report?
I noticed that, too. A large degree of skepticism is warranted here.
How in the world does the USA rate in the first chart as having the greatest "ability of the health sector to treat the sick"?
Occam's razor: the author was drunk.
The graph itself is labeled "Capacity", so presumably they're looking at beds per population. Which is a ridiculous proxy for quality.
From the last graph, it seems Germany is a small rich country and Belgium is a large rich country. Huh.
exceptions to prove the rule?
Kevin's circles--and rather broad descriptions...
I think this study misses the point of "preparedness" for a pandemic. Why compare results AFTER every country has relaxed their preparedness? What matters is how well countries respond to the pandemic during the period when the its population actually thinks they should be responding. COVID, for all the deaths, is a comparatively mild pandemic. Of course people were going to relax eventually. A pandemic with a much more virulent disease is what we are gearing the preparedness towards.
I seem to recall that at the start of the pandemic pundits near and far were frequently and vociferously decrying lack of preparedness. Was that then all just so much hot air?
It seems that about all you can do at the hospital level is: (1) have well equipped infectious disease wards with lots of staff and equipment like respirators, (2) an ENORMOUS supply of PPD because hospitals go through that faster than Russia does artillery ammo, and (3) good prophylactic drugs and vaccines which is more of a societal level of preparedness rather than individual hospital level.
Otherwise it is just administrative stuff like redeploying staff and resources from discretionary care to pandemic care.
Before the pandemic, the US was the "best in the world". After it started--oops.
Funding for pandemic preparedness faded and there was a shift to terrorist attacks...so focus on small pox, weaponized bacteria, etc. It was meant that stockpiles were now national security and kept secret--so no investigative journalism. Funding then fell off for that too as perceived threat changed.
We still have some capacity left to open up more hospital beds--but were left struggling to find qualified people. The fact that the initial wave was localized helped.
I wonder if the first chart reflects that less inherently healthy people are alive in countries with better heath systems? Maybe someone with asthma is still living in the US where they might have died in Egypt?
So, let me get this straight: A libertarian twit does a 'study' wherein he finds that the the stuff he doesn't like government doing -- mandated masking, school and business shutdowns, quarantines -- has no effect on covid mortality stats. And contrariwise, the stuff he does like government doing -- spending taxpayer dollars on public research that is given gratis to various and sundry business entities for their private profit -- has a positive effect on covid mortality stats. Who'da thunk?
In other news, water is wet.
Remember....
Before Covid, the US was thought to be the best in pandemic preparation.
The problems, however, were many....
1. Stockpiles were out of day and/or dry rotted to a large extent.
2. IF there was a real problem, we could just order more stuff fro China--which most other high income countries planned to do too.
3. Little excess/standby manufacturing capacity for PPE.
4. Pretend the next major outbreak will be a flu--so vaccines will be ready in 6 months and we don't have to worry about long term issues.
South Korea's response to SARS was to design an N95 type mask that was effective and one that people would wear. We didn't.
It's hard to take seriously anything from anyone whose first graph has the US having the best healthcare system in the world. In reality, it is by far the worst in the developed world. Nothing the certifiable imbeciles who produced that first graph should ever be taken seriously.
" Richer, more competent countries had more excess deaths than poorer countries." this is actually logical as richer countries have a substantially older population, and covid killed older people. This graph could be fixed by normalizing by total annualized deaths, i.e. excess deaths as a percentage of normal deaths rather than per capita.
Another Tabarrok skeptic here. My favorite bit of Tabarrok stupidity is the post he wrote advocating for fewer firefighters and fire stations, because deaths and economic losses from fire are down substantially. Pretty much every commenter pointed out that the crucial factor in firefighting is quick response, so as metro areas sprawl out, more fire stations need to be built and staffed in the second- and third-ring suburbs and the exurbs, close to where people are actually living.
So I didn’t read the article. The study seems to me to be wrongly designed from the start. If you were really interested in how to prepare for a pandemic, you would notice that many countries in the Asia/Pacific region had death rates far below the US and many European countries. You would then look at the differences in their preparations and responsive actions. I recall a report that Taiwan had an action plan of some sixty-odd items, which they promptly implemented (It was based on their experience with SARS).
Also: if you think it’s legit to draw sweeping conclusions from a single pandemic, then it is OK to conclude that the virtual disappearance of influenza during the two worst Covid years demonstrates the effectiveness of masking, distancing, etc.
Of course if you have an ideological axe to grind, you do a study like this one …
You'd think people like Tabarrok would be self-aware enough and canny enough to at least fake a good piece of academic research to keep their detractors guessing. But no, they have to live their identities by publishing drivel of which this latest is sadly representative. These are sad people.