Good news, everyone! Andrew Cuomo has resigned, and Andrew Cuomo is the worst.
I will damn well take it, because it’s not like he doesn’t also deserve to resign in disgrace for the stuff that officially got him, and again, also to say it for what is hopefully one last time, Andrew Cuomo Is The Worst. Hence, The Worst Is Over. Sing it high, sing it low. (HT: Meme source)
The title this week does not as reliably or fully refer to the Delta variant or the Covid-19 pandemic. Things are still steadily getting worse. But the turning point is plausibly in sight, as case growth slows, and I doubt we have more than one doubling left before things peak.
Main event this week was continued arguments over mandates, both for vaccines and for masks and other NPIs. I’m making one last attempt this week to explain my reasoning on vaccination mandates, as I continue to get people disagreeing for a variety of reasons, and disambiguating the disagreements seems worthwhile; I tested it out in the comments last week and it seemed productive.
Let’s run the numbers.
Prediction from last week: 855,000 cases (+45%) and 4,100 deaths (+40%).
Result: 744k cases (+26%) and 3,725 deaths (+29%).
The case numbers are very encouraging. They’re still increasing, and there’s always the chance this was a data fluctuation that will be actively undone, but it probably wasn’t and represents either the control system kicking in or us nearing a natural peak. I still expect a similar increase next week, but I’d estimate a 35% chance that within two weeks we get about as high case counts as we’re going to see in this wave, and 55% it happens within three weeks.
I’m still predicting a +35% rise in deaths, as the cases from the last few weeks make their way through the system, and hope to be pleasantly surprised.
Prediction for next week: 900k cases (+21%) and 5,028 deaths (+35%).
Deaths and Cases
Grouping these together, because there’s a combined mystery to solve.
Here’s the case numbers.
|Jun 17-Jun 23||23,854||12,801||26,456||6,464||69,575|
|Jun 24-Jun 30||23,246||14,521||31,773||6,388||75,928|
|Jul 1-Jul 7||27,413||17,460||40,031||7,065||91,969|
|Jul 8-Jul 14||45,338||27,544||68,129||11,368||152,379|
|Jul 15-Jul 21||65,913||39,634||116,933||19,076||241,556|
|Jul 22-Jul 28||94,429||60,502||205,992||31,073||391,996|
|Jul 29-Aug 4||131,197||86,394||323,063||48,773||589,427|
|Aug 5-Aug 11||157,553||110,978||409,184||66,686||744,401|
This is a substantial slowdown in new cases, cutting the growth rate in half. We might be peaking within a week or two.
Here’s the death numbers.
|Jun 24-Jun 30||550||459||706||186||1901|
|Jul 1-Jul 7||459||329||612||128||1528|
|Jul 8-Jul 14||532||398||689||145||1764|
|Jul 15-Jul 21||434||341||732||170||1677|
|Jul 22-Jul 28||491||385||1009||157||2042|
|Jul 29-Aug 4||693||477||1415||304||2889|
|Aug 5-Aug 11||705||605||2181||234||3725|
(Note: California reported -352 deaths yesterday, I changed that number to 0. Last week Delaware dumped 124 deaths on us, presumably a backlog, which is why the NE number last week was so high. I’m choosing not to correct for that for now but might smooth it back for next week as it is potentially importantly misleading.)
The death number was modestly better than I predicted, but definitely not good. This NYMag article (sorry about linking to Topol so often, world is strangely small) highlights the negative perspective of the American death rates not dropping this wave the way they did in other countries. Yes, the CFR is down a lot, but the bulk of that is lag due to cases rising so rapidly. If you undo the lag, you see something else…
[Lagged = cases from 3 weeks ago. Lagged and averaged = cases from 0.1*(1 week ago) + 0.2*(2 weeks ago) + 0.5*(3 weeks ago)+ 0.2*(4 weeks ago)+ 0.1*(5 weeks ago)], chosen quickly to be not crazy]
At the very beginning the CFR was much higher, but once we got adequate testing and reasonable care, things haven’t changed much on this chart. This is not at all what we see in the UK, where the CFR is clearly down a lot.
The uptick at the end represents the UK having declining case counts, rather than a higher death rate. The Netherlands looks similar to the UK but made the graph hard to read.
A simple theory is it has a lot to do with this, the positive test rate:
We went from 2% positive tests to 15% positive tests, which indicates our testing is not keeping pace with our cases. In fact, it’s not keeping pace at all?
Seriously, what the hell, people? It’s one thing to not keep pace, it’s another thing to be testing less now than we were when cases were at their lows. That means that, conditional on not having Covid, the chances of a given person getting tested have gone down a lot, despite their reasons to worry they have Covid having gone way up. Much higher chance they have a known contact with someone positive, and much higher background danger.
One possibility is that people are now increasingly using at-home tests first. We did this last week, when our four year old had a cough and we were asked to exercise an abundance of caution – it was annoying to stick that thing up his nose for a while, but it was cheap and quick, and got the job done. Whereas when we looked into getting a non-rapid non-home test, it was clearly going to be a pain in the ass to get. One of my friends posted a similar experience, where she couldn’t get her child tested for several days unless she got a test at a pharmacy. Both of us got negative results, and neither result counts in the charts above. If one of them had come back positive, it’s not clear how often that would have made it into our statistics either. If there was no need to escalate to official medical care, there’s no default mechanism to get those results into the statistics.
Whether or not that’s the main mechanism, I am confident that a large majority of cases, especially asymptomatic or mild cases, are being missed entirely by the system. The true IFR likely has not dropped here quite as much as in other places, but our vaccination rates are not that much lower and our medical care is quite good and holding firm, so it’s likely falling almost as fast here as elsewhere. Our CFR staying high says more about our rate of case detection than it does anything else.
In some ways, this undercounting of cases is very good news, as it puts an upper bound on how bad the pandemic can get and moves us more rapidly towards the turning point. In terms of hopes for containment, however, it’s very bad news. If cases have grown much more rapidly than our numbers naively indicate, then our hopes for containing this in a meaningful way, rather than waiting for enough people to get Covid that things die down afterwards, are much worse.
Here’s Zeynep, on point as always, on vaccine hesitancy and the reasons behind it, which are far more reasonable than they’re usually made out to be.
Also, it turns out that having a Bachelor’s or Masters makes you very likely to be vaccinated, but if you go on to get a PhD, you’re now in the least vaccinated group of all.
This week’s thread on relative infectiousness of the vaccinated versus the unvaccinated. As you would expect, when you do random population samples, you find lower average viral loads in vaccinated people.
Also, perhaps we could try publicizing this more? Ask 24 out of 25 doctors if vaccination is right for you? Maybe take the crosstab of Republican doctors which is presumably still over 90%? Playing to win the game takes many forms.
Baltimore’s anti-Covid ad posters. No idea if they’re effective but at least they’re playing.
This seems to me like it should be a rather large scandal. If people in Alabama don’t want the vaccine, and it’s going to expire, then it’s imperative to recognize that and send it elsewhere where people do want it. Worst case, you cycle out old vaccine to places cycling through what they have, and then move in new shipments so there’s still stock around when and if people change their minds. Also, ‘expired’ vaccines might not be good enough for us, but they doubtless mostly still work, so I’d still send ‘em off to whoever wants them.
Yet I see almost no discussion of such matters. Shame!
The Isreali can’t do but therefore do what you can spirit:
And the can’t get paid enough spirit, I too blame capitalism for all these vaccines:
Nate Silver broke down people’s current stance on Covid into a categories, and I think this is mostly accurate:
Jacob offers an alternative theory of Group A:
My guess is this is indeed a substantial percentage of Group A, but I’d be rather shocked if it was anything like a majority.
One thing we can do is compare this to last week’s survey results on mandates, which found that 62% favored the maximally coercive policy of a universal vaccine requirement. That would roughly be Groups A+B, which is 55%, and some of Group C1, then only C2 and some of C1 are vaccinated but don’t then favor a full mandate on others.
There aren’t that many people in the daylight between ‘willing to get vaccinated myself’ and, well, this:
I’d like to take one more stab at addressing various arguments against vaccine mandates, explain my perspective on it, and then move on to what’s actually happening.
There are a bunch of different arguments against vaccine mandates, and it seems the only one that convinces a lot of people is the argument that (A) one shouldn’t take the vaccine, presumably (I’d hope, anyway) with the implication that the vaccine also shouldn’t be mandatory.
(B) would be that bodily autonomy is super important, and thus vaccinations are in a different class from things like masks and lockdowns, and either (B1) allowing this is an escalation of authoritarianism, and will greatly expand authoritarian power and perception and lead to tyranny and/or (B2) this is going to piss a lot of people off, destroy their dignity, is generally bad on object level, and so on. And the claim that (B3) an employer mandate is authoritarianism and against freedom, as opposed to all the other things jobs require, and thus we should suspend freedom of contract or punish those who use it in this way.
So basically not buying into arguments like this:
There’s a lot of vocal support for both of these, both in my comments and in general. I’m sympathetic to these types of arguments, but not convinced, because mandating vaccinations to stop infectious disease has correctly been standard procedure for a while, and such precautions as a condition of employment or close physical proximity to many others are exactly how free people react to such situations. And if the choice is between ‘no indoor dining (or other X) for anyone’ and ‘no indoor dining (or other X) for the unvaccinated’ I know which one I’m choosing, and which one leaves me more free.
There was a lot of talk earlier worrying about tracking, but we’ve moved past vaccine passports and people just flash their cards, so that’s not a concern, and also a common alternative is ‘contact tracing’ which involves keeping a lot of records of exactly the type we’d worry about. Instead the concern here is the flip side of that, which is that (C) vaccine cards are easy to fake. That’s true, but also there’s a central database that knows the answer that already exists. I’d rather not push people to lie and commit fraud, but this doesn’t seem like that big a concern here.
A real concern is that (D) they got this one right, vaccines happen to be safe and effective, but it’s not clear that we wouldn’t be in a similar position in the future where the thing in question wasn’t safe and/or wasn’t effective. In this case, I actually don’t think this is true. I think both that the vaccines are safe and effective based on the evidence, and also that if the evidence did not strongly say they were safe and effective, we wouldn’t be contemplating such policies. The level of pushback we have now is when, scientifically, the case is overwhelming, and if the vaccines were instead not safe but still much safer than not getting vaccinated, we’d not only not make them mandatory, they’d be forbidden. We ran that experiment.
Finally, there’s (E) that more vaccinations won’t change the path of the pandemic at this point, so why are we bothering, choices have consequences, the unvaccinated will get sick but the vaccinated will mostly be fine, so all we’ll be out are a few medical bills (which will effectively get socialized, because insurance can’t discriminate and if you don’t have insurance mostly the government pays). I don’t buy this, there are a bunch of immunocompromised people, even for vaccinated people getting Covid is worth avoiding, and in practice if there’s lots of Covid out there the result will be lots of lost living of life.
Another disagreement I’ve found is (F) the idea that an individual is only responsible (in various senses) for either literally themselves, or only those who that individual infects directly, rather than the marginal cost being every infection that results from your actions that wouldn’t have otherwise happened (there’s a control system, and some people would have gotten infected later anyway).
Finally, there’s (G) that the mandates are covering people who already had Covid and thus don’t require vaccination. There’s the counter argument that vaccines are more effective than immunity from prior infection, but antibody tests could check and even worst case I doubt prior infection is that much less effective than J&J which we consider to fully count after one shot despite it not making much logical sense. I don’t find that convincing. I also don’t think the evidence that vaccination after infection is still worthwhile makes this sufficiently effective to convince me either, although it’s still a substantial additional reduction and I personally would still get the shot. What I do find convincing is that lots of people are wrong about whether they’ve had Covid, or would fool themselves or lie about it, and thus there’s no reasonable way to make this (otherwise correct) exception short of getting a confirmed antibody test, and the complexity costs and messaging and such involved make it not worth it. Sometimes you gotta suck up stupid things in the name of simplicity, but of course if anyone does want to make such exceptions that seems totally fine.
The high correlation of positions on all these points is, of course, both expected and suspicious, on all sides including my own.
Other times, incentives matter, and people enjoy using hyperbolic language. I don’t really know what he was expecting.
One cost of lack of vaccination is putting more strain on the hospital system, as they once again are forced to cancel elective surgeries, thus reallocating medical care from those who need it because life to those who need it because they are unvaccinated. The cost here is not purely monetary.
In conclusion, I’m strongly in favor of employer mandates, and on imposing the kinds of restrictions we’d otherwise impose on everyone (e.g. travel, indoor dining and so on) only on the unvaccinated, although of course we should be smart about it, and I’m happy that so far no one I’ve seen is suggesting excluding the unvaccianted from beaches or playgrounds.
I’m definitely in favor of letting gyms mandate vaccinations rather than masks, as opposed to being required by law to mandate masks instead as they are in Washington DC.
For now, lack of FDA approval is holding many mandates back, even as increasingly many go forward anyway.
If I knew the FDA was going to get this done in a few weeks, I’d be inclined to announce new restrictions but make them conditional on full FDA approval, so as to benefit from the cover that will provide and give them that much more of a nudge to hurry. Alas, while I hold out hope for it, I currently have no faith in that timeline, and we don’t need them to tell us what we already know.
I now consider that out of the way, and won’t be discussing it further unless something changes. So, what are this week’s new mandates?
Here’s an interesting local one that turns out not to be the full corporate policy, and a reminder that this is how attention works on the internet, and it looks like about one out of every thousand people who saw the original post saw the clarification that it wasn’t the whole chain.
CNN’s mandate showed it has teeth. Which is how it has to be. Once you have a mandate, for many reasons it needs to be properly enforced.
Meanwhile, the question as always with children is, should we forbid vaccinations as horribly unsafe, or should we stop doing that and turn on a dime to mandate them outright, with not vaccinating as horribly dangerous?
Yelp is doing something interesting, which is that you can search restaurants by ‘All Staff Fully Vaccinated’ and by ‘Proof of Vaccination Required.’ I verified this, while also noticing that Yelp’s rating sorting algorithm leaves something to be desired (e.g. having a 5-star average on 2 reviews seemingly puts you in the top 10 for all of NYC, whoops). This is sufficiently cool that I’m going to play around a bit more with Yelp, since I’m working on my list of places to go in NYC once I get back anyway.
The San Francisco Sheriff’s Deputy warns that when the full vaccine mandate is imposed, officers will quit en masse, whereas they wouldn’t if they only had to have a swab up their nose every week instead like the state suggests:
I wonder if this is a place where approximately zero people would be sad to see many of those 160 deputies go. The blue tribe locals are anti-police and will see these as bad actors and even outgroup members, and be happy to see them go. The red tribe will see this as the latest talking point in what they see as SF’s descent into crime and anarchy. The rest of us find out how many officers actually quit, which will be great data. Everybody wins?
In contrast to NYC’s teachers, the head of the American Federation of Teachers came out strongly in favor of a mandate.
France implements its Health Pass requirements with little fanfare, despite weeks of protests (WaPo). Sounds right.
Think of the Children
The request here comes from the American Academy of Pediatrics, representing 67,000 physicians.
It is quite the rebuke. Well said. When concerned physicians tell you to stop demanding so much child safety data and Get On With It, that is the opposite of the mistake they are most likely to make, and thus this is strong evidence that a lot more Getting On With It is urgently needed.
This thread points out the obvious, which is that anything picked up in the large sample, that wouldn’t have been picked up by the small sample, wouldn’t be big enough to make the vaccine not worth taking. Thus, the bigger sample is actively worse, because it is capable of finding rare effects that would scare either regular people into declining or scare the FDA into not approving, and such decisions would almost always be mistakes.
When tackling the question of schools, if you are going to take the position that children are at sufficient risk from Covid that they can’t be put into rooms together with one adult, one should notice it’s strange to also forbid them from being vaccinated, and it’s heartening to find advocates that at least realizes that much (and of course wants to go directly from forbidden to mandatory, as I am confident we will do for children).
So at least there’s that. Of course, this is in the world where even fully vaccinated children can’t safely be put into the same room without masks.
I’m also happy to see air quality mentioned as a key issue (as a reminder, air quality improvement in schools would be urgently necessary and worthwhile even if it didn’t matter for Covid or the moment to moment experience of breathing the air). The core of the argument, later in the thread, is the risk of Long Covid. You have to raise the specter of Long Covid when talking about children, since the risk of anything else is clearly not worth worrying about even without vaccinations, and here the proposal is to worry about it even after vaccinations.
As usual, the procedure in this thread was to gather together every possible symptom, of any severity, and any duration longer than a few weeks, that happens after someone has Covid (and that may or may not actually have anything to do with Covid) and count them all as Long Covid together, with no attempt to quantity what it means for someone if they get it. Also without any practical plan for how long proposals to avoid it might last or under what conditions they would be willing to stop using them.
The New York Times was also its usual self and did its best scare piece on Long Covid in children, but it’s only one of a chorus of such claims. That doesn’t mean Long Covid isn’t real, it’s clearly a thing and the primary risk factor for younger people, but it must be kept in perspective. Here’s a thread pushing back, and the related post from Gaffney:
It could be worse, and usually is. The standard line is that Delta is even more dangerous for children because they have a higher percentage of infections, hospitalizations and deaths than they did previously. Which is absolutely true, and can be explained by the fact that they’re mostly not vaccinated.
From post in question, ya don’t say, might I suggest something we might do about that?
This CNN post is similar and typical. It cites increases in cases in children similar to increases in cases overall, then has to explain why anyone should care. Its first reason is that this is critical to keeping them in school, because if we don’t protect kids from Covid then we’ll have to take them out to protect kids from Covid, and then we’ll be forced to detain them at home instead. The second justification is that the kids might spawn new variants, which is technically true but seriously, come on. Then they hold up the specter of MIS-C, with a total of 4,196 cases, which is at least a specific issue rather than generic Long Covid, but again, math.
Meanwhile, if you took Remote Schooling, treated it and its side effects as a pandemic, and ask what would happen if it was spreading across the country, I think the answer is full Australia-style stay-in-your-house lockdowns as needed.
I do get that this is now a strange position to be in, and if you’re deciding on school policies independent of the FDA, you’re in the same position you’d be in if this was a wait on manufacturing and distribution instead of regulatory approval – the kids will be vaccinated, but can’t be now, and the fact that other people could change that if they wanted to does not give you that option. And if there are enough cases you will be forced to go to remote learning no matter what you know about its consequences.
Tyler Cowen asks how many children are killed by school anyway.
As for how many are killed by Covid-19.
That could maybe change by an order of magnitude before it’s all over, but that’s an upper bound.
From an excellent post about the question of what to do for kids who it is illegal to vaccinate, here’s a chart of what happens if they do get Covid.
That death risk is consistent with what I had, and for those under 12 it will be lower still. I’m skeptical of the 1 in 50 line, but the word ‘any’ does strong work in such situations, so… maybe?
Long Covid is real and important, but so is Long School. Most people I know are permanently traumatized by it, many people have nightmares about it, and so on. Suicide attempts drop dramatically for young children when school is out, in a way that suicides of older people don’t. It doesn’t end when you’re allowed to leave. There’s also Long Vehicle Accidents, Long Suicide Attempts, Long Cancer, Long Drowning and so on, as one might expect.
We do the same thing with school shootings, where we force kids to take place in ‘live shooter drills’ and scare kids so much that they expect a school shooting to happen around them, whereas such things are exceedingly rare, schools don’t have more of them than the rest of life and the damage done by scaring everyone is orders of magnitude the bigger concern (and is probably doing far more to give kids ideas and causing such events than it is to prevent anything, if I had to guess).
One could also compare the moral panics over ‘stranger danger’ to the fact that most kidnappings of children are by family members, and most abuse is by people they know well.
The problem, in all these cases, is that some threats are put in a special category where any bad events are unacceptable, whereas other things are part of life, such as getting lots of people into close proximity in this thing we call a ‘city.’
Kids are not in a good place right now. We’ve disrupted their lives and kept them socially isolated for over a year. Making their new school year largely about Covid, and forcing them behind masks, will make things that much worse.
I am thrilled to see that lots of parents intend to home school their children for the coming school year. In-person school is bad enough, but choosing remote learning over home school is a true tragedy, either of misunderstanding the situation and/or a lack of sufficient resources to deal with the necessary obstructions, paperwork and actual educational efforts required. My heart goes out to anyone who knows and simply can’t do it.
At some point we will need to learn to live with Covid, or make an extraordinary effort to somehow live without it by vaccinating everyone and then moving on. Or we could doom ourselves to a young adult dystopia in yet another way, the same way kids are no longer allowed to play outside and are told not to talk to strangers and pretend periodically to hide from gunmen roaming the building, plus whatever you consider a baseline ‘school’. That’s also an option.
Mask and Testing Mandates
There’s an old improv game called standing, sitting, bending. May I present a new one: Eating, drinking, dancing:
Ministry of Truth
Even when the actual implementation in a given example seems fine, it’s important to focus on the reasoning, for this tells you what the ministry is looking to do next.
Facebook’s War on Supposed Misinformation continues, and has produced the following ‘fact check’ of ‘misinformation.’ I wouldn’t be focusing on Something Wrong On The Internet, except this type of ‘fact checking’ from this exact source is being used to censor Facebook and Instagram. Although in this case, the post wasn’t censored, merely given a warning label (and one assumes also a massive Streisand Effect), that’s not always the case.
The Covid survival rate is clearly over 99%, by the CDC’s own estimates. The CFR is 1.7% and the CDC conservatively estimates half of infections have been missed – I’m guessing there are at least twice as many as that, perhaps more.
Saying this is known to not have a CFR under 1%, as your headline that is then quoted around, or that survivability is known to not be over 99%, is blatant lying and scaremongering.
What’s this all about?
It’s about the new definition of misinformation, which as far as I can tell is information used to lead to a conclusion we don’t like.
The fact check admits that the data comes from CDC modeling estimates, and then uses those best guesses as best guesses. But because you can’t prove those are the correct numbers, and the conclusion is one they don’t like, the ‘fact checker’ thus concludes the claim is ‘false.’
What’s funny is that the exact claim being evaluated I too think is actually false. I’ll get to that later. But that’s not a fact that’s correlated with any of their reasoning.
There’s so many different things dangerously wrong here.
- Unproven or unknown does not equal false, and by a sufficiently strong standard we “know” almost nothing, paging various philosophers. And by this standard, since I can choose not to offer proof, I can get them to say (almost?) anything is false, and thus by flipping the sign say almost anything is true, provided it serves their purposes. Neat trick.
- Using the CDC’s numbers from their modeling is an excellent source of reasonable approximations. It comes (as per the fact check post!) directly from the CDC and is being used to predict things, so it’s a forward-looking estimation. When I disagree with such assessments because I think I know better than the CDC, which I do here, that’s because I’m the arrogant one who thinks he’s better than the CDC, not the other way around.
- The general survival rate for Covid is clearly over 99% as discussed above via the CDC’s own estimate of the true case count. That doesn’t then automatically extend to ‘most age groups’ which is why I end up thinking the claim as categorized by the fact checker is false, but that’s not how the original post categorized anything, so the actual disagreement is over exact numbers for particular age groups.
- Evidence that isn’t of the correct form or from the correct source (even within exactly the correct overall source, the CDC) is being selectively dismissed when it doesn’t suit them, which makes it easy to find a ‘lack of sufficient evidence’ to find something to be false.
- They do not cite what numbers they do believe, or any evidence for or against any numbers whatsoever except a general FUD about believing any numbers at all.
- Up front they are clear why they are doing this – it’s because the claim is being made in order to minimize the importance of vaccination. The fact is a soldier for the wrong side, ergo false.
- Again, in their conclusion, they’re judging their characterization of the central claim as false, rather than disagreeing with any particular claim or giving an alternative model.
Here’s the argument that if you have the best data available, you should ignore it, because there’s some factors it didn’t account for, and thus you should throw out all numbers and have no idea whatsoever. Which is a fully general argument against ever knowing anything at all:
This is not how knowledge works, unless you are banning forbidden knowledge due to its Unfortunate Implications. Yes, of course you should use data on how many people have survived Covid-19 to predict your own chances of surviving infection. What the hell else would you use as a starting point? And the whole idea here is to then condition that on age, which is by far the biggest risk factor, and then condition on vaccination status (where I think their 94% number is somewhat low, but it’s well within the range of Numbers Used By Official Sources To Scare People The Proper Way Depending on Context, and also not a crazy estimate, I just think defense against death is somewhat higher.)
Whereas the post is indeed taking overall estimated forward-looking numbers, then adjusting them by age, and also listing vaccine effectiveness. If one wanted completeness yes there are other factors but they’re far less important – see my graph below for my ranking of the next two in line (diabetes and obesity), and how much less important they are than age.
The advantage of telling people to throw up their hands is that you can simultaneously say vaccines are super effective and important (without specifying numbers) when telling people to get vaccinated, then turn around and tell them to be terrified of Covid afterwards anyway, even if they’re young.
Yeah, people are skeptical of authorities these days for some reason, can’t imagine why.
Next, I’m going to actually fact check the chart, since I think my estimates are better than the CDC’s estimates. Are the ratios by age here correct?
I actually think no, they’re too aggressive. Here was the result of my comorbidity work, which was pre-Delta and pre-vaccinations, and have younger people at more risk than this by an order of magnitude or so.
To compare apples to apples you should look at the All Pop column on the right, and focus on ratios between groups, and also remember that there aren’t many people over 90 when combining the top group together. With that adjustment, my conclusion is that the post above is underestimating risk to the young by about a factor of 10.
Now, let’s look at the actual post, and, huh, ok, I see it now…
(Note: That font and color scheme in the graphic is very recognizable as coming from Fox News, the outgroup’s relatively mainstream news source.)
Yeah, that’s… a very reasonable warning. This is indeed missing context and could mislead people, and the warning isn’t claiming it’s false, merely that it’s missing context. In particular, this is framed carefully to imply that the vaccine would replace the existing immune system rather than supplement it, and thus the vaccine would increase risk rather than decrease relative risk.
So in the context of the post, the label is at least understandable. It sets a bad precedent even if the written justifications for it had been relatively good, so I’d rather not do it, but certainly one can understand it, especially when combined with the numbers here being so aggressive, although the extra 9 likely doesn’t change the message here much.
As opposed to the reasoning in the justification post, which is… different.
I’ll also note that clicking on the warning doesn’t go anywhere when I tried it, which seems like a missed opportunity if one did want to communicate context.
More generally, the official reasoning remains the supremely broad claim that any disagreement with health authorities is not allowed. As we are periodically reminded, this is despite the health authorities changing their opinions over time as (A) the facts change, (B) we get better evidence and (C) they update to take into account new information and incentives and priorities. Usually their truth tracking improves over time on a given issue (and stays the same on average because they add new issues), but not always. Also you can’t contradict multiple health authorities, including the WHO who still refuse to admit Covid is airborne, and those different authorities frequently contradict each other. In the case above, the CDC’s numbers can’t be used in a way that wasn’t intended. By the standards that are being used to censor a United States senator who is raising a perfectly valid scientific hypothesis in the link earlier in this paragraph, you could censor not only at least most of my Covid posts, but almost anything remotely useful anyone might say, whether they were trying to provide useful information or trying to figure things out. If I wasn’t Against Facebook I’d probably be banned from it by now, and I’m curious to what extent they mess with those who post these weekly updates there.
Nate Silver offers some thoughts on exactly how hard it is to compare vaccinated to unvaccinated people, even in relatively ideal conditions for such comparisons.
Provincetown was the opposite of an ideal situation.
It seems very clear at this point that the Provincetown study did not mean anything like what the CDC was representing it to mean. This was a situation filled with activities that carry extreme Covid risks, among a unique and often immunocompromised population. The outlier results at most describe what happens in circumstances like that, and also fail to control for the population baselines appropriate to that situation.Despite that, there were zero deaths, only seven hospitalizations, and most vaccinated participants were not infected. The vaccines did their job. In hindsight, while I had a strong prior that the study wasn’t going to mean what the CDC was claiming, that prior wasn’t strong enough, and I gave the whole situation too much respect.
Thus, the focus shifts from the study and its claims to the actions of the CDC and media, and updating on what they did in response to this information. How much of this failure to update was due to people being afraid to point out the nature of the gathering, given today’s political climate, until enough others had done so first? Or was the narrative what everyone wanted to go with anyway, so it was too good to check regardless? Or was it that the CDC is no longer capable of reading scientific studies and analyzing data about the physical world in a reasonable way? Perhaps this was all kayfabe at the CDC and they knew exactly what they were doing, and were simply lying, and the media went along with it to show their deference to power and get clicks? Or was it something else?
Could the CDC actually be this bad at communicating about risk?
There’s being bad at talking about probability and risk, and then there’s treating everything as an absolute.
No matter what the cause, it is yet another reminder that the data all fits together into one physical world that runs with one set of physical laws and biological properties. Something that doesn’t fit and contradicts the data and results observed elsewhere must be treated with extreme skepticism, and any model must explain those other results and data points.
Vaccines work on it, J&J massive study edition, as in n=500k participants:
One J&J shot remains very good protection against death and good protection against infection and hospitalization, but not as good as two mRNA shots or one J&J plus one booster, and the logic of getting the second shot of mRNA is the same as the logic for an mRNA booster after getting J&J. Of course, if you request an mRNA booster after having had J&J, it might be tricky to get it, because the FDA and others are tying themselves up in knots denying the obvious is sufficiently obvious.
This isn’t the exact thing we most want, which is how effective the mRNA vaccines are against Delta, but it suggests only a small decline in effectiveness is likely.
Also, about the way the CDC goes about the business of gathering its data:
I would like to hold the CDC to higher standards here than I can afford to have writing these posts, but that option is not available at this time.
In Other News
What’s the difference between an EUA and full approval? Hundreds of thousands of pages of paperwork and a bunch of site inspections, among other things.
About a week and a half ago, Scott Alexander wrote a righteous post everyone should read on how horrible the FDA is and in particular how they are way, way too slow to approve drugs and also getting them approved costs eleventy billion dollars each (realistically something like 100 million). One thing that caught everyone’s attention was the infant fish oil story, where the FDA for years let children get sick and die rather than let fish oil get added to an infant formula, as he detailed in his first follow-up, then he wrote a second follow up when a critic pointed out that those involved in that story praised everyone at the FDA. Scott points out that yes, the individual people at the FDA did their jobs in this situation, but that doesn’t make it better, the system was working as designed and the design sickened and killed a bunch of babies and that’s the thing to be focused on. If anything that’s worse, if it was the people letting us down we could go fix that. He’s being careful not to outright say FDA Delenda Est, but as his alternative he’s holding them to the impossibly high standard of ‘better than the man on the street.’
I do think this concise statement of the argument goes slightly too far, but only slightly.
It’s no wonder that no one wants to be FDA commissioner:
Well, no one who counts, anyway, where one who counts would be someone without trouble getting approved. I certainly get it, in the sense that when I think of my life if I was made Commissioner of the FDA, in terms of my lived experience, oh my would it be infinitely worse. I’d happily do it anyway, because someone has to and if I don’t do it then someone else will, and also it would open doors to do additional important things after, but I have to assume it would be a nightmare.
If you’re someone who ‘you won’t have trouble getting approved’ then presumably you’re looking to run the FDA the way the FDA is traditionally run, which means someone has to but also someone else would if you didn’t, and if you’re doing it honestly it’s a giant paycut, so why take on all that trouble?
Did the NIH do better (MR)? Here’s the WSJ, here’s the full report, here’s part of MR’s summary, note the top line especially:
So, not that great, only a handful of billions while missing entirely many of the things we most need studied. The grant process isn’t working. In other distributional news, happy to see Aging get this attention, although it’s telling that it’s right behind Rare Diseases, even if they’re not in cute puppies.
Again, could be worse, you could be the WHO analysts and still, this week, be telling people Covid isn’t airborne. Delenda est indeed.
Obama had a birthday party, outdoors, with vaccinations and Covid tests required, but didn’t require masks, so naturally a bunch of Justifications are required for this living of life as if physical reality was exactly the way it is.
What happened was that Obama has a brain and occasionally thinks about physical reality, but to explain this in those terms would destroy the rest of the narrative, so what they say ends up sounding not great.
But seriously, how’s it going out there?
You can, of course, get an anecdote to say almost anything, for example “Idaho Covid ICU patients are already at an all time high” when the stats say that clearly isn’t true. Treat local reports with generous helpings of salt before generalizing.
When cancer survivor Anthony Rizzo was traded from the Cubs to the Yankees, life was proven unfair, and also there were many who noted that he was unvaccinated, which turned out to be unrelated to his cancer – he simply declined the vaccine. A few weeks later, he’s on the Covid injured list.
Israeli data seems to show that previous infection is not only highly effective at preventing reinfection, in their samples it looks even more effective than vaccination. This is the opposite of what is found in other reports, but definitely worth keeping an eye on.
Perspective on Louisiana hospitals being full. Looks like this is essentially by design and didn’t require that many Covid patients for it to happen.
You’re about to spend trillions on ‘infrastructure’ that is mostly transfer payments to people you like, to be paid for by people you don’t like, in the wake of a huge pandemic, and aside from potentially banning large areas of software development by requiring theoretically impossible tax reporting, how are we doing on spending on actual pandemic preparedness? Oh…
I’m putting this here because from time to time, it will be needed.
I finally tried Storybook Brawl this week, and it is excellent. Highly recommended to anyone who likes playing games of any kind, give it a shot, it’s already Tier 1 even though it’s in Early Access. I definitely have thoughts on it, but we’ll see when I get around to writing those down. In the meantime, great fun.
I’ve also been greatly enjoying Across the Obelisk. This is a unique roguelike deckbuilder, in that it is trying and largely succeeding at being like a lightweight D&D rather than being a lightweight Magic: The Gathering. You have a lot more control than in most such games over what your deck looks like, so it’s up to you to decide how to keep it fresh after a while, but there’s a bunch of viable options and this is great stuff, again even though it’s still in Early Access. I’d put it at Tier 2 in its current state. If you’re up for what’s being described, check it out.
I finally saw a movie, Black Widow, in a theater for the first time since the pandemic began. It would have felt ritually impure to have my first movie back be anything else. By waiting for several weeks, I got a mostly empty theater, so social distancing was excellent. As much as I was looking forward to it, I didn’t realize how much I missed the movies until I finally got to go. Excellent experience, can’t wait to go again, don’t think I have time to see Free Guy or Suicide Squad tonight but I’m not ruling it out. My review of the movie Black Widow is: Exactly meets expectations.
In Free Britney news, the system is even worse than you think. There was serious risk of having Britney Spears committed involuntarily, because of the supposed mental health strain of trying to free herself in court, and the strain of having her father as her legal enslaver against every scream she can muster:
A judge then refused to expedite the hearing, of course. One cannot rush such proceedings. The FDA would approve.
I’d also like to point out another parallel of horribly inefficient action that got highlighted this week, which is the War on Bags:
I am reminded of when my teammate Patrick Chapin went to get croissants from a gas station in Belgium (which were really good croissants, Europe has its advantages) and some other food, and was given an obviously horribly inadequate number of terribly flimsy bags. When he offered to pay unreasonably large amounts for additional bags, he was chastised for how little he cared about the planet. Then was forced to spend an hour getting back as the situation fell apart on him multiple times.
You know what costs vastly more energy and carbon to produce than paper bags? Food. Even a tiny risk of food being wasted is much worse than using extra bags. Yet what happens when bags break? Food containers break open, food is dropped on the ground and made dirty, and both lead to food being thrown out. That’s in addition to the hours upon hours of lost time.
And finally, in case you missed it, too good not to share and also insightful:
Here's what Zvi is missing on (D):
Does "we" refer to the same institutions that got nutrition entirely wrong for decades at a time, both at the micro level (individual foods) and macro level (food groups), whose entirely-wrong takes were taught in schools nationwide? I'm feeling way too much Gel-Mann skepticism here to say "yeah thankfully the powers-that-be will always be correct on vaccines".
Pushback is not correlated with scientific viability, but with political messaging. We've passed ineffective/dangerous policies with very little pushback (Patriot Act/NSA), and we've received plenty of pushback on effective policies (blocking travel from China). We cannot rely on pushback to bail us out of stupid object-level decisions. I hate to sound like such a libertarian ideologue, but I'm really not seeing a safer long-term policy than "stop giving govt's (potentially stupid) decisions so much power".
Also, if one is forced to get a medical procedure that one doesn't want, purely because they didn't have the amount of money that's required for bodily autonomy in their society, then yeah, I would call that "degrading" and a bunch of other stuff. A company is right to mandate what it wants for its employees, but it is not "hyperbolic language" to call some of that treatment degrading.
Am I the only one here who can easily relate to that twitter guy's sentiment? Do rationalists not value the whole "dignity of autonomy" thing as an end in itself?
In Lithuania, a bill has been passed that denies the unvaccinated rights to:
And their main slogan is "Turn your shoulder - become free!"
While these actions are supposed to be coercive, I feel they're doing much the opposite. And it makes non-swayed judgement really hard.
I had not noticed my own Gel-Mann amnesia when reading that bit, and therefore find your response quite convincing. I had thought that Ziv's answer to (D) made sense due to the FDA being over-cautious about approving things, but both the scope of the precedent and the kinds/directions of errors had not registered with me.
Absolutely, the whole blame-avoidance game would tend to make them over-cautious, but other hazards like regulatory capture (which I'm pretty sure is what happened with nutrition) threaten to make them recklessly wrong (as long as they can still find a way to avoid blame).
Have you ever met anyone that ACTUALLY TO THE LETTER follows the food pyramid? Or is it more like “I ate less fat but more sugar and I’m not healthy?”
Vietnam is the thinnest nation in the world, have a look at the link if you want to see their dietary guidelines and tell me if they look familiar.
Your argument is that food guidelines don't drive outcomes (in America), and also that a particular set of guidelines is correct, because obviously they're driving outcomes (in Vietnam).? This argument is missing a bunch of pieces.
In any case, if you believe the food pyramid is great for Americans, I'm not interested in convincing you otherwise, so feel free to ignore my point.
My argument is that guidelines are treated as a scapegoat and that they're largely unrelated to outcomes, in both America and Vietnam.
The real difference here, between America and Vietnam, is the prevalence and consumption of highly palatable foods.
Actually, yeah... I would say just about every American alive would be healthier if they strictly followed the macros and calorie intakes recommended by the USDA (there would be some exceptions for people with specific food allergies and the like), and I've never seen any evidence to the contrary.
Even if Americans understand them, most Americans don't follow them because self-control is hard and it's harder in an environment with abundances of cheap and highly palatable food, so virtually no Americans follow the USDA guidelines with any significant level of compliance. I would say Stephan Guyenet hypotheses about obesity are basically correct, and his critiques of fad diets are almost as good.
I would not underestimate the importance of US dietary guidelines.
For example, dietary guidelines are followed by schools, hospitals and military. They are also taught in medical schools and used by doctors to advise their patients. Additionally, lots of countries semi-blindly follow whatever guidelines US comes up with (see the parallel with covid treatments & measures?)
My gut feeling is that those guidelines directly contributed to a vast number of deaths / lost QALYs.
Okay. Why would those guidelines be awful for Americans but great for the Vietnamese?
Are they? Like to the exact calorie and proportion?
The effect could be different in Vietnam because of cultural differences, strictness of regulation or somethings else. Same as vaccine program compliance.
The central point is about adequacy of governmental decisions, not about compliance to them.
There are plenty of regulations about hospital food or child nutrition in the US that follow the dietary guidance. I have not looked into it but it would not surprise me if they regulate macro calorie intake for military (not that it matters for the central point of discussion).
I don't believe this. I could get Taco Bell and cookies and other junk food in my high school cafeteria out of proportion to the pyramid. No one was regulating calories or macros.
Maybe. But the point that USDA dietary guidelines causing are obesity is obviously wrong because the guidelines are the same in other parts of the world and they're thin. At best you could say "contributing" in some vague way, but even that's wrong.
Try strictly following the USDA diet guidelines, literally to the letter and calorie and macro and I will guarantee you that you will lose weight. I can also guarantee you that you will be in a group of maybe, 4 Americans that actually do this outside of metabolic wards.
The strictness of the regulations of pyramid in the US is basically zero, and the Vietnamese government doesn't go around punishing people eating fat or sugar either.
I think you're closer to the mark when you talk about cultural differences, but sill not quiet on it.
Scott (or Scott channeling Stephan) was on the mark here:
I'm generally for free markets, but they are guaranteed to make populations fatter overtime.
Something I've been wondering for a while: are organizations/journalists/individuals filing FOIA requests to get emails and other relevant documents about how the CDC and FDA made their COVID decisions?
Yes. They are. It's what they do.
"The true IFR likely has not dropped here quite as much as in other places, but our vaccination rates are not that much lower and our medical care is quite good and holding firm, so it’s likely falling almost as fast here as elsewhere."
Some people on Twitter had a go at calculating how protection from hospitalisation via vaccination differs between UK and US - due to higher uptake in the oldest age groups the UK ends up 2-3x better (though simplistic calculation ignoring e.g. different vaccines).
Could you explain how you arrived at the safety conclusion? Wait, let me explain why I myself am getting overwhelmed (maybe I start from the wrong viewpoint).
There is an unprecedented need for a vaccine, and a few companies / people have got an opportunity to get extremely rich fast (and so they have). I cannot seem to get it out of my head how media and papers are all unanimous in supporting the vaccine. How do we discern honest from swayed / funded unjustly?
Last February, you could still find articles / papers like this:
Now it's all just "safe and effective".
One more red sign in my head: there's a vaccine for a previously unknown virus made with completely new technology (granted, mRNA wasn't discovered yesterday, but it's never been used like this before), in an astonishingly short time, which is also safe and effective. How probable would this sound to someone completely ignorant of all the media and the whole Covid-19 thing?
Please note, I am not an angry antivax. I am confused and seeking answers.
The only thing that people can be really sure of, for all patients, and all disease conditions, in general, is that some things are NOT safe (like: literal poison or just peanuts for someone allergic to peanuts) and something are NOT effective (like: homeopathy or chemotherapy for something other than the relevant kind of cancer).
The entire concept of a legal declaration that a drug is totally Safe(tm) and totally Effective(tm) is basically just marketing.
The thing that actually makes things safe and effective is that the doctor diagnoses you correctly and prescribes the right thing at the right dose without causing complications FOR YOU. Sometimes some problems happen despite the best guesses and efforts (because every human is a snowflake), and this is just how biology is: extremely complicated in general.
Something to note is that antibiotics and vaccines are insanely more important than heart valve replacements and boob jobs, in terms of making life for humans possible under modern conditions. For basically all of human history cities were net death traps, full of disease, where the excess people born in the country went to have sub-replacement numbers of kids and then die of smallpox or whatever. If we can't make new communicable disease treatments fast enough... this is what cities will go back to.
However the REST of medicine is often nigh unto homeopathy itself?
Perinatal care, and gunshot trauma treatment, and setting bones, and insulin for type I diabetics work, but these are unusual.
A lot of stuff "treats" the thing you went in for... while causing a new problem. Making all cause mortality go down is HARD. This paper argues that ignoring all cause mortality is fine. I think it is fine if the goal is to give people quite a bit of make-believe-medicine that causes them to feel cared for and helps doctors pay off their med school debts.
Keep in mind: something like 80% of the dollars spent in medicine are spent in the last few months or weeks of life, and they are often miserable, and pointless, and not what anyone sane would want for themselves or their loved ones... but many people are not sane
The real experiments are the early patients. If the patients are smart and have a good doctor and the cost-benefit-analysis for THAT patient in THAT situation pencils out... then the risks are worth the benefits and you take the bet and get your outcome. Then the doctor learns something.
That's how medicine gets better in real life. The more clinical experience that builds up, the better a judicious clinician can make this determination. To pretend otherwise is crazy.
There have been a LOT of people taking the vaccine. Empirically, it seems to help more than it hurts. For a very large "clinical N".
Personally, I think that the thing that happened was: Moncef Slaoui (and Kushner?) did an end run around The Evil Ones?
Clinical practice reveals, over and over and over, that things approved by the FDA as "safe" actually weren't "safe" and should maybe be recalled (or maybe they were safe if used properly and doctors weren't using them properly, and so someone decided that rather than let people get hurt, and rather than purge the doctors of incompetence, they should purge the legal drugs of things that were being mis-used a lot)?
This is the fundamental lie of the FDA: they REALLY can't do, during clinical trials, what they claim to do, and they get in the way of the people who MIGHT be able to do it for real eventually by just trying shit and repeating what works.
I'm not entirely against trying random shit on consenting old people who are going to die anyway.
SUPPOSE that things are hopeless... then why NOT try something that is likely to fail? It MIGHT work?
The right argument against such experimentation is more complicated and more about economics than medicine: how many bits of information about what parameters of various biological systems are you really buying when you try something new in medicine and is that worth it to whoever is footing the bill compared to their alternative uses for the same money.
However, the FDA also forbids this in general. Experiments should be as cheap as possible to get as many of them as possible. And it is NEVER cheap right now!
In order to try such an experiment you'd first file a New Drug Application (NDA) which is like $1M a pop.
So you can't just notice that you have a weird disease, and are basically gonna die no matter in the near future for a predictable cause... and then "just try something that your doctor thinks MIGHT work based on first principles medical reasoning and wikipedia". You you have to get permission from people in DC first.
Sometimes I wonder if they are INTENTIONALLY holding off medical innovation in general because like... abortion and transsexuality and cures for venereal diseases are already out of pandora's box... what else is in there? Maybe immortality? Maybe EXPENSIVE immortality? So maybe they are outlawing "medical innovation in general" to the best of their ability? And they pretend that their destruction of medical innovation is actually in support of "safe and effective and scientific" medical innovation because... they think we're dumb enough to believe their lies? (And maybe they are right?)
So, turning off some of the dumber laws momentarily enabled us to invent a new and effective vaccine.
And this isn't surprising to me because science works. The thing in the US that's broken is our political economy, not our actual physical sciences (yet).
In terms of safety, the argument for LONG TERM safety of this vaccine technology is not, and never could be, empirical. To verify the safety empirically you'd... have to wait a long time for results.
Instead the thing you do is... guess. Just like with masks. Based on reasoning about reality?
So far as I'm aware the key idea here is Kariko's work with things like pseudouridine. That's what made this new kind of mRNA vaccine work where the old mRNA vaccines had unacceptable side effects.
Honestly, it doesn't seem totally impossible to me that having a lot of this in your body might do... something? (Keep in mind though: water is poison at the right dose.)
But it empirically hasn't done much yet now that it has been rolled out to millions. Like with masks... you reason about reality directly to the best of your ability, and ask for peers to check your thinking?
One central comforting thing for me (if you click through to Kariko) is that the clever chemistry ALREADY EXISTS in our bodies. Human biology makes chemical adjustment to the backbone and microstructure of mRNA, then looks for these adjustments actively. Then viruses either have to also attempt this (which is very hard for many of them) or else the lack of these adjustments in certain cellular compartments can work as a trigger of certain kinds of "kill it all with fire" immune reactions.
So the current clever mRNA vaccines are giving "viral code" with "human-like chemical signatures" to dodge this reaction, and thereby sneak viral protein manufacturing instructions "deeper into our cell's machinery with less trauma" for at round of protein manufacturing, in a way that gives us "pieces of virus" (for our immune system to learn to recognize), but no second generation of virus (to be an actual infection), while avoiding some innate immune side effects.
I personally think it would be foolish to say that it can't possibly hurt in any way ever at all. The best medicine is the ancient stuff like aspirin (ie the active ingredient in willow bark tea which is 4000 year old medical tech with mentions in Sumerian and Egyptian texts). Time allows information to accumulate <3
I just think that the bet seemed to be worth it. I have two doses of Pfizer. I got them as fast as I legally could because the testing on the old people seemed like "enough" basically? Also both parents got the vaccine, and presumably they have the same genes as me more or less, so if they didn't specifically have a reaction then I wouldn't either most likely?
Empirically: pretty safe and decently effective (for N>millions) over months against the strains that are out there right now.
Theoretically: clever and probably pretty similar to what human bodies already have in them.
Surprisingly: generated "unusually fast" because heroes started ignoring a bunch of catastrophically stupid laws.
This essay of yours might be worth its own post :)
Your comment got me thinking about the probability of what I described once again:
Such miracles only happen in people's imagination.
Previously, I noticed one simple explanation: the vaccine is not as safe / effective.
Now I realize there's another: the mRNA vaccines are not that new, they simply never made it public before. Just something that dawned on me.
I'll study the links and get back here. Thank you for your time and effort!
Early papers on mRNA therapeutics date back to the late 1980s/early 1990s, with a number of small scale tests and trials starting by the late 1990s. Making custom arbitrary mRNA has been affordable/feasible since at least the mid-2000s. BioNTech was founded in 2008, and Moderna was founded in 2011, which means the relevant tech at that point was already far enough along to warrant founding companies that were going to need a lot of funding to bring anything to market. But instead of making vaccines targeting infectious diseases, they both mostly targeted cancer immunotherapy. I assume that's because those are the treatments they were able to get funding for, even though it's a much harder problem technically.
I don't know when the first year was they they could have designed a successful vaccine against a novel virus in a day and a half, but the odds of that happening just before covid hit are obviously very low, especially since more recent trials and studies are showing that we can also quickly develop (better) vaccines against the flu and malaria, and the success with covid was not an unlikely outcome.
I did not get this part (maybe there's a missed word or something. Are you implying that they had all tech in place to successfully manufacture such vaccines quickly?
So, to sum up:
This does sound somewhat realistic: old tech is better-known and had more successful attempts at.
Manufacture? No. Use? Only at lab scale, in animals or a few patients for small studies. Design? Yes, and the design process did not require any additional new tech nor the resources of a large pharmaceutical company.
Yes, old school vaccines have a lot more history behind them and large organizations were more familiar with them and so they were better equipped to get them through trials and scaled up for deployment. But the mRNA vaccines that did make it through seem to be more effective than those old school vaccines.
Of those 18, how many actually failed trials vs. other reasons for not having come to market (didn't get funding, didn't have the pre-existing expertise needed, didn't move fast enough relative to competitors)? Also, four of those 18 were BioNTech, and counting that as a success and three failures seems like a mistake when it's the same company trying multiple things initially and then proceeding with the best one.
How many old-school vaccine development efforts didn't pan out, or only got approved because of extensive government support in their countries of origin?
My take is that we have had, for at least a handful of years, the ability to design a new mRNA vaccine against a novel virus in a matter of days, test it in a matter of months, and scale it up in less than a year. Instead, the companies founded to develop that kind of technology had to go in a different direction (targeting cancer), and without the pandemic they would have languished much longer without bringing any mRNA therapeutics to market at all. The pandemic cut through enough bureaucracy that they got a product out and built manufacturing capacity, and now that they have done that, they're quickly able to repeat that success for other diseases.
I do not expect the pandemic to lead to a flurry of other new traditional vaccines, because those haven't suddenly gotten easier or cheaper to develop, we just threw more resources at them for covid.
As far as I can tell, if we had had better regulatory and research policy, we could have lived in the world where Moderna or BioNTech had been working on infectious disease mRNA vaccines all along, and launched an improved flu vaccine back in 2016 or so, so that by early 2020 they already had some manufacturing capacity and supply chains in place that they could expand and replicate (with at least the medical community knowing this was a thing that had been used millions of times). I do not believe that that world ever had to have made any technological advances that ours didn't make, yet they would have been able to mass produce our most effective covid vaccines much, much faster than we did. They would know that they knew how to fight a virus.
Edit to add: I worry that many people (1) think this is what a worst-case-scenario pandemic looks like, and (2) think that next time there's a new disease, the solution will be to mask up and shut down indefinitely, instead of immediately designing an mRNA vaccine, conducting large trials as fast as possible, and pre-emptively manufacturing hundreds of millions of dose so they're ready to go ASAP, with an expectation that all relevant regulatory agencies will work round the clock to remove all unnecessary roadblocks to approval.
Suggestion: Pre-register how you imagine a truly safe approval process for a vaccine would look like. Take notes on a piece of paper: How many clinical trials would you expect? How long should they take? If a vaccine successfully passes all trials, how much time should official institutions like the FDA take to review the evidence before they made a decision on whether to authorize use of the vaccine?
Finally, does the process you've imagined account for the opportunity cost of delay during an emergency?
Only afterwards, look up how the vaccines were actually approved. For instance, this study (section "Results") provides an overview of how various vaccines were authorized in the USA, EU, and Canada.
Then compare the actual approval process with what you imagined it should look like. How do they compare?
This suggestion makes it sound like the prior for all vaccinations is the same. The sensible thing to do when faced with a pandemic is to run clinical trials for vaccines with the least risk possible. That means using tried and proven adjuvants. Then you test whether protein domains or whole proteins are more toxic in some animal model and use the thing that's less toxic.
There's no good reason to use a new and risky process like the mRNA process. It's risky because the body starts attacking the cells that produce the antigen and this might be valuable cells all over the body including the brain as polyethylene glycol goes through the blood brain barrier. Adjuvant + Antigen doesn't let cells produce the antigen so the body won't kill it's own cells.
Could it be that so little neurons are killed that it's safe? Yes, but there's no reason to take that risk with a speed up approval process.
Without knowing what goes into the evidence review it's very hard to have an informed opinion on this. If I'm a reviewer at the FDA and see that the vaccine does get measured in the brain up to 25 hours after administration and likely kills a few neurons while none of the measured endpoints in the trial give me a good idea of whether there are effects on cognition, I don't think the decision whether or not to approve is trivial. It might be that this is a decision that should have done way earlier in the trial process, but it's very hard from the outside to understand how these things work.
The amount of clinical trials isn't the prime critieria. What matters is whether the clinical trials look at the relevant outcome metrics for risks.
All the possible long-COVID outcomes you would have guessed based on SARS I long term effects should be measured in the clinical trials for vaccines. Heart health metrics like HRV and lowest night time heart rate should have been measured as an outcome. A mental metric like IQ or maybe something easier to measure should have been an outcome for a drug that crosses the blood-brain barrier.
One reason follow up incidence for CFS, depression should be included in the trials even if that's not looked at for the first approval.
How do you know what you think you know? Specifically, regarding the PEG enabling the LNP's to cross the BBB, and regarding a followup by immune cells that have crossed the BBB?
There are to lines here. PEG gets used to get other medication past the blood brain barrier in pharmaceutical applications where you want to get things past the blood brain barrier. Secondly, for getting the drug approval companies had to measure where in the body the vaccine goes. If you look at the EMA report for the Moderna vaccine it suggests that the vaccine goes into all parts of the body with the expection of the kidneys and that includes with the brain where it can be measured up to 25 hours after the vaccine gets injected.
https://pubmed.ncbi.nlm.nih.gov/17068976/ does suggest that immune cells can cross into the CNS and are active there. I don't think it's studied to what extend they do this here.
I sympathize with your warnings, but am unresolved on the forums and means to address them.
The mRNA vaccines are probably riskier than we’re let on to believe, but I see a lot of alternating between normative and descriptive.
We have the set of vaccines we have now, and we have Covid circulating. It would be great if we lived in a universe were Covid was less bad or vaccines were mor good…
I just don’t see a lot of “here’s what we should do right now to make the world a better place” that doesn’t involve using the tools the average person has at their disposal.
As Ben points out, people like Zvi are far from advocating using the tools that the average person has it their disposal and only advocate using a subset of them.
The FLCCC protocol is now at 7 tools that are recommended to be used every day. That list doesn't even include Taffix and at home air filters.
I do think LessWrong is the forum to speak about what's true and not only to speak about what's practical.
I would want my third vaccine dose to be Novavaxx and hopefully not with the spike protein from a year ago but Delta or the varient that's current at the time.
I'd also like RaDVaC to be funded better.
I think we’re all on board with D3. In terms of the risk-benefit analysis. If this is what you’re talking about.
I would say that for most other things on the list.
If people can get Ivermectin legitimately and aren’t taking horse pills or ordering it off the dark web, I don’t see an issue there.
*with the standard caveats that particular people may have contraindications, etc.
But all of those have to been taken daily, paid for out of pocket, and none of them are vaccines.
So how reasonable is this as a public health policy?
You don't need to take prophylatic Ivermectin daily. With Vitamin D I would recommend taking it daily but in theory you can also take it at less frequent intervals.
I'm not sure whether there's much of a quality difference between dark web sources and generic out of the pharmacy.
It's a question of how serious you think COVID-19 happens to be and therefore how serious you want to be to do something about it. If you think COVID-19 isn't serious enough to do something daily about it, that's a valid position but you should be clear about that being your position.
As a public health policy you can give Ivermectin to people for free. Given that it's cheap enough for the Indians to do that, it should be easier in richer Western countries.
If I were in charge of public health policy I would also say that vaccines can be brought to market by showing that they result in antibody creation in humans and disease prevention in animal studies.
There's also no need for public health policy to be a one-size-fits-all solution.
They only way I believe anyone should feel safe recommending it would be if they are sure it’s pharmaceutical grade and quality. Otherwise… it could possibly do more harm than good, or do nothing at all.
I don’t see how this is relevant. You could believe Covid is a very big deal and not have the money or means to spend ~50 dollars a month on supplements.
This the question is, even if you did, would this protocol be good enough to prevent catching Covid and transmitting it to someone that’s immunocompromised, for example.
I can? I’m not the FDA, Fauci or WHO. How can I make sure 7 billion people have enough Ivermectin to take several days a week for a year or more and ensure compliance?
I know you didn’t literally mean me, but this is a much harder problem than people make it out to be to coordinate giving the whole world until the pandemic ends, and that’s assuming Ivermectin would be effective here.
In general, I agree. Just think were overstating the case for how easy giving everyone seven different supplement regularly and ensuring that they do it… so say nothing about how effective they are compared to vaccines.
None of us are and none of us will be anytime soon, there’s a lot of discussion like this is plausible.
And there’s no real plan. How would be administer 100 of billions of doses of Ivermectin and ensure people are taking them for months or year?
The same is true with a generic that you buy at a pharmacy. It can possibly do more harm than good or do nothing at all. Ranbaxy sold generics for which that's true and even after the FDA was told about that by a whistleblower it took them years to do something about it.
You can ask the same thing with the vaccines. Vaccines do have the disadvantage that it's easier for viruses to mutate to escape them. High vaccination rates in the UK and Israel didn't prevent a rising case count but Ivermectin use (alone) coincides with it in India.
Price of supplements is a different issue then whether you have to take the supplement daily.
You don't have the power but you also don't have the power to set public health policy in other regards.
Public health policy is not about ensuring that people do things outside of totalitarian states. It's about providing people with options and informing them about the value of various actions.
Absent a studies comparing the quality of drugs from the dark web vs. the quality of drugs pharmacies, my prior is to assume that drugs from pharmacies are typically safer. Although I agree, yes, it's not perfect. I have recourse if I discover they're contaminated or don't contain the medication advertised. Best I could do on the dark web is leave a mean review and hope the dealer doesn't find a way to retaliate.
I've heard this repeated often, but I haven't seen evidence of it. How much as measles changed since we began vaccinating people for it? How about polio? How about smallpox? The evidence that I'm aware of also seems to be against this.
Price is a factor in compliance. If you can't afford supplements, you will be less likely to comply.
This is ultimately why I think this is an unproductive and to some degree dangerously misleading discussion (not just you and me, but also the vaccination vs early treatment and treatment protocols).
I don't take any joy citing the linked author, but I do feel like we're on a ship and we're heading towards and iceberg and everyone is like "what about zinc? what about ivermectin?" And, yes, those are all things that deserve more attention and I'm against censoring discussion of them.
Ivermectin may yet prove to be a miracle drug, and I think the evidence there is promising. I don't see the downsides to people taking zinc or vitamin d3 at reasonable and effective doses. I don't see any of it as having the potential to turn the ship around.
But right now as of August 16th at ~5:45pm mountain time what we have to turn the ship around that we know works are vaccines. Yes, the side-effects are probably worse than claimed. And, yes, the public health apparatus in the US sucks for a million reasons, one of which is that they talk to us like children when it comes to vaccine safety. But all the evidence I've seen is that this is better than the alternative.
Since I haven't seen other proven solutions for quickly and reliably turning the ship around, comparatively everything else seems like a distraction.
If you had infinite time and resources, you'd ideally test for all conceivable outcome variables when designing clinical trials for anything. Of course there's always a chance that something was missed in the trials, but it certainly matters what that chance is. Do we have reason to believe it to be non-negligible, now that more than enough people have been vaccinated for even the tiniest of risks to manifest themselves?
In any case, if someone is specifically worried about the novel mRNA vaccines, they can take one of the classically produced vaccines instead.
... What about the higher efficacy of the mRNA vaccines?
(I also tried to look up a timeline of manufacturing volume by vaccine type, but unfortunately couldn't find anything useful. I had had the impression that the mRNA vaccines had been quicker to manufacture.)
An omniscient being could make a full cost-benefit analysis on this kind of stuff, but we have to reason under uncertainty, and things certainly don't look so clear-cut to me.
How would we notice if the lowest night heart rate goes up for everybody who takes the vaccine by one point?
How would you notice if the IQ of everyone who takes the vaccine goes down by one point?
How would we notice if 0.5% gets a depression half a year after receiving the vaccine? (Brain trauma doesn't produce depression immediately but has lag time)
If someone gets a depression half a year after receiving the vaccine, why would they think that they should tell VEARS about it?
We know that the mRNA vaccines produce some brain damage, because we find the vaccine in the brain and the it gets cells to produce the antigen and then the immune system kills those cells. What we don't know is how much damage that it. If the damage would be enough to reduce IQ by an average of 10 points we likely would notice. I don't think we would have noticed if it's 1 point.
Myocarditis that's strong enough to produce clinical effects seem to happen enough that it's flagged as a risk to investigate. Most cases of myocarditis caused by the vaccine are likely not strong enough to be clinically noticeable. If someone has myocarditis that raises their lowest nightly heartrate by one, they are not going to put anything into VAERS. As a patient non-clinical side-effects matter.
Look at a discourse of side-effects of something like microplastic. Such a discourse takes decades to come to good conclusions about what the side-effects are.
I don't think there's evidence that shows mRNA vaccines outperforming Novavaxx currently. Even if two doses of Novavaxx would give less immunity there's less risk in simply giving more shots.
Novavaxx uses a patented adjuvant instead of a well tested one, but it's the choice that's available for classically produced vaccines.
I think you can make a good argument that in the shitty situation we are in it still makes sense to get vaccinated but pretending that we have strong evidence of lack of side-effect stretches it because we have not studied relevant outcomes to an extend where we would see the effects.
Epistemically, this kind of argument reminds me of god-of-the-gaps or shrinking parameter spaces in string theory. That doesn't make the argument wrong, but it means that I don't really see a fruitful way to engage with it.
I suppose that if one's prior is that this kind of risk is negligible, the argument will sound unconvincing, whereas if it sounds plausible a priori, then lack of such studies seems concerning? Let's leave it at that. Though I could be convinced otherwise if I learned that this concern was taken seriously by a significant fraction of doctors or other public health professionals.
If you learn anything about a rationalist is that knowing things is hard. If you look at the replication crisis we see that it's hard to know things even when there are studies that intend to measure an outcome.
Claiming strong evidence for something should require evidence and not just lack of concern.
Why is the prior that a drug that causes brain damage should have a negliglible risk of causing brain damage that's relevant reasonable?
How is it a god-of-the-gaps argument to ask for checks to see whether the brain damage is large enough to cause problems? If you haven't check claiming you have strong evidence that there are no side-effects seems to me very unfounded.
I had a doctor tell me that removing a rib of me is no problem because there's no evidence that it produces any problems. While that evidence isn't in the clean form that doctors like, I do feel like it makes the some things in my body more complicated.
I don't have the expertise or training to evaluate detailed medical claims myself. I wasn't even able to find sources for the blood-brain-barrier thing (neither claims nor rebuttals), except for this thread on askreddit which I was too exhausted to peruse. In any case, at this point the discussion is not about medicine but about epistemology.
I have not yet been convinced that the vaccine causes brain damage. I think that at the very least, that argument requires sources for both a link between mRNA vaccines and an inflamed brain, and for the claim that this is an exceptional occurence / that this is something worse than what happens in e.g. an average fever.
I guess my prior is that bodies are pretty robust, and that most contrarian claims are wrong. Identifying correct contrarians is hard.
My god-of-the-gaps comment was directed at what I perceived as a complex hypothesis which looked like it was (over?)fitted to the available evidence. In such a situation, one can't falsify the hypothesis without new evidence, even though one figures there should be plenty evidence regarding most conceivable side effects by now.
I do agree about the issues with doctors, though. I have had several suboptimal encounters with the medical system, which have left me rather unimpressed with medical care (diagnosis in particular). I have an essay draft on this topic, but it's going to be a long while until I get to it.
The EMA is the EU equivalent of the FDA. When they approved the drug the wrote a report indicating all the risk related information about the COVID-19 Vaccine from Moderna.
In it they say:
The fact that your sources don't tell you about this tells you how much they are interested in having a serious discussion about side-effects.
Generally, there are a lot of possible side-effects a drug could potentially have.
There are many situations where people claim to know more then they actually know for political reasons. A claim like "I know that the mRNA that's found in the brain produces significant problems" is one that needs a lot more evidence then one that says "It possible that this happens but we don't know".
You have presented evidence that the mRNA vaccines "cause brain damage" to, let's say, the same extent as drinking a glass of wine "causes brain damage". That is, you can trace a sequence of events likely to kill at least one brain cell.
You haven't shown any evidence that mRNA vaccines do anywhere near enough damage with anywhere near enough probability to be cause for concern.
The fact that the EMA report says what it does but doesn't say anything at all like "the risk of brain damage is a downside to using these vaccines" seems to me to indicate that the people who wrote that report don't think that what they found about small numbers of lipid nanoparticles crossing the blood/brain barrier is cause for concern. This means that either they don't think brain damage would be a problem (which seems ... unlikely), or else they don't think the danger is substantial enough to be worth worrying about.
The comments from user yesitsnicholas in the Reddit thread linked above by MondSemmel seem to be (1) written by someone who actually knows something about this stuff, and (2) very confident that there's no danger to speak of.
Now, whether or not yesitsnicholas is an expert, I am not, and maybe I'm failing to recognize the dangers here. I'm willing to be persuaded. Do you have any evidence that goes beyond "look, at least one lipid nanoparticle will get into the brain and that may lead to the death of at least one brain cell"?
I am not disagreeing with the narrower point that what we know at present about the safety of COVID-19 vaccines -- or, in fact, pretty much any drugs -- or in fact, pretty much anything at all -- is not enough to be very confident that there aren't very small adverse effects. Or indeed very small beneficial effects; we wouldn't have noticed if getting the Pfizer vaccine raises your IQ by one point, either. Identifying very small effects is difficult.
But you go further and say e.g. that there was no point in trying novel approaches (with, therefore, more scope for wholly unsuspected adverse consequences) like mRNA vaccines. But available evidence suggests that the mRNA vaccines happen to be the most effective against COVID-19. A policy for which we can see with hindsight that it would have stopped us finding the most effective vaccines is, it seems to me, not obviously correct. "But for all we know Novavax's vaccine is just as good as the mRNA ones", I hear you say. Maybe it is. But it's still in trials and the Pfizer and Moderna vaccines have been widely available and widely used for months.
We can calculate the upper bound of risk from the document you provided. Moderna says 2% of plasma level of LNP ends up in the brain. There are 10 billion LNP in each shot of Moderna vaccine and at most 10% goes into general circulation unless nurse made a mistake and put it in your vein. So, 2% of one billion is 20 million LNP, that is the maximum that will end up in a person's brain following a vaccine shot. So, maximum 20 million brain cells are at stake after each shot. Not all of them will be neurons.
Thank you for detailed comments!
I have similar thoughts about the approval process, though much less coherent.
From a citizen (non-medical education) level of knowledge, I wonder how we should go about reaching a decision regarding getting a jab.
Though I am obliged to say, where I and my SO currently live (Lithuania and Russia) it will soon become not a "whether", but "which" in a month due to regulations.
I think that COVID-19 is bad enough, that even with the risks as described I still got a shot of the BionTech vaccine three weeks ago.
If there's a real free choice I think the answer is currently Novavaxx as it's the classic adjuvant + antigen combination. Evidence suggests that it has less average side-effects and it doesn't get your body to kill it's own cells. Not getting your body to kill it's own cells means that certain immune responses are not triggered but the trials we have shows Novavaxx to have comparable effectiveness to the other vaccines.
Interesting information, thanks. However, the choice is as follows (numbers indicate available units):
1. Moderna (4990)
2. Comirnaty (Pfizer) (25111)
3. Vaxzevria (AstraZeneca) (6073)
4. Janssen (3611)
The viral vector technology has previously been used for Ebola, right? What do we know about that?
UPD: apparently, we might get Novavax sometime soon. I might want to wait for that.
The UK hasn't had one since 1992. That's exceedingly rare.
There are around 250,000 schools in the US. So, that is a .01% chance of an event at your school each year. With little evidence that the active shooter behaviors actually work.
So it still makes sense to do some thing about the drills and nothing about the shootings ... even though the shootings are very frequent compared to other countries. 0.01% is 100 times higher than 0.0001%
The fact about "school shootings" that usually gets ignored in these discussions is that almost none of them are of the type "single shooter trying to inflict mass casualties in a pre-planned attack," the template that the media treats as prototypical. Those kinds of shootings are exceedingly rare, less than one per year, but they take up almost all of the media coverage.
The shootings that make up the bulk of the 25/year take place in urban schools, almost always involve black or occasionally Hispanic students, and fall under the broad umbrella of gang/drug violence. If you or your children go to a majority white/asian school, your chance of getting involved in a school shooting are lower by a factor of 100.
Gang type school shootings are also extremely rare in countries with strict gun control. Alongside all other shootings.
I was responding to the bit about "active shooter drills", which are a thing that mostly occur in jittery suburban schools, ie. the kinds of schools least at risk of this kind of thing.
I agree that "no indoor dining for anyone" is worse than mandating vaccination for indoor dining. But I also don´t think the situation merits either. Protecting the immunocompromised and people that want but can´t get vaccinated doesn´t make up for the concerns.
Can you elaborate? If not mandating vaccination for indoor dining, then what?
Full disclosure, I'm actually not a big fan of vax passes either, but coming from the opposite end: I think vaccination should be mandatory across the board and backed up by very large fines, whether or not one chooses to enter public spaces. In my opinion this would actually be the minimally coercive approach, averaged over the entire population - since it doesn't require everyone else to be constantly policing vaccination status.
Despite my reservations, if asked to pick a side I'll always land on Team Vax Passport.
Even that minimally coercive approach you describe is pretty coercive; I don´t expect the benefits to outweigh the ugly side of making many tens of millions of people be injected with something they don´t like or trust or want. Some people are still getting convinced to get vaccinated just with time alone, and many other things could be done better to convince more people without more restrictions. I don´t know what to expand on without making this too long.
Sure, it's coercive, but at least the scope of coercion is smaller (in terms of who is being coerced to do stuff)
The first part is just a jab at politics. IIRC the second part comments on some kinds of new proposed cryptocurrency regulations. When politicians regulate new technology, they compare it to old technology, and sometimes these comparisons make no sense and put an undue regulatory burden on the new technology. From what I understand, the proposed regulations could treat cryptocurrency miners as brokers, in which case miners would presumably fall under the purview of some kinds of financial regulation.
If this article is to be believed, the legislators tried to fix that problem. The article's last section implies that this attempt failed, however:
I've started emote-ing at you at the start of our first fight each brawl to say hello (IGN: GodWithAShotgun), I hope it's taken in the intended spirit of camaraderie (and happy to stop if it's annoying, I know opinions on emotes are mixed). Looking forward to hearing your thoughts on the game, that's a discussion I'll be able to contribute to more thoroughly.
I look forward to these weekly posts, thanks for doing them.
It just occurred to me why Israeli data on comparison between vaccinated and recovered from covid is different from the other studies. I bet the other studies were all before Delta variant became prominent.
I am truly baffled as to who you think is being tested for Covid.
I work in Hollywood, and I have been tested dozens of times, just about weekly, because a recent (24-hrs) negative test is REQUIRED to go to any stage or even office building or shop. Surely workplace requirements are the majority (maybe vast majority) of all testing. So I would think changes in # of people returning to work, or changes in employer policies, would be causing weekly fluctuations in # of tests, not any medical reason (or any reason based in reality.)
I cannot imagine I would ever seek a test unless it was required. And only the fact that we are a very small operation and my employer REALLY needs me on these on-sites, keeps me from refusing.
Also, a VERY IMPORTANT fact that I never hear mentioned:
At a nominal cost of $175/test, (paid for by Somebody), testing companies are raking in huge amounts of cash. They have 100% incentive to make sure testing continues to be mandatory.
That said, thank you for being just about the only writer who is both rational and honest. I trust you. That means more than it ever has.
Just as a counterpoint to "I cannot imagine I would ever seek a test unless it was required" -- but with an important caveat -- here are a couple of recent times when people in my household (me and my wife, both aged around 50, both fully vaccinated; teenage daughter, not vaccinated) have been tested:
The important caveat: these are rapid lateral flow tests, done at home, which are available for free in the UK. They have a high false negative rate (ballpark estimate: if you have COVID-19 and are infectious, there's maybe a 50% chance they'll catch it); I don't know about the false positive rate. I'm not sure whether these, or anything roughly equivalent, are readily available in the US; obviously the cost/benefit tradeoffs are different if getting tested means driving somewhere and paying $175 than if you can do it at home for free with the total inconvenience being sticking something up your nose and waiting half an hour.
This sort of testing seems pretty obvious to me, and a long way from being so pointless as to make it hard to imagine why one would do it. We would prefer not to give COVID-19 to others, if we get it. We would prefer to know, if we get it. We would prefer to know (or at least have some evidence) if we haven't got it despite some reason for suspicion that we might have it. BUT, again, this is quick-and-cheap-and-convenient testing, not hopefully more accurate slow and expensive and inconvenient testing. I bet that is indeed almost always done because there's a requirement to do it (for the workplace, or maybe for some plane flights, etc.).
I'd love it if someone could work out a system where you pay $X*p where $X is the coat of quarantining and p is the probability of testing positive.
Sort of. For some months now, the WHO states that it can spread "in poorly ventilated and/or crowded indoor settings [...] because aerosols remain suspended in the air"
EDIT: (used to ask why the link wasn't formatting properly)
(Meta comment: Formatting is in rich text by default; selecting text displays a hover with formatting options. You can switch to markdown formatting in your user settings ("Activate Markdown Editor").)
Is there some option you’re aware of for markdown on mobile a rich text on Desktop?
The space between those two is very small, maybe even negative.