A post from Gregory Cochran's and Henry Harpending's excellent blog West Hunter.
One of the many interesting aspects of how the US dealt with the AIDS epidemic is what we didn’t do – in particular, quarantine. Probably you need a decent test before quarantine is practical, but we had ELISA by 1985 and a better Western Blot test by 1987.
There was popular support for a quarantine.
But the public health experts generally opined that such a quarantine would not work.
Of course, they were wrong. Cuba institute a rigorous quarantine. They mandated antiviral treatment for pregnant women and mandated C-sections for those that were HIV-positive. People positive for any venereal disease were tested for HIV as well. HIV-infected people must provide the names of all sexual partners for the past sic months.
Compulsory quarantining was relaxed in 1994, but all those testing positive have to go to a sanatorium for 8 weeks of thorough education on the disease. People who leave after 8 weeks and engage in unsafe sex undergo permanent quarantine.
Cuba did pretty well: the per-capita death toll was 35 times lower than in the US.
Cuba had some advantages: the epidemic hit them at least five years later than it did the US (first observed Cuban case in 1986, first noticed cases in the US in 1981). That meant they were readier when they encountered the virus. You’d think that because of the epidemic’s late start in Cuba, there would have been a shorter interval without the effective protease inhibitors (which arrived in 1995 in the US) – but they don’t seem to have arrived in Cuba until 2001, so the interval was about the same.
If we had adopted the same strategy as Cuba, it would not have been as effective, largely because of that time lag. However, it surely would have prevented at least half of the ~600,000 AIDS deaths in the US. Probably well over half.
I still see people stating that of course quarantine would not have worked: fairly often from dimwitted people with a Masters in Public Health.
My favorite comment was from a libertarian friend who said that although quarantine certainly would have worked, better to sacrifice a few hundred thousand than validate the idea that the Feds can sometimes tell you what to do with good effect.
The commenter Ron Pavellas adds:
I was working as the CEO of a large hospital in California during the 1980s (I have MPH as my degree, by the way). I was outraged when the Public Health officials decided to not treat the HI-Virus as an STD for the purposes of case-finding, as is routinely and effectively done with syphilis, gonorrhea, etc. In other words, they decided to NOT perform classic epidemiology, thus sullying the whole field of Public Health. It was not politically correct to potentially ‘out’ individuals engaging in the kind of behavior which spreads the disease. No one has recently been concerned with the potential ‘outing’ of those who contract other STDs, due in large part to the confidential methods used and maintained over many decades. (Remember the Wassermann Test that was required before you got married?) As is pointed out in this article, lives were needlessly lost and untold suffering needlessly ensued.
The Wasserman Test.
Agreed that there are costs, but 35 to 1. If you're not categorically opposed to quarantine, that probably makes it on cost-benefit terms.
This is solved by compulsory testing.
I think this has been seen as solidly the right move for centuries, and I think the fact that this is in question is a sign of how rare epidemics are, not of moral progress.
The actual suggestion at the time was to tattoo them somewhere private- so that only potential sexual partners would be communicated of the risk.
Is that 35-1 difference because of the quarantine, though? I thought we were supposed to know better than to conflate correlation and causation? The former might wink and nudge, but that doesn't actually make it correct -- especially when we're talking vastly different sets.
Cuba's first known cases of HIV didn't show up until 1985, the majority of the island's population was socially and politically isolated, the island's blood transfusion system was very easily isolated, and the place at least claims to have vastly lower illegal IV drug use. Contrast the United States, which has confirmed cases at least as far back as 1968 (West Hunter's estimate of first noticed cases in 1981 is highly off : GRID was proposed as a name that year), had and continues to have serious abuse of IV heroin, and by the invention of the ELISA blood test already had people receiving infected blood transfusions.
These are not similar groups. The low rate of infection in Cuba tells us that one or more of these matters probably explains the large difference, but as the number of differences increase the certainty that the quarantine was responsible or even helped decreases. If you look to other countries with similarly low infection rates -- Finland as one high-profile example -- you don't see such heavy-handed quarantines. This doesn't tell us anything for certain, but it's a pretty strong hint.
Deaths in the US without quarantine to deaths in Cuba with quarantine. The two countries aren't directly comparable- Cochran is only confident estimating the number of AIDS deaths prevented as 'at least half'- but that's still 300k people. (If we had tested everyone in the US in 1987, that would be 300 deaths prevented for every person falsely quarantined.)
The project is obviously coercive: otherwise it won't work. We're asking whether or not it's excessive, but I think in order to draw a line we need to have cases that clearly fall on each side of the line. Do you think it was excessive to, say, imprison Typoid Mary for three decades?
The US has federal laws on the books regarding quarantine since 1799. That's not because government quarantine is only 200 years old; that's because the US is only 200 years old. When churches have carried out quarantines, I would suspect it's because they are the ... (read more)
Agreed 100%. There has been an undertone in my posts of moral condemnation; and it's intentional. I do not want someone like Cochran making decisions about individual liberty.
I don't know what this means. Could you explain? It seems to me that the AIDS response put people's liberty before people's lifespan. This is not an uncontroversial choice, but it doesn't seem an obviously wrong one; both are about people, neither about 'feelings,' - except to the extent that 'feelings' reside within people. As for civilizational competence, it strikes me that civilisation is rolling along just fine; if anything, the AIDS epidemic appears to have played a major role in the major shift from homosexuals whining about "heteronormativity" to campaigning for gay marriage.
Of course there would be problems wi... (read more)
Moving the level of that thing down is limited at 0, and thus the effect of bias and abuse is also limited. Moving the level up is not so limited.
Deciding that you'll condition on a particular thing is itself subject to the same bias and abuse that deciding to add something is. Imagine regulators saying "we've already decided that we're going add sterility drugs to the water, we just need to decide how much". It's also solved the same way; just like you say "without satisfying very high standards, you may only filter stuff out and not add stuff", you say "without satisfying very high standards, you may only condition on things that are already present in significant amounts".
It is possible ... (read more)
If you tested literally every person in the US, you would end up with about a thousand false positives. (This assumes that this is 1987, and we have the second, independent test, rather than just 1985 when we have only the one test.) If you restrict your sample to, say, New York City and San Francisco and so on, then you dramatically lower the number of false positives while still covering a large part of the at-risk population.
Yes, and the people who already have HIV don't have a long expected lifespan. Note that the suggestion was based on existing procedures for other STDs and those were anywhere near as lethal.
It's not in the interest of the people who already have HIV, it is in the interest of the people who might get it.
I think my favorite example is food rationing in the UK in WW2. It's a great example because it shows both sides are right:
(a) Rationing resulted in people eating healthier (much more veggies, much less processed sugar and fats), and as a result many public health measures actually went up during the war, even as the public perception was that food quality was poor.
and yet at the same time
(b) Once the infrastructure for rationing was set up the temptation was irresistible to continue with it past immediate need (rationing in the UK continued for decades after WW2) for reasons that basically amounted to bureaucratic convenience.
So it's both true that government paternalism works (the 'leftist view'), and that giving the government tools to coordinate better simply results in the government using those tools for its ends, not yours (the 'libertarian view.')
Not decades , about nine years.
You missed a golden opportunity:
I liked this comment from Rudolf Winestock
Is that an euphemism for "imprisoned for life"?
Frito Bandito writes:
A government that isn't crazy huh? (u_u)
That problem seems insolvable except it somehow has been solved from time to time.
People should consider the Trolley problem. Except this time the fat person isn't one that is killed, but is sent off to live in the equivalent of a Leper Colony.
For context to the following question, the West Hunter blog is on my feed reader, so I'm familiar with its content.
In your opinion, on what basis is the blog "excellent"?
Let the mind-killing begin!
Besides, it would be interesting to know why the difference existed in the first place. Assuming no basic difference between Cuban and American epidemiologists' education, why the (supposedly) poorer choice was made in the US?
Was it political, bureaucratic, molochian... what?
A big difference about outing someone with syphillis vs with AIDS is back then it was thought by a lot of folks that AIDS was only transferrable by anal sex, i.e. you would also be outing them as probably gay/bi.
Which was also much more dangerous to be outed as back then.
So Cuba was chosen for comparison because it provides the best statistics.
Compare China, Russia, for how well they did with their authoritarian governments, sprawling population size, and lack of economic incentives for mass-training of medical workers.
It was a red herring. This comment section has been pwned. You should have known better.
Ebola diagnosed in US for first time – Center for Disease Control
Cochran's cleverness and excellent track-record of predictions me wonder if he knew something.
Edit: He has since explicitly written on Ebola contianment.