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Posts Tagged ‘Public Health’

Some folks are using the coronavirus crisis to say that libertarianism is an inadequate approach to governance.

Noah Smith got the ball rolling with a snarky tweet.

Since total government spending is at an all-time high and since even left-leaning fact checkers have debunked the assertion that public health bureaucracies have been reduced, Smith’s core claim is grossly inaccurate.

But what about the underlying assumption that a large government is necessary?

Farhad Manjoo of the New York Times hopes the crisis will usher in a new era of big government as everyone realizes the supposed benefits of collectivism.

Overnight, workplaces across the country were transformed into Scandinavian Edens of flexibility. Can’t make it to the office because your kid has to unexpectedly stay home from school? Last week, it sucked to be you. This week: What are you even doing asking? Go home, be with your kid! …Then politicians got into the act. The Trump administration…is now singing the praises of universal sick pay. …it’s almost funny: Everyone’s a socialist in a pandemic. …There may be a silver lining here: What if the virus forces Americans and their elected representatives to recognize the strength of a collectivist ethos?

Is Mr. Manjoo right? Just like there are supposedly no atheists in foxholes, are there no libertarians in a pandemic?

Here are four basic points to show why this is wrong.

1. Libertarians believe government should protect life, liberty, and property

A core tenet of libertarianism is that government should exist to protect against threats to the aforementioned core liberties. That presumably includes a role in responding to pandemics.

Yes, libertarians will appropriately worry that government will botch its response (see below, for instance), and we’ll also worry that government will use a crisis to accumulate new powers (the “ratchet effect” mentioned in this column).

But it’s silly to argue that a pandemic is evidence that libertarianism is impractical. As silly as arguing in the 1980s that you couldn’t be a libertarian and still favor a defense capacity to resist the Soviet Union.

To be sure, there are anarcho-capitalists who don’t believe in any government. Whether that’s a good idea involves an entirely separate set of arguments about how private governance associations would respond to a pandemic, which could be an interesting topic for some future column.

2. Libertarians correctly warn that a big sprawling federal government means it is less capable of handling the few things it should be doing

I’ve repeatedly explained, most recently this past January, that the federal government is more likely to do a good job if it focuses on core responsibilities (such as the ones assigned in the Constitution).

And observers ranging from Mark Steyn to Robert Samuelson have made the same point.

There’s plenty of academic evidence in support of this position, though this anecdote from Belgium may be even more persuasive.

3. Other government-run health systems have not done a good job

The virus originated in China, where government controls the healthcare system. It’s also spread most significantly in nations such as Iran and Italy, where government also plays a dominant role in health care.

By the way, since I don’t believe in demagoguery, I don’t necessarily blame those governments. I’m sure bad luck plays a big role in the spread of the disease.

Though this set of tweets from a guy in England is a damning indictment of that nation’s government-run system.

4. The federal government has hindered an effective response to the coronavirus

We’ll start with excerpts from an article by Ronald Bailey, who writes about science for Reason.

…officials at the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) stymied private and academic development of diagnostic tests that might have provided an early warning and a head start on controlling the epidemic that is now spreading across the country. …the CDC required that public health officials could only use the diagnostic test designed by the agency. That test released on February 5 turned out to be badly flawed. The CDC’s insistence on a top-down centralized testing regime greatly slowed down the process of disease detection as the infection rate was accelerating. …On February 29, the FDA finally agreed to unleash America’s vibrant biotech companies and academic labs by allowing them to develop and deploy new tests for the coronavirus that causes COVID-19.

The New York Times has a depressing report about government red tape has prevented quick action.

Here’s the main takeaway.

…existing regulations and red tape — sometimes designed to protect privacy and health — have impeded the rapid rollout of testing nationally, while other countries ramped up much earlier and faster. Faced with a public health emergency on a scale potentially not seen in a century, the United States has not responded nimbly.

And here are some of the relevant details.

The Association of Public Health Laboratories made what it called an “extraordinary and rare request” of Dr. Stephen Hahn, the commissioner of the F.D.A., asking him to use his discretion to allow state and local public health laboratories to create their own tests for the virus. …Dr. Hahn responded two days later, saying in a letter that “false diagnostic test results can lead to significant adverse public health consequences” and that the laboratories were welcome to submit their own tests for emergency authorization. But the approval process for laboratory-developed tests was proving onerous. Private and university clinical laboratories, which typically have the latitude to develop their own tests, were frustrated about the speed of the F.D.A. as they prepared applications for emergency approvals from the agency for their coronavirus tests. Dr. Alex Greninger, an assistant professor at the University of Washington Medical Center in Seattle, said he became exasperated in mid-February as he communicated with the F.D.A. over getting his application ready to begin testing. “This virus is faster than the F.D.A.,” he said, adding that at one point the agency required him to submit materials through the mail in addition to over email. New tests typically require validation — running the test on known positive samples from a patient or a copy of the virus genome. The F.D.A.’s process called for five.

Fortunately, some folks in Seattle were willing to disobey federal bureaucracies at the start of the crisis.

In Seattle, Dr. Helen Chu, an infectious disease expert who was part of an ongoing flu-monitoring effort, the Seattle Flu Study, asked permission to test their trove of collected flu swabs for coronavirus. State health officials joined Chu in asking the CDC and Food and Drug Administration… The CDC and FDA said no. “We felt like we were sitting, waiting for the pandemic to emerge,” Chu told the Times. “We could help. We couldn’t do anything.” They held off for a couple of weeks, but on Feb. 25, Chu and her colleagues “began performing coronavirus tests, without government approval,” …Later that day, the CDC and FDA told Chu and her colleagues to stop testing, then partially relented, and the lab found several more cases. On Monday night, they were ordered to stop testing again. …the Times notes. “The scientists said they believe that they will find evidence that the virus was infecting people even earlier, and that they could have alerted authorities sooner if they had been allowed to test.”

And an article in the Atlantic reveals how bureaucracy and regulation have been hindering an effective response.

…the CDC sets the parameters for state and local public-health staff regarding who should be tested. The agency’s guidelines were very strict for weeks, focusing on returning international travelers. Even as they have been loosened in the past few days, there are persistent reports that people—including a sick nurse who had cared for a coronavirus patient—have not been able to get tested. …A week ago, the FDA eased some regulations on the types of coronavirus tests that can be used. This means that testing capacity will increase, but not overnight. …Soon private laboratories such as LabCorp and Quest Diagnostics will begin testing people…each lab must have the FDA’s permission to operate, under an Emergency Use Authorization, a new FDA policy allows labs to immediately begin testing people, and requires that they submit their paperwork to the agency within the next 15 days. …more than a week after the country’s first case of community transmission, the most significant finding about the coronavirus’s spread in the United States has come from an independent genetic study, not from field data collected by the government.

Last but not least, a column in the New York Post summarizes the impact of federal regulation.

Overregulation of diagnostic testing has played a major role in this delay. …Test protocols using the polymerase chain reaction (PCR) were publicly available shortly after Chinese researchers published (or described) the sequence of the virus in mid-January. The World Health Organization (WHO) used a freely available German procedure to create a test kit, shipping 250,000 tests to 159 laboratories worldwide.CDC testing criteria have precluded recognizing community spread because of requirements stipulating recent travel to China or exposure to an infected person. Adherence to these guidelines delayed testing in the first probable case of community transmission… The FDA has not allowed the experienced and highly skilled professionals at public-health, academic and commercial laboratories to set up their own laboratory developed tests (LDTs), and no manufactured test kits have been authorized for sale in the US. In Europe, several companies, at least one US-based, have regulatory approval to sell test kits there.

The bottom line is that libertarians have no theoretical objection to a federal role in fighting pandemics, but we’re not very confident that we’ll get effective policies from the bloated bureaucracies in Washington.

After all, let’s not forget that the the CDC has a long track record of waste when it does get more money. And the FDA also is infamous for undermining health with excessive bureaucracy, as well as silly – and even dangerous – policies.

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Back in 2012, I shared a chart showing that workplace deaths declined substantially after the creation of the Occupational Safety and Health Administration.

But I then shared a second chart showing that workplace deaths declined just as much before OSHA was created.

The moral of my story was quite simple. Deaths primarily fell because America become much more prosperous. And there’s a lot of evidence that wealthier is healthier.

Today, let’s look at a similar example.

A study published by the National Bureau of Economic Research looks at the impact of public health measures in the early 1900s. They start by sharing some good news.

Since the mid-19th century, mortality rates in the Western world have plummeted and life expectancy has risen dramatically. Sometimes referred to as the mortality transition, this development is widely recognized as one of the most significant in the history of human welfare (Fogel 2004). Two features characterize the mortality transition. First, it was driven by reductions in infectious diseases and diseases of infancy and childhood (Omran 2005; Costa 2015). Second, it was concentrated in urban areas.

Do government policies deserve the credit?

There’s some evidence for that hypothesis.

…recent reviews of the literature emphasize the role of public health efforts, especially those aimed at purifying the water supply. For instance, Cutler et al. (2006) argue that public health efforts drove the dramatic reductions in food- and water-borne diseases at the turn of the 20th century. Similarly, Costa (2015) argues that clean-water technologies such as filtration and chlorination were “the biggest contributor[s] to the decline in infant mortality”

To be sure, there were huge public projects in the first several decades of last century. Here’s the data on sewage treatment facilities.

And here’s some data on milk purification efforts.

And the study has data on other aspects of public health as well.

The key question is whether all these efforts were successful. The three authors decided to investigate.

Using data on 25 major American cities for the years 1900-1940, the current study revisits the causes of the urban mortality decline at the turn of the 20th century. Specifically, we conduct a statistical horse race that attempts to distinguish the effects of ambitious, often extraordinarily expensive (Costa 2015, p. 554), public health interventions aimed at controlling mortality from food-and-water-borne diseases. Following previous researchers (Troesken 2004; Cutler and Miller 2005; Beach et al. 2016; Knutsson 2018), we explore the extent to which filtering and chlorinating drinking water contributed to the decline in typhoid mortality observed during the period under study and, more generally, to the observed declines in total and infant mortality. In addition, we explore the effects several other municipal-level efforts that were, at the time, viewed as critical in the fight against typhoid and other food- and water-borne diseases (Meckel 1990; Levitt et al. 2007; Melosi 2008) but have not received nearly as much attention from modern-day researchers. These interventions include: the treatment of sewage before its discharge into lakes, rivers and streams; projects designed to deliver clean water from further afield such as aqueducts and water cribs; requirements that milk sold within city limits meet strict bacteriological standards; and requirements that milk come from tuberculin-tested cows. Because the urban mortality transition was characterized by substantial reductions in infant and childhood mortality (Omran 2005) and because exclusive breastfeeding was not the norm during the period under study (Wolf 2001, 2003), improvements in milk quality seem a particularly promising avenue to explore.

But here’s the surprising result.

They did not find much evidence that public health efforts made a difference.

…our results suggest that the building of a water filtration plant cut the typhoid mortality rate by nearly 40 percent. More generally, however, our results are not consistent with the argument that public health interventions drove the extraordinary reductions in infant and total mortality observed between 1900 and 1940. Specifically, we find that efforts to purify milk had no appreciable effect on infant mortality and no effect on mortality from non-pulmonary tuberculosis (TB), which was often transmitted through infected milk. Likewise, neither chlorinating the water supply nor constructing sewage treatment plants appears to have been effective. …Our results point to other factors such as better living conditions and improved nutrition as being responsible for the sharp decline in urban mortality at the turn of the 20th century.

Here’s the chart showing that infant mortality consistently declined, largely independent of public health efforts.

I’m not suggesting, by the way, that public health spending is bad. Nor am I asserting that it’s a waste of money.

Notwithstanding some of the jokes that target libertarians, the goal isn’t to abolish every regulation or program governing safety and health. Maybe I’m a bad libertarian, but I’d pick a city with sewage treatment over one without.

But my main point is that I don’t need to make that choice. Nobody does.

The data strongly suggests that economic growth and rising levels of prosperity are the real drivers of improved health outcomes. Market-driven prosperity is what generates the wealth needed to improve public health, whether the actual delivery takes place via public or private action.

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