Sunday, May 31, 2020

What values do we bequeath to our grandchildren? Alberto Alesina et al. on the generations following the Cultural Revolution in China

In what is perhaps the last paper he completed before his recent untimely death on May 23 from a heart attack, Alberto Alesina (1957-2020) and colleagues consider how effectively the Cultural Revolution in China in disrupting the old pattern of elites, and of how it looks today in the grandchildren's generation.

Persistence through Revolutions
Alberto F. Alesina, Marlon Seror, David Y. Yang, Yang You, Weihong Zeng
NBER Working Paper No. 27053, April 2020.

The Chinese Communist Revolution in the 1950s and Cultural Revolution from 1966 to 1976 aimed to eradicate inequality in wealth and education, to shut off intergenerational transmission, and to eliminate cultural differences in the population. Using newly digitized archival data and linked contemporary household surveys and census, we show that the revolutions were effective in homogenizing the population economically and culturally in the short run. However, the pattern of inequality that characterized the pre-revolution generation re-emerges today. Grandchildren of the pre-revolution elites earn 17 percent more than those from non-elite households. In addition, the grandchildren of pre-revolution elites differ in their cultural values: they are less averse to inequality, more individualistic, more pro-market, more pro-education, and more likely to see hard work as critical to success. Through intergenerational transmission, socioeconomic conditions and cultural traits thus survived one of the most aggressive attempts to eliminate differences in the population and to foster mobility.

Saturday, May 30, 2020

Discussiong the pandemic with the Indian magazine Open

The Indian magazine Open published a brief interview with me, conducted by email:

‘Not only is wealth inequality rising, but the consequences of wealth inequality are also growing’

Here is the most interesting Q&A exchange:

"How concerned are you about the loss of jobs, especially in countries such as India where people in very low-income (informal) jobs are bearing the brunt of the lockdown? Is wealth inequality set to rise rapidly? ...
"In the near term I am very concerned by the loss of jobs. Not only is wealth inequality rising as a consequence, but also the consequences of wealth inequality are growing. Prosperous office workers can work remotely and be paid, but many manual workers can’t work remotely, and aren’t being paid."

Friday, May 29, 2020

Human Challenge Trials for COVID-19 vaccines

Yesterday I blogged about trying to speed up vaccine development and distribution by taking some of the risk out of it for pharma companies via an advanced market commitment, and today let's consider again one of the proposals being discussed  for speeding up the testing process.

Here's a white paper proposing some steps to further consider and prepare for human challenge trials (aka controlled human infection studies)  to speed up the testing of potential Covid-19 vaccines.It is put out by the organization 1 Day Sooner, which seeks to promote such trials, and has started assembling a list of volunteers in case challenge trials should become practical, to help vaccines become available sooner.

Evaluating use cases for human challenge trials in accelerating COVID-19 vaccine development
Linh Chi Nguyen , Christopher W Bakerlee, T. Greg McKelvey, Sophie M Rose, Alexander J Norman, Nicholas Joseph, David Manheim,, Michael R McLaren, Steven Jiang, Conor F Barnes, Megan Kinniment, Derek Foster, Thomas C Darton, Josh Morrison; for the 1Day Sooner Research Team

Abstract: Recently, human challenge trials (HCTs) have been proposed as a means to accelerate the development of an effective SARS-CoV-2 vaccine. In this paper, we discuss the potential role forsuch studies in the current COVID-19 pandemic. First, we present three scenarios in which HCTs could be useful: evaluating efficacy, converging on correlates of protection, and improving understanding of pathogenesis and the human immune response. We go on to outline the practical limitations of HCTs in these scenarios. We conclude that, while currently limited in their application, there are scenarios in which HCTs would be vastly beneficial and, thus, the option of using HCTs to accelerate COVID-19 vaccine development should be preserved. To this end, we recommend an immediate, coordinated effort by all stakeholders to (1) establish ethical and practical guidelines for the use of HCTs for COVID-19; (2) take the first steps toward an HCT, including preparing challenge virus under GMP and making preliminary logistical arrangements; and (3) commit to periodically re-evaluating the utility of HCTs amid the evolving pandemic.

Here's the main experimental design element:

"In HCTs, a relatively small number of healthy volunteer participants are administered a vaccine candidate or a placebo. However, unlike in conventional trials, consenting HCT participants are then administered an infectious dose of pathogen, and the outcomes of this infection is tracked. By challenging participants with pathogens under close observation in a clinical setting, HCTs can provide a unique opportunity to assess efficacy of a vaccine candidate."

And here are their concluding recommendations:

"To preserve the option to implement HCTs in scenarios such as this, we recommend an immediate, coordinated effort by all stakeholders to address the considerations outlined in this manuscript and make the necessary preparations. These include:
 1. Convening experts to discuss the ethical and practical considerations associated with HCTs for COVID-19, concluding in a set of  recommendations and guidelines for their use in the present pandemic and their role in the licensure process (which, notably, could provide guidance that is broadly useful in the event of future pandemics, too),
2. Taking the first practical steps toward an HCT, including preparing challenge virus under GMP and making preliminary arrangements with volunteers, vaccine developers, regulators, academic institutions, and clinical researchers to run HCTs in situations where they are expected to be highly useful,
3. Keeping informed of the evolving situation, periodically conducting a systematic reevaluation, and adjusting course based on the progress of the pandemic and the outcomes of the first drug and vaccine trials.

"HCTs have the potential to considerably shorten the COVID-19 pandemic, saving many lives and enabling economies and societies to return to normality. But we must act now to ensure this opportunity is not missed."

It's an admirably careful and balanced paper for one with a policy recommendation, and it sets the stage for a useful and timely debate.

As an experimenter,  I have one reservation about the proposed controls. In the passage I quoted above, they said " healthy volunteer participants are administered a vaccine candidate or a placebo," i.e. the control is a placebo.  That strikes me as potentially controversial given that the next step of the experiment is to infect the participants with Covid-19.  I might prefer a study in which the control for one vaccine was a different potential vaccine, so that no subjects were (relatively) sure to contract the disease.

But this doesn't detract from the usefulness of the preparations they recommend: conducting further discussions, and taking initial practical steps.
Here is my earlier post on this subject:

Friday, May 8, 2020 

Here's a similar in spirit paper, considering when and why human challenge trials might be appropriate, put out by the World Health Organization

Key criteria for the ethical acceptability of COVID-19 human challenge studies
WHO Working Group for Guidance on Human Challenge Studies in COVID-19
Authors:  WHO

"Overview: This document aims to provide guidance to scientists, research ethics committees, funders, policy-makers, and regulators in deliberations regarding SARS-CoV-2 challenge studies by outlining key criteria that would need to be satisfied in order for such studies to be ethically acceptable."

Here's a news story from CNN, complete with some anecdotes about the sometimes sketchy history of human challenge trials:

Thousands of people want to be exposed to Covid-19 for science
By Robert Kuznia

"Human challenge studies date all the way back to the first vaccine, for the highly lethal smallpox disease. The vaccine was developed in the late 18th century by physician Edward Jenner, who aimed to put a piece of folklore to the test: that milkmaids seemed to contract a milder form of the disease, called cowpox.
"In an experiment that today would warrant steep criminal charges, Jenner took pus from the scab of a milkmaid and inserted it into an incision on the arm of an 8-year-old boy. The child, James Phipps, developed a headache, chills and other mild symptoms, but when directly exposed to smallpox -- again through incisions on the arm -- he proved impervious."

Here's an op-ed from the Washington Post, by the philosophers Richard Yetter Chappell and Peter Singer:

Pandemic ethics: The case for experiments on human volunteers

They conclude:
"We are ethicists, not medical or biological scientists. When it comes to factual beliefs about the pandemic, we defer to expert scientific opinion, as everyone should. But what we ought to do with the facts we have, and how we should go about seeking facts we still lack, are ethical questions. Ethicists have a crucial role to play in this debate.

"There is too much that we don’t know about covid-19. The longer we take to find it out, the more lives will be lost. (That’s why the website asking for vaccine volunteers is called “1 Day Sooner.”) If healthy volunteers, fully informed about the risks, are willing to help fight the pandemic by aiding promising research, there are strong moral reasons to gratefully accept their help. To refuse it would implicitly subject others to still graver risks."

And here's a  post  from the Volokh Conspiracy (pointed out to me by Frank McCormick) focusing on the question of paying volunteers for human challenge trials:

The Moral Case for Testing Coronavirus Vaccines through "Challenge Trials" on Paid Healthy Volunteers
Doing so can potentially save many thousands of lives. And moral objections to this practice are weak. The issues here are very similar to the longstanding debate over whether we legalize organ markets.  by ILYA SOMIN .

He concludes:
"Like others who risk their lives to benefit others, challenge trial volunteers deserve our gratitude, and proper compensation for their efforts. And there is no good moral justification for forbidding them to take those risks. To the contrary, we should move ahead with challenge trials as soon as feasible. Every day of delay could literally be a matter of life and death—a great many lives and deaths."

Thursday, May 28, 2020

Advanced market commitment for a successful COVID-19 vaccine

Vaccines take a long time to develop and test, and so are risky for pharmaceutical firms to invest in. Here's a NY Times op-ed by several prominent economists suggesting that a market design solution, a government commitment in advance to support the market price of a successful vaccine, could be applied to speeding the development and widespread availability of a COVID-19 vaccine.

In the Race for a Coronavirus Vaccine, We Must Go Big. Really, Really Big.
We should commit tens of billions toward a program.
By Susan Athey, Michael Kremer, Christopher Snyder and Alex Tabarrok

"Vaccines often take 10 years to bring to market. We want a new vaccine as fast as possible, where each month matters.

The fact is that starting from the early stages of development, most vaccines fail. We cannot afford to fail, so we need to plan for success. To do that, we must think and invest as ambitiously as we can — and that means in a Covid vaccine advance market commitment.

The A.M.C. model was proposed in the early 2000s. And in 2007, the pneumococcus advance market commitment guaranteed vaccine manufacturers sales at a fixed price in return for an effective vaccine. It led to the successful development and distribution of hundreds of millions of doses of vaccine ...

"An advance market commitment for Covid-19 should combine “push” and “pull” incentives. The “pull” incentive is the commitment to buy 300 million courses of vaccine at a per-person price of $100, for vaccines produced within a specified time frame. If multiple vaccines are developed, the A.M.C. fund will have authority to choose products to purchase based on efficacy, the availability of sufficient vaccine for timely vaccination or suitability for different population groups. So firms compete to serve the first 300 million people with the most attractive vaccines, and the “pull” component provides strong incentives for both speed and quality.

"The “push” incentive guarantees firms partial reimbursement for production capacity built or repurposed at risk and partial reimbursement as they achieve milestones. The partial reimbursement ensures that manufacturers have “skin in the game,” while inducing them to build large-scale capacity before approval is certain."

Earlier post: Monday, March 16, 2020

Wednesday, May 27, 2020

Convalescent plasma collection ramps up

Here's a story from the WSJ:
Blood Banks, Pharma Join Microsoft to Sign Up Covid-19 Survivors for Plasma

"A coalition of research institutions, blood banks, drug companies and recovered Covid-19 patients is working to overcome a major challenge in developing new therapies based on survivors’ blood plasma: a shortage of donors.

"With a campaign launched Tuesday called The Fight Is In Us, the group aims to get tens of thousands of people who have recovered from Covid-19 infections to donate plasma using a self-screening tool developed by Microsoft Corp. MSFT -0.17%

"So far nearly 15,000 seriously ill Covid-19 patients have received plasma transfusions in an emergency, expanded-access program authorized by the Food and Drug Administration
"The Red Cross has collected plasma from 4,000 recovered Covid-19 donors to date through its website, according to a spokeswoman. She said the organization supports the efforts of the coalition but didn’t join it. “At this time, the Red Cross is fortunate to be able to meet the needs of our hospital partners,” she said. “We also have the capacity to ramp up our supply if necessary.”
"Despite the unusual efforts to work together, for-profit companies in the coalition also continue to look for donors on their own through digital advertising and other online outreach, according to industry experts.

"Potential donors who go to the website start by using a self-screening tool. It asks if they were diagnosed for Covid-19 infection, have been symptom-free for more than 14 days, meet age and weight requirements for blood donation and have ever been diagnosed with HIV, hepatitis C or hepatitis B, which affects eligibility. The potential donors enter a ZIP Code and get a list of nearby donation centers.

"Peter Lee, corporate vice president at Microsoft, which developed the self-screening tool, said donors are currently directed to centers based on location. Coalition members are still discussing ways to determine how donors are allocated.
"Some plasma donors might prefer to give to a for-profit plasma company, where they might be reimbursed. Others might choose a local blood bank, where the plasma would be used right away for sick patients in a hospital and reimbursement isn’t offered
"In New York and other places affected early in the outbreak, many recovered patients have encountered long wait times to donate"

Tuesday, May 26, 2020

Incentive compatibility is not enough: evidence from the Israeli matching market for psychologists, by Hassidim, Romm and Shorrer

While it has taken some time for this paper to be published, I think it was the first to discover that some applicants in a labor market clearinghouse organized as an applicant proposing deferred acceptance algorithm were systematically misrepresenting their preferences, perhaps out of confusion. (This has since been observed in other markets as well.)  Their data are from the Israeli match for psychology graduate programs, which the authors also designed and organized.

Online early in Management Science:

The Limits of Incentives in Economic Matching Procedures
Avinatan Hassidim, Assaf Romm, Ran I. Shorrer
Published Online:13 May 2020

Abstract: Organizations often require agents’ private information to achieve critical goals such as efficiency or revenue maximization, but frequently it is not in the agents’ best interest to reveal this information. Strategy-proof mechanisms give agents incentives to truthfully report their private information. In the context of matching markets, they eliminate agents’ incentives to misrepresent their preferences. We present direct field evidence of preference misrepresentation under the strategy-proof deferred acceptance in a high-stakes matching environment. We show that applicants to graduate programs in psychology in Israel often report that they prefer to avoid receiving funding, even though the mechanism preserves privacy and funding comes with no strings attached and constitutes a positive signal of ability. Surveys indicate that other kinds of preference misrepresentation are also prevalent. Preference misrepresentation in the field is associated with weaker applicants. Our findings have important implications for practitioners designing matching procedures and for researchers who study them.

Monday, May 25, 2020

India NDTV interview on coronavirus, convalescent plasma, etc. (5 minute interview by Dr. Prannoy Roy)

My 5 minutes come at 1:12, but if I've embedded this right the video should begin from there when you start it...

Sunday, May 24, 2020

Olly Williamson (1932-2020)

The great student of transaction costs, Oliver (Olly) Williamson, has died.

Here's the Berkeley obit:
Nobel laureate Oliver Williamson, pioneer of organizational economics, dies at 87

"His multidisciplinary approach to analyzing organizational structures was unconventional in economics at the time—he described it as a melding of soft social science with abstract economic theory. He looked not only at formal firm structure but at culture and social norms. Prof. Ernesto Dal Bó, the Phillips Girgich Professor of Business, called Williamson’s work “a fountain of vocation-shaping epiphanies.”

“After reading his work, we could no longer think of markets, organizations, and legal or political institutions in the same way. And so we didn’t,” Dal Bó said. “His insights are now part of the common sense of social scientists.”
He won the Nobel prize in economics in 2009: here's his autobiographical statement on the Nobel site. I was struck by this paragraph:

"Although I would not come to appreciate this last until later, there was a major difference between engineering and economics with respect to hypothetical ideals. Thus whereas assumptions of weightlessness or perfect gas laws or frictionlessness etc. served the purpose of simplification in engineering, these assumptions would give way to realities (in the form of friction, resistance, turbulence, and the like) as engineering applications were attempted. In economics, however, assumptions of frictionlessness (of which the standard assumption of zero transaction costs was one) often went unquestioned or, even worse, were invoked asymmetrically. Thus whereas markets were subject to “failures” for which corrective public policy measures were prescribed, there was no corresponding provision for failures in the public sector. A more symmetrical approach would be to recognize that positive transaction costs were the economic counterpart of friction and that all forms of organization experience such costs – albeit in variable degree (depending on the attributes of the transaction to be organized). I credit my engineering background with giving me a receptive attitude toward transaction costs, to include an interest in pinning down and working out the organizational ramifications of such costs."

Saturday, May 23, 2020

Should emergency medical supplies go to the highest bidders? (That isn't necessarily what economists think...)

Should prices clear markets for emergency medical supplies? Many economists don't think so:

Prices of Medical Supplies

"About the European IGM Economic Experts Panel
This panel explores the views of European economists on vital public policy issues. It does this by polling them on important policy questions, by including a way for them to explain their answers briefly if they wish, and by disseminating these responses directly to the public in a simple format."

Friday, May 22, 2020

What makes a market transaction morally repugnant? by Leuker, Samartzidis, and Hertwig

Here's a new working paper on repugnance, from the Max Planck Institute for Human Development in Berlin.

What makes a market transaction morally repugnant?
Christina Leuker, Lasare Samartzidis, & Ralph Hertwig
April 23, 2020

Abstract: For many people, it is morally impermissible to put kidneys, jury duty exemptions, or permits for having children on the free market. All of these are examples of repugnant transactions—market transactions that third parties want to prevent. In two studies (N = 1,554), using respondents’ judgements of 51 different market transactions across 21 characteristics, we show that repugnance can be characterized along five higher-order dimensions: moral outrage, need for regulation, incommensurability, exploitation, and unknown risk. Repugnance toward the 51 market transactions was highly consistent across two samples. Our results can help identify mismatches between public sentiments and current regulations (selling carbon emissions is currently legal but considered repugnant), anticipate responses to novel markets that have not been publicly scrutinized (often arising from technological advances, such as markets for “designer babies”), and help design less repugnant markets (e.g., by making the risks involved in a transaction known to sellers).

And, in conclusion:

"Our studies have shown that perceived repugnance is quantifiable, and that market transactions can be profiled based on their underlying psychometric properties. The extent to which certain market transactions are considered repugnant is fairly stable across different respondent samples. Perhaps the most important finding from this research is that people’s judgments of a transaction’s repugnance can reflect a range of legitimate and important concerns. These concerns can be measured and possibly harnessed to predict how the public will perceive new, rapidly emerging transactions"

Thursday, May 21, 2020

Blood and plasma: a brief history, from 1628

With all my discussion of convalescent plasma for Covid-19 this week*, here's a historical perspective on the technology and changes in medical practice since the discovery of blood circulation in 1628 that allows blood and plasma to be used in medicine.

A history of blood transfusion: a confluence of science—in peace, in war, and in the laboratory
by Kevin R. Loughlin
Hektoen International, Volume 12, Issue 2 – Spring 2020.

"Since 1628 when William Harvey discovered the circulation of blood, there had been hope that blood transfusion would be possible.
"After Harvey’s discovery, transfusion attempts began. In 1665 Richard Lower kept dogs alive by transfusing blood from other dogs.2 In 1667 French physician Jean Denys transfused nine ounces of blood from the carotid artery of a lamb into the vein of a young man. He continued the practice until the third patient so treated, died.3 Denys was sued by the wife of the deceased patient, who presumably died from a hemolytic reaction, but was exonerated. However, the French Parliament, the Royal Society, and the Catholic Church subsequently issued a general prohibition against transfusions.4

"It would not be until 1818 when transfusions were seriously considered again. A British obstetrician, James Blundell, performed a human blood transfusion in the setting of a postpartum hemorrhage.5 However, the debate over transfusions continued over the remainder of the nineteenth century. In 1849 C.H.F. Routh reviewed all the published transfusions to date and remarked in the Medical Times that of the 48 recorded cases, 18 had a fatal outcome and concluded that the mortality rate was unacceptably high.5 The next major advance in transfusion therapy would wait until the turn of the century.

"Karl Landsteiner was an Austrian physician and immunologist. While working at the University of Vienna, he became interested in blood serum work, specifically the factors that led to hemagglutination of red blood cells. This resulted in two landmark publications in 1900 and 1901 that described the evidence of blood groups that he named A, B, and C.6,7 These would later be modified to A, B, and O. Two years later, two of his colleagues, Alfred Von Decastelo and Adriano Sturli, would add a fourth blood type, AB.8,9 Landsteiner would be awarded the Nobel Prize in 1930 for his elucidation of the blood groups.

... in 1912, Doctor Roger Lee demonstrated that O blood could be given to a person of any blood type (universal donor) and that a person with AB blood could receive blood from any blood group (universal recipient).
"As blood transfusions became more widespread in medical practice, the concept of establishing blood banks became attractive. In the 1930s Bernard Fantus at Cook County Hospital20 and Carl W. Walter at Peter Bent Brigham Hospital started blood banks. In Boston, Walter’s efforts were viewed with such skepticism and disdain that his facility was relegated to a basement room at Harvard because some trustees thought the storage and use of blood was “immoral and unethical.”21 Fifteen years later he invented the plastic blood bag, which greatly facilitated transfusion therapy.21
"In 1940 Edwin Cohn developed ethanol fractionation, the process of breaking down plasma into component products. Albumin, gamma globulin, and fibrinogen were isolated to become available for clinical use.

"In 1944 dried plasma became available for the treatment of combat injuries. Component transfusion therapy became more widely used as the war progressed. The Red Cross concluded its World War II blood program in 1945 after 13 million pints had been collected.11

"In 1961 platelet concentrates became recognized for reducing mortality from hemorrhage in cancer patients. In 1964 plasmapheresis was introduced as a means of collecting plasma for fractionation. In 1971 Hepatitis B surface antigen (HbsAg) testing of donated blood began and in 1992 testing of donor blood for HIV-1 and HIV-2 antibodies commenced.

*here's a recap of my earlier coronavirus posts relating to plasma this week:

Sunday, May 17, 2020

Wednesday, May 20, 2020

Convalescent plasma collection and distribution

Efforts to collect and distribute convalescent plasma from recovered Covid-19 patients are ramping up: there are lots of options.

I donate convalescent plasma at the Stanford Blood Center, in their program on
"This exciting initiative involves taking plasma donations from recovered COVID-19 patients and transfusing that plasma into critically ill COVID-19 patients in the hopes that the antibodies present in the donated plasma will help save the lives of the recipients."

Modern plasma collection is a one-arm process: the machine on my right in the photo alternates between taking blood and returning red blood cells through the same needle (in contrast to the old technology which had blood go out of a needle in one arm and red blood cells return through a needle in the other arm).

Collecting convalescent plasma is not regulated as a research activity, it is just ordinary plasma donation. However giving it to patients is done under FDA guidance, either as a research activity or as an emergency intervention for very ill patients:
Recommendations for Investigational COVID-19 Convalescent Plasma
"Because COVID-19 convalescent plasma has not yet been approved for use by FDA, it is regulated as an investigational product."

There are three FDA-approved pathways right now by which convalescent plasma can be administered to patients.
"Pathways for Use of Investigational COVID-19 Convalescent Plasma:
1. Clinical Trials,
2.  Expanded Access "for patients with serious or immediately life-threatening COVID-19 disease"
3. Single Patient Emergency"

Here is a consortium of nonprofit blood centers, there's likely one near you if you're reading this in the States:
America's Blood Centers (association of independent blood centers)
Here's the American Red Cross effort: Plasma Donations from Recovered COVID-19 Patients

My impression is that the nonprofit blood centers don't pay donors, but are able to sell plasma to customers, including the commercial plasma industry, as part of the thriving domestic and international market in plasma. (I blogged Monday about U.S. plasma exports, all over the world, including especially countries in which compensating donors is repugnant.)
The for-profit plasma industry (which compensates plasma donors) is represented by The Plasma Protein Therapeutics Association (PPTA)
Here's an announcement about their plans for Covid-19 antibodies:
  1. CoVIg-19 Plasma Alliance Builds Strong Momentum Through Expanded Membership and Clinical Trial Collaboration
"The CoVIg-19 Plasma Alliance, an unprecedented plasma industry collaboration recently established to accelerate the development of a plasma-derived hyperimmune globulin therapy for COVID-19, is rapidly building momentum. Its membership has expanded globally to include 10 plasma companies, and now also includes global organizations from outside the plasma industry who are providing vital support to encourage more people to donate plasma.

"In addition to those announced at its inception - Biotest, BPL, CSL Behring, LFB, Octapharma and Takeda - the Alliance welcomes new industry members ADMA Biologics, BioPharma Plasma, GC Pharma, and Sanquin. Together, these organizations will contribute specialist advisory expertise, technical guidance and/or in-kind support to contribute to the Alliance goal of accelerating development and distribution of a potential treatment option for COVID-19."

"In Minnesota, a program coordinated by the Mayo Clinic has collected plasma from more than 12,000 COVID survivors for transfusion into more than 7,000 gravely ill patients, the result of a massive public appeal led by government leaders and nonprofit groups such as the Red Cross.

"Meanwhile, for-profit companies that typically pay $50 per donation of plasma used in other lifesaving therapies are advertising aggressively — and significantly bumping up their rates for COVID donors.

"In Utah, John and Melanie Haering, who contracted COVID-19 aboard the ill-fated Diamond Princess cruise ship, received gift cards worth $800 after making two donations apiece at a Takeda Pharmaceuticals' BioLife Plasma Services center. BioLife runs several of the more than 800 paid-plasma collection sites in the U.S., part of an industry that produces plasma protein therapies used to treat rare, chronic conditions such as hemophilia and in medical emergencies."

Tuesday, May 19, 2020

Surrogacy amidst the corona virus pandemic lockdowns

The coronavirus pandemic isn't only a story about disease, it's also a story about lockdowns, and restrictions on travel (among other things), especially international travel.  This is having a big, unintended effect on surrogacy markets, as surrogate pregnancies begun before the pandemic come to term. Here are two stories about the situation in the U.S. and in Ukraine.

The Guardian has the story about surrogacy in the U.S.:

Surrogates left holding the baby as coronavirus rules strand parents
The US surrogacy business is in turmoil, with parents overseas unable to pick up their baby and others unable to leave America

"Commercial surrogacy is legal in some US states, making it a hotspot for parents looking to have children through assisted reproduction. But the coronavirus travel ban has seen President Trump close the country’s borders to almost all international visitors, while a nationwide US passport office shutdown has made it impossible for parents who do manage to get into the country to obtain the necessary documentation to take their children home.

"As a result, babies are being born without their parents present at the birth (immigration authorities will only let parents in once the surrogate has given birth to the child). In at least one case, a mother flew from France to attend the birth of her child, only to be turned back by border control. Some parents aren’t being allowed in the country at all.

"Surrogates and surrogacy agencies are scrambling to look after babies themselves."
"The solution, Brisman says, is for the US immigration authorities to allow parents into the US to collect their children, and expedite the process by which they can leave the country. “I would like to see the government allow these people in quickly, and allow them home quickly,” she says. “We need expedited passports, birth certificates and visas for people whose babies are being born.”"

The NY Times has the story from the Ukraine:

100 Babies Stranded in Ukraine After Surrogate Births
Travel bans have prevented the babies’ parents from entering the country. One official says as many as 1,000 babies will be born before restrictions are lifted.

"Dozens of babies born into Ukraine’s booming surrogate motherhood business have become marooned in the country as their biological parents in the United States and other countries cannot travel to retrieve them after birth. For now, the agencies that arranged the surrogate births care for the babies.

"Authorities say that at least 100 babies are stranded already and that as many as 1,000 may be born before Ukraine’s travel ban for foreigners is lifted.

“We will do all we can to unite the children with their parents,” Albert Tochilovsky, director of BioTexCom, the largest provider of surrogacy services in Ukraine, said in a telephone interview.
"Ukraine does not tally statistics on surrogacy, but it may lead the world in the number of surrogate births for foreign biological parents, Mr. Tochilovsky said. His company alone is awaiting about 500 births. Fourteen companies offer the service in Ukraine.

"Ukraine is an outlier among nations, though not alone, in allowing foreigners to tap a broad range of reproductive health services, including buying eggs and arranging for surrogate mothers to bear children for a fee. The business has thrived largely because of poverty.

“The cheapest surrogacy in Europe is in Ukraine, the poorest country in Europe,” BioTexCom’s website explains. Surrogate mothers in Ukraine typically earn about $15,000.

"Some members of Parliament who have long opposed the business have renewed their calls for banning surrogacy services for foreigners now that the babies are stacking up without parents.

"Surrogacy is available in Ukraine only if a woman in a heterosexual partnership can demonstrate that she cannot bear children herself.
"The babies’ parents are now in the United States, Italy, Spain, the United Kingdom, China, France, Romania, Austria, Mexico and Portugal, the company said.

"Lyudmila Denisova, a human rights ombudsman for Ukraine’s Parliament, said the stranded babies underscore a pressing need for the country to bar foreigners from hiring Ukrainian women as surrogate mothers.

"A human rights official in the presidential administration, Nikolai Kuleba, has also demanded an end to the practice. “Ukraine is just turning into an online store for little ones,” he said."

Monday, May 18, 2020

Qingyun Wu defends his dissertation--remotely

Qingyun Wu successfully defended his dissertation at Stanford today, remotely, as we are all sheltering in place from the coronavirus pandemic.

He presented three papers, the screenshot above is from the third.

1. The lattice of envy-free matchings." Games and Economic Behavior 109 (2018): 201-211.
2 Entering Classes in the College Admissions Model." 
3 "Forbidden Transactions and Black Markets." 

Welcome to the club, Qingyun.

Plasma and plasma products (such as antibodies) are a big business (and the U.S. dominates the international market)

These days I'm thinking about corona virus covid-19 convalescent blood plasma, which I blogged about yesterday, and about which I hope to say more soon. But that has gotten me to think again about blood plasma generally, which is a source of many therapies, including antibodies, immunoglobulins, that defend against a large variety of diseases.

The U.S. is the Saudi Arabia of blood plasma and plasma products, with both a large domestic commercial market and annual exports valued in the billions of dollars. The reason is largely that it is legal in the U.S. to pay plasma donors, so there's ample supply through a big network of hundreds of  for-profit and nonprofit blood and plasma centers (the nonprofits mostly don't pay donors, I think). In many countries, paying their residents for plasma is repugnant and illegal. Fortunately for their citizens, they mostly don't also suffer from severe shortages of life-saving plasma medicines, because it can be bought from the U.S. (See e.g. my posts on Canada's plasma policies.)

Here are some relevant export figures. They make clear that the U.S. exports billions of dollars of plasma, and tens of billions of dollars of plasma products.

For those who would like to study these data, let me explain where they come from.  (They  include some things that aren't plasma products, and may miss some that are...) It's not so easy to find the U.S exports of exactly blood plasma and plasma products (I needed some help).

In Chapter 30 of the U.S. International Trade Commission (USITC) Harmonized Tariff Schedule (HTS),is the code:
HTS 3002: "Human blood; animal blood prepared for therapeutic, prophylactic or diagnostic uses; antisera, other blood fractions and immunological products, whether or not modified or obtained by means of biotechnological processes; vaccines, toxins, cultures of micro-organisms (excluding yeasts) and similar products:
 Antisera, other blood fractions and immunological products, whether or not modified or obtained by means of biotechnological processes"

That sounds good, but it includes (aside from plasma products) things that I don't want to include e.g. Malaria diagnostic test kits, and Fetal Bovine Serum.

On the other hand the subcategory 3002.12.00  is for "Antisera and other blood fractions" which includes sub-subcategories for things I do want to include:
3002.12.10 Human blood plasma.
3002.12.20 Normal human blood sera, whether or not freeze-dried
3002.12.30 Human immune blood sera

And then there are are codes 3002.13.00, 14.00, and 15.00 which cover the promising (very similar) categories in which most of the immunoglobulins are probably found, but maybe some other things too:

Immunological products, unmixed, not put up in measured doses or in forms or packings for retail sale
Immunological products, mixed, not put up in measured doses or in forms or packings for retail sale
 Immunological products, put up in measured doses or in forms or packings for retail sale.

The place to go to turn these numbers into export figures is  (But getting data there isn't completely straightforward, and I got help from Julia Fabens.)  The table above shows that whole plasma itself has over $2 billion of annual exports from the U.S., and together with plasma products, including those involving antibodies (immunological products) there are almost $20 billion of exports from the U.S.

So, I'm guessing that soon, if clinical trials show that antibodies against covid-19, are useful, they will become readily available, commercially, in plasma and in pharmaceuticals.  A year ago, those human antibodies didn't exist, and so there was no way to use it to help patient zero or the next many thousands.  But now there's a lot of it, more each day, in the blood of recovered patients.  And there's a whole industry devoted to collecting it and purifying the antibodies into "immunological products." 

I hope human antibodies against covid-19 are clinically useful, to help mitigate and cure the disease if not to prevent it, because my sense is that a vaccine is (at least) many months away.
102,597,746 2,627,504 1,586,634
102,597,746 2,627,504 1,586,634

Sunday, May 17, 2020

Cascades of convalescent plasma for Covid-19, and chains of exchanges, by Kominers, Pathak, Sönmez, and Ünver

Covid-19 convalescent plasma is a new thing in the world, that came into existence only when the first human was infected and recovered from the Covid-19 disease that is now pandemic. It isn't clear yet whether it will be clinically valuable, but recovered antibodies have been valuable for some other diseases, so there's excellent reason to hope that will be the case now too.  And as the number of people grows who have recovered from Covid-19, it is likely that the supply of antibodies is growing much faster, since antibody-containing plasma can be donated once a month or so. (There are  ongoing studies of antibody production by recovered patients, examining how long the antibodies remain at high levels, post-recovery). Of course, most of that supply is sequestered in the blood of recovered patients, so there's a non-trivial issue of collection and distribution.

As readers of this blog know, many countries prohibit the sale of plasma. Will Americans continue to support a commercial market for Covid-19 convalescent plasma in the current pandemic?  A distinguished group of market designers has written a paper considering how to apply techniques developed for kidney exchange to the task of collecting convalescent plasma from recovered Covid-19 patients, if it becomes impossible to buy and sell it. In particular, they consider how to create chains of donations, without using money, to overcome the shortages they anticipate.

Here's an easy to read account by Scott Kominers, one of the authors.

Scott Duke Kominers, Bloomberg News  May 11, 2020

"convalescent plasma is in short supply: although it’s hard to estimate precisely, some statistics suggest the U.S. may need twice as much as we have on hand.

"In a new paper, Parag A. Pathak, Tayfun Sonmez, M. Utku Unver and I propose a market design strategy that could help close the gap. Our approach makes use of two special features of the way plasma donation works.

"First, convalescent plasma is collected from recently recovered patients, which means that today’s patients become tomorrow’s prospective donors, assuming they manage to beat the virus. ... That suggests the shortage isn’t from lack of potential supply.

"Second, plasma donation is more than one-for-one: the typical donor can give enough plasma at one time for multiple treatments, and they can potentially donate more than once. As a result, assuming plasma therapy does help patients recover, there is a so-called flywheel effect: the more we use the treatment, the more plasma is available -- provided enough recovered patients are willing to donate.

"Many people would like to donate plasma to help a loved one, but can’t for various reasons:  Their blood types might be incompatible or they might live far away and be unable to travel. To address these sorts of obstacles, my collaborators and I suggest that each plasma donor could receive a voucher that can be used to give a family member or friend priority for plasma treatment. Because donation is more than one-for-one, it’s possible to honor vouchers while still increasing the pool of plasma available to treat other patients.
"A similar analysis suggests a role for a pay-it-forward system, where we make a point of treating patients who pledge to donate plasma, assuming they recover and are medically able to do so. Because recovered patients can typically donate more plasma than was needed for their own treatment, this again can help increase the plasma supply in the long run. As a result, my collaborators and I show that, somewhat paradoxically, prioritizing patients who pledge to donate can still end up expanding treatment for the patients who are unable to pledge, or just choose not to.

"Both of these policies are similar to systems we’ve used to expand kidney donation in the U.S.: Priority vouchers are sometimes granted when a living donor gives a kidney to a third-party before one of their family members needs a transplant. And pay-it-forward incentives are used in kidney exchange chains, where a patient with a medically incompatible prospective donor receives a kidney from a third-party donor, and then their donor later gives a kidney to some other patient."
Here is the paper itself:

Paying It Backward and Forward: Expanding Access to Convalescent Plasma Therapy Through Market Design
Scott Duke Kominers, Parag A. Pathak, Tayfun Sönmez, M. Utku Ünver
NBER Working Paper No. 27143
Issued in May 2020

Abstract: COVID-19 convalescent plasma (CCP) therapy is currently a leading treatment for COVID19. At present, there is a shortage of CCP relative to demand. We develop and analyze a model of centralized CCP allocation that incorporates both donation and distribution. In order to increase CCP supply, we introduce a mechanism that utilizes two incentive schemes, respectively based on principles of “paying it backward” and “paying it forward.” Under the first scheme, CCP donors obtain treatment vouchers that can be transferred to patients of their choosing. Under the latter scheme, patients obtain priority for CCP therapy in exchange for a future pledge to donate CCP if possible. We show that in steady-state, both principles generally increase overall treatment rates for all patients—not just those who are voucher-prioritized or pledged to donate. Our results also hold under certain conditions if a fraction of CCP is reserved for patients who participate in clinical trials. Finally, we examine the implications of pooling blood types on the efficiency and equity of CCP distribution.

Here's some of the motivation for their model:
"There is an active debate in economics and philosophy on the appropriate role of market-based
mechanisms with compensation for human products used in medicine or medical research like kidneys, blood, blood products, sperm, breast milk, bone marrow, and other.11 Since, as far as we know, there is no current market where infected patients can buy CCP or where recovered patients can sell CCP, we do not consider this possibility as part of our model.
"Because CCP is a form of plasma, a natural question is whether a compensated market for CCP will develop. In our model, there is no option to pay to receive CCP or be paid for donating CCP, but a donor can designate the voucher in our model to particular patient in need. As a result, our model of CCP falls between the two extremes described above. We expect that in a crisis moment, there is unlikely to be an active compensated market for CCP (even though it may be impossible to fully prohibit resale of vouchers). If a price-based market does develop, society may deem it unacceptable."

I am more optimistic than they are about the likely available supply of convalescent plasma if it proves useful, through existing commercial channels. My optimism is based on the large thriving commercial market for plasma and plasma-derived antibodies in the U.S., and around the world.  I'll try to blog about the general plasma and antibody (immunoglobulin) market tomorrow, and perhaps more on Covid-19 antibodies later this week.

Saturday, May 16, 2020

Transplants dropped as Covid-19 rose, in France and the U.S.

In France, even more than in the U.S., kidney transplants were considered elective surgery.

In the Lancet:

Organ procurement and transplantation during the COVID-19 pandemic
Alexandre Loupy, Olivier Aubert, Peter P Reese, Olivier Bastien, Florian Bayer, Christian Jacquelinet
Published:May 11, 2020

Here is a set of figures showing "Trends in COVID-19 spread over time in France and the USA and recovery of organs and solid-organ transplantation procedures from deceased donors" (The top two figures are France, the bottom two US)

Here's an updated snapshot of American transplants from UNOS, for all organs:

and for kidneys:

Friday, May 15, 2020

Search and matching models of marriage (with emphasis on search or on matching)

Often when economic theorists (particularly matching theorists) speak of "marriage" we don't mean the real thing, we mean a metaphor embodied in a simple one-to-one model of matching. But marriage is a very real thing, and matching models of various sorts are used to study it.  Here's a survey from the Annual Review of Economics, by one of the leaders of this literature.

The Theory and Empirics of the Marriage Market by  Pierre-André Chiappori

"the economic analysis of the marriage will aim at answering two sets of questions: (a) Who marries whom? and (b) How are the benefits distributed between spouses? Mostly, these questions have been analyzed using either of two different frameworks: frictionless matching theory and search models. The basic distinction between the two is related to the emphasis that is put (or not) on frictions in the description of the market. In search models, frictions are paramount. Typically, each individual sequentially and randomly meets one person of the opposite gender; after such a meeting, both individuals must decide whether to settle for the current mate or continue searching. The latter option involves various costs, from discounting to the risk of never finding a better partner. If both individuals agree to engage in a relationship (which can be marriage or, in some models, cohabitation), then a negotiation begins on the way the surplus is shared.

"Matching models, on the contrary, assume a frictionless environment. In the matching process, each woman (say) is assumed to have free access to the pool of all potential men, with perfect knowledge of the characteristics of each of them—and vice versa. In other words, matching models disregard the cost of acquiring information about potential matches as well as the role of meeting technologies of all sorts (from social media to head hunters and from dating sites to pure luck).

I haven't absorbed the whole paper yet, but the introduction reminded me of the plurality of approaches to studying search and matching (not just restricted to the study of marriage). Chiappori shares the view that the big difference between search models and matching models is that matching models are "frictionless," they assume away all the search frictions that are the subject of search models. 

Search models, on the other hand, concentrate on search effort, and take the actual matching technology to be random meetings. (To my mind, that's vastly different from taking account of the actual technology of matching, which is central to the market design literature on matching.)

The 2010 Nobel prize in Economics went to Diamond, Mortensen, and Pissarides, the founders of the search and matching macro literature "for their analysis of markets with search frictions." I recall that Dale Mortensen expressed the view that one of their big contributions was to notice that matching could be regarded as a "black box," rather than being studied explicitly, i.e. that actual matching didn't need to be incorporated in the model. Here's a 2001 paper from the JEL that discusses that:

Looking into the Black Box: A Survey of the Matching Function
Barbara Petrongolo and Christopher A. Pissarides
Journal of Economic Literature Vol. 39, No. 2 (Jun., 2001), pp. 390-431

" The matching function summarizes a  trading technology between agents who  place advertisements, read newspapers and  magazines, go to employment agencies,  and mobilize local networks that eventually bring them together into productive matches. The key idea is that this  complicated exchange process is summarized by a well-behaved function that  gives the number of jobs formed at any  moment in time in terms of the number  of workers looking for jobs, the number  of firms looking for workers, and a  small number of other variables.

" The matching function is a modeling  device that occupies the same place in  the macroeconomist's tool kit as other  aggregate functions, such as the production function and the demand for money  function."
That work, which is focused on search and which treats matching as a black box, provides some big insights. For example, if search is costly but the benefits of matching are shared equally by the one who searches and the one who is found, then there can be free riding in the form of too little search, and hence unemployment by qualified job seekers at the same time that there are unfilled positions, and unsold houses at the same time as there are people who would actually like to buy them.

But models of matching via aggregate matching functions or via random matching are nowhere near the level of detail that allows the kind of micro-micro economics that market designers practice in analyzing marketplaces or in trying to design them. I'm mostly talking about markets that resemble labor markets more than marriage, but dating sites are marketplaces designed for something related to marriage, and there are some explicitly matrimonial sites. Much of what makes one dating site different from another is how they deal with congestion and other frictions.

A not-atypical market design project begins with an analysis of matching in an existing system,  focused on precisely the details of how matching occurs. A next step is that designers sometimes take responsibility for redesigning those details, or aspects of them, to reduce frictions in marketplaces e.g. for labor, schools,  kidneys, MBA courses, financial exchanges, dating sites themselves, etc.

I think there has been too little intersection between those who study search with random matching and those who study matching without explicitly modeling the costs of search. (That isn't to say that there aren't people working and making progress in that intersection.)  Possibly one barrier is a misunderstanding between these two groups of what the models are good for.

Thursday, May 14, 2020

Does the porn industry provide a model for disease testing and contact tracing to end corona virus lockdowns?

The adult film industry--which produces films in which performers engage in sex with one another--has a testing service called PASS (Performer Availability Screening Services) intended to control the spread of sexually transmitted diseases on film sets.

"Testing facilities screen patients for HIV using the Aptima HIV-1RNA Qualitative Assay test. Other tests on a full performers’ panel also include Chlamydia, gonorrhea, hepatitis B & C, trichomoniasis, and syphilis."

Stat provides some detail:
Why the porn industry has a lot to teach us about safety in the Covid-19 era

"Since the late 1990s, when an outbreak of HIV infections threatened to shutter the multibillion-dollar industry, the mainstream porn community has implemented procedures that require all performers to be tested for HIV and a host of other sexually transmitted infections every 14 days before they can be cleared to work. Any HIV-positive test leads to an immediate shutdown of all U.S. sets, followed by detailed contact tracing before sets can reopen.
"In the 20 years it has been in place, PASS has met, and overcome, many of the same challenges that any large-scale coronavirus testing program might encounter, from issues of keeping databases of private medical information secure, preventing the forging of test results, dealing with false positive results, and educating workers about the need for repeated testing to keep workplaces safe.
"“You could imagine TSA verifying someone had tested negative before they were allowed on a flight,” he said. “Testing is particularly important for areas that are high risk, like airplanes or meatpacking plants.”
"Mike Stabile, communications director for the Free Speech Coalition, the adult entertainment trade association that runs PASS, said the adult film industry understands “better than most the discussion that has to happen for businesses to reopen.”

"Yet for all of that expertise, it would be hard to imagine the Trump administration, or state politicians, reaching out to the porn industry for guidance.
"Repeat testing will be necessary for the coronavirus, too, because — like with HIV — there is so much asymptomatic spread of the coronavirus, said Elizabeth “Betz” Halloran, a professor of biostatistics at the University of Washington who directs the Center for Inference and Dynamics of Infectious Diseases at the Fred Hutchinson Cancer Research Center in Seattle.

“You’ll have to keep testing, maybe every 10 days. We need simpler tests that people can just do at home,” said Halloran, who envisions a low-cost “10-pack” of tests for home use."

Wednesday, May 13, 2020

College admissions, late in the season

Each year, around this time of year, as the main round of college admissions comes to a conclusion, NACAC (the National Association for College Admissions Counseling) publishes a list of colleges that still have positions for qualified students.  Here's this year's listing:


"NACAC’s annual College Openings Update: Options for Qualified Students (formerly the Space Availability Survey) is a voluntary listing of NACAC member postsecondary institutions that are still accepting applications from prospective freshman and/or transfer students for the upcoming fall term. Now in its 33rd year, the College Openings Update is designed as a tool for counselors, parents and others assisting students who have not yet completed the college admission process. Typically, colleges will continue to join the update after the May 5 public release date, so check back periodically to see additional colleges still accepting applications."

Tuesday, May 12, 2020

Confusion in NYC high school wait lists

In August, the New York City Department of Education announced a change in the school choice assignment process--without announcing any details.  But the plan was that after the initial run of the deferred acceptance algorithm, they would institute some sort of wait lists. I blogged about it at the time, and was concerned by the lack of detail.

Here's a current story from Chalkbeat that suggests that the details are still opaque, but that families are learning that the waitlist position they were given isn't reliable:

How can you move back on a waiting list?’: NYC’s high school admissions tweaks spark confusion
By Alex Zimmerman  May 8, 2020

"students vying for the city’s most coveted schools are discovering that their position on high school waitlists can worsen over time, a situation that has come as a surprise to some families — adding anxiety to an admissions process that is already famous for its complexity.
"Every student who fills out an application and does not get into their top choice is automatically waitlisted. If you get your third choice school, for example, you’ll be on the waitlist for your No. 1 and 2 choices. Nearly 44,000 students did not get into their first choice high school this year, automatically placing them on at least one waitlist.

"The second way is that students can add themselves to any waitlist once the initial matching process is over, even for schools a student didn’t initially apply to.

"In general, students who initially applied to a school but didn’t get in and are automatically added to its waitlist should be ranked ahead of students who add themselves later on, officials said. But there are exceptions.

"The first major exception is if a student is in a higher priority group than someone who is already on the waitlist. Some schools, for instance, give preference to students who live in certain neighborhoods, which can override a student’s position on the waitlist even if they were added first. (Officials said this is the most common reason a student would see their position worsen.)

"Olga Ramos, the admissions director at Bard High School Early College Queens, pointed to a second reason families can move backward — something that surprised her at first.

"If a student got into their first choice school, and listed Bard as their second choice, they could still add themselves to Bard’s waitlist and be considered as if they had been automatically added — potentially bypassing students who were already on the list."

Here's an earlier story in Chalkbeat by Mr. Zimmerman, indicating that the system was still pretty opaque as the school choice process got ready to announce admissions in March:

NYC high school offers are coming this week with a big change: waitlists. Here’s what you should know.  By Alex Zimmerman  Mar 18, 2020

Here's what was known then...

"What are these waitlists, anyway?
"New York City students must apply to high school, listing up to 12 schools they want to attend. A complicated algorithm, developed by a Nobel prize-winning economist, then matches a student to one of their choices.
"That fundamental algorithm is not changing. But for the first time this year, any student who does not get into their first choice school will automatically be added to the waitlist of every single higher-ranked school they didn’t get into.
"Every school that has more applicants than seats will have a waitlist. It’s a similar model that the education department uses for pre-K, kindergarten, and middle schools — something education department officials said is an advantage."
Here's a story from the time of the initial announcement:

Goodbye round two applications, hello waitlists: NYC announces changes to high school admissions
By Christina Veiga and Alex Zimmerman   Aug 15, 2019

"Starting next year, the city will allow students to sit on waiting lists for schools they wanted to attend, but didn’t get into. The city is also eliminating the second round of admissions, which it now uses to for students who aren’t matched to a school they applied to during the typical process.
"“It’s like going to a store and getting the ticket, you know what number you are, and you know how many folks are ahead of you, and you’ll be able to watch the process go,” said Deputy Chancellor Josh Wallack. “You’ll also be able to talk with an administrator in a school who can give you a sense of how much waitlists move each year and that varies a bit by school.”

I'm still confused about a different issue that I haven't yet seen addressed. In the original school choice system using the deferred acceptance algorithm, there was a second round in which students unmatched in the first round were asked for additional preferences over schools, so that they could be matched.  How were those unmatched students assigned to schools this year?

Here's my August post:

Friday, August 16, 2019 

Monday, May 11, 2020

Double bubble: Locking up with exactly one other household during lock down

You thought your hard interpersonal decisions ended in high school, or when you married?  Not if you live in parts of Canada, where households will now be allowed to expand their social-distancing radius to include exactly one other household.

The WP has the story:

Canadian provinces allow locked-down households to pair up — threatening hurt feelings all around

"While jurisdictions around the world begin to relax their coronavirus restrictions, a handful are pioneering a novel — and potentially fraught — approach: The double bubble.

"There are rules — and they are not for the commitment-phobic. Each household may join with only one other household. Both sides must agree — for better, for worse — to a mutually exclusive relationship. The decision applies to all members of both households. And it’s final.
"The arrangement isn’t unique to Newfoundland and Labrador. New Brunswick has also introduced it. So has New Zealand. And the English Channel island of Guernsey.

Sunday, May 10, 2020

Buying and selling blood plasma, with focus on Canada, continued

Peter Jaworski writes:

"I had a video with Big Think come out recently where I defend paying for plasma against a number of objections. It’s a bit on the long side (17 minutes), but I thought you might be interested in posting it to your blog:

"I also had an opinion piece on the same topic published in the National Post (with Kate Vander Meer, who is a patient that used plasma therapies):"

From the video transcript:

"Out of all the countries in the world only the ones that pay people to make that donation are self-sufficient in plasma therapies. And even the ones that pay not all of them are, in fact, sufficient. So there are only seven countries in the world that legally permit paying people for plasma donations – Germany, Austria, Hungary, Czechia or the Czech Republic, parts of Canada. And I'll talk about Canada in a second. The United States, of course, and China. Those are the seven countries in the world that permit payment. Every other country that does not allow payment for plasma donations imports plasma therapies that make use of plasma primarily from Americans. Germans as well, but primarily Americans. "
And here's the op-ed:

Opinion on COVID-19: Canada needs to pay plasma donors to protect its domestic supply
Kate Vander Meer and Peter Jaworski: In order to ensure that enough people are willing to give plasma to meet the ever-expanding need, we must urgently adopt a pay-for-plasma model here at home

"There’s no evidence that anything other than paying for plasma will work. According to an expert panel formed by Health Canada in 2018, paid donors in countries that permit payment are responsible for providing 89 per cent of the plasma used to make therapies, with the United States alone providing 70 per cent of the global supply. The panel also revealed that no country in the world that forbids paid donations collects enough plasma to meet its needs — not one!"

Saturday, May 9, 2020

Repugnant but legal: can strip shows and payday lenders get Paycheck Protection Program support in the pandemic?

The Washington Post has the story:

Strip clubs, payday lenders, lobbyists fight to get emergency federal loans
In wave of lawsuits, companies battered by coronavirus shutdowns but excluded from aid seek small-business funds

"The Little Darlings strip club in Flint, Mich., was forced to turn off its stage lights and close its doors by the state’s stay-at-home order, but it failed to get a federal small-business emergency loan aimed at softening the financial blow from the pandemic.

"Owners of Little Darlings, along with clubs such as Baby Dolls in Dallas and Cheerleaders Gentlemen’s Club in Philadelphia, said it was wrong that they were excluded from the more than $600 billion Paycheck Protection Program created by Congress and the Trump administration to try to save businesses and jobs during the coronavirus crisis.

"So the strip clubs sued the Small Business Administration. And a federal judge in Wisconsin recently sided with the strip clubs, granting a preliminary injunction to force the government to issue loans to four of them, which government lawyers quickly appealed."

Friday, May 8, 2020

Human Challenge Trials (aka Controlled Human Infection studies) for corona virus vaccines

What do we want?  A vaccine for covid-19.

When do we want it?  After clinical trials and peer review.

How can we get it faster?  By asking healthy young (not at too much risk) volunteers to permit themselves to get infected with covid-19, so we can try out vaccine candidates.

Is that crazy?  Well, maybe not. (But not everyone is sure of that.)

Here's a recent paper considering the proposal.

Human Challenge Studies to Accelerate Coronavirus Vaccine Licensure 
Nir Eyal, Marc Lipsitch, Peter G Smith
The Journal of Infectious Diseases, jiaa152,
Published: 31 March 2020

Abstract: Controlled human challenge trials of SARS-CoV-2 vaccine candidates could accelerate the testing and potential rollout of efficacious vaccines. By replacing conventional phase 3 testing of vaccine candidates, such trials may subtract many months from the licensure process, making efficacious vaccines available more quickly. Obviously, challenging volunteers with this live virus risks inducing severe disease and possibly even death. However, we argue that such studies, by accelerating vaccine evaluation, could reduce the global burden of coronavirus-related mortality and morbidity. Volunteers in such studies could autonomously authorize the risks to themselves, and their net risk could be acceptable if participants comprise healthy young adults, who are at relatively low risk of serious disease following natural infection, if they have a high baseline risk of natural infection, and if during the trial they receive frequent monitoring and, following any infection, the best available care.

Here's another paper, in Science, 07 May 2020, by a big group of authors consisting of medical ethicists and physicians: they think it might be ok.

Ethics of controlled human infection to study COVID-19
Seema K. Shah, Franklin G. Miller, Thomas C. Darton, Devan Duenas, Claudia Emerson, Holly Fernandez Lynch, Euzebiusz Jamrozik, Nancy S. Jecker, Dorcas Kamuya, Melissa Kapulu, Jonathan Kimmelman, Douglas MacKay, Matthew J. Memoli, Sean C. Murphy, Ricardo Palacios, Thomas L. Richie, Meta Roestenberg, Abha Saxena, Katherine Saylor, Michael J. Selgelid, Vina Vaswani, Annette Rid

 Abstract: High social value is fundamental to justifying these studies

 Here are the articles opening lines:

"Development of an effective vaccine is the clearest path to controlling the coronavirus disease 2019 (COVID-19) pandemic. To accelerate vaccine development, some researchers are pursuing, and thousands of people have expressed interest in participating in, controlled human infection studies (CHIs) with severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2) (1, 2). In CHIs, a small number of participants are deliberately exposed to a pathogen to study infection and gather preliminary efficacy data on experimental vaccines or treatments. We have been developing a comprehensive, state-of-the-art ethical framework for CHIs that emphasizes their social value as fundamental to justifying these studies. The ethics of CHIs in general are underexplored (3, 4), and ethical examinations of SARS-CoV-2 CHIs have largely focused on whether the risks are acceptable and participants could give valid informed consent (1). The high social value of such CHIs has generally been assumed. Based on our framework, we agree on the ethical conditions for conducting SARS-CoV-2 CHIs (see the table). We differ on whether the social value of such CHIs is sufficient to justify the risks at present, given uncertainty about both in a rapidly evolving situation; yet we see none of our disagreements as insurmountable. We provide ethical guidance for research sponsors, communities, participants, and the essential independent reviewers considering SARS-CoV-2 CHIs."

Kim Krawiec points out to me that, among the things the authors disagree about among themselves is compensation to donors:
"Members of our group disagree about the ethical permissibility of offering payment to CHI participants, and there may be relevant regulatory limits in different jurisdictions. Nevertheless, as SARS-CoV-2 CHIs require confinement and follow-up, fairness seems to demand offering participants compensation for their time. This may total several thousand dollars in the United States, assuming compensation at a fair minimum wage for unskilled labor, as in other CHIs. By contrast, incentives beyond compensation could be avoided, given the number of people already indicating willingness to participate. Concerns that the undue influence of monetary compensation compromises risk judgments are unsupported by the available data, as financial motivations are associated with greater attention to risk (15). Moreover, a rigorous informed consent process could maximize understanding. In case payment tempts participants to withhold disqualifying information, eligibility criteria should be objectively verifiable."

And here is a group of activists, at an organization called 1 Day Sooner.
You can sign up here*,

COVID-19 Human Challenge Trials
"Human challenge trials deliberately expose participants to infection, in order to study diseases and test vaccines or treatments. They have been used for influenza, malaria, typhoid, dengue fever, and cholera. Researchers are exploring whether human challenge trials could speed up the development of a vaccine for COVID-19, saving thousands or even millions of lives."

*"Sign up here if you may wish to participate in a human challenge trial for COVID-19 if one were to occur, and, potentially, advocate for safe and rapid vaccine development. "