A Health Economist to lead the NIH – The Health Care Blog

By SAURABH JHA

Early on in the COVID-19 pandemic a seroprevalence study from Santa Clara indicated that the viral spread was far greater than was believed. The study suggested that the infection fatality rate (IFR) was much lower than the case fatality rate and perhaps even lower than the suspected IFR. The researchers estimated that 2.8% of the county had been infected by April 2020. The virus was contagious and, most importantly, caused many asymptomatic infections.  

The study, released as a preprint within a month of the lockdown, should have been published by the NEJM or Lancet. The specificity of the immunoassay was a whopping 99.5% and could not have been lower than 98.5%. Instead, it was roundly criticized by born-again methodological purists. Noted statistician, Andrew Gelman, known expert at dealing with (very) imperfect statistical methods, wanted an apology from the researchers for wasting everyone’s time by making “avoidable screw ups.”

Around the same time, a similar study published in JAMA came to similar conclusions. Researchers found that the seroprevalence COVID-19 antibodies in LA county was 4.65%, 367 000 adults had SARS-CoV-2 antibodies, substantially greater than the 8430 confirmed infections. They concluded that “contact tracing methods to limit the spread of infection will face considerable challenges.” No one asked the researchers for an apology, presumably because the study had passed anonymous peer review and had escaped the wrath of the medical commentariat.

A few months later, a German study suggested that many infected with COVID-19 had myocarditis. This meant that the asymptomatic were not just reservoirs of viral transmission, but walking tombs of cardiac doom. By many, the researchers, who used cardiac MRI to look for myocarditis, put a figure at nearly 80%. That’s a lot. No virus had ever done that. That number itself should have invited scrutiny. The animated, born-again empiricists, who has been energized by the Santa Clara study into becoming methodological sleuths, went into hibernation after the German myocarditis study. The study was swallowed uncritically by many and was covered by the NY Times.

If the rigor demanded of the Santa Clara study was that of a Pythagorean proof, the German myocarditis study received the scrutiny of a cult prophet. The burden of proof in them days was like shifting sand, which shifted depending on the implications of the research. The Santa Clara study suggested the test – isolate strategy was forlorn, as controlling the viral spread was akin to chasing one’s tail. The German myocarditis study was cautionary, emphasizing that that the virus should not be under estimated, as even asymptomatic infections could be deadly. The Santa Clara study challenged lockdowns, the German study supported lockdowns.

The senior author of the Santa Clara study, Jay Bhattacharya, has been nominated by President Trump to be the next NIH director. His nomination has surprised a few, upset a few, irritated a few, shocked a few and, as befits a polarized country, pleased many. Bhattacharya may well have won the popular vote, though I’m uncertain he will win the institutional vote.

Bhattacharya’s anti-lockdown views rapidly made him a persona non grata in academic circles.

But he was no slouch, but a Stanford health economist, with an MD and a PhD, who had researched human behavior during pandemics, the sort of academic who makes health policy, who once advocated for improved access to Hepatitis C treatment. He believed that the lockdowns caused more harm than good. You may disagree with him and I certainly do – I believe early lockdowns did save lives ( I’m unsure of the efficacy of the later lockdowns). However, to hold Bhattacharya’s premise as fringe is itself a sign of how unhinged the medical fraternity became during the pandemic.

Bhattacharya was guilty of thinking like an economist, of always asking about trade-offs, of weighing the harms against the benefits of public policies, including lockdowns. What was remarkable was that many public policy experts, such as the celebratory economist, Justin Wolfers, saw little trade-offs between lives and the economy in the early lockdown. I get the allure of that position. Once you deny trade-offs you don’t have to make hard decisions, even in thought experiments in your head. It’s cognitively appealing.

I had a long conversation with Bhattacharya during the pandemic. There were many things we disagreed about. Bhattacharya viewed lockdowns as a black swan event. He believed that lockdowns could cause societal upheaval, a Hobbesian breakdown of the delicate forces which maintain social order. I have no idea if he was right. Thanks to Operation Warp Speed, which enabled vaccine development in record time and ended the pandemic, we never had to find out. But was Bhattacharya’s belief fringe, like “earth is flat” fringe, or was it “I don’t like your opinion and therefore I will call you a Nazi” type of fringe?

His nomination is ironic, and certainly karmic, as there was a concerted effort to discredit Bhattacharya after he spoke against the lockdowns and was one of the signatories of the Great Barrington Declaration which advocated focused protection. Bhattacharya was shadow banned by Twitter’s moral police. The ham-fisted attempts to censor him backfired spectacularly. Instead, of being consigned to irrelevance, Bhattacharya’s fame grew – it was the Streisand Effect on steroids. He was not censored in the Stalin/ Mao/ Starmer version of censorship. But academia did something else. They ignored him, were unwilling to debate him, considered him beneath their dignity to engage respectfully, but spoke about him incessantly on Twitter. Alas, this was a missed teaching moment. A rigorous, moderated, structured scientific debate between Bhattacharya and a lockdown advocate, such as Ashish Jha, would have been valuable, mostly for Bhattacharya’s critics who now appear like that angry old man yelling at the clouds.

The major criticism of Bhattacharya is that he under estimated the pandemic death count. Few academics emerged from the pandemic unblemished. If some made errors of underestimation, others made errors of over estimation. It is an odd morality where underestimating the virus is a vice but underestimating the harms of lockdown is a virtue. School closures, to cite one example, caused considerable everlasting harm to children.

Collectively, society lost its marbles during the pandemic. One moment Nancy Pelosi was in San Francisco’s Chinatown, signaling her solidarity with Asians, whilst the virus was wreaking havoc in China and Iran. Next moment, people socializing were deemed remorseless granny-killing Droogs. One moment community masking was useless and people were discouraged from wearing them. The next moment I saw joggers wearing N-95s. The masks could be taken off when we ate at restaurants but not when we entered restaurants or used the rest room. It was as if the virus had telepathy and decided not to infect people with the right political inclinations who congregated for the right causes. If you were virtuous you’d wear a mask, and if you believed you were an incarnate of William Wallace, you’d defiantly take it off. Never in human history were positive attributes made so cheap.

As Oscar Wilde noted, tragedy overdone becomes comedy. The pandemic was the worst of times and the most absurd of times. It wasn’t our finest moment. Many rode the sinusoidal trajectory of tragic peaks and profoundly absurd troughs. When the vaccines were rolled out, some, far from throwing the masks away, double masked. It was like using a double condom after a vasectomy! Outrage reigned supreme. A memorable example was Emily Oster who received widespread backlash for suggesting that an unvaccinated kids are like vaccinated grandmas. She’s an economist (for some reason, it’s always an economist).

I asked Bhattacharya whether he was surprised by the death toll from India’s Delta wave. He did not minimize the death toll. He believed that had the government focused on the vulnerable – the elderly and infirmed, and vaccinated them first, the toll might have been a lot lower. I don’t know if he was right. I don’t know how the government could have immunized the high risk first and turned the low risk away. What I do know is Bhattacharya’s call for focused protection was not outside pales of civilization – it wasn’t a fringe idea. It might have been impractical but impracticality didn’t make it evil. Amongst other things Bhattacharya was called a eugenicist indulging in social Darwinism, an accusation which is prima facie absurd. Bhattacharya would be the first Eugenicist to advocate focused protection of the most vulnerable in society. LOL! How did such nonsense rise to the surface of our discourse?

Is Bhattacharya the best choice for the NIH director? I have no clue. All I know is that I’m not the right choice. I can’t vouch for anyone else. But one quality Bhattacharya has, and in spades, is courage. It took balls to go against peer consensus in academia during the pandemic particularly in an era where the cancel culture was rife and generating outrage was easier than excretion. And in so far as courage has any correlation with integrity, he has that, too. That surely can’t be a bad thing.

More importantly, as an economist Bhattacharya brings fresh perspective to the NIH, by two oppositional but co-existing frames: trade-offs and uncertainty. As he’d be inclined to assess the economic value of research, where feasible, he might prioritize research depending on net health benefits to society. On the other hand (sorry, couldn’t resist the cliche), he might, considering the difference between risk and uncertainty, a distinction formalized by economist Frank Knight and popularized by Donald Rumsfeld’s known unknowns and unknown unknowns, support tinkering by funding scientists who are allowed to experiment for its own sake, with no strings attached. The rest of the researchers can live from one grant writing cycle to another. Who knows what the results of the tinkering might be? No one – and that’s kind of the point. Bhattacharya might also consider a formal analysis of all statistical methodologies. Many statistical techniques, such as risk adjustment, are imperfect and this imperfection leads to wild and unpredictable results, which are difficult to verify, and often lead to absurd and inflammatory conclusions.

Bhattacharya is of Bengali origin. Bengalis love eating fish. I do not expect him to change the palate of the NIH researchers but fish is a metaphor for diversity, being an extremely biodiverse

– both the great white shark and the goldfish are “fish.” Though not solely the responsibility of the NIH, its medical institutions have an abundance of intellectual diversity, not the “some of my best friends are conservative” type of faux diversity, but where the person sitting opposite you voted for a different person and believes your voting choice will lead to global catastrophe but is still willing to engage because you’re part of something bigger than politics – an institution, the greatest institution – the House of Medicine. That type of diversity. It would do no good repainting institutions with red. Since neutrality can’t be enforced, and is an illusion anyway, it’s better that red and blue learn to co-exist in healthcare institutions.

The NIH should house a center for scientific debates where consensus is eschewed and ideas, priorities, methodologies – anything with a patina of science – are debated in an intelligent, structured, fair, and rigorous manner. The incentives in academia favor consensus. Contrarians, who often emerge outside academia, are viewed as grifters. The institutions would not want all the interesting debates to be held on TikTok. It’s time to bring the outlaws home.

Bhattacharya, likely familiar with West Bengal’s history, will have a congenital appreciation for institutions. Post-independence, unmoored populism destroyed Calcutta’s institutions, rendering the region to an interminable cycle of destructive populism. Some might want Bhattacharya to “shake things up”. Whatever this sentiment means, the reality is that institutions are necessary for populism to work its magic. It is true that the institutions have become politicized but the solution isn’t in their irrelevance, but towards a gentle reformation, a cultural change where institutional pride transcends political and cultural differences rather than amplifies them. The NIH is a glorious institution – a jewel in the American crown. I wish Bhattacharya luck in steering it to greater glory.

About the Author

Saurabh Jha (aka @RogueRad) is a radiologist currently on a sabbatical in India exploring digital health

A Health Economist to lead the NIH

By, SAURABH JHA

Early on in the COVID-19 pandemic a seroprevalence study from Santa Clara indicated that the viral spread was far greater than was believed. The study suggested that the infection fatality rate (IFR) was much lower than the case fatality rate and perhaps even lower than the suspected IFR. The researchers estimated that 2.8% of the county had been infected by April 2020. The virus was contagious and, most importantly, caused many asymptomatic infections.  

The study, released as a preprint within a month of the lockdown, should have been published by the NEJM or Lancet. The specificity of the immunoassay was a whopping 99.5% and could not have been lower than 98.5%. Instead, it was roundly criticized by born-again methodological purists. Noted statistician, Andrew Gelman, known expert at dealing with (very) imperfect statistical methods, wanted an apology from the researchers for wasting everyone’s time by making “avoidable screw ups.”

Around the same time, a similar study published in JAMA came to similar conclusions. Researchers found that the seroprevalence COVID-19 antibodies in LA county was 4.65%, 367 000 adults had SARS-CoV-2 antibodies, substantially greater than the 8430 confirmed infections. They concluded that “contact tracing methods to limit the spread of infection will face considerable challenges.” No one asked the researchers for an apology, presumably because the study had passed anonymous peer review and had escaped the wrath of the medical commentariat.

A few months later, a German study suggested that many infected with COVID-19 had myocarditis. This meant that the asymptomatic were not just reservoirs of viral transmission, but walking tombs of cardiac doom. By many, the researchers, who used cardiac MRI to look for myocarditis, put a figure at nearly 80%. That’s a lot. No virus had ever done that. That number itself should have invited scrutiny. The animated, born-again empiricists, who has been energized by the Santa Clara study into becoming methodological sleuths, went into hibernation after the German myocarditis study. The study was swallowed uncritically by many and was covered by the NY Times.

If the rigor demanded of the Santa Clara study was that of a Pythagorean proof, the German myocarditis study received the scrutiny of a cult prophet. The burden of proof in them days was like shifting sand, which shifted depending on the implications of the research. The Santa Clara study suggested the test – isolate strategy was forlorn, as controlling the viral spread was akin to chasing one’s tail. The German myocarditis study was cautionary, emphasizing that that the virus should not be under estimated, as even asymptomatic infections could be deadly. The Santa Clara study challenged lockdowns, the German study supported lockdowns.

The senior author of the Santa Clara study, Jay Bhattacharya, has been nominated by President Trump to be the next NIH director. His nomination has surprised a few, upset a few, irritated a few, shocked a few and, as befits a polarized country, pleased many. Bhattacharya may well have won the popular vote, though I’m uncertain he will win the institutional vote.

Bhattacharya’s anti-lockdown views rapidly made him a persona non grata in academic circles though he was no slouch, but a Stanford health economist, with an MD and a PhD, who had researched human behavior during pandemics, the sort of academic who makes health policy, who once advocated for improved access to Hepatitis C treatment. He believed that the lockdowns caused more harm than good. You may disagree with him and I certainly do – I believe early lockdowns did save lives ( I’m unsure of the efficacy of the later lockdowns). However, to hold Bhattacharya’s premise as fringe is itself a sign of how unhinged the medical fraternity became during the pandemic.

Bhattacharya was guilty of thinking like an economist, of always asking about trade-offs, of weighing the harms against the benefits of public policies, including lockdowns. What was remarkable was that many public policy experts, such as the celebratory economist, Justin Wolfers, saw little trade-offs between lives and the economy in the early lockdown. I get the allure of that position. Once you deny trade-offs you don’t have to make hard decisions, even in thought experiments in your head. It’s cognitively appealing.

I had a long conversation with Bhattacharya during the pandemic. There were many things we disagreed about. Bhattacharya viewed lockdowns as a black swan event. He believed that lockdowns could cause societal upheaval, a Hobbesian breakdown of the delicate forces which maintain social order. I have no idea if he was right. Thanks to Operation Warp Speed, which enabled vaccine development in record time and ended the pandemic, we never had to find out. But was Bhattacharya’s belief fringe, like “earth is flat” fringe, or was it “I don’t like your opinion and therefore I will call you a Nazi” type of fringe?

His nomination is ironic, and certainly karmic, as there was a concerted effort to discredit Bhattacharya after he spoke against the lockdowns and was one of the signatories of the Great Barrington Declaration which advocated focused protection. Bhattacharya was shadow banned by Twitter’s moral police. The ham-fisted attempts to censor him backfired spectacularly. Instead, of being consigned to irrelevance, Bhattacharya’s fame grew – it was the Streisand Effect on steroids. He was not censored in the Stalin/ Mao/ Starmer version of censorship. But academia did something else. They ignored him, were unwilling to debate him, considered him beneath their dignity to engage respectfully, but spoke about him incessantly on Twitter. Alas, this was a missed teaching moment. A rigorous, moderated, structured scientific debate between Bhattacharya and a lockdown advocate, such as Ashish Jha, would have been valuable, mostly for Bhattacharya’s critics who now appear like that angry old man yelling at the clouds.

The major criticism of Bhattacharya is that he under estimated the pandemic death count. Few academics emerged from the pandemic unblemished. If some made errors of underestimation, others made errors of over estimation. It is an odd morality where underestimating the virus is a vice but underestimating the harms of lockdown is a virtue. School closures, to cite one example, caused considerable everlasting harm to children.

Collectively, society lost its marbles during the pandemic. One moment Nancy Pelosi was in San Francisco’s Chinatown, signaling her solidarity with Asians, whilst the virus was wreaking havoc in China and Iran. Next moment, people socializing were deemed remorseless granny-killing Droogs. One moment community masking was useless and people were discouraged from wearing them. The next moment I saw joggers wearing N-95s. The masks could be taken off when we ate at restaurants but not when we entered restaurants or used the rest room. It was as if the virus had telepathy and decided not to infect people with the right political inclinations who congregated for the right causes. If you were virtuous you’d wear a mask, and if you believed you were an incarnate of William Wallace, you’d defiantly take it off. Never in human history were positive attributes made so cheap.

As Oscar Wilde noted, tragedy overdone becomes comedy. The pandemic was the worst of times and the most absurd of times. It wasn’t our finest moment. Many rode the sinusoidal trajectory of tragic peaks and profoundly absurd troughs. When the vaccines were rolled out, some, far from throwing the masks away, double masked. It was like using a double condom after a vasectomy! Outrage reigned supreme. A memorable example was Emily Oster who received widespread backlash for suggesting that an unvaccinated kids are like vaccinated grandmas. She’s an economist (for some reason, it’s always an economist).

I asked Bhattacharya whether he was surprised by the death toll from India’s Delta wave. He did not minimize the death toll. He believed that had the government focused on the vulnerable – the elderly and infirmed, and vaccinated them first, the toll might have been a lot lower. I don’t know if he was right. I don’t know how the government could have immunized the high risk first and turned the low risk away. What I do know is Bhattacharya’s call for focused protection was not outside pales of civilization – it wasn’t a fringe idea. It might have been impractical but impracticality didn’t make it evil. Amongst other things Bhattacharya was called a eugenicist indulging in social Darwinism, an accusation which is prima facie absurd. Bhattacharya would be the first Eugenicist to advocate focused protection of the most vulnerable in society. LOL! How did such nonsense rise to the surface of our discourse?

Is Bhattacharya the best choice for the NIH director? I have no clue. All I know is that I’m not the right choice. I can’t vouch for anyone else. But one quality Bhattacharya has, and in spades, is courage. It took balls to go against peer consensus in academia during the pandemic particularly in an era where the cancel culture was rife and generating outrage was easier than excretion. And in so far as courage has any correlation with integrity, he has that, too. That surely can’t be a bad thing.

More importantly, as an economist Bhattacharya brings fresh perspective to the NIH, by two oppositional but co-existing frames: trade-offs and uncertainty. As he’d be inclined to assess the economic value of research, where feasible, he might prioritize research depending on net health benefits to society. On the other hand (sorry, couldn’t resist the cliche), he might, considering the difference between risk and uncertainty, a distinction formalized by economist Frank Knight and popularized by Donald Rumsfeld’s known unknowns and unknown unknowns, support tinkering by funding scientists who are allowed to experiment for its own sake, with no strings attached. The rest of the researchers can live from one grant writing cycle to another. Who knows what the results of the tinkering might be? No one – and that’s kind of the point. Bhattacharya might also consider a formal analysis of all statistical methodologies. Many statistical techniques, such as risk adjustment, are imperfect and this imperfection leads to wild and unpredictable results, which are difficult to verify, and often lead to absurd and inflammatory conclusions.

Bhattacharya is of Bengali origin. Bengalis love eating fish. I do not expect him to change the palate of the NIH researchers but fish is a metaphor for diversity, being an extremely biodiverse

– both the great white shark and the goldfish are “fish.” Though not solely the responsibility of the NIH, its medical institutions have an abundance of intellectual diversity, not the “some of my best friends are conservative” type of faux diversity, but where the person sitting opposite you voted for a different person and believes your voting choice will lead to global catastrophe but is still willing to engage because you’re part of something bigger than politics – an institution, the greatest institution – the House of Medicine. That type of diversity. It would do no good repainting institutions with red. Since neutrality can’t be enforced, and is an illusion anyway, it’s better that red and blue learn to co-exist in healthcare institutions.

The NIH should house a center for scientific debates where consensus is eschewed and ideas, priorities, methodologies – anything with a patina of science – are debated in an intelligent, structured, fair, and rigorous manner. The incentives in academia favor consensus. Contrarians, who often emerge outside academia, are viewed as grifters. The institutions would not want all the interesting debates to be held on TikTok. It’s time to bring the outlaws home.

Bhattacharya, likely familiar with West Bengal’s history, will have a congenital appreciation for institutions. Post-independence, unmoored populism destroyed Calcutta’s institutions, rendering the region to an interminable cycle of destructive populism. Some might want Bhattacharya to “shake things up”. Whatever this sentiment means, the reality is that institutions are necessary for populism to work its magic. It is true that the institutions have become politicized but the solution isn’t in their irrelevance, but towards a gentle reformation, a cultural change where institutional pride transcends political and cultural differences rather than amplifies them. The NIH is a glorious institution – a jewel in the American crown. I wish Bhattacharya luck in steering it to greater glory.

Saurabh Jha (aka @RogueRad) is a radiologist currently on a sabbatical in India exploring digital health