Trust, but verify

Reagan’s famous quip is a bit of a contradiction, but nonetheless gets at something important about life. We cannot live effective lives without some level of trust, but blind trust can be quite counterproductive.

In a book entitled Trust, Francis Fukuyama showed that a certain type of social cohesion is associated with greater economic success. Corporations tend to do better in societies where people are willing to work with strangers, whereas the private sector in low trust societies often fails to evolve very far beyond small family-owned firms.  Governments are also more effective in high trust countries.

I’ve met people who told me that they weren’t getting vaccinated because they didn’t trust the vaccines (and by implication the authorities that recommended vaccines), and were instead relying on a drug not recommended by experts—ivermectin. This got me wondering if this was a general pattern or just the people I happened to meet.

In Europe, there is a vast gap between vaccination rates in the east and the west.  (This is from November 2021):

While 75.6% of European Union citizens are fully vaccinated, the share in Bulgaria is 26.2% and 39.6% in Romania. In countries outside the EU, the numbers are even bleaker. Only 20.2% of Ukraine’s population, and 36.3% of Russia’s, is fully vaccinated.

What is wrong with Eastern Europe? In a word: disinformation. The region is awash in it, a legacy of the breakdown of public trust in governmental institutions after communism. Feverish conspiracy theories have gripped these countries like the coronavirus’s shadow.

A Ukrainian doctor recently summed up the situation in her country: “Fake stories have spread widely, making people believe in microchips and genetic mutations … Some Orthodox priests have openly and aggressively urged people not to get vaccinated, and social networks have been filled with the most absurd rumors. Ukrainians have learned to distrust any authorities’ initiatives, and vaccination isn’t an [exception].”

In contrast, ivermectin is extremely popular in that region:

Veterinarians have seen a rush on doses of ivermectin meant for large animals as people battle to get hold of doses meant for humans, while black markets cash in and a fervent media campaign pushes inconclusive research.

The Czech Republic now allows its off-label use, while Slovakia imports tens of thousands of doses. Promising research on the drug’s potential to treat and prevent coronavirus, combined with desperation over rising case numbers and deaths and a tidal wave of disinformation, has led to use of the drug skyrocketing in Central and Eastern Europe, as well as Latin America and South Africa. . . .

The bombshell arrived on December 8, when U.S. physician Pierre Kory spoke before a Senate hearing on early outpatient treatment for coronavirus. Ivermectin, alongside other medicines such as vitamin C, zinc and melatonin, could “save hundreds of thousands of people,” he testified, citing more than 20 studies. . . .

Kory’s appearance reverberated across the globe. . . . Many miles away, in South Africa, a black market for ivermectin soon emerged. In Romania, stocks of ivermectin at both human and veterinary pharmacies were reported to be depleted in January. 

Ivermectin has become so popular in places like Peru that it is increasing difficult to find enough non-users to do a clinical testy:

[C]linical trials in Latin America have struggled to recruit participants because so many are already taking it.

“Of about 10 people who come, I’d say 8 have taken ivermectin and cannot participate in the study,” says Patricia García, a global-health researcher at Cayetano Heredia University in Lima and a former health minister for Peru who is running one of the 40 clinical trials worldwide that are currently testing the drug. “This has been an odyssey.”

Interestingly, Peru has the highest official rate of Covid deaths in the world, roughly 650 per 100,000.  But official death tolls can be misleading, and many believe that excess deaths are a far more accurate measure of Covid mortality.  The Economist reports that 11 of the 12 highest excess death rates are in Eastern Europe:

Bulgaria’s excess death rate (nearly 1% of its population) is particularly shocking.   BTW, excess death rates in a few countries with extremely low Covid mortality were actually negative; as social distancing resulted in fewer cases of the flu than would normally occur.  So even the excess death data may undercount the true death toll for Covid itself.  Also note that while the US excess death rate (337 per 100,000 in mid-February) is below that of Eastern Europe, it is far higher than in Western Europe and Canada (and higher than the official figures). 

To be clear, I do not believe Ivermectin directly causes more Covid mortality.  Most experts believe it has little effect, while a few claim that it is beneficial.  Rather, I suspect that a third factor—low social trust—explains both the high use of ivermectin and the very low vaccinations rates in Eastern Europe.   But there is also a risk that the people I met are not an exception; there’s a risk that many people around the world are avoiding vaccines because they view ivermectin as a substitute.  In other words, a risk that ivermectin is crowding out vaccination. If so, that would be very unfortunate:

Derived from a compound discovered in a soil microbe in Japan, ivermectin has been called a “miracle drug” and “the penicillin of COVID” by Pierre Kory, a critical care physician in Madison, Wis. Kory is president of the Front Line COVID-19 Critical Care Alliance (FLCCC), a group of physicians and scientists who champion ivermectin, along with other drugs and vitamins with dubious efficacy against COVID. The organization, along with two others called the British Ivermectin Recommendation Development (BIRD) Group and America’s Frontline Doctors (AFLDS), have drawn criticism from many other physicians and scientists. Yet treatment protocols, links and videos from these groups are sweeping through social media, promoted by vaccine skeptics.

The notion that ivermectin is a miracle medicine gives people who reject vaccines a false sense of security, says Daniel Griffin, a physician and infectious disease researcher at Columbia University and Chief of the Division of Infectious Disease at the company ProHEALTH. A recent poll by the Economist and YouGov indicated that a total of about 56 percent of people who believe ivermectin is effective against COVID either do not plan to get vaccinated or are unsure about the vaccine. But unlike the data supporting vaccines, Griffin says, the evidence behind that use of ivermectin is questionable and unclear. 

[My hypothesis works better for Eastern Europe than for Peru, which has a good vaccination rate.  The vast majority of deaths in Peru occurred before vaccines were widely available. In contrast, Covid death rates in Bulgaria remained very high even after vaccines were widely available.]

Back in March 2020, the experts told the public that masks were not effective. I did not believe them.  That wasn’t because I had expertise in the area; rather it was because their rationale made no sense.  We were told that the masks were desperately needed by doctors treating Covid.  I though to myself, “Well, if masks are ineffective, why do we need to reserve them for doctors?”  We were also told, “Don’t rub your nose”.  The best way to stop me from touching my nose when it itches is with a mask.  That’s what I mean by, “Trust, but verify.”  I trust that the widespread use of masks by medical personnel probably occurs for good reasons.  But I also verify the pronouncements of authorities by considering whether their recommendations make sense. Subsequent studies showed that masks are modestly effective at reducing Covid among the general public (mostly protecting others, not the mask wearer), and the experts have now come around to my view.

One reason I trust the authorities on vaccines is that I’ve done my own look at the data and found that areas with low vaccination rates tend to have much higher Covid death rates, especially in the period after vaccines were available. (Obviously not in 2020.) 

On average, the views of experts on a technical issue will be superior to the views on non-experts.  Thus my default position is to trust the experts more than I trust my own intuition.  But I never stop there.  Where possible, I also look at the evidence to see if it makes sense. The mistake some people make is to reflexively distrust experts and instead trust random people on the internet that are telling them what they want to hear.

PS.  My read of the ivermectin data is that a lot of low quality studies say it’s effective and several high quality studies say it is not.  Given my general view of the biases in scientific research toward positive results, that’s not a very promising picture.  (This also makes me skeptical of the vast majority of published economic research.)  Overall, I am agnostic on ivermectin’s effectiveness, and believe it might or might not have a modestly positive effect. But evidence in favor of other generic drugs seems stronger than for ivermectin, so I personally would not take it without seeing further evidence of its effectiveness.

PPS.  Interestingly, Uruguay seems to have the lowest Covid death rate in South America.  It also has a relatively high level of social trust by Latin American standards.