Peltzman Revisited

Casey Mulligan checks up on the old Peltzman work on the opportunity costs of FDA delays.

FDA shifts to encourage competition in generics added a lot of value. Mulligan runs some Cournot models showing that while the first generic's entry may reduce overall welfare, additional ones help. The basic intuition is that the first generic doesn't do a lot to reduce prices in a Cournot game, but does reduce the return to the initial innovation. Later entrants push down prices to consumers to provide net benefits. 

Scott Gottlieb seems to have been an excellent appointment:

Three related changes occurred in 2017. By May 9, Scott Gottlieb was nominated and confirmed to head the FDA. He had been an outspoken critic of the FDA’s slow approval process, which he described as “evading the law” (Gottlieb 2010). He immediately told Congress that his FDA would prioritize competition (US House 2017). In June, the FDA (2017a) announced the Drug Competition Action Plan with procedural details published in November (FDA 2017d). The FDA (2017c) immediately promulgated, and subsequently maintained, a list of drugs with no blocking patents or exclusivities but still no approved generics. Section 801 of GDUFA II, which became law in August 2018, instructs the FDA to prioritize the review of drugs with no blocking patents or exclusivities that have three or fewer ANDAs or NDAs already approved. On paper at least, the FDA appeared to be looking toward competition rather than purely bureaucratic metrics such as numbers of applications and approval times. 

Table 1, based on the FDA’s Orange Book listing of approved NDAs and ANDAs, shows approvals at a higher rate during Gottlieb’s tenure as compared with either the 2 years before it or the 2 years after it. Before Gottlieb’s leadership, and therefore also before GDUFA II, the FDA averaged 54 approvals per month (1,286 for the 24 months). The average was 73 per month during Gottlieb’s tenure (through April 2019) and 61 in the subsequent 24 months.7 Table 1 also shows that FDA approvals of new drugs were also high during his tenure. The corresponding approvals for biosimilars and biologics are from the FDA’s Purple Book; they are a large share of expenditures on physician-administered drugs but a small share of retail prescription drugs.8 

Drug market performance appears to reflect additional competition. Berndt, Conti, and Murphy (2018) find that, as of April 30, 2017, Teva Pharmaceutical owned 1,611 ANDAs of about 10,000 in existence. The second largest owner was Mylan Inc., with 668 ANDAs. Teva’s stock crashed in the summer of 2017, with its chief executive officer reporting that the company would henceforth be less profitable owing to “greater competition as a result of an increase in generic-drug approvals by the U.S. FDA” (Sheetz 2017). Real retail prescription drug prices fell 1.5 percent during Gottlieb’s tenure, as compared with a 3.7 percent increase in the prior 2 years and a 5.1 percent decrease in the subsequent 2 years.9 These findings are consistent with the hypothesis that GDUFA II, Gottlieb’s management, or some combination thereof increased drug-market competition by reducing entry barriers.

Mulligan also goes through the benefits of project Warp Speed. Every 6 months' delay in getting the vaccine out had social cost of just under half a trillion dollars - just on mortality. 

Evening roundup

I was out on leave last week, touring around Lake Taupo with the family, hoping desperately for snow that didn't come. 

We had fun anyway. 

But the browser tabs... a week's worth of emails, and stuff saved up... egads. 

Some worthies as I try to clear six different Chrome instances...

• Wikipedians don't like research on IQ. They're even slowly memory-holing the Flynn Effect.


• Time to end the Canadian Dairy Cartel


• Neat evil DMCA hack: create a fake-dated earlier version of content you don't like, then claim the original is a copy. 


• DevPolicyBlog on reducing remittance costs in the Pacific. I hadn't known that getting money from Oz/NZ to the Islands has some of the highest remittance costs in the world. But it makes sense: NZ is overly enthusiastic about AML, and that's a fixed cost in a small place. 


• John McDermott on the case for another Saturday Night Special. When credibility is lost, getting inflation back under control is costly. The RBNZ forgot its job, and we will all bear a cost. 


• Jem Traylen tries to figure out why the government won't fast-track residence for migrant nurses. There are no good answers. 


• The Australian Therapeutic Goods Administration has approved Moderna's Covid vax for under-5s. Unclear that Medsafe has even started looking at it. 


• The McGuinness Institute maintains an archive of Government Department Strategies. There are 221 operational GDS and 327 archived ones. I did not know there were so many. 


• Frank Newman on a few problems in the government's Three Waters financial modelling. Oh - and the IT systems alone could cost half a billion. 


• I wonder how much income protection insurance premiums are going to go up because of Long Covid risks. Would be fun if cautious mask-wearers could get a discount...


• Survey evidence of misperceptions could just be miseducated guesses. But wouldn't that predict unbiased means?


• The flu-normal sucks.


• New Zealand's defamation law is even worse than I'd thought. Its reach extends to America.


• Prof Beaglehole on Smokefree 2025.


• Three cheers for the three Christchurch councilors who voted against the stadium.


• Infometrics warns inflation expectations look unanchored. 


• Cameron Bagrie warns of a lack of expertise on the RBNZ Board. I remember Suzanne Sniveley telling us at the NZAE meetings that all is fine. 


• This is just lovely. How the world's worst golfer kept getting to play at big golf tournaments. Great fun story. 


• Pandemic-related losses in education. New Zealand did manage to get through the early period with some of the shortest periods of school closure in the developed world. But we're still showing shocking results on literacy and numeracy - though tough to tell whether it's worse than pre-Covid. 


• Russ Roberts' chat with Ran Abramitzky and Leah Boustan was great while we were on our drive back from Taupo. Just such an enormous amount of core data work in that project on immigration and outcomes. Here's Noah Smith with Boustan.

Afternoon roundup

High time the computer gets a reboot. And so, the closing of (some of) the browser tabs:

• The Australians approve vax for 5-11 year olds. Omicron is spreading, though not in NZ yet as far as we know, and there is some indication it is sending more kids to hospital. Canada has been vaccinating kids since 23 November, and America weeks before that. But Medsafe, like a New Zealand city council that just doesn't wanna approve a resource consent, has punted the application back to Pfizer for more detail. Medsafe Delenda Est. 
• Maybe, for Labour, Immigration NZ being a complete mess and chasing away potential migrants is a feature rather than a bug. 
• Aranui, Avonside, Woolston West, Rawhiti, Wainoni, Bexley, Styx, New Brighton. Sounds like a rollcall of neighbourhoods most hit by EQNZ in 2011 (maybe not Woolston West). But it's the Christchurch suburbs with the lowest vaccination rates. 
• Hayden Donnell on the anti-housing media blitz. 
• Point of Order on the mess at Royal Society. Bottom line: Profs should be joining the Free Speech Union rather than either the Royal Society or the TEU. 
• City Journal has a couple of excellent pieces on corporate culture. The Genealogy of Woke Capital and Why Woke Organisations All Sound the Same. A usual rule of thumb is to avoid pieces with 'woke' in the title. Don't miss these. Gabriel Rossman is author on the latter - seriously good academic sociologist. 
• From the "Well, can't blame 'em for trying it on but really?" files: Council adds sand to some Auckland beaches, prompting nearby property owners to assert that their riparian rights extend further down the now extended beach. 
• If car insurance companies could overcome collective action problems, there would be a case for them to fund wolf reintroduction programmes in US states with a lot of deer. 
• The Herald has started putting up lovely tables showing case and hospitalisation rates sorted by vaccination status.
  
  
  

Missed opportunities

Kate MacNamara keeps digging into New Zealand's botched vaccine procurement last year. 

Things could have been so different.

Labour Minister David Clark was sent a key Pfizer letter on June 30 last year, in which the drug company pressed the head of New Zealand's "vaccine taskforce" to meet and discuss its vaccine candidate.

Taskforce officials, however, were not equipped at the time to begin talks with the drug company, and over six weeks elapsed before a first meeting took place.

The Cabinet finally armed the taskforce with funds both to contract specialist negotiation expertise and to make vaccine purchases on August 10; officials signed a non-disclosure agreement with Pfizer on August 13 and a first meeting with the company took place the following day, on August 14.

Clark, the then Health Minister, refused to answer questions about the letter, including whether he read it at the time and whether he made any effort to hasten the readiness of the taskforce to begin meetings and negotiations with the drug company.

Clark was beset by calls to quit his post at the time the Pfizer letter arrived and he resigned as Health Minister two days later, on July 2. An upcoming election, then scheduled for September 19, added sensitivity to Clark's predicament.

...

Pfizer's June letter noted: "We have the potential to supply millions of vaccine doses by the end of 2020, subject to technical success and regulatory approvals, then rapidly scale up to produce hundreds of millions of doses in 2021.

"I would welcome an opportunity to discuss our candidate vaccine development in more detail, and open discussions on how we might work together to support planning for potential Covid-19 vaccinations in New Zealand and continue to build a strong partnership for the future," the letter said.

...

It's unclear whether earlier engagement with Pfizer could have secured a larger quantity of early vaccine doses for New Zealand.

New Zealand contracted to buy 1.5 million doses of the Pfizer vaccine candidate on October 6, 2020.

Earlier this year an Auditor-General Report noted that "the Taskforce wanted to purchase more doses of the Pfizer vaccine [in its first contract] but, at the time the agreement was signed, Pfizer was in negotiations with other potential purchasers and could not commit to supplying more doses of the vaccine to New Zealand. However, the purchase agreement included an option to purchase further doses of the vaccine if they became available."

By October, New Zealand lagged many of its peers in signing so-called bilateral advance purchase agreements with drug companies for vaccine candidates.

The delay in starting negotiations, because Clark was distracted and because, for incomprehensible reasons, the bureaus hadn't prepped themselves to think about vaccine procurement, meant we were competing against other places for supply. 

If we'd started when Pfizer sent the letter, decent odds we could have started the vax rollout with a lot more doses a lot sooner.  

Think about what that means.

The government made a laudable effort to push vaccines out to elderly Māori in remote communities. But they had hardly any doses at the time and were also trying to vaccinate border and health workers. They could have made that push a vaccination event, vaccinating whanau at the same time. The vax rates by ethnicity by age, at least when I'd last looked at them, had no particular ethnic gap for Māori at older ages - because of that push. But the gap at younger ages is substantial. How much of that gap could have been bridged if they'd had enough doses to vaccinate the whole community while they were out there? 

Here's the most recent data.

The lowest vaccination rates are for younger Maori in more remote places. 

But their grandparents are vaccinated. 

They could have been vaccinated at the same time, or at least everyone 16+ could have been.

But the government didn't have enough doses. 

And it's awful likely that that's because Clark, Bloomfield, and Crabtree sat on a letter from Pfizer for 6 weeks.

When the letter was released, only its main recipient was noted: Dr Peter Crabtree, the chair of the vaccine taskforce.

However, in response to a subsequent written question by Bishop last month, Hipkins revealed that the letter, delivered by email, was copied to Minister Clark and also to Bloomfield.

You'd think they'd have learned by now. But while Canada's vaccinating 5-11 year olds, and the US has been for weeks, New Zealand just isn't. And the odds-on bet on why we aren't is that they screwed up procurement again, because they didn't see any need to hurry.  

Afternoon roundup

The day's worthies:

• The complicated mess of regulations that make it hard for supply chains to keep up.
• Pentecostalism. According to the 2018 Census, there are 81,300 in NZ.  They outnumber Jedi 4:1. 
• Getting vax out to where people are. Robertson had promised that there would be no funding barrier to dealing with the pandemic. We supported him in taking on debt to get this job done - it's what debt is for. But he blew it on envirojob nonsense, and hasn't been funding what's been necessary in getting vax out. Just incredibly disappointing, and costly. The money that would be involved here is rats and mice stuff, and in too many places it just hasn't gotten done. 
• Wouldn't it be simpler if we stopped using general government revenue to build highways while also stopping using money from road user charges and petrol excise to pay for busses? 
• Should overstayers have been included in the general grant of a path to residence? Would have helped with this problem.
• Superb piece on the problems in copyright extension. It's at best a dead rat we have to swallow for the trade deal with the UK. But I'd hope we can make it less awful. 
• And relevant to that last one: a shift to weaker copyright during WW2 encouraged scientific discovery by making it easier for scientists to get access to scientific papers. Sci-Hub is a wonderful thing.
• Looks like early treatment for Covid with a common antidepressant with few side effects, fluvoxamine, reduces hospitalisation by a third - and to a third for those reporting optimal adherence to the protocol (people who didn't miss doses). Something that reduces hospitalisation by a third to two thirds is like increasing hospital capacity by a third to two-thirds, except way less expensive and with way less hardship. I wonder whether MoH will get orders in before the rush hits - enough to at least trial it to make sure it isn't green jellybeans. Note that this was one of the trials funded by Tyler Cowen and Alex Tabarrok at FastGrants. 
• Bit of a shame that nobody in NZ government bothered getting a vaccine passport system readied earlier. It was obvious that one would be needed at least from June 2020. AirNZ now reports the absence of one is why they can't set a vax requirement for domestic travel.

Vax for kids

The FDA's decision on vaccines for 5-12 year olds should be up today. The workings from their meeting of 26 October are here.

I expect that kids in the US will be able to be vaccinated in November.

Last week, I emailed MedSafe to ask where things were in the process here. I'd hoped that they'd have been asking Pfizer to get its data to them at the same time, so that MedSafe might consider things in parallel with the US. We'd then be able to hit the ground running.

Ever the optimist. 

Their reply:

Here is our response attributable to Chris James - Group Manager, Medsafe:

In order for Medsafe to consider granting provisional approval for the Pfizer vaccine for 5 to 11-year-olds, Pfizer must submit an application to Medsafe, which has not yet been received.

We understand Pfizer has submitted an application to the US FDA for Emergency Use Authorisation of their COVID-19 vaccine for use for children aged 5 to 11.

Pfizer does not carve up its data for different countries. Regulators have harmonised requirements on the format and supply of data for applications. It is Pfizer’s decision who and when to submit applications to. We recommend you direct any further questions in this area to Pfizer.

If, and when Pfizer does submit an application, Medsafe will prioritise the assessment of the data for this age group. If Medsafe provisionally approves this, further clinical and scientific advice will be sought from the COVID-19 Vaccine Technical Advisory Group before it goes to Cabinet for a “decision to use”.

And if there is a decision to use, please rest assured, we will have enough vaccines for everyone. We will provide updates on progress.

So when Pfizer gets around to getting an application in to a small country at the far end of the world, Medsafe will start thinking about it. It may go over summer break. Then the Technical Advisory Group has to weigh in. Then Cabinet has to decide. It's a political decision, after all, about whether I should continue to be banned from having my daughter vaccinated.

It would be nice if drugs approved elsewhere were also just here available, without having to jump through Medsafe, then the Technical Advisory Group, then Cabinet. 

In the absence of being able to have my 11 year old vaccinated, it would be great to have a stock of rapid antigen tests around the house. If any of us develop any symptoms, we'd be off for a Covid test. But it can take a while to get results back. A rapid test could help while waiting. 

Alas, those are also still banned. 

Morning roundup

 The morning's worthies:

• Dileepa Fonseca still on target on Covid testing. 
• Supply shortages in construction as far as the eye can see (Newsroom, $). All of the Covid messes are running up against a sector that geared up for the amount of construction that had been allowed (not much) and that has to expand as Auckland allows more growth and as the NPS-UD starts kicking in (though there is much yet to do in enabling growth - see the last bullet). 
• Employer vaccine mandates remain a legal mess that needs to be sorted out (Newsroom, $). Can an employer mandate vaccination? "It depends" isn't good enough.
• Me, in the Stuff papers, on the interim report of the latest local government review. This one's a slow burn: it's got well over a year to go. But they're asking some good questions. I'll be in a webinar at lunchtime with the Property Council going over related issues. 
• Duncan Greive on the need to involve the private sector in the Covid response.
• Once housing is properly considered a human right, can we round up Mission Bay objectors and send them off to The Hague?

Afternoon roundup

It's been a busy week of lockdown. On Monday, we released my report looking at cap-and-trade solutions for freshwater quality. Yesterday, Matt and I sent in our submission on the Commerce Commission's inquiry into supermarket competition. 

Don't think the computer's shut down this week. The browser tabs....

• It's a shame that rapid antigen tests are illegal in NZ. They aren't nearly as accurate as PCR. But when people are waiting six days for a test result and, in some cases, trying to run at-home isolation from the rest of the family during that period, having rapid antigen testing as a complement would be really good. RNZ reported on nurses living with close contacts being told to turn up for work even where those contacts' results hadn't come in yet. We could have had rapid antigen tests rolled out for staff starting shifts in hospitals and care homes. MedSafe banned them in April 2020 and re-upped the ban in April 2021. 
• I love this. North Canterbury's MainPower is telling staff to "Take Two for the Team". If 90% of their workforce is fully vaccinated by 1 December, every vaccinated staffer gets an extra day of special leave. Vaccination isn't just for you, it's for the team. Perfect. 
• I had a bit of fun in our Insights newsletter comparing the stringency of SmokeFree rules with the stringency of rules for MIQ exercise facilities. I'm pretty sure the Crowne Plaza's exercise area would not have been approved as an outdoor smoking patio for the bar.
• Meridian is putting in battery storage. Presumably they'll use it during times of peaking demand when power prices are through the roof. And of course, screwing around with the electricity market with price caps would discourage these kinds of investments. 
• Scientific American makes the case for the combination of carbon prices and carbon dividends. The Climate Commission pretends this option doesn't exist. It's depressing. I suppose the advice from NZ for Americans looking at this option: make damned sure that they're actually going to distribute the money back as a dividend, because the political establishment very much prefers to turn that money into its own discretionary slush fund to target to their voters. New Zealand's Green Party understands the case for carbon dividends. But they'd rather give their own voters a subsidy for a Tesla. It's depressing. Standard logic-of-collective-action stuff: concentrated benefits to Tesla-buying people, distributed cost to everyone who doesn't get a carbon dividend. And it'll make it easier to claim that reg measures on carbon are needed because of political pressure on ETS if prices rise - the sign on which would reverse if we had a carbon dividend. 
• The Atlantic continues to be great on Covid coverage. Best case, stupid endemic Covid becomes more like colds and flus because everyone will have some protection through vaccination and our immune systems will be able to handle it. But the virus could mutate to evade vaccines and immunity from prior infections. 
• My Dom column on the freshwater management report.

Vaccines for children

Good news! Cabinet has decided to end its prohibition on vaccinating children aged twelve and up. From 1 September, parents will no longer be banned from protecting their children against Covid. 

At least if their children are at least 12 years old. 

The Prime Minister framed it at the press conference as a difficult decision, because they're talking about other people's children.

But they've shown absolutely no similar concern about banning parents from vaccinating their children. 

I could understand her framing it as she did if she were talking about mandating vaccination for children. And I can see a very good case for mandating vaccination. But that isn't what she was talking about. She was talking about removing a prohibition that currently prevents parents from getting their kids vaccinated. 

Medsafe approved the vaccine for those aged 12 and up back in June. The FDA approved it on 10 May. We've known it's safe for over three months. Cabinet has just not seen fit to allow it to be used. There is no medical reason for it. 

I expect that the main problem has been a lack of vaccine supply. 

Because of the lack of vaccine supply, it has been convenient to consider those aged 12-16 as ineligible. All the comms on New Zealand's terrible vaccine roll-out have been around vaccination as proportion of the eligible population. One easy way of juking that stat is by artificially restricting the number of people considered eligible. If you don't have enough vaccines to go round anyway, then you can make a terrible figure look marginally less terrible at low cost. 

The ban continues for children younger than 12. 

The trials on the younger cohort are still continuing. If the FDA doesn't give a ruling on it until October, then we might not have a MedSafe determination before November, and then Cabinet extending to younger kids in December?

Given that we continue to tapdance on landmines in MIQ, and there is Covid in the community, might we consider allowing emergency authorisation for vaccinating kids younger than 12 if there is strong medical reason for it?

While risks for children on average are lower than for others, pediatric wards in the US are filled with kids with Covid. If might not make sense to make an 11 year old with co-morbidities wait the extra few months for her birthday, where the vaccine risks for 11 year olds are going to be awfully similar to the risks for 12 year olds, and delta's risks for kids seem kinda high. 

Dosed

Driving home from Palmerston North last night around 6pm, a man was waiving a Covid-19 Vaccination Centre banner on the median of the road outside of the Onslow Medical Centre. 

We rolled down the window. They had end-day extra doses and wanted to get them into arms.

So the cats had to wait an extra half-hour for their dinners, and we got dosed. 

All went very smoothly. 

On checking in, I offered my NHI number but they didn't need it - they pulled it from name and date of birth.

About five minutes later Susan and I got jabbed. They wouldn't jab the kids, unfortunately. While MedSafe has approved the vaccine for those aged 12+, there is currently no way in New Zealand for a 13-year-old to be vaccinated. And the 11-year-old certainly isn't allowed, though I'd have very happily given her my dose.

We were told to book in for the second dose, along with a workaround for an issue they were having with the website for second-dose bookings. 

Great that they're getting any spare doses into arms. The banner on Moorefield Road was far more welcome than the set of antivax placards outside of Otaki.

Vaccination class

If, as the Skegg report suggests:

1. A Delta outbreak is not unlikely before the vaccine rollout completes;
2. Border restrictions will start easing when the adult vaccination programme reaches completion, but under an aggressive containment model that will push hard to knock out any outbreaks that we do get; and,
3. "The degree of community protection will be increased if eligibility for vaccination is extended to people between 12 and 16 years of age"

then why aren't we aggressively pushing vaccination for 12-16 year olds before the end of the school year? MedSafe approved it for that group back in June. Government's said nothing about where those kids sit in the rollout. 

Right now, kids are in classrooms. They will be until December. 

Classrooms are risky: tightly packed enclosed spaces with poor ventilation. If something gets in there, it will spread, and Delta has been proving far worse for kids than prior variants have.

Classrooms are also a massive opportunity. If you send public health nurses out to the schools, you can jab all of them right there where they are. That's how we did the normal kid vaccinations when I was in elementary school in Manitoba. The public health nurse was Beth Kissick. She'd go from school to school and get all the Grade (whatever) kids with whatever jab was needed for them. The kids would line up outside the gym, then go in to get jabbed. Each kid was instructed to yell as loud as possible; she'd tell everyone ahead of time it was a yelling contest to see who could yell the loudest after the jab. Then nobody who was actually scared would feel bad about screaming. 

This stuff isn't rocket science. 

Getting everyone to make appointments to bring their kids to wherever vaccines are being administered is a hassle compared to sending nurses and jabs out to the schools where the kids are. 

If we do this, there's less risk to kids, there's less risk of the virus being spread by kids if it gets out here, and there's less chance that the risk posed by a big unvaccinated population would cause problems in any planned easing of border restrictions later.

If we don't do this, there's every chance that, when the adult vaccination programme completes, we'll get the following from the Prime Minister. Maybe December, maybe January:

"We have now completed the adult vaccination programme. Vaccination rates have been high. If you haven't gotten yours, we still urge you to get yours. And our plan has always been to ease border restrictions at the completion of the vaccination rollout.

But now that we have had time to think about it, Delta looks very scary for children. And those aged 12-16 have not yet been included in our vaccination rollout. If we opened now to vaccinated travelers, there's a high chance that Covid would get through into the schools. We cannot take that chance. We ask you all to wait just a little longer.

Unfortunately, it looks like the most effective way of doing that will be when school starts in February. Everyone is out on summer holiday now, and we can't expect people to make vaccination appointments for their teenagers during that time. The programme will begin mid-February and should complete by mid-March. It won't take that much longer.

We are aware that international regulators approved the Pfizer vaccine for those aged 5 to 11 years old back in late September 2021. We have today asked MedSafe to begin its evaluation of the vaccine for that younger cohort; we have decided that we cannot order any vaccines until MedSafe approves them. We blame Pfizer for not submitting applications to MedSafe to start this process earlier. We will start thinking about whether to finalise orders for vaccines for that cohort after MedSafe approves them, and we will start thinking about how to roll out vaccines to younger children after they have been delivered."

Surely there's a case for shifting some of the sequencing to get kids done before summer holidays hit. Make vaccination at school the default. Provide an opt-out mechanism for those with a doctor's certificate if there's any kid for whom there'd be a real medical risk in providing the shot. But otherwise, line 'em up outside the gym and jab 'em. 

I cannot remember a single kid who opted out of in-school vaccination in the 1980s. We all just lined up and got the shots. It was fine. This will be fine too. We just need to do it. 

Afternoon roundup

The afternoon's closing of the browser tabs:

• Tons of port workers have been avoiding getting vaccinated. In principle this should have been simple: have public health nurses drive out to the sites and administer it. But it's not been compulsory, antivax stuff has been influential among those workers, and they're probably (and rightly) pissed off with the regular nasal swab test requirements that could have been replaced by saliva testing over seven months ago - which would feed into a strong 'not gonna do whatcha told me' attitude. More results are out on the effectiveness of the Illinois protocol saliva tests - the one that the government doesn't want to use. And, just for fun, a plague ship berthed at Taranaki, where port worker vaccination rates are low. Let's hope we keep getting lucky, despite tapdancing on landmines. Looks now like only 11 of 98 border workers involved in this one had any vaccine. 


• Bernard Hickey has a chat with me and Oliver about Oliver's column last week. The prior link is to his column; the podcast is here. Our Insights newsletter column, reprinted in the Stuff papers, called on the government to extend residence to everyone who has been here with us since last year's March/April lockdowns - as a way of rectifying some of the harm that our immigration system has imposed since then. Oliver, Matt and I chatted about it here as well. 


• We'll be getting proof-of-vaccination that can work as a vaccine passport, but so far only intended for use in international travel. If Covid is ever here circulating, I will be happy to pay a premium to exclusively attend establishments requiring proof-of-vaccination for entry. 


• Damian Grant has a superb column on corporate social responsibility. 


• Union leader Matt McCarten on the merits of not banning speech. I agree with him. 


• The Taxpayers Union points to some odd-looking public health grants. This stuff wouldn't bug me so much if they were also putting appropriate funding into classical public health - contagious disease, vaccination promotion, the usual kinds of stuff that you might expect in the context of a global pandemic. But I could only see two grants in the whole set that seemed to have anything to do with the pandemic, and a third on measles. Just under $900k to try to get an assessment tool gauging barriers to vaccination and $1.2m looking at mucosal delivery for vaccines (not specifically to Covid, but in general). Both of those seem like really good ideas. They're also putting $1.16m toward waning measles immunity - good! But they're also putting $1.2m toward research on alcohol warning labels. It feels like infectious disease is still the poor cousin of whatever public health has more recently turned into. 


• Donal summarizes the Competition conference that was on in Wellington this past weekend. I missed it; these things usually cost an arm-and-a-leg, presumably due to cartel activity by conference organisers in preventing other conferences from emerging. Plus, I was in Christchurch Friday and Saturday teaching Canterbury's MBA students about the Emissions Trading Scheme. The session on three waters regulation would have been excellent.

The post-vaccination future

This week's column in the Stuff papers got me angry letters from the anti-vax people. 

I mostly look out to the US and Canada, and what things they're up to now that vaccination rates are high. There's a lot of support for vaccine passports in helping people avoid venues that have a lot of riskier people in them. 

Majorities of Canadians surveyed in late May, when only 54% of Canadians had had at least a first vaccination dose, and again in July, supported proof-of-vaccination requirements to board commercial airline flights; to travel internationally; to attend public events or large gatherings; to visit public places like restaurants, movie theatres and churches; and, to attend one’s own place of work.

Quebec will be requiring proof of vaccination for entry into high-risk places like gyms, concerts, and festivals in any fourth wave. And, last week, the University of British Columbia’s alumni association urged the university to require vaccination for students in the residence halls – a measure supported by 82% of students.

Across the US border, vaccination rates have plateaued at about 56% and the costs of low vaccination rates are more obvious.

America’s National Football League last week set a new policy. If a vaccinated player returns a positive test, without symptoms, he can return to play after two negative tests a day apart; unvaccinated players must quarantine for ten days.

If a game is cancelled due to a Covid outbreak among unvaccinated players, the team with unvaccinated players does not just forfeit the game. It also bears responsibility for any resulting financial losses.

The League’s policy does not mandate vaccination. It simply ensures that the costs of not being vaccinated fall where they should.

Once vaccination is readily available, I will be happy to pay a premium at venues that cater exclusively to the vaccinated, to use airlines making vaccination a condition of carriage, and so on. 

I would prefer to drink at a bar that allowed smoking but mandated vaccination, than to drink at a bar that forbade smoking but did not require vaccination. And similarly for restaurants, even though the smell of smoke while eating puts me off my food. The risks of second-hand smoke, at any levels to which I might be exposed occasionally at bars and restaurants, are far lower than the risks of fleeting exposure to Covid. 

Before Covid, and during the measles outbreak, I'd written a short bit on compulsion and vaccination. 

Were I suggesting policy targeting vaccination, rather than playing into other things, I'd be looking at:

• Compulsory vaccination as employment condition in the state-funded health sector, for both new and existing staff. They impose substantial direct risk. And how many antivaxxers will look at the recent reporting on low sector uptake and take it as reaffirming their beliefs? 
• Compulsory parental notification of vaccination status of employees at ECE centres, and consider making it a condition of receipt for 30-hours free. Like, the government made it compulsory that piles of workers in ECE have qualifications - even where there's no good justification for it - but we don't even know whether ECE workers are vaccinated? Come on. 
• Bring back the BPS targets around vaccination, penalise DHBs for vaccination rates less than 90%, reward them for rates above that. The DHB-level vaccination stats are hardly secret, but DHBs have no particular incentive to go and figure out what works or learn from each other. If DHBs faced financial incentives to ensure broad immunisation coverage, they might decide it's worthwhile to send somebody out to see just what Canterbury is getting right - or whatever DHB has population most comparable to theirs but higher immunisation rates. 
• There are piles of things you can imagine DHBs trying out. Catch-up vaccinations at school for those who missed them. Making sure that all schools get a visit from the nurse with the jabs. Sending a public health nurse along on Plunket visits. Sending public health nurses along to ECEs where vaccination rates are known to be low. How far can you get just by making it really really easy for folks to be vaccinated?
• Tell the Health Research Council that funding for research in public health, aimed at policy changes or behavioural interventions, should focus on the traditional remit of public health in vaccination and contagious disease rather than noncommunicable disease. I have OIA requests in now with MoH trying to get a handle on whether they've been putting any funding at all into vaccination work. We get piles of HRC grants for stuff like discouraging youth smoking and drinking and advocating for sugar taxes; it's hard to see anything like it for vaccination. It looks like they made a grant to Auckland Uni's immunisation centre. But there just hasn't been much research work there yet on encouraging vaccination uptake. They've done literature reviews, and they have an annual set of charts that come out of the Tier One vaccination stats, but nothing like the research push that HRC makes into noncontagious disease. I suspect that Janet Hoek, all on her own, gets more funding for anti-tobacco work than the government's provided for research into encouraging vaccination. But I'd like to know. 

It applies in the current case as well, particularly around BPS targets for DHBs to encourage them to find what works in encouraging vaccination. I note that in my old home province of Manitoba, they're sending out vaccination teams into the provincial parks to find people where they are at the weekend and jab them. Here it's all bookings. And that'll be great for those who are happy to get a booking. What happens after that?

Morning roundup

The morning's browser tabs:

• Newsroom picks up on BusinessDesk's prior reporting on MIQ ghost rooms. Much credit goes to Cameron Conradie's constant reporting on the numbers. BusinessDesk pointed out that the MIQ system is constantly overwriting its own data so that it is impossible to get, from them, the prior track. I wonder what the Archivist would make of this because it sounds like deliberate destruction of Official Information which may have to have been backed up by a Disposal Authority. Anyway we're losing skilled migrants who rightly view there as being no chance that the government will fix the system, because the government starts by hating migrants and viewing allowing any of their families in as actually being a bad thing. While it is still good to live in NZ as a permanent resident, I could not recommend that anyone try moving here, unless their utility enters negatively into my utility function - and I don't have that kind of utility function. 
• The government is going to run into real problems in maintaining nursing staffing. If I've understood the state of play correctly, nursing salaries in NZ are similar to salaries in the UK but Australia has some of the highest pay rates going for nurses. Training nurses here in a common labour market with Australia can result in outflow. NZ has made up the gap by importing nurses - some from the Philippines, some from the UK. But while there's provision for entry through MIQ for nursing staff, it's still a big constraint. Australia is far richer than NZ and can afford to pay more. It's entirely plausible that the government here is behaving as monopsonist in keeping nursing wages down, but even if that weren't the case there would still be a problem. 
• NZ is importing and burning a lot of coal currently. In one sense, this is not a problem at all: the Emissions Trading Scheme sets a binding cap, the current ETS price roughly doubles the cost of using coal, so any coal that's used is very likely in spots where it would be real expensive to substitute away from. But there are still two more substantial problems. First, some of the coal burning is because Megan Woods banned gas exploration in Taranaki, reducing capacity in those fields. So we're being forced to use a worse alternative because the government set very bad policy. Second, optics. While all that coal is accounted in the ETS, nobody understands the ETS, and seeing coal imports makes people think the ETS isn't working. And that builds pressure for even worse interventions. I wish that National would aim for less political point scoring here and instead be looking to underlying causes. 
• The government is going to be having an inquiry into crypto. I kinda knew what was going on in crypto 3 years ago; that tech is moving crazy fast and keeping up with it would be a full time job. I hope Auckland's Alex Sims helps them out a bit, and I also hope they seek some of the expertise over RMIT. Parliament's Select Committee couldn't figure out how the Uber app works a few years ago. This won't end well unless they get some serious help. 
• NovaVax also looks pretty good. Seems futile to hope it will get evaluated and considered for roll-out here, where dose availability is a binding constraint. We are sitting ducks here if Delta gets out. 
• Environment Minister Parker is holding off on nitrate limits on waterways - for now. I still think cap and trade solutions can get that job done. Report on that will be out soon. 
• The government's reluctance to have effective vaccine mandates for border workers - it's just incomprehensible. There can be practical difficulties that need to be overcome; sending nurses out to worksites over a few shifts could make a lot more sense than trying to get all those workers separately to make long commutes out to places where they can be vaccinated. If compulsion is warranted anywhere in public health, it's in vaccination. There are very real and substantial negative externalities from not being vaccinated - and especially among workers who are at risk of contact. We wind up with a health system happy to ban soda in the hospital cafeteria but that can't manage to get workers vaccinated. It's nuts. 
• Another for the "is government actually evil?" file: The Ministry of Ed refuses to fund a teacher's aide for a special needs student (limited budgets; understandable) but also refuses to allow the parents to privately fund the aide. 
• Industrial policy as casino economics. Do you feel lucky?
• Cuba's health policy successes are wildly exaggerated and based on bad data. Here's hoping that the new revolution brings down the communist dictatorship. 
• Remote work won't work for everything. Face-to-face still matters. Planet Money interviews Enrico Moretti. 
• Not crazy to worry about inflation. But if you have strong opinions about it and you think you're right, well, here's the data series on nominal bonds and here's the series for inflation-protected bonds. If you think inflation is going to go through the roof, make the appropriate play. If you think that everyone else is just way too worried about inflation, take the opposite appropriate play. 

Turns out you can pay to get vaccines faster

Alex Tabarrok and coauthors have argued, convincingly, for substantial investment in vaccine manufacturing capacity by richer countries. 

Paying a lot up front to get vaccines faster doesn't have to be about shifting vaccines from one place to another. It can instead be about getting more resource to those companies to scale up production more quickly. And that matters because the lines can then just keep running, pumping out more vaccine more quickly for everybody. 

So, for rather some time, I've argued that New Zealand should have at least tried paying a lot more to boost capacity and to get vaccines here faster. Our border walls are expensive and less secure than they could be; getting everyone vaccinated faster reduces risk and would restore more normal travel arrangements more quickly. Getting that capacity in place matters a lot too. 

And I've often been told that that would be impossible because things don't work that way. 

Here's CTV news on how Canada got their vaccines faster by paying more.

Canada paid a premium to get more than 250,000 doses of the Pfizer-BioNTech vaccine delivered last December, weeks earlier than planned.

The detail is contained in heavily redacted contracts released to the House of Commons health committee late Friday, but any specifics on what price was paid or how the delivery schedule was amended were deleted before the contract was published.

Canada reached a deal with Pfizer in July 2020 to buy at least 20 million doses of the COVID-19 vaccine it was developing with German-based BioNTech. The first contract was signed on Oct. 26.

Pfizer Canada CEO Cole Pinnow told The Canadian Press in February that Canada's negotiations were based on an expectation the first vaccines wouldn't be authorized for use until late January at the earliest, and deliveries were planned to start after that.

But within a month of the contract being signed, Health Canada's chief medical adviser, Dr. Supriya Sharma, was signalling that her department was about two weeks away from giving the vaccine the green light.

That appears to have sent Canada racing back to Pfizer to see if its contract could be amended to get some doses delivered early. On Dec. 4, Canada and Pfizer signed an amendment allowing for that, but at a cost.

"Whereas (the) purchaser has requested, and Pfizer has agreed .... to amend the delivery schedule so that a certain number of contracted doses are delivered prior to Jan. 1, 2021 and in consideration thereof the parties have agreed to increase the price contracted doses which are delivered prior to Jan. 1, 2021," the contract says.

Every detail in the contract related to the price paid for dose was deleted before the documents were made public.

The contract with Pfizer stipulated nothing would be shipped until Health Canada had authorized the vaccine, which happened on Dec. 9. The first shipment of 30,000 doses was on a plane to Canada within days and the first Canadian was vaccinated on Dec. 14.

Ultimately, Pfizer shipped 255,450 doses before Jan. 1. It has since delivered more than 22.5 million shots, and its vaccine has become the main component of Canada's effort to get all 38 million residents immunized against COVID-19.

Canada expects to have the whole country fully vaccinated by the end of September. 

Update: No rush on vaccination though really. No Covid here, no chance the Delta variant will make it through the border defences...

11/ Why is Delta scarier? First, it appears to be even more infectious than the Alpha variant, probably by a similar amount (~40% more infectious than Alpha.)(h/t @EricTopol for @BBC table below) This means the same exposure that a person might have had last year is now about… pic.twitter.com/wjMkpuDSIL

— Bob Wachter (@Bob_Wachter) June 13, 2021

Vaccine patents

This week's Newsroom column covered some of the arguments around increasing vaccination rates in poor countries by voiding patents. It won't work. 

A snippet:

Fundamentally, voiding patents is an unserious way of dealing with a serious problem. The world needs substantial expansions in vaccine manufacturing capabilities as quickly as possible. Replicating the processes used by successful manufacturers is not simple, and constraints against expanding capacity need to be solved by investment.

New Zealand’s contribution to the COVAX effort is laudable. But we remain pound-foolish. Spending a lot more on vaccines by contracting for greater capacity would help New Zealand become vaccinated more quickly, protecting us and providing some hope of normal international travel.

Contracting for capacity would also mean that more vaccines could be produced more quickly for everyone else too, reducing the risk of new variants that could lead to new border closures after New Zealand completes its first round of vaccination.

And, unlike voiding patents, it would preserve incentives to develop vaccines against new threats that might yet emerge.

I also chatted about it with Bryan Crump last night on Radio New Zealand's Nights programme.  

The tech transfer problem seems nearly insurmountable under compulsory options. 

What do I mean? 

Plenty of vaccines are produced under license by other manufacturers. When that happens, the developer spends a fair bit of time in due diligence making sure that the plant is up for it. There's a lot riding on it. A bad batch is costly; a bad released batch would be very bad. Quality assurance really matters. 

Under voluntary licensing, the IP holder has strong incentive to get this right. They'll want to make sure the plant can do it, and they'll want to provide the assistance necessary to make it work. And there'll be plants whose requests to be licensees get knocked back because they just can't do it. 

Now suppose we followed the abolish patents people's suggestion. They'll sometimes acknowledge the importance of tech transfer. But how in heck would they effect it? 

There are plenty of cudgels they might threaten the vaccine's developer with. Governments are like the mafia, they have plenty of ways of making convincing threats. So they make some threats and force the company to send its experts to teach other plants how to use the stolen plans for making vaccines. Now suppose those experts report back that the plant isn't actually up to the job - it's likely to produce bad batches. 

How can the government's bullies distinguish between false claims intended as IP protection, and real claims? Remember: If the government actually knew how to build this stuff, it wouldn't need to rely on the company's experts to effect the tech transfer. It could just void the patents and send its own officials to teach other plants how to do it. 

The only workable ways of doing this seem to be ones that provide strong incentive for the company with the knowledge to have lots of quality output coming out of those licensee plants with incentives for quality control, but that's what a standard licensing agreement could already provide. 

To paraphrase an Alex Tabarrok tweet, it's as though the anti-patent people think that buying the French Laundry's cookbook would automatically get a Michelin star for your home kitchen. There's a reason that top restaurants branching out don't just send over the cookbook to the new venue. 

I think a lot of the anti-patent people are grinding old axes about patents, combined with an innate hostility to the idea that anyone should ever be able to make money in medicine.

Priority groups

If you live in New Zealand and need a vaccine for travel, the process doesn't look simple unless you're on the government's radar as a person of national significance. 

There are two further categories we are still looking at: one for people who may need to get a vaccine on compassionate grounds; and a national significance category, which could include groups who need a vaccine in order to represent New Zealand overseas.

There will be plenty of folks who will need to travel for business reasons and won't be able to access vaccines easily. The framing has generally been around the unfairness of queue-jumping, but where there's no community transmission in New Zealand, it perhaps matters less if an at-risk person in a remote spot is vaccinated in June or in September. 

There's now an option to crowdfund support for Covax: the facility that buys vaccines for poor countries. Give them $10, they'll get a vaccine to someone in a country that can't afford them otherwise. You can go and do it right now. Click the link. I just did. $50 plus $3.90 to cover credit card and transaction fees, and I've just bought vaccines for 5 people. But I cannot get a vaccine in my own country despite very much wanting one so that I'd be vaccinated in case I needed to travel in a hurry.

I wonder whether we could set an additional channel for priority access here. If someone makes a donation to Covax that would see 5 more people abroad vaccinated, could they get a vaccine that would enable them to travel? Is 5 too few? Is there a number that would do it?

If you need to travel for compassionate reasons, you might need to be travelling in a hurry. That requires being vaccinated long enough ahead of travel for the vaccine to be effective. That means getting vaccinated before you've got a compassionate case to plead to MBIE. 

Business travel can more typically be planned in advance, but unless you're an America's Cup sailboat or involved in films or an Olympic athlete or whatever is currently exciting one of the Ministers of MBIE, good freaking luck. You're not going to be of national significance, because you do not have pull. 

Public health and vaccination

There could well be a case for having a public agency focused comprehensively on vaccination and communicable disease. 

But the proposal that the folks over at Public Health Expert isn't that. In a post framed around the recent measles outbreak and noting the risks around antimicrobial resistance and pandemics, we get this conclusion:

Business as usual is not a rational or viable option for NZ. There are almost daily reminders about the large current and impending public health challenges faced by this country. These challenges include the health consequence of persistent inequalities, the increasing burden from rising obesity and non-communicable diseases such as diabetes, and persisting problems of poor mental health and suicide. Possibly even more alarming are the rising environmental consequences of climate change and ecological collapse that take us beyond ‘planetary boundaries’, and emerging infectious diseases including rising levels of antimicrobial resistance and the emerging coronavirus pandemic. The current national measles epidemic is just another reminder that our national public health capacity and systems are no longer fit for purpose.

The good news is that the present Health and Disability System Review could map out the design for a new kind of public health agency to lead the transformative change that NZ needs to achieve its goals of improved public health and equity, and support its shift to a sustainable future.  Public Health Aotearoa could well provide the high quality sustained public health leadership needed to eliminate measles, improve our health security, and manage other long-term public health challenges.

It would be ...surprising... if this kind of agency maintained any kind of focus on pandemic prevention and vaccination promotion. It would quickly instead become an agency pushing for greater controls around lifestyle issues related to noncommunicable disease and, from the description above, social justice issues. And when that shift resulted in another great forgetting of the importance of vaccination and core public health, it would complain come the next measles outbreak that it simply hadn't had enough funding.

I could rather strongly favour there being an agency solely responsible for reducing the risk of communicable disease. That's core public health work. It would encourage research into vaccination uptake - finding ways to get folks vaccinated who are averse to vaccination. It would have targets around vaccination rates. It would make sure that public health nurses get into the schools to make vaccination routine. If it ever came to it, it could help coordinate quarantine regimes.

I really like the kinds of things that Nick Wilson writes about pandemics and preparedness. But I have no confidence that a new public health agency would pay any attention to pandemics or vaccination rates outside of a crisis.

Like, why would it be any different than the general focus of the current regime, in which it is dead simple to find millions of dollars in grants to Otago Uni to run focus groups about smoking (while Marewa does the real work out on her own) but hard to find much evidence of support for research into encouraging vaccination?

I'd put in an OIA request last year asking the Ministry of Health to list any research it's commissioned around vaccination. This is what I got back. It isn't much, despite waning vaccination rates.

Vaccination just seems to be low priority until there's a crisis. I wonder whether one tobacco researcher, by herself, has gotten more funding than the whole vaccination research agenda noted below.

Vaccination, compulsion, and paternalism for the lower orders

The National Party has come out in support of encouraging greater vaccination uptake.

But it sure isn't the way I'd do it.

National's suggested docking the benefits of those on benefit whose kids aren't keeping up with their vaccinations. Some in National have suggested extending that to payments under Working for Families, but that appears more controversial.

We can go back to first principles and note that there's a reasonable case for government intervention to encourage vaccination - as I have done previously. There is compulsion all over the place in public health, except where there's an actual market failure case for using compulsion.

I think that case is strongest when it comes to those workers most likely to be in contact with not-yet-vaccinated youths, and with people whose immunity may otherwise be compromised. So, ECE workers and workers in the hospitals and public-facing parts of the health system.

A case for docking benefits as a way of encouraging vaccination you'd think would have to start with data showing far worse vaccination rates among beneficiaries - is there a there there?

Unfortunately, it's hard to find data on anything like that. The closest we've got are the Tier 1 immunisation stats which sort immunisation coverage by DHB area, by deprivation, and by ethnicity. They have those stats for immunisation status as of 6 months, 8 months, 12 months, 18 months, 24 months, and 5 years.

When I look at those stats, differences by DHB are huge as compared to differences by deprivation.

Take immunisation coverage at 8 months for example. Look at the gap between immunisation coverage for the least deprived quartile and the most deprived quartile. On average, the difference is 5.7 percentage points in the most recent data. In MidCentral, the gap is 13.4 percentage points - and it's 38.1 percentage points over on the West Coast, albeit with small sample issues. But in Tairawhiti, the gap is -4.6 percentage points: vaccination coverage rates there are higher for the cohort more likely to be in receipt of benefit. And similarly in Canterbury: vaccination rates among the most deprived are five percentage points higher than for the least deprived.

Why is it that vaccination rates among the most deprived quartile in Canterbury DHB is higher than the vaccination rate among the least deprived in 13 of 20 DHBs? Have they done something there that other DHBs should be replicating? Variability in immunisation rates among the most deprived, across DHBs, is larger than variability in immunisation rates among the least deprived. What on earth is going wrong over on the West Coast, where there's that 38.1 percentage point gap and only 61.9% of the most deprived quartile bother with vaccination?

The standard deviation of immunisation rates across DHBs is 4.1; the standard deviation of vaccination rates across deprivation quartiles is 1.9. There's nasty stuff in some DHBs and in particular in some DHBs for the most deprived quartiles, but it's harder to see this as a generalised poor people problem. National immunisation rates for the most deprived, at 8 months, are 88.3%; for the least deprived, it's 92.6%.

Were I suggesting policy targeting vaccination, rather than playing into other things, I'd be looking at:

• Compulsory vaccination as employment condition in the state-funded health sector, for both new and existing staff. They impose substantial direct risk. And how many antivaxxers will look at the recent reporting on low sector uptake and take it as reaffirming their beliefs? 
• Compulsory parental notification of vaccination status of employees at ECE centres, and consider making it a condition of receipt for 30-hours free. Like, the government made it compulsory that piles of workers in ECE have qualifications - even where there's no good justification for it - but we don't even know whether ECE workers are vaccinated? Come on. 
• Bring back the BPS targets around vaccination, penalise DHBs for vaccination rates less than 90%, reward them for rates above that. The DHB-level vaccination stats are hardly secret, but DHBs have no particular incentive to go and figure out what works or learn from each other. If DHBs faced financial incentives to ensure broad immunisation coverage, they might decide it's worthwhile to send somebody out to see just what Canterbury is getting right - or whatever DHB has population most comparable to theirs but higher immunisation rates. 
• There are piles of things you can imagine DHBs trying out. Catch-up vaccinations at school for those who missed them. Making sure that all schools get a visit from the nurse with the jabs. Sending a public health nurse along on Plunket visits. Sending public health nurses along to ECEs where vaccination rates are known to be low. How far can you get just by making it really really easy for folks to be vaccinated?
• Tell the Health Research Council that funding for research in public health, aimed at policy changes or behavioural interventions, should focus on the traditional remit of public health in vaccination and contagious disease rather than noncommunicable disease. I have OIA requests in now with MoH trying to get a handle on whether they've been putting any funding at all into vaccination work. We get piles of HRC grants for stuff like discouraging youth smoking and drinking and advocating for sugar taxes; it's hard to see anything like it for vaccination. It looks like they made a grant to Auckland Uni's immunisation centre. But there just hasn't been much research work there yet on encouraging vaccination uptake. They've done literature reviews, and they have an annual set of charts that come out of the Tier One vaccination stats, but nothing like the research push that HRC makes into noncontagious disease. I suspect that Janet Hoek, all on her own, gets more funding for anti-tobacco work than the government's provided for research into encouraging vaccination. But I'd like to know. 

But National's push does play into my general theory of where we get paternalistic regulation - it's generally targeted at poor people, whether or not it makes sense. And it will be fun to watch people explain why it's okay to make it a condition of benefit, but not okay to make it a condition of WFF. Maybe there's finer-grained data that would let them show that the gap is far larger when you look at beneficiaries compared to other kids in low income quartile households, but I really doubt anybody's even looked at it.