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So here's a fun, and topical, story. 2005, I'm a Peace Corps volunteer in Cameroon. I get placed in the middle of nowhere south Cameroon - a 6+ hour motorcycle ride through rainforest from a paved road, that kinda thing. Very rural. I worked at this tiny clinic, but one of my side jobs was assisting this Walter Reed-Johns Hopkins joint project on retroviral surveillance. Basically, they were studying whether/how often retroviruses jumped species lines from apes to humans, mostly as a result of bushmeat hunting, which is extremely common. Turns out, species-jumping happens A LOT. 99.8% of those viruses that move to humans are completely inert and die out. And then occasionally, you get an HIV or Marburg or Ebola or whatever.

In the terms of international development work, it cost nothing. A few million dollars. I, as a Peace Corps volunteer, was there sorting sample identification cards and stuff on the floor of my concrete hut and greeting these guys who showed up to my house with a dead chimp on the back of a moto, that kind of thing.

Anyway, they found a ton of this stuff and apparently it raised enough eyebrows that USAID plowed $200M into massively expanding the program in 2009. It was called the PREDICT program: https://en.wikipedia.org/wiki/PREDICT_(USAID)

People only know about it now because the Trump admin shut it down as soon as they got into office because, you know.

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And of course Biden restarted it because, you know.

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Its insane that we won’t fund pandemic preparedness *during* an ongoing pandemic. Compare it to 9/11, where we suffered billions of dollars of damage and spent trillions in reaction. With COVID we suffered trillions of dollars of damage and won’t even spend billions. I really don’t get it.

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The billion spent as a result of 9/11 -- Iraq, security theatre -- mainly made things worse.

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Yeah it was a huge overreaction. Really bad. What we’re doing now with covid is a huge underreaction; also really bad.

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Agreed. It's because the pandemic stupidly became part of the culture wars. If our doom comes it will be well deserved.

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If only we had an ex-pharma CEO as Vice President

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Every single blue state union leader who jaw droppingly is fighting vaccine mandates for their membership has blood on their hands. With friends like them, who needs Ron Desantis?

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Outlawing public sector unions should be part of our planning for the next pandemic. It would have all sorts of other benefits, too.

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Too bad we have this thing called the First Amendment that guarantees freedom of association.

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There is no freedom to force an employer to collectively bargain.

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Correct! But that's not what you said. You said outlaw the union.

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Yes, exactly.

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I don't mean to engage in petty squabbling about wording. I hear people all the time say that we should outlaw this or that union. I think what they mean is "the government shouldn't force employers to negotiate with unions" or "the government shouldn't force itself to negotiate with unions." You can't outlaw people meeting up, talking about work, pooling resources, slowing down labor, or striking because of the First Amendment.

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yeah if ending evictions is within the scope of fighting a pandemic then clearly ending public sector unions should be as well

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Do you have a better solution solution to labor market monopsony power?

(C.f. https://www.nber.org/system/files/working_papers/w7258/w7258.pdf)

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Civil service laws? Something we already have?

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Yeah I might be able to teach in a public school if there were no unions.

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It looks like we're backing into vaccine passports, at least for big cities. I'm OK with this, but man, if we were going to do this anyway, I wish it had been properly standardized, rather than weird ad hoc approaches

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founding

And I'm starting to get really worried that my Texas vaccine card will end up being useless - I traveled to California a few weeks ago and tried to get the California app, but they would only verify vaccines given in California. Texas seems to have banned Texas businesses from verifying vaccinations, and in any case, the vaccine center that vaccinated me shut down months ago so there's no one to call to verify my shot. I really wish someone had started tracking these things centrally earlier.

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On the plus side, you can walk in and get a free "booster" 3rd shot in CA!

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if you billed insurance, it might be able to verify

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I certainly agree that we need to fund these agencies, and no doubt there are all sorts of things money can do, like building a PPE stockpile. However, if we want better chances of success the next time, we need a "9/11 Commission" to look at the bureaucratic performance of the FDA and the CDC, and to recommend improvements. From internal lawyers stopping academic Covid testing early on (who did that, and why?) to the failure of the CDC's own test, which it insisted upon, to the reliance on flimsy data, to the arrogation of power over such things as landlord-tenant law, the country needs to understand how these agencies can perform with much more flexibility and effectiveness the next time. Because right now confidence in these agencies -- the permanent government -- is really low.

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"9/11" type commission would appear to be anti-FDA/CDC. Ordinary reporting should have been looking into these decisions. The list of questions is almost endless. Some of the answers might even show the agencies in a better light.

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Well, fair enough.

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Very much agreed. But building a stockpile is IMHO insufficient. We need to make sure we have enough domestic capacity to ramp up PPE and testing quickly.

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"A lot of the reporting on Delta breakthrough infections has been confusing or irresponsible in my view, but the basic point is that if a vaccine is 90% effective at blocking infection, you’re still left to worry about the baseline number of infected people you’re running into. So Delta ends up being a cause for concern among both the vaccinated and the unvaccinated."

This is has been by dilemma for the past 2-4 weeks. Among the medical community right now there is a quiet understanding that the vaccine is not 90% effective for the Delta variant. At my husband's hospital in LA, one infectious disease doctor speculated more like 85-88% effective, and at my brother's hospital in SD - 65-70%. That's a BIG difference. And hospitalizations are 13% vaccinated at my husband's hospital, though only 1% of ICU admissions. So this effects how I counsel my patients. Back in the spring, I told most of my seniors to hug their grandkids: "yes, your grandkids aren't vaccinated, but your risk of illness is 5-10%. It's not 0%, but it's pretty close." Now I'm telling them to be careful again, especially the more vulnerable ones.

I'm frustrated b/c I think CDC is withholding accurate data on vaccine effectiveness b/c they don't want to discourage people from getting the vaccine. They don't want to admit that it's not as effective as they originally claimed. I get it. But people need to know accurate risks in order to alter their behavior.

And I'm completely in favor of vaccine mandates now, where I was hesitant about them before. Especially if the vaccine is not quite as effective as we thought, it becomes abundantly obvious that the unvaccinated are putting everyone at risk. I have to be careful with patients b/c getting angry at the unvaccinated does not help to convince them to vaccinate, but it's difficult not to show how frustrated I am. Yesterday, I had an 83 yr old patient with severe rheumatoid arthritis on immunosuppressive medication who is vaccinated. But b/c he is so severely at risk, I asked at the visit if he is around anyone unvaccinated. His 63 yr-old son who accompanied him to the visit pipes up, "I'm not vaccinated." And when I try to convince him to get vaccinated, he says he's ready to die if need be. "But are you willing to kill your dad?" I asked. Yeah, that didn't go so well.

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“ They don't want to admit that it's not as effective as they originally claimed.”

I very much object to your phrasing. If you test the vaccine against covid-variant A and it’s 95% effective and then covid-variant B arrises and the vaccine is only 85% effective you don’t have to “admit” anything. The facts have changed. That doesn’t make what you said before untrue.

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Absolutely. Totally agree. But you need to update people on the current truth and I don't see that happening.

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Is this not a base rate fallacy? If everyone is vaccinated, 100% of hospital admissions will be vaccinated people. That proportion doesn't tell us anything about effectiveness.

I have a lot of complaints with CDC messaging, but I don't think they are intentionally withholding data to push a message.

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Good point. Again - look at the CDC study I sent the link to below. There were flaws with that study but the data is still disconcerting. My complaint is not so much with CDC messaging as frustration with not knowing actual truth in order to accurately protect people -not to either over-represent or under-represent risk. When I got tested for Covid recently after an exposure, there was no question of whether or not I was vaccinated in the list of questions they ask when you register for the test. Is public health even collecting the data on what percentage of people are vaccinated but testing positive? I do have actual data about hospitalizations and that data is somewhat disconcerting. I don't see that data being reported either on the national level, or locally with LA public health.

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founding

CDC decided to stop asking this back in May. It makes no sense.

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I know it's futile to bitch about things that cannot be, but, it shouldn't be necessary for the CDC to "ask" this question. Here in the um, "Asian" country in which I reside, this is the way that is handled:

1) Everybody's been using a health status app for the past year, connected to one's phone number, and verified via uploaded, government-issued ID (in the case of foreigners like me, a passport).

2) When you get tested they ask you to scan in (OCR) with your app.

3) Your test results are sent to your app, which then displays updated information. In my case now it reads "264 days" as it's been quite a while now since I've been tested..

4) When you get vaccinated they likewise ask to scan in with your app, which likewise gets updated (my status now indicated "fully vaccinated").

5) Your app, and the government's public health records, are updated in real time.

Technocracy in action!

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If the responses weren’t accurate it would make sense to stop asking.

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The problem is if someone arrovea at the Er with Covid and they ask, “Have you been vaccinated?” What percentage of unvaccinated people will claim they were vaccinated? 80%? I wouldn’t be surprised. No one wants to admit they are an idiot.

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You'd be surprised. It's a point of pride with a lot of people. They are more than happy to tell you all about government over-reach, their liberty, and the dangers of a new vaccine with emergency authorization only. (eye-roll)

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As they are gasping for breath in the ER?

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See my comment about the Freedom Death Cult

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Is it really disconcerting? "Among persons with breakthrough infection, four (1.2%) were hospitalized, and no deaths were reported." Your experience may be a bit different though.

I agree that would be a good question to ask and collect data on, although a positive test doesn't necessarily imply infectiousness (as myrna pointed out a few days ago).

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Yes, but that's an edge case. A lot can be inferred by comparing the proportion of hospitalized or ICU patients to the proportion who are vaccinated. If 70% of the population is vaccinated and 70% of those hospitalized are vaccinated, then it's clear the vaccine isn't doing much. If 70% are vaccinated and 14% of those hospitalized are vaccinated, then (based upon the odds ratio) you are about 14 times less likely to be hospitalized if you are vaccinated.

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Fair, so if we take LA county as ~70% vaccinated but 13% of admissions, that suggests that the vaccinated are at a (0.13/0.7) / (0.87/0.3) = 0.064 relative chance of being admitted, i.e., a reduction of 93.6% (I think I did that right).

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It could easily be even better than that for the vaccine. It's clear that older people are vaccinated at higher rates and it's clear that they are at higher risk from covid. If those 13% are older than the 87%, and they probably are, then the vaccine is working very well.

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Thank you so much. I'm admittedly not so good at statistics so your presentation in numeric terms is extremely helpful to me. I think I still need to counsel my older and sicker patients to be more careful, but this helps me get a mental picture of the risk reduction for most of my vaccinated patients, which is exactly what I was looking for.

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Oh sorry, I realize now that you did the same math and that we agree!

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“And hospitalizations are 13% vaccinated at my husband's hospital”

Around here it has been pretty consistently reported that less than 5% are unvaccinated and considerably less than 1% of ICU cases are unvaccinated.

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Don't know what to tell you. Perhaps this reflects the underlying vaccinated population. Here in LA, the vaccinated are mostly likely a higher proportion of the population than Miami (I assume that's where you are based "MIA") and the older and sicker are more vaccinated than the younger -- who are still getting it and spreading it, but less likely to be hospitalized. I just looked at today's data btw - now 5% vaccinated in the ICU at my husband's hospital, not 1%.

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“Here in LA, the vaccinated are mostly likely a higher proportion of the population than Miami”

Looking at the WSJ’s map, based on CDC data and updated 22 minutes ago:

Miami-Dade Los Angeles

All ages 61.6% 53.9%

12+ 71.2% 62.6%

18+ 74.2% 64.2%

65+ 83.9% 73.9%

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Look at the study from the CDC of the outbreak from Massachusetts. https://www.cdc.gov/mmwr/volumes/70/wr/mm7031e2.htm

(I think this is the source of the "confusing" and "irresponsible" reporting that MY is referring to b/c the Washington Post reported about this study last week.) In a population 67% vaccinated, 75% of the cases were in the vaccinated. And of 5 hospitalizations, 4 were in the vaccinated.

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I have read that while the population in Barnstable County is 67% vaccinated, the percent vaccinated in Provincetown itself is much higher-like 90-95%. And in Provincetown during the 2 week period, the weather was crummy and most people there were hanging out in crowded bars, not outside. If you take that such a high percentage was vaccinated, then of course most of the Covid cases were among the vaccinated. What this tells me is that everyone should avoid crowded indoor spaces as the vaccines are not perfect. Here is an article which I read--I know the author makes assumptions, but he really makes the point that probably, only about 1-2% of those vaccinated people, many of whom crowded into bars,Provincetown got sick.

https://inguyun.medium.com/the-provincetown-outbreak-is-actually-good-news-if-you-are-vaccinated-93a1edd763b6

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Provincetown is a resort town and it was one of if not the busiest weeks of year for them. The number of visitors wildly outnumbered the number of residence so the vaccination rate of the locals wouldn’t tell you much.

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I know the guy in the article made assumptions. But the fact still remains that when you have a high percentage of people vaccinated and breakthrough infections are possible, the absolute number of breakthrough infections of vaccinated people will also be higher. So I wish that instead of implying that "the vaccine doesn't work well with Delta," (which is what a lot of people hear) we give the message, "Don't crowd in indoor spaces, even if you are vaccinated." This is the reasoning that masks were always still required on public transportation and trains and airports

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founding

Wait, a third of the people traveling to Provinceton for gay party weekend were unvaccinated?! That seems crazy to me! Urban gay party people are almost certainly far more vaccinated than the counties they live in, and those counties are almost certainly far more vaccinated than the county Provincetown is in!

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Wouldn't they be young, though? Party weekend sounds like younger people to me. And under 40s are, on average, not vaccinated at high rates. When you subtract out the highly vaccinated 65+ pop the overall rate is much lower.

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founding

Yeah, I think it's hard to know. Middle of July is typically "bear week" in Provincetown, which probably has a median age in the 40s. It's hard to know if being a party *destination* makes it higher income/education (therefore more vaccinated) or if being a *party* destination makes it more reckless (therefore less vaccinated). And it's hard to know whether the timing in early July of *this* year means that it's the first time out for everyone who was cautiously isolating at home and just got vaccinated, or if it's the people who were jetting off to Puerto Vallarta every weekend last winter.

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Sure, makes sense. All I'm saying is 67% vaccinated actually is a good bit higher than the baseline if the partiers are mostly under 50, so you're original assumptions sound correct to me.

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“When trouble is sensed well in advance, it can easily be remedied; if you wait for it to show itself, any medicine will be too late because the disease will have become incurable. As the doctors say of a wasting disease, to start with, it is easy to cure but difficult to diagnose; after a time, unless it has been diagnosed and treated at the outset, it becomes easy to diagnose but difficult to cure. So it is in politics.” — Niccolò Machiavelli, The Prince

So it also is with the politics of medicine.

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To point out the obvious: this is a global pandemic and the longer it takes to distribute and administer vaccines globally the more likely it is that a new variant will develop against which the current vaccines are mostly or totally ineffectual. Higher vaccination rates are essential in the US, of course, but they won't matter if vaccine uptake in most of the rest of the world doesn't go up fast, and soon. The vital role the US could play in making that happen should also be obvious.

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Well unless of course we cut off travel for other countries (like we should have from the start). Or make travelers quarantine for 2 weeks upon entry.

And of course stop illegal immigration

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Wouldn’t producing a new vaccine to protect against the Delta variant be great practice for rolling out new vaccines on an even more aggressive schedule. I certainly am loathe to embrace the “distance for 13 months while we develop a vaccine strategy” ever again

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founding

Yes. But I think Moderna's plans to make annual flu vaccines using mRNA technology will also do this: https://www.healthline.com/health-news/why-a-new-mrna-based-flu-vaccine-may-be-the-most-effective-yet

One of the other stories I saw mentioned that they will include not just four flu strains, but covid, and two "common cold" coronaviruses, in a single shot.

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I'm conservative, but I think this is one of the best articles you've written (because I agree with it of course).

Like national defense I believe that pandemic preparedness is a core government function. And even a relatively mild pandemic like COVID (fatality rates could have easily been 10% like SARS, or 30% like MERS) can do enormous amounts of harm to the country.

Thus I believe an extremely robust response is needed to prepare for the next pandemic. As I wrote in April 2020. I believe we need to have enough domestic capacity to churn out enough N95 masks (and other PPE) for everyone to use them daily.

I would suggest government stipends to private companies to keep that domestic capacity online, along with national guard units to be trained to staff that production to bring it online at the time of the next pandemic. It's quite likely you might need to do something similar for testing capacity.

When the next crisis hits we need to be ready. I submit we also need additional funds to be prepared for an EMP/solar flare. Like a pandemic it's not a question of "if", but a question of "when".

https://medium.com/the-national-discussion/face-masks-use-them-love-them-24c627ab9f3d

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I feel like it is really important to actually define what we mean by “pandemic preparedness,” since likely everyone has their own ideas. I could easily imagine that $30 billion going to increase the number of bureaucrats and medical ethicists at the CDC, which would be counterproductive. Alternatively, recall that Peter Daszak told us that the best way to be prepared for the next pandemic was to go collect lots of bat viruses in caves and bring them to the Wuhan lab, which at best has been completely useless in this pandemic. I strongly approve of your suggestion to stockpile equipment and factories, but I worry that since that money is largely going to industry and not the agencies tasked with disease prevention it will not be popular with the public health community.

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Yes, the CDC needs a complete revamp. It should be completely focused on actual diseases. It's mission creep into other things has distracted it from what IMHO should be it's core mission. Infectious disease control.

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1. “A lot of the reporting on Delta breakthrough infections has been confusing or irresponsible in my view”

Reporting has been confusing because public health officials continue to act like super private health providers, giving recommendations about what to do to protect the person hearing the recommendation. There is nothing wrong with that per se, but if they are not careful (and in general they have not been careful) this can get in the way of messaging about what to do to prevent the person hearing the recommendation from harming others by not going to crowded venues, not social distancing, not wearing a mask or not getting vaccinated.

2. “And we have leaders in some of the blue states (though frustratingly not D.C. where I live) talking about similar mandates for their workers.”

And why has there been no political reporting on this. Who was pushing for and against? What nefarious deals were made or rejected to prevent to mandates? Thinking just about DC, what is the politics holding up requiring vaccinations of DC employees? A majority of citizens have been vaccinated, showing that they do not want to become spread a dangerous disease and suffer severe illness themselves. So why wouldn't they want their employees not to spread that disease? Don't most city workers want to be protected from infection by their fellow workers? Don't most parents want to prevent their children from being infected by teachers and administrators? Is it just inertia or is there real if silent opposition and from whom? Don’t political reports usually love to report on this kind of dirt?

3. Overcoming logistical barriers and making up-front investments in vaccine production IS hard. What ought NOT to be hard is to develop procedures for testing, approving vaccines that take account of the value of speed and make realistic cost benefit analyses of risk of the disease and risk of side effects. And again, if it is hard, what about reporting on WHY it is hard?

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This quote from Matt:

“If we take vaccination as the solution, then we may need booster shots from time to time or we might not. If we take masks as the solution, then we’ll never be done.“

Is in some ways a nail on the head and in some ways a starting point for a thought fest. My end points after thinking about it.

A) Either mandate vaccination or learn to live with the unvaccinated getting the disease. Do not do (which we all know is what’s going to happen!)… the thing where you just blame the unvaccinated forever and call them bad people, imagine them as manifestly MAGA and never mandate the vaccine.

B) Masks. Just as we learned that delta can slip the defense of the vaccine, has anyone asked the question as to whether or not the mask’s impenetrable stopping power has been maybe slightly compromised by Delta? NPR did an article about how great India had done with COVID before the delta outbreak attributing it greatly to masking mandates, and cited measured compliance studies showing masking to be high. Yet Delta clearly, and tragically did major damage there.

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An admittedly cursory examination of COVID rates around the world during the last 17 months suggests to me that COVID appeared in two-month surges at staggered moments in different countries, regardless of mask mandates. In other words, looking at real world data (rather than hypothetical arguments over whether viruses can penetrate woven materials) suggests masks don't actually work at preventing the spread of the disease. I could be wrong or I could be right, but it's sad that the credulous stenographers of our national media have no interest in looking into the matter.

Because if I'm right, and policy reflected the inefficacy of masks, it would sure go a long way to eliminating a lot of the social unrest, impatience and conflict related to the government's response to the pandemic.

Some of us would regard that as a good thing. Who out there benefits from social unrest, impatience and conflict?

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I have been wondering about mask's effectiveness against Delta for a long time. Why are we not saying that it is important to keep distance from people you don't know instead of lauding masks?

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founding

It's really frustrating that no one has ever figured out whether masks are 90% effective or 50% effective or 10% effective even against "classic" covid, let alone delta. But figuring out whether masks are effective is even harder than figuring out whether restaurants or gyms are bigger sources of spread, and we haven't been able to figure that out either.

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I've been thinking the exact same thing over the past few weeks. There's an enormous difference between the policy implications of 10% and 90%. But I'm as ignorant of the true impact of masks as I was in March of 2020. Meanwhile the world either "knows" they're useless or treats them like a silver bullet

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I imagine it depends on the masks as well. Why not have us all wearing N95 masks?

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founding

Last spring and early summer, we didn't have access to N95s. And by then, we had enough cheap Amazon cloth masks that I guess no one wanted to switch up their local requirement to make us get the effective kind. Not to mention that we have no idea whether the effectiveness of N95s at slowing air flow will mean that people wear them more sloppily, defeating their entire advantage.

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And useful for preventing the wearer from becoming infected? (hard for me to believe it does much good) or for diminishing the spread from the wearer/non-wearer to others (plausible to me that it might be significant, at least enough to justify putting on to go inside a shop, but to wear all day???) But how would one go about investigating that? Have an infected person breath with and without a mask and measure the number of virus particle that reach 6, 12, 24, 48 ft away?

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I’ve had similar thoughts looking at the data. I’m sure that the mask is doing something. However, I can’t help but to think that masks have a lot of conveniences especially for politicians. Most notably that they can always claim “noncompliance” as a reason for cases going up.

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My thoughts exactly!

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Great piece, and I strongly agree with your points. Just a small correction: the Pfizer and Moderna vaccines got their EUAs in December of 2020, not November of 2020 https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine

https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/moderna-covid-19-vaccine

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How much does an mRNA vaccine factory cost? How easy is it to switch to a different vaccine once the capital is in place? I’m more interested in answers to those questions than “throw $30 billion at the problem and hope the results will be better than throwing $30 billion at the northeast corridor.”

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founding

Moderna is trialing mRNA-based cold and flu vaccines right now. It sounds like it's much easier to switch an mRNA vaccine factory from one vaccine to another, since all you have to do is change the strand that you're copying, rather than having to grow a new virus for a live/attenuated/dead traditional vaccine, which might require a new growth medium.

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I feel you in the kids mask thing. People have no sense of risk analysis or cost benefit analysis.

I’m hoping the Delta wave peaks by September and crashes like in the UK, so we can go back to normal. I feel sorry for kids in schools that mandate masks.

On another Covid related thing, my two nieces are heading to Santorini Greece today. They manage to get fake vaccination papers. I told them they were dumb, but “they heard a friend of a friend died from the vaccine”… this is what we are dealing with.

Anyway, I’m on board with mandatory vaccinations as much as possible. Require for air travel, Military, Federal Workers, etc… this would spur corporations to follow and eventually it would be too difficult not to get vaccinated.

What we really need to do is to have health insurance premiums based on vaccination. Hit people in the wallet.

Prepping for pandemic… yes let’s do it. But we all know it will be cut in 8-years to fund tax cuts.

Anyway. I’m on a plane heading to Atlanta, then working in Mexico this weekend. (Funny enough my nieces are on same plane) on way to Greece.

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How hard is it to get fake vaccination papers? It keeps crossing my mind when I hear about potential mandates because it seems like it could be easy. The little pieces of paper I got didn't seem very official or hard to forge.

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Maybe I'm naive but I'm going to a large-ish (~2k people) board game convention in November and I want them to "require" vaccination (or say that you medically can't), but I'm ok with an "honor system". (Provided you tell people that's the requirement with sufficient time to get vaccinated -which in the U.S. at least is just 6 weeks - the time it takes to get both doses + 2 weeks)

Yeah, some people will cheat it but I feel like (especially for a voluntary convention like this) the chance is low.

I know if you mandate vaccination some people will cheat the papers, but I think a lot of people, especially for voluntary things (if you have to fly TOMORROW you might cheat the paper rather than get vaccinated) would either get vaccinated or not do it.

I like to think the % of people who would cheat is low enough.

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