There is a through line to MY's pieces: let's do the sane and straightforward things first rather than constantly looking for 'smart' takes. Let's strive for competence before reaching for brilliance. Let's lower the temperature and try to be normal rather than exotic.

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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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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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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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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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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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"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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“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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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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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".


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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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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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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


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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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