How Trump can lead on vaccine development, again

It’s time to get ready for bird flu

One of the biggest substantive disappointments of the Biden Administration is that even though he was elected in the wake of a massive global pandemic, his administration did not accomplish very much on pandemic preparedness.

That’s particularly relevant because the world might be teetering on the brink of an alarming H5N1 bird flu pandemic. People keep getting sick from working in the poultry and livestock industries, and on November 12, a Canadian teenager with no known contact with animals was hospitalized, apparently with a strain that is circulating in wild birds rather than in dairy cows. That’s probably good news, because it raises the possibility that it was caught from an animal in a chance encounter rather than, more alarmingly, being passed from human to human.

I hate it when people in the media say “don’t panic,” because panic is by definition the wrong response to any situation. That said, I’m not panicking about the bird flu just yet.

But we know that pandemic respiratory viruses can be extremely deadly and extremely costly. Even if you take a hard-core dovish view of the SARS-Cov-2 outbreak, you have to concede that it caused massive economic damage. Some of that damage you could say was caused by the non-pharmaceutical interventions (NPIs) adopted in response to the pandemic rather than by the disease itself. But while a new administration could discourage NPIs in the face of a deadly flu outbreak, you can’t make it illegal to have a behavioral response to disease risk. When bars and restaurants reopened in the fall of 2020 (which they did in most blue states, as well as red ones), they generally weren’t full. When I booked a hotel in Austin in December 2020, it was incredibly cheap because demand was very low. You can’t force people to not notice that a deadly virus is circulating, even if you take a libertarian view toward the appropriate government response.

Beyond the specifics of H5N1 (though I think we should pay attention to the specifics of H5N1), the structural conditions for increasing pandemic frequency are clearly worsening. There are more people alive than ever before, and this larger population is also richer and therefore eating more meat and poultry. This means, mechanically, that there is much greater opportunity for infectious diseases to spread, and for new diseases to cross the barrier between farm animals and humans.

It’s also the case that engineering new viruses keeps getting easier. A couple of years ago there was a cool report out of the UK about a genetically modified herpes virus that fights cancers. That’s incredible. But the same toolkit that makes it possible to explore possibilities like this also allows bad actors to do bad things. The good news is that technology should also let us improve our defenses. But we have to take the problem seriously and actually make the improvements, ideally before there’s an acute crisis.

America’s fitful engagement with pandemic prep

George W. Bush read John Barry’s book “The Great Influenza” in 2005 and started pushing for pandemic preparedness policy.

Those Bush-era exercises were the basis of Covid-era NPIs that eventually came to be associated with Democrats. In 2007, the Bush administration adopted as its official policy guidance “Interim pre-pandemic planning guidance: community strategy for pandemic influenza mitigation in the United States: early, targeted, layered use of nonpharmaceutical interventions.” We got an early opportunity to put this to the test with the H1N1 swine flu outbreak of 2009, but after some initial alarm, this virus proved to be pretty mild (on average — I personally got dramatically sicker from H1N1 than I have from anything else). Still, the threat lingered as a possibility. When I interviewed then-president Barack Obama in 2015, he said the United States underinvests in pandemic preparedness because of the “if it bleeds, it leads” mentality in both the media and the political system. After he left office, the CDC issued a new update on NPIs, “Community mitigation guidelines to prevent pandemic influenza.”

When SARS-Cov-2 started spreading in the winter of 2019-2020, the Trump administration (to the extent it cared at all) basically broke out this flu playbook that the CDC had been working on across administrations.

The playbook was based on studies of policy responses to the Spanish flu. These studies found that a wide range of NPIs — closing schools, canceling public events, encouraging people to stay home — worked, which suggested we should adopt those policies in the event of a pandemic. But these lessons fell a bit short in their application to Covid, because the data they drew on was from fairly mild short-term interventions.

To quote myself:

One of the studies, by Howard Markel et. al., finds that “School closure and public gathering bans activated concurrently represented the most common combination implemented in 34 cities (79%); this combination had a median duration of 4 weeks (range, 1-10 weeks) and was significantly associated with reductions in weekly [excess death rate].”

The other study (this one from Richard Hatchett, Carter Melcher, and Marc Lipstitch) found that “cities in which multiple interventions were implemented at an early phase of the epidemic had peak death rates 50% lower than those that did not and had less-steep epidemic curves.” But they also find that “few cities maintained NPIs longer than 6 weeks in 1918.” Across 17 cities, the most common interventions were bans on public gatherings (15 cities) and shutdowns of places like theaters (15), churches (15), and schools (14). Eight cities implemented “staggered business hours to reduce congestion in stores and on transit systems.” And just one city used “community-wide business closures.”

The logic of the CDC playbook was that if drinking two beers is fun, you should try drinking 20. Conservatives reached the correct conclusion that stringent, long-term NPIs were not viable and moved away from them. But they did a very poor job of explaining what they were actually doing and of distinguishing their thinking from conspiracy theories or denialism. Liberal jurisdictions, meanwhile, were a lot laxer in their actual rules than you would gather from some of the media discourse, but the implementation was horribly compromised by interest group politics and a reluctance to explicitly contradict those further to the left.

The result is that long-term NPIs ended up having no discernible impact on mortality, in part because enforcement was so weak and arbitrary, and the public health community was discredited in the eyes of conservatives. And then the events that unfolded around the vaccines were genuinely tragic:

• Trump-era efforts to accelerate vaccine development (Operation Warp Speed) turned out to work and created life-saving vaccines in record time.

• The efficacy of these vaccines, though pretty good, turned out to be less than one might have hoped compared to some previous vaccines.

• Conservative rage against the public health establishment led them to hypercorrect against claims of vaccine effectiveness and downplay the virtues of vaccines that were genuinely quite virtuous.

As a result, a large red/blue mortality gap opened after Trump left office, because Republicans polarized against vaccines. Biden took over and sunset the “Operation Warp Speed” brand, though his administration created a broadly similar program called Project NextGen (a less cool name) to continue with Covid vaccine development. The administration also fitfully embraced a much more expansive idea, a $65 billion Apollo Program for Biodefense that would try to greatly expand on OWS-style work to develop ambitious pharmaceutical countermeasures. They never got that through Congress, which is mostly Congress’ fault. But the Biden administration signed a lot of spending on various things, mostly Covid-related stimulus measures and climate spending, and doing a little less of that and more on biodefense would have been a good idea.

Gathering clouds of bird flu

In terms of Obama’s “if it bleeds it leads” point, the news on October 30 that H5N1 is now infecting pigs did not attract a lot of attention. After all, it’s just pigs.

But when a bird virus goes from infecting cows to infecting cows and pigs, the number of possible opportunities for it to infect humans are greatly multiplied. And while of course, we still have no documentation of human-to-human transmission of H5N1, this is basically a numbers game. Each time a human is infected by an animal, we’re rolling the dice on a mutation that allows human-to-human transmission. Beyond that, the genetic difference between a chicken and a pig is much smaller than the difference between a pig and a human. Multiple crossovers into mammals is bad news.

It doesn’t mean that we should “panic” about bird flu.

H5N1 might not ever cross over in a way that allows human-to-human transmission. I wouldn’t bet on that, but it’s certainly possible that it won’t happen in the next five years. And if it does cross over, it might just not be very deadly. Normal influenza burden has a lot of variability, and even unusually bad winters (like 2014-2015 or 2017-2018) don’t disrupt ordinary life. Still, if an extra 10-20,000 people had died of something other than an unusually bad flu season, I think that would be considered a pretty big deal.

But it’s also perfectly possible that it does cross over and proves to be as bad as Covid, or even worse. That’s important because a worse pandemic would be bad (obviously), but also because there’s incredible ambiguity running through a lot of conservative takes as to whether they think mainstream public health recommendations on Covid were wrong in a deep sense, or just that the virus wasn’t deadly enough to warrant these measures.

We need better pharmaceutical interventions

Trump has announced prominent NPI critic Jay Bhattacharya as his choice to lead the National Institutes of Health. I have no idea whether he’s qualified to oversee the main functions of the NIH, which are mostly around making grants to fund medical research. But considering the specific controversies he was involved with and pandemic management, I think this is one of Trump’s best picks. Bhattacharya’s criticisms of NPIs during 2020 went further than I would have, and I don’t agree with him per se. That said, he is well-credentialed and smart and also aligned with Trump on the substantive question.

Four years ago, Trump had a lot of people in place who he didn’t have confidence in and didn’t listen to, and then he had a lot of unqualified people articulating his views.

Bhattacharya can do what an executive branch official is supposed to do, and channel Trump-style views in a professional way.

What’s more, precisely because his anti-NPI credentials are unimpeachable, if a much deadlier virus comes around that shifts Trump’s sense of the cost-benefit balance, he would be the right person to deliver that message.

The concern I have with Trump is on the other side.

The most effective weapon against Covid was pharmaceutical interventions. Trump, at the time he was in office, advocated for those — he funded vaccine development, he worked with industry, his team worked with credentialed scientists, and they did a pretty good job of it. But then conservatives ended up being way less likely to actually use the vaccine, Trump was hesitant to affiliate himself with vaccine research and development, and for the past few months, we’ve been in this bizarre mirror universe where Trump has recruited an anti-vaccine crank to run the Department of Health and Human Services.

What’s particularly disturbing about this is that Donald Trump obviously doesn’t agree with RFK Jr.’s other political opinions. Trump isn’t going to be shutting down nuclear power plants. And it would turn everything we know about Republican Party politics on its head for the Trump administration to start cracking down on agribusiness use of pesticides or manufacture of high-fructose corn syrup. It’s kind of fun to speculate about a crunchy-pilled Republican Party, but it’s just not real. This is the party of business and of rural America, and it’s not going to sink massive amounts of political capital into indulging health food fads.

By contrast, lending a federal imprimatur to anti-vaccine activists is a plausible political agenda.

And it would undermine the thing that we actually need to do, which is invest in more and better vaccine development. There’s reason to think it’s scientifically possible to develop vaccines that target entire virus families, and therefore give us protection against novel pandemics before they start. In other words, you could make a vaccine that doesn’t just target one influenza virus, but targets all influenza viruses and means we don’t need to worry about new crossovers from birds to mammals. Or instead of targeting one particular coronavirus (with customizations for new variants), you could tackle all the coronaviruses. That would protect us against Covid’s ongoing circulation, it would protect us against potential new pandemics, and it would even protect us against the couple of long-circulating coronaviruses that are the cause of many cases of the “common cold.”

This kind of technology is within our grasp, but it requires money, and it also requires some of the imaginative work I associate with OWS in terms of figuring out how to get regulatory approval. And that all requires an administration that believes in science and progress. There is clearly a techno-futurist side to the current iteration of the Trump movement (see Elon Musk and his mission to Mars), but Trump’s personal politics have always been paranoid and nostalgia-oriented, and the alliance with RFK Jr. seems to reflect that. But conservatives should take seriously the idea that, especially if you hate NPIs and “lockdowns,” you need to make the sort of big, proactive investments in science and technology that render them unnecessary.