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Omicron is a reminder of how little we're doing on pandemic prevention
Our science is impressive — our investments in logistics and manufacturing capacity much less so
In January of 2021, the Bipartisan Commission on Biodefense issued a proposal for an ambitious Apollo Program for Biodefense. The Biden administration largely embraced this vision and released a call for a $65 billion pandemic prevention initiative, but that turned into a $30 billion budget request as part of the original White House version of the Build Back Better proposal, which dwindled to a mere $2.7 billion in funding as BBB made its way through Congress.
There’s a lot of good stuff in the bill. But even perfectly worthy ideas like larger maximum Pell grants ($11 billion), expanding the Low-Income Housing Tax Credit ($12 billion), or electrifying the federal vehicle fleet ($9 billion) are not three or four times as important as reducing the odds of future pandemics. And there are worse ideas than these in the mix.
Avoiding an issue that may not crop for 10 or 20 years feels easy, and of course if you do prevent a pandemic, it’s hard to get credit for something that didn’t happen.
But while I won’t make any strong predictions about the Omicron variant in the absence of clearer scientific evidence, its emergence is a reminder that not only is the current pandemic not over, but it’s possible things will get worse. And we should be investing in both the scientific firepower and the organizational and logistical competencies we need to fight it.
The case of the missing therapeutics
One piece of good news about Omicron is that two recently developed anti-viral drugs — the somewhat effective Molnupiravir and the highly effective Pavloxid — will likely be just as effective against Omicron as they seem to be against previous variants.
The bad news is that these drugs are not actually available.
In the immediate term, this is because we’re in the annoying wait-and-see period during which experts fully expect the drugs to be approved by the FDA, but they have not yet been approved. As has consistently been the case throughout this crisis, there are questions about why the FDA can’t do a review of this kind on a more rapid basis given the urgency of the situation. And it continues to rankle that over a year after Election Day, Biden does not have a confirmed FDA commissioner. As of today, there is — at last — a nominee, but months and months of hand-wringing and searching only to come up with the guy who was FDA commissioner in 2016 suggests a real lack of thought during the campaign about a critical role.
That said, despite my longstanding concerns about the inflexibility of key public health institutions, bureaucratic slowness is not actually the key constraint here.
According to Merck’s investor communications, the company anticipates making 10 million courses of Molnipiravir by the end of this year and 20 million more in 2022.
Pfizer says it’ll have about 180,000 packs of Pavloxid by the end of 2021 and then a very rapid ramp up to 21 million in the first half of next year.
Those are large numbers, but they are not that large relative to a world population of seven billion or even the 630 million people worldwide who are over 65. It is annoying that the FDA isn’t faster on this stuff, but given the supply constraints over the next few months, it’s not clear this is making a huge difference.
“Amateurs talk strategy, professionals talk logistics”
I took a class in college called “War” taught by an eccentric right-winger with an old-fashioned affection for pure military history. He liked to say that “amateurs talk strategy, professionals talk logistics.”1
And we’ve seen this again and again during the pandemic.
The creation of the mRNA vaccines on a record timeline was a scientific miracle. But actually manufacturing and distributing these vaccines at a massive scale was an enormous challenge. You hear a lot about patent protection from left-wing types, but I think that’s a case of starting with a general view (patent protections for medications are bad for poor countries) and then strong-arming it to apply to a case where it doesn’t really fit. The signature symptom of an IP-induced deadweight loss is that the product is available, but poor people can’t get it because the market price is too high. That was the situation with AIDS medications in the late-1990s, and it’s a very real issue in the world. But mRNA vaccines are genuinely scarce. It’s not a fake scarcity where if Malawi would just fork over some more cash they’d get more vaccines. Poorer countries ended up at the back of the line because they are poor, but the line exists because there aren’t enough doses.
That’s also the source of the raging controversy in the public health community about booster shots. Because the doses are genuinely scarce, every booster shot that goes into the arms of a non-elderly westerner can be seen as depriving a person in a poor country of their first dose.
We need much more focus on and investment in actually increasing vaccine throughput. Not just to address Covid-19, but to address future illnesses. We want enough infrastructure in place that we can start churning out a billion doses of any new vaccine within a month. There may well be an intellectual property reform component to that, but getting to the good place here involves making the vaccine manufacturing business more profitable rather than less.
We need huge amounts of excess capacity in vaccine manufacturing, and someone has to pay for that. You could do it with explicit subsidy or you could do it with windfall profits when the vaccines are needed. But right now, on both vaccines and antivirals, we just can’t make them quickly enough to unlock the full potential of the underlying science, and it would be worth spending tons of money to be able to do so. For context, Pfizer is anticipating about 36 billion in vaccine revenue in 2021. If handing them 10 times that revenue made it possible to triple vaccine production, it would be money well spent.
Operational public health agencies
Over the course of its seven decades, the Centers for Disease Control and Prevention has really shifted from its origins as an operational agency.
I used to assume the CDC was in Atlanta for some pork-barrel reason. But it’s actually in Atlanta primarily because the CDC is the successor agency to the Malaria Control in War Areas Program, a military undertaking launched during World War II when malaria was rampant in the southeastern United States. The program was run by the U.S. Public Health Service under the auspices of the U.S. Army’s Fourth Service, which had responsibility for American bases and war production in the southeastern states and was headquartered in Atlanta, the region’s biggest city.
Medical doctors were obviously deeply involved in this malaria control effort, but as Elizabeth Etheridge writes in her history of the CDC:
From the beginning, engineers and entomologists dominated. Physicians assessed malaria cases in the field, and parasitologists ran the laboratory, but major emphasis was always on mosquito control, the engineers’ specialty. They determined control methods, directed operations, surveyed and designed drainage construction projects, and mapped field activities. Entomologists first commissioned in large numbers in 1943, provided the necessary expertise on mosquitos. The wartime need to save time, money, and equipment dictated that temporary measures like larvicidal control take preference over permanent drainage projects.
Basically, it was a military campaign to kill mosquitos.
This is the version of the CDC that you see in movies sometimes — an operational agency that can be swiftly dispatched to do things in the world. But as Jeneen Interlandi explained in a great NYT Magazine piece, the actual CDC is a bunch of budgetary silos with almost no flexibility. And as a freestanding agency, it doesn’t have the sort of authority that Fourth Service Command had during wartime.
This funding system also hobbles emergency-response efforts, because there is no real budget for the unexpected. When something like swine flu or Zika or Covid-19 emerges, the agency must rely on Congress for additional resources — almost always a large, one-time infusion that can’t be used for longer-term planning — and then deploy those resources, quickly, in the middle of the crisis. Public-health experts like to call this “building the plane while flying the plane.” In the past, they say, it made the C.D.C. scrappy and fostered an esprit de corps among its officers that helped the broader operation thrive. But in recent decades, these privations appear to have done the opposite. “I’d go into a meeting and say, ‘What needs to be done?’” William Darrow, a former chief of the agency’s Behavioral and Prevention Research branch, told me. “And they’d give me a five-point chart. And then I’d ask, ‘Well why aren’t we doing those things?’ And it was all hemming and hawing about whether we could convince the states, or get top leadership to support it, or if it would be controversial.”
I think a potentially underrated turning point came during the 1970s swine flu episode when the CDC, fearing a recurrence of the 1918 flu pandemic, recommended a crash vaccination campaign against a virus that turned out to be fairly benign. This was seen as a huge error at the time. But when making decisions in the face of uncertainty, you are either going to launch some crash anti-pandemic efforts that prove unnecessary, or else you are going to underreact to some outbreaks that do turn into pandemics. The CDC’s director got fired over this “mistake” (which seems like a perfectly reasonable ex-ante decision), and we now have an agency that at its best does academic-style work and at its worst advises you to overcook your turkey because it thinks a full explanation of the interplay of time and temperature is too confusing.
Build the supervaccine
If you want an even less generous assessment of the CDC, I really recommend Noah Smith’s interview with Dr. Eric Topol in which he puts forward the theory that CDC reluctance to recommend booster shots wasn’t about vaccine equity at all.
Instead, Topol thinks it was just parochialism: the CDC didn’t want to recommend action based on Israeli data, so it waited for American data, which meant waiting for Delta to spread far and wide. I hope he is wrong because that is frankly a very stupid reason.
But in the most important part of the interview, Topol talks about how his lab and several others are working on a candidate vaccine that would offer protection against all coronaviruses. Not just all variants of SARS-Cov-2, but SARS and MERS and HCoV-OC43 and future animal coronaviruses that could make the jump to infect humans. Science did a good overview of this research program back in the spring, including the upsetting fact that the NIAID doomed a 2017 similar grant proposal purely on the grounds that “the significance for developing a pan-coronavirus vaccine may not be high.”
Of course it’s easy to see the significance now, but this ought to be the kind of major research priority that requires congressional legislation, not just smarter NIAID grantmaking. Huge sums of money should be made available through the normal NIAID channel and a whole other DARPA-for-biodefense channel and a third channel that’s just prizes or whatever. It’s a huge deal!
But we ought to be thinking even bigger. While coronaviruses are hot right now, there are only 26 virus families, and we ought to be funding research programs to target the other 25 families as well. We should also claim to believe that over and above the inherent virtues of supervaccines, they are a huge prestige project where success will help us defeat the Chinese. Hopefully, that will inspire the Chinese to invest in their own supervaccine programs. And then maybe Japan and Korea get in the game.
I don’t necessarily want to disparage Build Back Better’s aspiration to spend $150 billion on reducing waiting times for in-home rather than institutional care services for the elderly and disabled. But I’d rather spend $150 billion on supervaccines if I had the choice.
This is a big fucking deal
I really don’t mean to posit a zero-sum tradeoff between the social policy goals of Build Back Better and the idea of investing in pandemic prevention. The annual defense budget is getting close to $800 billion, and redirecting some of that to biodefense priorities is a total no-brainer.
But there is a tradeoff is in terms of what people pay attention to. High-profile Joe Biden speeches about the importance of this issue may not be the way to go (presidential speeches can often be counterproductive and polarizing), but if Democrats have decided not to make this a partisan priority, then they need to work on making it a bipartisan one. Someone needs to make phone calls and find one or two GOP champions and start working with them on ideas. That probably means listening to some of the longstanding FDA critics on the right and incorporating some of their ideas for reform along with whatever spending is happening. There are a lot of different ways you could attack this problem, but it deserves to be attacked in a way that it just isn’t right now.
George W. Bush and Barack Obama both liked to muse occasionally about how underrated pandemic defense was as an issue, and they both did small things to elevate it. But they also both operated in political contexts where a big Apollo-like push was totally inconceivable.
Today that’s not the case. We’ve seen the damage a pandemic can do. Right now, though, we’re stuck in a culture war dynamic where the argument people are emotionally invested in is whether our non-pharmaceutical interventions have been too strict or not strict enough. But the basic truth is that our pharmaceutical interventions just haven’t been good enough. We were too slow to roll out tests, then too slow to make rapid tests widely available. We haven’t developed more generic tests that could be used against any virus. We invented great vaccines but couldn’t manufacture them fast enough, and it looks like we’re about to go through the same loop on anti-viral medications. All this science is really cool, but we’ve failed to bring it to bear in the highest-impact possible way.
We can’t just hope that the problem of pandemics will fade away; we have to step up and do something about it.
This is apparently one of those shopworn sayings whose origins are a little unclear. It’s often attributed to Omar Bradley, but the real source may have been the more-obscure Robert Barrow.