We need to try harder to prevent the next pandemic

Congress is spending peanuts when we need a moonshot

The Covid-19 pandemic has killed between five and 17 million people, depending on whether you go by the official counts or excess deaths methodologies, and despite the development of highly effective vaccines, it continues to wreak havoc.

Even with the Delta wave fading and the majority of the most vulnerable people vaccinated, twice as many people died of Covid in the U.S. last week as died on 9/11. And while there is reason to hope that this has been our last really severe wave, there is also some reason to fear that cold weather and holiday travel will spark a new wave comparable to the deadly winter 2020-21 wave. Meanwhile, much of the world still lacks access to vaccines or else is reliant on formulations (Sinovac, AstraZeneca) that, while much better than nothing, are considerably less effective than mRNA vaccines.

Credible estimates of the economic impact of the pandemic vary from roughly $7 trillion to $10 trillion to even $16 trillion.

Long story short, pandemics are really bad.

But thanks to general improvements in DNA and RNA technology along with some specific Covid-linked investments, we have the potential to fight them much more effectively in the future. Not just treating sick patients or launching population-scale vaccination campaigns, but actually detecting new pathogens quickly, and then moving to safely treat the infected and halt the spread before mass-scale restrictions on normal activity are even necessary.

Unfortunately, Congress seems broadly uninterested in a big push on pandemic prevention, preferring instead to focus a modest amount of funding largely on bolstering America’s existing public health workforce — a nice idea, but one that will still leave America’s front-line caregivers without the tools they’ll need to win the war on new pathogens.

The moonshot that wasn’t

Over the summer, the Biden administration unveiled a proposal for a $65 billion dollar pandemic preparedness program that they compared to the Apollo Program in its scope and ambition. Not coincidentally, back in January the Bipartisan Commission on Biodefense (chaired by Joe Lieberman, Tom Ridge, Tom Daschle, and other worthy graybeards) put out a PDF titled The Apollo Program for Biodefense: Winning the Race Against Biological Threats.

These two documents are not identical, but they are similar both in their specific recommendations and in the scope of their ambition.

Both involve small sums of money relative to the economic and human costs of pandemics and even to the $550 billion investment in climate programs that persists in the latest Build Back Better framework. But $65 billion is gigantic compared to what the United States is currently spending on pandemic prevention.

And frankly, it’s a really good idea.

New viruses emerge from time to time, but there are only 26 virus families known to impact humans. SARS, MERS, and SARS-Cov-2 all popped up in the 21st century and are all members of the coronavirus family. Researchers are currently making headway on developing a universal coronavirus vaccine that they believe should offer protection against every virus in that family. To the extent that we are willing to “waste” a bunch of money on developing vaccines of unknown commercial potential, we could (and should) be funding comparable efforts for the other 25 families. We could then test these vaccines and work with regulators during a non-stressed, non-emergency period and have them ready to go at least through Phase 1 trials in advance of any pandemic — though I would advise pushing even further and trying to get to Phase 3 with challenge trials.

Both the White House and the Commission also proposed investing in meta-genetic sequencing. The way I understand this is that in normal genetic sequencing, you need to worry a lot about contamination of your sample. You want to sequence specific DNA, but there are all kinds of junk floating around. With a meta-genetic approach, you do the opposite, monitoring pneumonia patients at hospitals and deliberately sequencing whatever the hell you find in their lungs — and if you find something new, you ring the alarm bells.

We’ve had success with wastewater sampling for SARS-Cov-2 to help measure how prevalent the virus is in a given community. You could do the same thing but with a more generic approach — monitor the sewage in all large cities to see if anything new pops up. And similarly, you could move from virus-specific rapid tests to generic tests so that we could manufacture and stockpile rapid tests for any new virus. If a pneumonia patient shows up somewhere with a new virus, we could instantly flood the city with rapid tests to prevent it from spreading while monitoring wastewater to see if it’s present anywhere else — even if the cases only present with mild symptoms that don’t require hospitalization.

Finally, we could be doing R&D on PPE.

Right now the most effective masks are N-95s, but they need to be fitted to work properly. So for most people most of the time, the best option is probably a different mask that’s less effective but easier to use. These aren’t laws of nature, though; they are contingent aspects of the traditionally limited commercial market for high-quality masks and their intersection with the regulatory and certification process. A concerted national effort to develop better mask standards would have large ongoing benefits for all respiratory illnesses.

But sadly, almost none of this is happening.

The shrinking anti-pandemic agenda

After coming up with a $65 billion moonshot plan, Biden asked for about half of that as part of his initial Build Back Better proposal. But as the entirety of BBB shrank in an effort to secure the support of Joe Manchin and Kyrsten Sinema, the pandemic prevention shrank to about $2.7 billion, of which roughly half is to modernize the CDC’s labs.

And it’s far from clear that even this relatively small amount will pass.

The extreme shrinkage of the pandemic prevention agenda in part reflects a partisan calculation. To Democrats who agree that this should be a priority, it doesn’t feel like it’s a distinctively progressive priority that should squeeze out ideas like free preschool or Medicaid expansion, which everyone understands Republicans oppose. They feel like this bill is supposed to be dessert, and pandemic prevention is vegetables.

And the good news is that it’s true — pandemic prevention is not a super partisan topic, and there are prospects for bipartisan cooperation.

The problem is that once you get into the regular appropriations process, the logic of base rates starts to dominate everything. To secure a 30% increase in pandemic preparedness funding would be a big step for appropriators since obviously most programs can’t score increases nearly that large. But we are currently spending peanuts on a problem that has both massive economic consequences and carries genuine existential risk. We don’t need a large increase in pandemic preparedness funding; we need to go from “not seriously investing in preventing pandemics” to “genuinely trying to prevent pandemics” with a gargantuan investment in funds.

What’s particularly galling is that even as the need exceeds the demand of standard appropriations, it’s still relatively modest compared to the $725 billion defense budget for fiscal year 2020. And due to base rate issues, the Biden administration’s 2021 requested increase — though modest in percentage terms — still amounts to $12 billion for one year in a world where asking for a $7 billion per year increase in defending ourselves against pandemics is considered outrageous.

Some partial remedies

It’s hard to see the way through to anything resembling the original Biden moonshot proposal. But it’s not quite too late to reconfigure BBB to include more generous pandemic funding.

The original BBB draft, for example, not only included $30 billion in pandemic prevention but $617 billion in climate investments. As the scope of the bill was reduced, pandemic prevention took a 91% haircut vs. 11% for climate initiatives. If you instead cut both requests by 14.5% you’d save the same amount of money, leaving you with $528 billion for climate initiatives and a bit under $26 billion for pandemic prevention. Now don’t get me wrong, climate change is very important (it’s why my house gets over 100% of its electricity from solar panels, and 5% of our subscription revenue will go to Stripe Climate starting on November 14), but it’s not a wildly larger threat to humanity than pandemics. You could do a lot of good on net by rebalancing.

Beyond that, it seems crazy to be spending so much on the military and so little on the pandemic threat. But as Noah Smith has written, oftentimes the U.S. gets useful things done (the original Interstate Highway System, the foundation for the Internet, etc.) by calling them national security. There’s no reason the next NDAA can’t find some way to smuggle in billions of dollars for pandemic prevention.

Last but by no means least, there really should be scope for bipartisan legislation here. I’ve been focusing mostly on the spending side, but I do think the pandemic has raised a bunch of questions about the operation of our regulatory institutions that Republicans are very attuned to. And the Biden White House has had its own fights with the institutional caution at the CDC and the FDA. Legislation pushing through reforms and also more money to build on the successes of Operation Warp Speed would be a good thing for Biden to try to work with Republicans on after whatever happens with BBB gets wrapped up.

The importance of important things

Electoral politics is a big deal, but it’s a big deal largely because policy matters. It’s easy to get wrapped up in a mindset where it feels like the most important policy issues are the ones the parties are fighting about the most. But oftentimes that fighting is based on the happenstance of history and coalition politics.

There have been big political fights about masks for over a year, so a marginal question like “does it make sense for school kids in blue states to still be wearing masks?” attracts a ton of attention even though objectively, it’s not that important. By the same token, imposing a vaccine mandate at this point on airline pilots is marginal in terms of both its costs and its benefits. The stakes in the secondary controversy over a Southwest pilot who may or may not have used an anti-Biden slogan over the PA system has essentially no stakes at all.

But whether or not we deploy our current technological prowess to drastically improve the detection and tracking of novel pathogens is a big deal. Whether we unleash mRNA vaccine technology after a virus has already gone pandemic (thus creating a huge commercial market for it) or whether we work preventatively so that focused ring-vaccination1 can play a role on the front end is a big deal. Whether NPIs for the next pandemic means “large-scale instant testing near the initial site of an outbreak to contain it” or “shutting down restaurants for months nationwide” is a big deal.

And fundamentally, we should remember that the next pandemic could easily be much worse than Covid — either deadlier, more transmissible, or even just more lethal to children, whose deaths would be more socially shattering than even the tragic loss of life we’ve seen these past 18 months. We all — but especially Congress — need to tackle things that matter, not just things that are fun to fight about.

1

Basically, when an outbreak starts, you do focused vaccination in the specific community to halt the spread of the disease, without trying to run a nationwide vaccination campaign.