It's "metagenomic", not "meta-genetic." Genetics is the study of inheritance; genomics is the study of genomes (the complete DNA sequence of an organism.)
Great post! More sequencing would be great! One thing that has long puzzled me is how often we get sick and never find out what we had (“oh it’s a bad cold”). Pre-pandemic my kid would get sick all the time from daycare, and unless he tested positive via the rapid flu or rapid strep tests we basically never knew what he had, and the doctor would just prescribe antibiotics and either they would work or he would get better on his own. Clearly we can and should do much better, either on a patient level or at a macro level as Matt suggests.
One of the reasons Seattle figured out that it had the Coronavirus circulating so early on is that the Seattle Flu Study had been collecting nasal swabs to monitor the flu. The Governor told them to test them for the coronavirus and that revealed that the virus was circulating more widely than they had realized. That was a huge advantage for Seattle when it came to controlling the virus’s spread
Not to mention they did so in violation of the FDA/CDC! One of the moments where going rogue really saved some lives and helped the country see that the virus was already here.
>> “One thing that has long puzzled me is how often we get sick and never find out what we had (“oh it’s a bad cold”).”
This is because your insurance company fines you for going to the doctor. You, and most Americans, face strong incentives *not* to seek medical care. These perverse incentives don’t just stem from nickel-and-dime insurers or extortionate medical practices. Some are cultural. Wouldn’t it be nice if we weren’t looked down on by bosses and coworkers for taking a sick day? Or if businesses and schools encouraged employees and children who felt like they had the flu to stay home and stop spreading disease?
Heck, some of us don’t even really embrace a germ theory of disease! We get sick because of personal moral failings, thus deserving our fate. How many times do we hear COVID deaths brushed off as people with other health problems as though they deserved to die for having a heart condition or diabetes?
Cancer? Well, you cure that by “fighting” and keeping a positive attitude. Never mind what all those doctors and drugs do, you are the one who gets credit. You beat cancer! Or, you didn’t fight hard enough.
So, to MY’s point though not OP’s point, we don’t invest enough in public health and don’t care about pandemic prevention because the American people live in a fantasy land where diseases strike down the unworthy to punish them and health is purely a matter personal grit and willpower all while we have a medical system that financially disincentivizes seeking timely care and a work/school culture that discourages taking time to get over illnesses. There is no space for “preparation” or better sequencing or a big government role in this worldview.
Disagree. people shouldn't be running to the doctor for every little thing. Most people don't need and shouldn't go to the doctor for a cold or flu.
In regards to cancer, there's actually a pretty strong argument that all of our early cancer screening has been a net negative. I suggest reading the book "less medicine more health'
In many civilized countries where people love much longer than in the US, people see their doctors far more often and have better outcomes while spending less. It’s only because we have created a system of intense healthcare scarcity that we have to ration care.
If we had statistics on how common each minor illness is, and learned whether one or two of them had significant harms to particular populations (the way RSV does for children) then we could mitigate those harms. Not to mention that we would know when a new unknown pathogen pops up that presents like a cold in most (but not all) people.
Some kind of surveillance testing may be a good idea (though I think you're pretty hand-wavy about exactly how they'd help because it's not clear that is would help).
But "some kind of surveillance testing" probably still wouldn't be "we try to figure out what every virus that every person gets is."
Yeah I think this is the sort of thing where the benefit is not exactly clear, but it could provide us so much information that it’s likely that some bits of it would be helpful in unexpected ways. I agree that “identify everything” is an unrealistic goal, but there would be clear benefits to broader surveillance of flu and covid, and if it’s easy to add on tests to identify additional viruses one by one, then we can start to learn more about whether there are useful patterns in cold viruses to know about. Are they they same mix in all parts of the world and at all times of year? Are there regularly novel cold viruses or is it generally just variants of the same things, with novel viruses emerging only once every few decades? Are there surprising correlations between particular rare cold viruses and unexplained chronic conditions?
Look to foodborne diseases as an example. Our track record isn't great but we do have a fairly functional system that tracks foodborne illness throughout the united states. Every month-ish, state public health departments collect data from hospitals and medical practices around their states. Largely these are test results for someone who came in with some GI illness. They submit that data to the CDC who does some statistical analysis and genome matching to get a picture of which common foodborne diseases are causing people illness. There's always some background level of illness and that data isn't super useful on a day-today basis. But, when there's a sudden spike, state and feds can use this data to begin doing the epidemiological footwork to track down the source. Peanut butter, spinach, tainted meat, microwave dinners, etc. They go to the FDA and whoever produces the products and negotiate a recall, taking the unsafe products off the shelves.
The CDC also maintains a very advanced global flu surveillance system. Not that anything comes of it besides trying to formulate a good annual flu vaccine because we don't take any major steps to mitigate flu in the population despite it killing tens of thousands per year.
But, the point to make is that there is precedent for large scale and comprehensive data collection about common diseases and, sometimes, those can even be combined with actionable prevention measures. But, see my other comment where I think we face large problems wanting to do something more comprehensive to broadly surveil for and address diseases.
Is it typical to know if an illness is serious at symptom onset? Many pathogens (flu, cold viruses, pneumonicoccal bacteria) present with the same symptoms. Treatments are invariably more effective early than late, so the benefits of knowing what you have should be clear.
That's an intuitive conclusion that is, I think, wrong. Whenever I've looked at scholarly papers on the subject, they've broadly found very little benefit in early diagnosis (with perhaps some narrow, specific exceptions). It has, admittedly, been some years since I did any research, and conceivably new evidence has come to light.
Molnupiravir and monoclonal antibodies for COVID are useless if not given early in the infection. Same for tamiflu/influenza. Not sure about antibiotics, but I would be shocked if they weren’t more effective at an early stage in an infection. I’m sure you’re right though about certain chronic conditions, perhaps many cancers etc. My specific point was about infectious illnesses, and I do think it’s correct in that sphere.
And antibiotics are like broad spectrum herbicides for the gut biome. Maybe wiping out your internal bacterial ecosystem at the drop of a hat is harmless but it seems like another prudent reason not to use antibiotics unless necessary.
We can, but the multiplex PCR is expensive and doesn't change management significantly in most cases. When I admit kids to the ICU we Lay's tested pre covid but that's because it could change decision-making.
I’m leery of increased pandemic preparedness because I don’t like coercive distancing. There has been exactly one pandemic in the last 100 years that (arguably) justified widespread coercive distancing. The more detection and surveillance we pay for, the more false alarms we will get. Places that take strong “protective measures” like Australia and New Zealand, deprioritized personal freedom and mandated a much higher degree of risk aversion than I like. I’m certainly willing to fund more vaccine research and streamline the approval process, but I doubt we have enough qualified molecular biologists to spend more than several billion usefully. $1 billion will pay for 5,000 scientist man years at $200/k a pop.
If you think the FDA, CDC, et al did a below-average job compared to peer countries (and bear in mind there were plenty of large blue states who followed those recommendations to the letter), an all-carrot-no-stick future may not sound so appealing.
Justify what your agency is getting before clamoring for more. Certainly the notion of the well-meaning noble lie has been soundly disproven and should be gutted from the culture of these agencies. The "we'll take no action because our data isn't good enough for regular-times peer-reviewed journals, even though taking no action will get lots of people killed" posture continues to not impress me.
> I’m leery of increased pandemic preparedness because I don’t like coercive distancing.
Increased pandemic preparedness reduces the need for coercive distancing by making it much more likely that we discover novel threats and react to them with specific, limited instruments that work well early (e.g. targeted travel restrictions --- think "no travel in or out of Wuhan for 2 weeks, starting mid-December"; ring vaccination; massive testing near the site of the novel threats) rather than having to use blunt instruments like physical distancing, shutting schools, and locking down much of the planet.
Think "what if we could have made COVID-19 response much more like SARS or Ebola?".
Just because the US seems to be (politically) incapable of doing them effectively doesn't mean the rest of the world isn't --- they're done routinely for all sorts of other diseases, even in war zones. Much of the money the US would be spending on pandemic preparedness would be forward-deployed, i.e. increasing capacity elsewhere where new biothreats tend to emerge, so its manifest inability take fairly simple public health measures isn't really a blocker....
"$1 billion will pay for 5,000 scientist man years at $200/k a pop"
This is not a great hot take.
It costs $400 million just to build a single BSL-4 lab. The Tufts Center for the Study of Drug Development says it costs $1.4 billion to develop a single vaccine. Matt is posting about creating 20+ vaccines. The European Molecular Biology Lab has a budget of $280 million a year under standard non-moonshot conditions.
The BLS says there are an estimated 38,000 molecular biologists just in the US. And there's no reason to limit ourselves to just them. We can hire from a global pool of talent. Suddenly that 5,000 scientist-years doesn't sound like very much.
And, obviously, the job market is a market, so increased demand would result in increased supply. We're not in a static equilibrium with numbers of qualified personnel.
It would have been less painful, not just in terms of deaths but in terms of fiscal costs *and* in terms of total impact on “freedom,” to slam the border shut in late February and institute a genuine lockdown for a month until cases fell to zero.
An obvious impossibility in the US, but I’d much rather a month of boredom and then life back than 18 months of rolling restrictions and self-modified behavior.
That month would be a massively reduced infringement on my freedoms compared to what did happen.
Also if you do a super harsh lockdown, it had better actually work and work fast.
If it doesn’t work you’re locking people in their homes indefinitely. They’re not getting sunlight or fresh air. Their mental state wanes. Their physical state wanes. That makes it harder to beat the disease when you eventually, inevitably get it.
Australia has a very low covid death rate, but its 2021 all cause mortality rate is elevated. Many countries in europe have 2021 all cause mortality rates that are below average. It’s important to make sure that your infection control policies don’t cause a lot more people to die of stuff like heart disease and cancer than would have died of the virus.
Does a legal framework even exist for such a policy in the United States? IANAL--serious question. I never heard any proposal like that discussed in any serious way.
If you find the disease early you get a better idea of IFR and r0. A big issue with COVID is we got that wrong. Early testing is likely to stop rapid shelter in place orders more than not. Additionally, most of these start in the tropics, so the initial mitigation efforts are unlikely to happen here first.
I think you cover all the bases. Rational policy would a) increase ongoing funding for pandemic prevention research; b) increase and maintain stockpiles of emergency materials; and c) repair regulatory mechanisms to permit a sane emergency response to the next pandemic. That we have already lost interest in supporting infrastructure necessary to ameliorate the threat of the next pandemic even while we suffer from this one does not speak well for the US political system.
Yeah categorizing pandemic preparedness as defense spending actually makes sense on the merits as much as it’s politically a good strategy. Like the defenses you need against a natural disease are the same ones you need against a bio-weapon pretty much
The line about base rates was interesting. What if we charged the Dept of Defense with the responsibility for biodefense? The budget required could be found in their couch cushions.
Stop pooh-poohing climate change. As nasty as the covid pandemic has been, the effects of climate change are way worse.
That out of the way, your point that governments should invest more in pandemic preparedness is essentially correct, and you identify many of the right targets. I'd add that what we could really do with is *instant* virus tests. With an instant (or, say, 30 second) test of sufficient accuracy and cheapness, we could have stopped covid in its tracks, including Delta, without a vaccine, and without mass lockdowns. Or, at least, sane developed countries could have stopped covid in its tracks. The United States is of course another matter.
I haven’t seen much comparison of the impacts of climate change and the impacts of pandemics. You say climate change is worse, but it’s not exactly obvious to me that this is true, if it is. Do you have some sketch of why I should think that?
Certainly this year’s pandemic has been worse than the past year or two of climate-related disasters, and HIV was worse than the previous 40 years of climate related disasters. I see the case that future climate related problems will be worse than the ones of the past few decades, but will they be enough so to outpace future pandemics?
Isn't climate change more exponential? Doing something now would be much more helpful than doing the same thing in 10 years. Postponing pandemic prevention for 10 years is only bad if we're unlucky and get another pandemic before then. Otherwise it will make no difference. (Not that we shouldn't worry about getting unlucky, but the risks are just different.)
OK, I should have been more precise - the predicted future impacts are potentially way worse than likely pandemics.
Civilisation-threatening pandemics are not that common. Really, only plague and smallpox fit that bill (particularly if accompanied by European invaders). Covid (and a future influenza pandemic) are temporary disruptions. It's been pretty unpleasant to live through, but things are getting back to normal and will continue to do so (at least in societies with the means and the structures to make it so).
By contrast, unchecked climate change is civilisation-threatening (though that possibility is thankfully receding given the mitigations already in place), and unless effective global action is taken there is little we can do personally to avoid immiserating ourselves for the lifespan of our children and our children's children.
I think it's hard to compare pandemics and climate change on some levels. Sure, climate change has and will kill people, and so do pandemics, but if climate change causes wet-bulb temperatures to become deadly to humans in southern India for weeks at a time, it's not like everybody in southern India will die; some will, but the rest will move, and those population shifts will cause political and economic disasters elsewhere. Or hurricanes get more powerful, but we also get better at forecasting, so fewer people die but they cause more property damage (which strains local and state budgets, so other essential programs face cuts).
And, pandemics can be related to climate change. As climate change gets worse or as the human processes that cause climate change get worse (thinking of encroachment on natural habitats, convenient cheap air travel), then we might also see more risks of pandemics than in the past. It's an ambiguous relationship, to be sure.
That said, we need rapid testing for everything. Normalize getting a rapid test every day before going to work or school, expand those rapid tests to flu, then other pathogens, then unknown pathogens, and use those results to produce local “weather reports” that people can use to proactively protect vulnerable friends and family.
I’m treating that as equivalent. Maybe it’s air monitoring in public spaces or something else. But some sort of routing surveillance that gives people a general knowledge of current disease conditions seems like it has to be part of the future.
I would need an easier test. Right now we've normalized "take temperature with infrared scanning thermometer" every morning because the school requires it and it's super easy, barely an inconvenience.
But the few times we've administered the rapid at-home test(due to some symptom that probably-isn't-but-maybe-it-just-might-be-Covid19) it's more of a pain. My 6 year-olds are not fans (and having taken the test myself, not a fan either, although more willing to do it). Subjecting myself to that every day is a tough sell.
Climate change is like HIV. Climate change doesn't kill people, but heat waves, floods, etc. do. Industrialization in the tropics +more AC needed +more humans close to species rich areas +shift in vector populations leads to pandemics. You could even say an increase chance of pandemics starring is a consequence of climate change. So really pandemic preparedness money is Climate change money.
>>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.<<
Yeah, I don't buy this. Regarding the IHS, while Eisenhower was impressed by Germany's autobahn system, national defense was at best a very minor factor for selling the IHS to the American people: economic growth was the big selling point (https://www.fhwa.dot.gov/interstate/interstatemyths.cfm#question3). And while the creation of the transformational Internet was a serendipitous outcome of the ARPANET, there was zero possibility of anticipating such a thing coming from this infinitesimal part of DoD R&D spending. Sometimes you get really lucky. (Sometimes you get Tang and Teflon, too.)
DoD is focused on traditional ideas of national defense. The idea that we could "smuggle in billions of dollars for pandemic prevention" in the DoD budget is laughable.
Is there a way we can start some policies local and then build up without needing federal involvement early? If companies start requiring daily rapid tests, as prices fall to the $1 range (the way they have been in Europe for months), then we could gradually add new virus tests to those rapid tests. This would then provide a local “weather report” for that region, which others might like to emulate.
I don't think there is any point to throwing more money at America's public health apparatus without root and branch reform. Despite being far better funded per capita and overall than any peer countries, they completely beclowned themselves throughout the COVID response.
Why should congress entrust these organizations with such a large sum of money?
Posts like this put one in mind of the "availability" bias trap. We're all focused on the dangers of pandemics because, well, duh. So many of us are focused on doing things because COVID has been such a disaster. That's great. But how will we feel in five or ten years if, as is highly likely, nothing as damaging as COVID has recurred? We'll feel like we have much bigger fish to fry and while preparing for the next pandemic would be great, right now we have to concentrate on crisis X or Y. We'll be like the Obama administration, which cut funds for PPE in the national stockpile because national debt and the deficit were such large concerns.
Hey, if we can do things like throw money at research that will lay the basis for general spectrum vaccines, great. Scientists are great at long-term research. But beyond that I cast a gimlet eye.
For example, in the Biden proposal Matt cites, the administration writes: "There should be a centralized ‘Mission Control’, acting as a single, unified program management unit,
that draws on expertise from multiple HHS agencies, including NIH, CDC, BARDA, FDA, and CMS, as well as other departments such as DoD, DoE, and VA." I have no doubt that within five years, and no pandemic emergency in the meantime, this "Mission Control" will be an empty shell of no importance, with at best pro forma meetings and each agency and department pursuing their own agenda and jealously guarding their autonomy.
Memories fade and people will lose any sense of urgency they may have now. That's just life.
Agreed that memory fades. On the other hand, COVID was a REALLY big deal. Look at all the additional security we still have 20 years after 9/11 and that was 3,000 people that died. COVID's over 500,000.
That being said, I think what you want is to make CDC's only job to be infectious diseases/pandemics. Let other agencies handle the rest, that way CDC stays focused
There needs to be some organization that sees disease prevention framed as a question of national defense, not framed as a way to publish research papers. Whether that should be the CDC, a firewalled half of the CDC, or some completely different agency, I'm not sure. But the civil defense voice, that *type* of response, was almost invisible IMHO.
The next pandemic is likely to come from an authoritarian country with tight control over the media. The US and other open societies need to figure out the signs that there’s an outbreak in an authoritarian country. The next pandemic may not come from China. It might come from Russia or one of the other former Soviet republics with a cartoonish authoritarian ruler, especially if he doesn’t want to look bad in front of other world leaders. I don’t know much about gathering intelligence but if the country suddenly starts buying up PPE or doctors are mysteriously falling out of windows, that may be a clue that there’s an outbreak and it might be a good idea to start collecting that kind of information. I don’t know how the US would start doing that but that’s what intelligence experts are for.
Classic SARS also came from China and it didn’t become a pandemic in part because of traits of the virus: it was less transmissible and is only transmitted when you’re symptomatic. However, Hong Kong was under leas control from Beijing and it had a much freer press than today. The Hong Kong press really did investigate what was going on. Foreign journalists had more access to mainland China where SARS had first emerged.
For all the many flaws of our media, an outbreak of a novel virus in the US would be something that the media were all over.
It's "metagenomic", not "meta-genetic." Genetics is the study of inheritance; genomics is the study of genomes (the complete DNA sequence of an organism.)
Great post! More sequencing would be great! One thing that has long puzzled me is how often we get sick and never find out what we had (“oh it’s a bad cold”). Pre-pandemic my kid would get sick all the time from daycare, and unless he tested positive via the rapid flu or rapid strep tests we basically never knew what he had, and the doctor would just prescribe antibiotics and either they would work or he would get better on his own. Clearly we can and should do much better, either on a patient level or at a macro level as Matt suggests.
One of the reasons Seattle figured out that it had the Coronavirus circulating so early on is that the Seattle Flu Study had been collecting nasal swabs to monitor the flu. The Governor told them to test them for the coronavirus and that revealed that the virus was circulating more widely than they had realized. That was a huge advantage for Seattle when it came to controlling the virus’s spread
Not to mention they did so in violation of the FDA/CDC! One of the moments where going rogue really saved some lives and helped the country see that the virus was already here.
“…the doctor would just prescribe antibiotics and either they would work or he would get better on his own.”
You should look for a better doctor.
>> “One thing that has long puzzled me is how often we get sick and never find out what we had (“oh it’s a bad cold”).”
This is because your insurance company fines you for going to the doctor. You, and most Americans, face strong incentives *not* to seek medical care. These perverse incentives don’t just stem from nickel-and-dime insurers or extortionate medical practices. Some are cultural. Wouldn’t it be nice if we weren’t looked down on by bosses and coworkers for taking a sick day? Or if businesses and schools encouraged employees and children who felt like they had the flu to stay home and stop spreading disease?
Heck, some of us don’t even really embrace a germ theory of disease! We get sick because of personal moral failings, thus deserving our fate. How many times do we hear COVID deaths brushed off as people with other health problems as though they deserved to die for having a heart condition or diabetes?
Cancer? Well, you cure that by “fighting” and keeping a positive attitude. Never mind what all those doctors and drugs do, you are the one who gets credit. You beat cancer! Or, you didn’t fight hard enough.
So, to MY’s point though not OP’s point, we don’t invest enough in public health and don’t care about pandemic prevention because the American people live in a fantasy land where diseases strike down the unworthy to punish them and health is purely a matter personal grit and willpower all while we have a medical system that financially disincentivizes seeking timely care and a work/school culture that discourages taking time to get over illnesses. There is no space for “preparation” or better sequencing or a big government role in this worldview.
Disagree. people shouldn't be running to the doctor for every little thing. Most people don't need and shouldn't go to the doctor for a cold or flu.
In regards to cancer, there's actually a pretty strong argument that all of our early cancer screening has been a net negative. I suggest reading the book "less medicine more health'
https://smile.amazon.com/Less-Medicine-More-Health-Assumptions-ebook/dp/B00N6PB6BS/ref=sr_1_2?crid=2E5AOPPDDZA17&dchild=1&keywords=less+medicine+more+health&qid=1635963186&qsid=147-8710976-1375956&sprefix=less+med%2Caps%2C502&sr=8-2&sres=0807077585%2CB078K93HFD%2CB00RH5K26I%2C0062747517%2CB01DBTFO98%2CB07HCNM7KQ%2CB07212DK9F%2CB01NB0G1V8%2CB074F1RWV9%2C1592339719%2CB01GVJK3XW%2CB07TK4VYWS%2CB07YMNYX5Y%2CB07R8GD47V%2C1610395484%2CB007ADOL28&srpt=ABIS_BOOK
In many civilized countries where people love much longer than in the US, people see their doctors far more often and have better outcomes while spending less. It’s only because we have created a system of intense healthcare scarcity that we have to ration care.
What's the benefit of finding out exactly which untreatable minor virus you have when you get a minor illness?
If we had statistics on how common each minor illness is, and learned whether one or two of them had significant harms to particular populations (the way RSV does for children) then we could mitigate those harms. Not to mention that we would know when a new unknown pathogen pops up that presents like a cold in most (but not all) people.
Some kind of surveillance testing may be a good idea (though I think you're pretty hand-wavy about exactly how they'd help because it's not clear that is would help).
But "some kind of surveillance testing" probably still wouldn't be "we try to figure out what every virus that every person gets is."
Yeah I think this is the sort of thing where the benefit is not exactly clear, but it could provide us so much information that it’s likely that some bits of it would be helpful in unexpected ways. I agree that “identify everything” is an unrealistic goal, but there would be clear benefits to broader surveillance of flu and covid, and if it’s easy to add on tests to identify additional viruses one by one, then we can start to learn more about whether there are useful patterns in cold viruses to know about. Are they they same mix in all parts of the world and at all times of year? Are there regularly novel cold viruses or is it generally just variants of the same things, with novel viruses emerging only once every few decades? Are there surprising correlations between particular rare cold viruses and unexplained chronic conditions?
Look to foodborne diseases as an example. Our track record isn't great but we do have a fairly functional system that tracks foodborne illness throughout the united states. Every month-ish, state public health departments collect data from hospitals and medical practices around their states. Largely these are test results for someone who came in with some GI illness. They submit that data to the CDC who does some statistical analysis and genome matching to get a picture of which common foodborne diseases are causing people illness. There's always some background level of illness and that data isn't super useful on a day-today basis. But, when there's a sudden spike, state and feds can use this data to begin doing the epidemiological footwork to track down the source. Peanut butter, spinach, tainted meat, microwave dinners, etc. They go to the FDA and whoever produces the products and negotiate a recall, taking the unsafe products off the shelves.
The CDC also maintains a very advanced global flu surveillance system. Not that anything comes of it besides trying to formulate a good annual flu vaccine because we don't take any major steps to mitigate flu in the population despite it killing tens of thousands per year.
But, the point to make is that there is precedent for large scale and comprehensive data collection about common diseases and, sometimes, those can even be combined with actionable prevention measures. But, see my other comment where I think we face large problems wanting to do something more comprehensive to broadly surveil for and address diseases.
Is it typical to know if an illness is serious at symptom onset? Many pathogens (flu, cold viruses, pneumonicoccal bacteria) present with the same symptoms. Treatments are invariably more effective early than late, so the benefits of knowing what you have should be clear.
That's an intuitive conclusion that is, I think, wrong. Whenever I've looked at scholarly papers on the subject, they've broadly found very little benefit in early diagnosis (with perhaps some narrow, specific exceptions). It has, admittedly, been some years since I did any research, and conceivably new evidence has come to light.
Molnupiravir and monoclonal antibodies for COVID are useless if not given early in the infection. Same for tamiflu/influenza. Not sure about antibiotics, but I would be shocked if they weren’t more effective at an early stage in an infection. I’m sure you’re right though about certain chronic conditions, perhaps many cancers etc. My specific point was about infectious illnesses, and I do think it’s correct in that sphere.
"we basically never knew what he had, and the doctor would just prescribe antibiotics"
so frustrating to me. overuse of anti-biotics is creating antibiotic resistant super bugs. Antibiotics don't work against viruses
(also need to stop using them the way we do in lifestock)
And antibiotics are like broad spectrum herbicides for the gut biome. Maybe wiping out your internal bacterial ecosystem at the drop of a hat is harmless but it seems like another prudent reason not to use antibiotics unless necessary.
*livestock
We can, but the multiplex PCR is expensive and doesn't change management significantly in most cases. When I admit kids to the ICU we Lay's tested pre covid but that's because it could change decision-making.
No reason it has to be. The cost of sequencing has come way down.
I’m leery of increased pandemic preparedness because I don’t like coercive distancing. There has been exactly one pandemic in the last 100 years that (arguably) justified widespread coercive distancing. The more detection and surveillance we pay for, the more false alarms we will get. Places that take strong “protective measures” like Australia and New Zealand, deprioritized personal freedom and mandated a much higher degree of risk aversion than I like. I’m certainly willing to fund more vaccine research and streamline the approval process, but I doubt we have enough qualified molecular biologists to spend more than several billion usefully. $1 billion will pay for 5,000 scientist man years at $200/k a pop.
I feel like there must be a better way to avoid false alarms than saying "let's make sure we don't find out about pathogens at all."
If you think the FDA, CDC, et al did a below-average job compared to peer countries (and bear in mind there were plenty of large blue states who followed those recommendations to the letter), an all-carrot-no-stick future may not sound so appealing.
Justify what your agency is getting before clamoring for more. Certainly the notion of the well-meaning noble lie has been soundly disproven and should be gutted from the culture of these agencies. The "we'll take no action because our data isn't good enough for regular-times peer-reviewed journals, even though taking no action will get lots of people killed" posture continues to not impress me.
> I’m leery of increased pandemic preparedness because I don’t like coercive distancing.
Increased pandemic preparedness reduces the need for coercive distancing by making it much more likely that we discover novel threats and react to them with specific, limited instruments that work well early (e.g. targeted travel restrictions --- think "no travel in or out of Wuhan for 2 weeks, starting mid-December"; ring vaccination; massive testing near the site of the novel threats) rather than having to use blunt instruments like physical distancing, shutting schools, and locking down much of the planet.
Think "what if we could have made COVID-19 response much more like SARS or Ebola?".
we haven’t shown much ability to do contact tracing efficiently, so i think we’ll get lock downs rather than the types of interventions you suggest
Just because the US seems to be (politically) incapable of doing them effectively doesn't mean the rest of the world isn't --- they're done routinely for all sorts of other diseases, even in war zones. Much of the money the US would be spending on pandemic preparedness would be forward-deployed, i.e. increasing capacity elsewhere where new biothreats tend to emerge, so its manifest inability take fairly simple public health measures isn't really a blocker....
"$1 billion will pay for 5,000 scientist man years at $200/k a pop"
This is not a great hot take.
It costs $400 million just to build a single BSL-4 lab. The Tufts Center for the Study of Drug Development says it costs $1.4 billion to develop a single vaccine. Matt is posting about creating 20+ vaccines. The European Molecular Biology Lab has a budget of $280 million a year under standard non-moonshot conditions.
The BLS says there are an estimated 38,000 molecular biologists just in the US. And there's no reason to limit ourselves to just them. We can hire from a global pool of talent. Suddenly that 5,000 scientist-years doesn't sound like very much.
And, obviously, the job market is a market, so increased demand would result in increased supply. We're not in a static equilibrium with numbers of qualified personnel.
It would have been less painful, not just in terms of deaths but in terms of fiscal costs *and* in terms of total impact on “freedom,” to slam the border shut in late February and institute a genuine lockdown for a month until cases fell to zero.
An obvious impossibility in the US, but I’d much rather a month of boredom and then life back than 18 months of rolling restrictions and self-modified behavior.
That month would be a massively reduced infringement on my freedoms compared to what did happen.
Completely sealing the border was never possible. Even New Zealand has had cases.
Also if you do a super harsh lockdown, it had better actually work and work fast.
If it doesn’t work you’re locking people in their homes indefinitely. They’re not getting sunlight or fresh air. Their mental state wanes. Their physical state wanes. That makes it harder to beat the disease when you eventually, inevitably get it.
Australia has a very low covid death rate, but its 2021 all cause mortality rate is elevated. Many countries in europe have 2021 all cause mortality rates that are below average. It’s important to make sure that your infection control policies don’t cause a lot more people to die of stuff like heart disease and cancer than would have died of the virus.
Does a legal framework even exist for such a policy in the United States? IANAL--serious question. I never heard any proposal like that discussed in any serious way.
i.e. I don't like paying insurance, I'd rather have several trillion dollars worth of losses in the next pandemic.
If you find the disease early you get a better idea of IFR and r0. A big issue with COVID is we got that wrong. Early testing is likely to stop rapid shelter in place orders more than not. Additionally, most of these start in the tropics, so the initial mitigation efforts are unlikely to happen here first.
I think you cover all the bases. Rational policy would a) increase ongoing funding for pandemic prevention research; b) increase and maintain stockpiles of emergency materials; and c) repair regulatory mechanisms to permit a sane emergency response to the next pandemic. That we have already lost interest in supporting infrastructure necessary to ameliorate the threat of the next pandemic even while we suffer from this one does not speak well for the US political system.
Yeah categorizing pandemic preparedness as defense spending actually makes sense on the merits as much as it’s politically a good strategy. Like the defenses you need against a natural disease are the same ones you need against a bio-weapon pretty much
The line about base rates was interesting. What if we charged the Dept of Defense with the responsibility for biodefense? The budget required could be found in their couch cushions.
Go Braves!!! Can’t stop the chop!
More ventillation/filtration and indoor CO2 monitoring in schools and public places would be great too!
Stop pooh-poohing climate change. As nasty as the covid pandemic has been, the effects of climate change are way worse.
That out of the way, your point that governments should invest more in pandemic preparedness is essentially correct, and you identify many of the right targets. I'd add that what we could really do with is *instant* virus tests. With an instant (or, say, 30 second) test of sufficient accuracy and cheapness, we could have stopped covid in its tracks, including Delta, without a vaccine, and without mass lockdowns. Or, at least, sane developed countries could have stopped covid in its tracks. The United States is of course another matter.
I haven’t seen much comparison of the impacts of climate change and the impacts of pandemics. You say climate change is worse, but it’s not exactly obvious to me that this is true, if it is. Do you have some sketch of why I should think that?
Certainly this year’s pandemic has been worse than the past year or two of climate-related disasters, and HIV was worse than the previous 40 years of climate related disasters. I see the case that future climate related problems will be worse than the ones of the past few decades, but will they be enough so to outpace future pandemics?
Isn't climate change more exponential? Doing something now would be much more helpful than doing the same thing in 10 years. Postponing pandemic prevention for 10 years is only bad if we're unlucky and get another pandemic before then. Otherwise it will make no difference. (Not that we shouldn't worry about getting unlucky, but the risks are just different.)
OK, I should have been more precise - the predicted future impacts are potentially way worse than likely pandemics.
Civilisation-threatening pandemics are not that common. Really, only plague and smallpox fit that bill (particularly if accompanied by European invaders). Covid (and a future influenza pandemic) are temporary disruptions. It's been pretty unpleasant to live through, but things are getting back to normal and will continue to do so (at least in societies with the means and the structures to make it so).
By contrast, unchecked climate change is civilisation-threatening (though that possibility is thankfully receding given the mitigations already in place), and unless effective global action is taken there is little we can do personally to avoid immiserating ourselves for the lifespan of our children and our children's children.
I think it's hard to compare pandemics and climate change on some levels. Sure, climate change has and will kill people, and so do pandemics, but if climate change causes wet-bulb temperatures to become deadly to humans in southern India for weeks at a time, it's not like everybody in southern India will die; some will, but the rest will move, and those population shifts will cause political and economic disasters elsewhere. Or hurricanes get more powerful, but we also get better at forecasting, so fewer people die but they cause more property damage (which strains local and state budgets, so other essential programs face cuts).
And, pandemics can be related to climate change. As climate change gets worse or as the human processes that cause climate change get worse (thinking of encroachment on natural habitats, convenient cheap air travel), then we might also see more risks of pandemics than in the past. It's an ambiguous relationship, to be sure.
That said, we need rapid testing for everything. Normalize getting a rapid test every day before going to work or school, expand those rapid tests to flu, then other pathogens, then unknown pathogens, and use those results to produce local “weather reports” that people can use to proactively protect vulnerable friends and family.
Wastewater monitoring and the like is a much better stategy for mapping local conditions
I’m treating that as equivalent. Maybe it’s air monitoring in public spaces or something else. But some sort of routing surveillance that gives people a general knowledge of current disease conditions seems like it has to be part of the future.
I would need an easier test. Right now we've normalized "take temperature with infrared scanning thermometer" every morning because the school requires it and it's super easy, barely an inconvenience.
But the few times we've administered the rapid at-home test(due to some symptom that probably-isn't-but-maybe-it-just-might-be-Covid19) it's more of a pain. My 6 year-olds are not fans (and having taken the test myself, not a fan either, although more willing to do it). Subjecting myself to that every day is a tough sell.
...do you also watch the screenrant movie pitches?
Yes sir I do.
"the effects of climate change are way worse."
maybe eventually, but surely not right now
Climate change is like HIV. Climate change doesn't kill people, but heat waves, floods, etc. do. Industrialization in the tropics +more AC needed +more humans close to species rich areas +shift in vector populations leads to pandemics. You could even say an increase chance of pandemics starring is a consequence of climate change. So really pandemic preparedness money is Climate change money.
Really good article! Wish these kinds of articles were more popular rather than clickbait culture war stuff
>>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.<<
Yeah, I don't buy this. Regarding the IHS, while Eisenhower was impressed by Germany's autobahn system, national defense was at best a very minor factor for selling the IHS to the American people: economic growth was the big selling point (https://www.fhwa.dot.gov/interstate/interstatemyths.cfm#question3). And while the creation of the transformational Internet was a serendipitous outcome of the ARPANET, there was zero possibility of anticipating such a thing coming from this infinitesimal part of DoD R&D spending. Sometimes you get really lucky. (Sometimes you get Tang and Teflon, too.)
DoD is focused on traditional ideas of national defense. The idea that we could "smuggle in billions of dollars for pandemic prevention" in the DoD budget is laughable.
Is there a way we can start some policies local and then build up without needing federal involvement early? If companies start requiring daily rapid tests, as prices fall to the $1 range (the way they have been in Europe for months), then we could gradually add new virus tests to those rapid tests. This would then provide a local “weather report” for that region, which others might like to emulate.
In five years, how many people will be getting those frequent tests? (Hint: any answer above zero will led to loss of points).
I don't think there is any point to throwing more money at America's public health apparatus without root and branch reform. Despite being far better funded per capita and overall than any peer countries, they completely beclowned themselves throughout the COVID response.
Why should congress entrust these organizations with such a large sum of money?
"Defund the public health apparatus!"
Posts like this put one in mind of the "availability" bias trap. We're all focused on the dangers of pandemics because, well, duh. So many of us are focused on doing things because COVID has been such a disaster. That's great. But how will we feel in five or ten years if, as is highly likely, nothing as damaging as COVID has recurred? We'll feel like we have much bigger fish to fry and while preparing for the next pandemic would be great, right now we have to concentrate on crisis X or Y. We'll be like the Obama administration, which cut funds for PPE in the national stockpile because national debt and the deficit were such large concerns.
Hey, if we can do things like throw money at research that will lay the basis for general spectrum vaccines, great. Scientists are great at long-term research. But beyond that I cast a gimlet eye.
For example, in the Biden proposal Matt cites, the administration writes: "There should be a centralized ‘Mission Control’, acting as a single, unified program management unit,
that draws on expertise from multiple HHS agencies, including NIH, CDC, BARDA, FDA, and CMS, as well as other departments such as DoD, DoE, and VA." I have no doubt that within five years, and no pandemic emergency in the meantime, this "Mission Control" will be an empty shell of no importance, with at best pro forma meetings and each agency and department pursuing their own agenda and jealously guarding their autonomy.
Memories fade and people will lose any sense of urgency they may have now. That's just life.
Agreed that memory fades. On the other hand, COVID was a REALLY big deal. Look at all the additional security we still have 20 years after 9/11 and that was 3,000 people that died. COVID's over 500,000.
That being said, I think what you want is to make CDC's only job to be infectious diseases/pandemics. Let other agencies handle the rest, that way CDC stays focused
There needs to be some organization that sees disease prevention framed as a question of national defense, not framed as a way to publish research papers. Whether that should be the CDC, a firewalled half of the CDC, or some completely different agency, I'm not sure. But the civil defense voice, that *type* of response, was almost invisible IMHO.
The way to prevent pandemics and epidemics is to eliminate all animal use industries and stop damaging wildlife habitat.
The next pandemic is likely to come from an authoritarian country with tight control over the media. The US and other open societies need to figure out the signs that there’s an outbreak in an authoritarian country. The next pandemic may not come from China. It might come from Russia or one of the other former Soviet republics with a cartoonish authoritarian ruler, especially if he doesn’t want to look bad in front of other world leaders. I don’t know much about gathering intelligence but if the country suddenly starts buying up PPE or doctors are mysteriously falling out of windows, that may be a clue that there’s an outbreak and it might be a good idea to start collecting that kind of information. I don’t know how the US would start doing that but that’s what intelligence experts are for.
Classic SARS also came from China and it didn’t become a pandemic in part because of traits of the virus: it was less transmissible and is only transmitted when you’re symptomatic. However, Hong Kong was under leas control from Beijing and it had a much freer press than today. The Hong Kong press really did investigate what was going on. Foreign journalists had more access to mainland China where SARS had first emerged.
For all the many flaws of our media, an outbreak of a novel virus in the US would be something that the media were all over.