The Last Pandemic December 2020

Introduction

Covid-19 should go down in history as the world’s last pandemic. We have let this tragic process devolve for too long. We sequenced the virus in weeks, and from there had an mRNA vaccine candidate in 72 hours. It took 45 days to ship the first batch from the day it was sequenced. While that is happening in future, we need to have the production capacity in place, and the logistical capacity in place, to bury the virus before it reaches pandemic status. Test, trace, isolate and vaccinate in 90 days. Shorter seems romantically unfeasible. We’ve seen longer.

I propose that we view Covid-19 as paying the iron price for our future preparation for super viruses. Industrial animal agriculture, global air travel and liberal social policies are a near perfect environment for a virus to reach a global maximum of hosts. We need to view this experience with a degree of indignant love for life and for our collective future. We need to find the motivation to prepare rigorously and resourcefully so that this never, ever happens again.

We (literally) have the technology to stop the pandemic. What we have lacked is the will to upend pointless out of date regulation and cultural norms to put the virus into nonexistence. It would be idealistic if not for the fact that humanity has now summoned the collective efforts of billions of people on multiple occasions to end prior plagues. We cannot let our intolerance for change make us vulnerable to problems that can be solved with the right approach. The purpose of this essay is to lay out a series of actions we can take in the future, to solve emerging pathogens in 90 days. We should translate this concept into policy and action it.

Tactics

Sequencing

Certain countries and regions have had an easier time understanding what kinds of pathogens are spreading through their population because they fund genetic sequencing efforts. The most critical first step when serious illness is detected that may be transmissible is to sequence it.

Without understanding the nature of the source of the illness, you cannot defeat it. This is self-evident but depending on where the virus originated, it’s important that it be identified. Necessary maintenance costs here pay off every time an issue like this emerges. So the most important first step is to enable sequencing to happen and open source the results. We should aim these efforts at the sum total of pathogens in nature, so we can jump to conclusions sooner.

Testing

The top of Taiwan’s Covid-19 case chart y axis is 30. That’s because they have never had a day during this “pandemic” with more than 18 cases. They have had 7 deaths (total). I live in a medium sized Canadian city that had more than 7 deaths yesterday, and we act like that is to be expected (due to: “pandemic”). Taiwan absolutely zeroed out the virus by acting early and testing aggressively. Taiwan beat the virus for many reasons, but one of the main ones was mass testing. You cannot defeat a virus that you are not able to detect. When a new pathogen is detected, the most important tool available is to sequence it and develop tests. It does not matter how much this costs, at all, all paths that don’t ramp testing will be more expensive.

More tactically, testing should be about frequency and turnaround time. More tests, faster. It doesn’t matter if it’s a 96% accurate antigen test or 99% specific PCR test. Some false positives and negatives are okay, 96% is better than 0%, and you can take a confirmatory PCR test to reduce statistical noise. The government should blank check fund at home antigen testing. At home testing should be encouraged and normalized. People should be able to access work and school, but only if they can produce a recent negative test (as often as daily). This alone can allow society to act more normally. Positive cases can be lab verified later. False negatives can be identified through other forms of surveillance, isolated, and again all their contacts tested.

Many of the most successful countries arguably could stop here (sequencing and testing). If you can simply understand the nature of the pathogen and test for its presence in sufficient volumes (e.g. every person who wants to access society tests themselves daily) it becomes extremely hard for the pathogen to continue to spread. However, there are additional steps that are clearly necessary to ensure that normalcy is sustainable, that should also be parallel pursued.

Protective Equipment

Depending on the nature of the pathogen, you’re going to need a seriously significant amount of PPE. It is a matter of national security to possess an entire PPE supply chain ‘in country’. We don’t let the nukes “go bad”, or the bullets the army fires from their guns, or the ships they ride into war on. We keep them in working order just in case, not because of imminent threat, but to ensure preparedness in the event of one. We ensure that our entire supply chain for critical national security related supplies remain even in the event of changing political environments.

We simply need to do the same for PPE, under the same assumptions. We cannot assume that when we give China or any other actor PPE they will return the favor. Every relevant piece of PPE needs to be manufactured in the country, and the government should make a market for upkeep. No other company or individual is going to be able to carry the externalized costs.

Second to the strategic nature of PPE is the tactical benefit. While a vaccine is production ramping, PPE potentially enables a more normal life than not. But it’s important to focus policy on PPE that actually works for a particular illness. In the case of Covid-19, it was clear from studies in China as early as March that it was airborne. And yet still where I live, hospitals observe droplet precautions. Literally bringing flu PPE to a covid fight is the reason that countless hospital staff end up with severe, high viral load cases of Covid-19.

We need to accept the true nature of the pathogen, and immediately tool up our PPE. We need to have N95 masks and other relevant supplies available to healthcare staff (who will be blazing through it) and the population at large (who need something that works, not just reducing viral load by 20% like cloth masks). If you want to end a pandemic in 90 days, you need 100% effective (like P100 respirators), not 20% effective (like cloth masks). No one left unprotected. That healthcare workers struggled with this for months is hard to fathom, but that level of rigor should be extended to everyone in the population, and the production needs to happen locally.

Contact Tracing

Contact tracing only works if you have testing. The more testing you do, the less this matters, but it’s still important for controlling low case count spread. You need to understand who has been in contact with positive cases to the extent possible and as appropriate for the pathogen (e.g. everyone in the restaurant in the event it’s airborne, vs. people with close contact in the event that it’s droplet or fluids based transmission). Contact tracing by app would be appealing in theory, but it’s clearly not enough to make sure close contacts of positive cases are isolated. Build the necessary graphing software to make this function highly effective, and use it.

Vaccination

Vaccination is the end of the measures. We have the technology to variably target almost any pathogen nature can cook up for us. The key milestones are sequencing the virus, generating potential candidates, proving safety and efficacy in animal challenge trials, proving safety in limited human trials, proving efficacy in volunteer-led challenge trials, and scaling production.

The goal is to pursue those milestones in parallel, over the course of 90 days, for every emerging pathogen. It will end up resulting in some waste, but prepaying for those vaccines creates the market incentive, and going through the fire drills will ensure tight feedback loops. We don’t want to learn about the nature of testing mRNA vaccines when we need it, we need to be constantly formulating and deploying new vaccines into the pipeline in order to be prepared. We should not limit warp drive to diseases currently causing issues, we need to attack any surface area for human harm in the form of a disease with equal rigor. Like Bill Gates with polio.

Once we have a safe vaccine that triggers an immune response (regardless of “effectiveness” which is a moving target and somewhat pointless measure as long as an immune response is triggered) we start to vaccinate healthcare workers and anyone else who has emerged of being at high risk. The entire focus is on getting a single dose in the arm of those at highest risk.

We can optimize for other things (“effectiveness”, second doses, cost) later on. Until the emerging pathogen stops being the bottleneck to the progress of the country at large, this is the number one most important use of time, energy and money that can exist. It should be treated as a sacrosanct obligation for any member of society. We should stop short of mandating it, but requiring vaccination to access normal life, and paying people to get it, provide the appropriate level of carrot and stick incentive to make sure people do the thing that benefits the group.

Vaccination should be an incremental game. Create candidates, test, do animal trials, do human trials, do challenge trials and mass vaccinate. It should be handled iteratively with open sharing of information and results. It’s clearly going to result in some side effects, but clearly reasoned trade offs must be made to maximize the expected value of the vaccine and minimize the preventable harm. If 0.5% of people who get the virus die, and 1/30000 people have a treatable allergic reaction like in the case of covid vaccines, you should not slow down for “safety”.

Therapeutics

Therapeutics allow you to treat someone already sick with the emerging pathogen. Platforms like monoclonal antibodies are clearly effective at treating an in progress viral infection. We have the technology, what we have not had is the regulatory will and aggressive production and distribution ramp needed to use this technology to save lives. We need to prepay for significant numbers of therapeutic doses before it is clear that they are effective or safe.

We need to assume the underlying platforms (monoclonal antibodies) and assumptions (general effectiveness) are sound and proceed to harm minimization. If someone is likely to die, it justifies experimentation in order to keep them alive. With consent, monoclonal antibody treatments should be used liberally along with other therapeutics relevant to the pathogen from the very start of availability and ramped aggressively in parallel with other measures.

If needed, medical systems and patients should be incentivized. It doesn’t take a large sample size to prove something reduces the odds of death, and in doing so, improve the outcomes.

Education

None of this will be possible without education. Throw out any part of the current curriculum as needed in order to prepare people for the inevitability of another emerging pathogen. This will happen again, the pathogen will be as bad or worse and as easily spread or more so. What will we do about it? What obligation do we have to respond with PPE, to take tests, to be vaccinated? Not just to blindly “listen to public health” but to actually be a part of the solution.

It is critical that each person act both in their own interests (in protecting themselves) and in the interests of the people around them (in protecting those people). That cannot happen without education and goodwill, and goodwill does not happen when you force things on people. It happens when you bring them along and show them how they can help to solve the problem. We need to do that before it is necessary or we will experience the equal and opposite response from people who do not want to be forced to do things. Don’t force, show the better path.

Conclusion

I present ideas here without sources, but I challenge the reader to help me sharpen these assumptions. Tackling the idea of being able to solve an emerging pathogen in 90 days is one that excites me a great deal and something I feel is entirely realistic in the future with current technology. We need to move past massive regulatory debt, bureaucratic dysfunction and cultural burn out in order to solve emerging pathogens in the future the way that a select few counties have already with Covid-19. Because it can be done, it must, the cost is too high.