How can we end the 'virus business cycle'?
The health system needs a series of reserves and mechanisms to operationalise surge capacity when the annual problematic variant comes around.
“Speed now illuminates reality whereas light once gave objects of the world their shape.”
― Paul Virilio, The Administration of Fear
Britain was one of the best placed countries to deal with the now infamous Omicron variant. They have one of the highest global administrations of booster shots, and possess world-renowned genomic sequencing systems enabling a clear understanding of variant development.
And yet here they are. Staring down the barrel of inevitability. Staring at what looks like several weeks of tough (and unnecessary, as in, way too late in the course of the wave) restrictions.
If governments don’t begin to actually learn, then every single year, this is our new reality. New strains will come about. Nations will freak out and implement travel bans on countries they consider to be ‘others’, and fail to actually act quickly on the points that matter, to the point where we are forced to implement a sort of quasi-lockdown to prevent our health systems being overwhelmed.
This is a horrifying image, for a panoply of reasons. This “virus business cycle” as James Meadway describes in this prescient 2020 New Statesman essay, is not the future we want.
It also doesn’t have to be the future.
If we assume that there is going to be an Omicron-style variant hitting us every year or so (which will continue to be the case so long as the world isn’t sufficiently vaccinated), then there needs to be a lightspeed-like response to any emergent variant that does begin to circulate.
This is going to require completely resetting the way that pharmaceutical regulatory frameworks are navigated and surge capacity is operationalised.
Below is a list of some things that I think should have happened from around December 2nd when it became pretty clear that Omicron was at the very least going to become the dominant variant in Britain (note, this list is not exhaustive but what I think would have collectively made a substantive contribution to dealing with the oncoming onslaught):
An increase in mandatory sick pay by a magnitude of 4-6x (note, the UK has the lowest sick pay of any OECD country)
Do not introduce travel bans on countries that are sharing important serological data with the international community once it was obvious that the variant was endemic within Britain
Preparing of a sectoral furlough scheme to be returned in some format to the hospitality sector, should things really go south
The opening of 24 hour vaccine centres, 7 days a week (they are currently open 12 hours a day), with payment to volunteers who work outside of the regular 12 hours a day
Each person who was boosted is to be entered once into a daily lottery with the chance of winning £500k, with the winner announced the day after they are boosted
The approval, scaling and roll out of Molnupiravir, an anti-covid drug currently being trialed in the UK
Beginning challenge trials for anti-covid pill Paxlovid
The final four are in my opinion, slightly different to the first three, in that they are questions of state capacity. Is the NHS able to operate 24 hour vaccination centres? Can a drug that is currently only being used by 10,000 people be scaled and distributed to the millions of people that are about to get covid in the coming month? Are health centres and universities able to organise large-scale challenge trials that will effectively pay people to expose themself to the virus so that we can test for new treatments and booster-specific vaccines?
It is arguable to suggest that you cannot operate like this all year round. The budgetary and mental strain this would put on public services would be enormous. Yet it is clear that you could have a ‘sprint’-like process which operationalises surge capacity to prevent things from spilling over.
This, by the way, would be much less costly than a situation whereby you allow a pandemic to overwhelm the public health apparatus and not only cause months of strain to the health system, but also results in lockdown and restrictions on much of the economy.
Take two pharmaceutical interventions that are important in fighting COVID-19; vaccines and drug treatment.
Since Omicron arrived in the UK, Britain has administered around 10mn booster shots. Some may laud this as impressive, especially given that the most at risk people had already got their booster before Omicron was a known problem.
Yet we are now at the point where many boosted people are getting infected anyway, either because the booster isn’t completely immune to evasion or because individuals are getting infected before their immunity has kicked in.
Had a booster campaign (1) begun a little earlier and (2) allowed every single Briton to be able to book a booster no more than a week from the moment they were eligible (by removing barriers such as opening hours, creating monetary incentives etc), there would have been a significant boost in immunity that would have made Omicron much, much more manageable.
A more infuriating problem is the lack of use for drugs that are known to be highly effective at treating COVID-19. See this LessWrong post from Zvi on Paxlovid, Pfizer’s anti-covid pill which is 89% effective at preventing hospitalisation and death.
The trial was stopped due to ‘ethical considerations’ for being too effective. You see, we live in a world in which:
It is illegal to give this drug to any patients, because it hasn’t been proven safe and effective.
It is illegal to continue a trial to study the drug, because it has been proven so safe and effective that it isn’t ethical to not give the drug to half the patients.
Who, if they weren’t in the study, couldn’t get the drug at all, because it is illegal due to not being proven safe and effective yet.
So now no one gets added to the trial so those who would have been definitely don’t get Paxlovid, and are several times more likely to die.
But our treatment of them is now ‘ethical.’
For the rest of time we will now hear about how it was only seven deaths and we can’t be sure Paxlovid works or how well it works, and I expect to spend hours arguing over exactly how much it works.
For the rest of time people will argue the study wasn’t big enough so we don’t know the Paxlovid is safe.
Those arguments will then be used both by people arguing to not take Paxlovid, and people who want to require other interventions because of these concerns.
Now, since this November post from Zvi, things are changing, and the FDA in the US is probably going to approve Paxlovid’s use by Mid-January. This is great for the next variant but will be largely a bit too late for a big group of Americans who by then will have already had Covid for at least a week (Paxlovid is supposed to be used 2-3 days after symptom onset).
From blocking the scaling of testing in EARLY 2020, to taking ages to get Paxlovid approved, these institutions are clearly so dysfunctional at dealing with fast-moving crises like pandemics.
For one reason or another, the governing institutions are not designed to operationalise surge capacity. They cannot move fast when it matters.
There are clearly some exceptions in government. For example, the U.K. Treasury developed and rolled out their furlough scheme in tandem with the DWP in a formidably smooth manner.
Bioethics, the Law of no Evidence and the rebirth of institutions
But when it comes to questions of public health, things often get a bit trickier.
Part of this is for understandable reasons within the medical ethics community. Taking actions on patients without sufficient data can be tantamount to malpractice, and dangerous. This is partly what underpins the ‘precautionary principle’ which saw a lot of countries back out of allowing Astra Zeneca to be used for younger age groups, because there had been a few blood clots in some recipients of the Oxford jab.
But we now know that in pandemics you cannot wait for perfect data. You cannot hold out for the stars to align. If politicians wait for the perfect data to emerge, by then, the system will be overwhelmed by cases.
In an exponentially developing pandemic, you unfortunately have to make decisions with imperfect information. But crucially, you have to decide, and often fast. For some strange reason, one of the systems which requires the fastest crisis decision-making is actually the slowest moving.
This, in my view, explains why a lot of people who are frustrated with the grinding sludge of these institutions are seeking to make new ones.
The Arc Institute is the latest example of this. Set up by Stripe CEO Patrick Collison, Silvana Konermann and Patrick Hsu, Arc is going to be funding people, rather than projects. They want to remove the burden of applying for grants that stymies scientific inquiry.
This work has been heavily inspired by the Fast Grants initiative, which provided funding in 48 hours for scientific projects covering a range of areas.
This is truly magnificent and I look forward to seeing the outcomes of Arc’s research. I am fairly confident that when the next big public health crisis comes around, something that we use to help fight it will have been developed at Arc.
But Arc is not without it’s big questions. The main one is a question of accountability. Arc is funded by the Collision Brothers, Etherium’s Vitalik Buterin, and Facebook co-founder Dustin Moskovitz.
For the record I think that these men (and they are unfortunately mostly all men) are incredibly, incredibly smart people that the government and public should spend more time listening to. They have a brilliant way of problem-solving, show a magisterial grip of problems across multiple disciplines and offer at times very smart solutions to dealing with such problems.
But if cutting-edge research institutions are being bankrolled by a handful of Silicon Valley bros, we risk replicating the eternal Palo Alto problem of these institutions becoming hubs of unaccountable, concentrated power.
This problem strikes at what seems to be a bit of a trade-off for science R&D policy. Too much accountability can often restrain innovation. You cannot fail on a government-backed science project because that would be seen to be wasting taxpayer money. Therefore you put a lot of barriers in the way to research, such as long grant forms stacked with conditionalities that blight the research.
But on the other hand, if you operate on a ‘no questions asked’ or ‘no way to ask questions’ policy, then there is a serious problem around who the innovation is for. In the hands of the Patrick Collision’s of this world, I don’t necessarily mind too much. In the hands of the Peter Thiel’s, well that is a different box of frogs.
Preparing for the Next Agile Delivery
Back to Covid. Here is a list of the things that I suggest if Christmas 2022 sees another problematic variant become a global phenomena. Note that I have added some new features in bold that wouldn’t have been possible in early December 2021 for logistical reasons
An increase in mandatory sick pay by a magnitude of 4-6x (note, the UK has the lowest sick pay of any OECD country)
Not introduced travel bans on countries that are sharing important serological data with the international community once it was obvious that the variant was endemic within Britain
Preparing of a sectoral furlough scheme to be returned in some format to the hospitality sector, should things really go south
The opening of 24 hour vaccine centres, 7 days a week (they are currently open 12 hours a day), with payment to volunteers who work outside of the regular 12 hours a day
Each person who was boosted is to be entered once into a daily lottery with the chance of winning £500k, with the winner announced the day after they are boosted
Distribution of ‘variant-specific’ boosters and Paxlovid
An 8% nominal pay increase for frontline health workers
Nations contributing to Covax engage in ‘vaccine buyouts’, redesigning Covax, buying the IP of excess vaccines from manufacturers and redistributing to the rest of the world
Scale PCR Saliva Testing and Paxlovid for instant treatment
Build excess reserves of tests, antivirals and PPE during smoother times so that they can be quickly deployed in crisis moments
Variant-specific boosters are the golden ticket to dealing with new variants that come out of mRNA vaccines. Rather than wait months and even years for new vaccines to emerge, new updates can be developed and approved in a matter of weeks.
But for this to be a success there are two important things necessary. The first is actual investment in the pandemic infrastructure to make this a reality. This includes everything from the genomic sequencing apparatus to be able to understand new variants and the spike protein to ensuring that there is a flexible vaccine supply chain ready to be deployed with fierce speed.
But the second crucial element is around this function of ‘approving’. A Covid mRNA vaccine should arguably require much less regulatory scrutiny, given the data we already have on Covid mRNA vaccines.
In this sense, the health system needs to build up a series of reserves and spare capacity over 11 months. It needs to have a ‘crisis’ switch that can be turned on in an instant to ramp up surveillance, testing, vaccine and antiviral treatment and ICU beds. It would be unrealistic to have this ramped up all year round. The system and its people running it would become too stretched. But to be ready to do a sprint at a moment's notice, to operationalise surge capacity in a matter of hours, that is what will keep life going on and mean large restrictions are no longer the winter norm.
However, systems need to improve their learning mechanisms. If the dysfunction of institutions to decide leaves us paralysed, we will have a much smaller set of choices to decide on in the future.
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