It's good to act before the emergency

It's good to act before the emergency

(Steve Parsons/PA Images via Getty Images)

I’ve been pleased to see that since I wrote “Let’s Get More People Vaccinated,” American society has started to show a lot more urgency about getting more people vaccinated. I would of course like to think that’s because my take was extremely persuasive, but the real cause appears to be the Delta variant, which is highly infectious and spreading like wildfire among the unvaccinated community in a way that is starting to fill up the hospitals again.

A lot of the reporting on Delta breakthrough infections has been confusing or irresponsible in my view, but the basic point is that if a vaccine is 90% effective at blocking infection, you’re still left to worry about the baseline number of infected people you’re running into. So Delta ends up being a cause for concern among both the vaccinated and the unvaccinated.

And now we have vaccination rates ticking up again, especially in the least-vaccinated areas. We have Biden talking about mandatory vaccination for federal workers. And we have leaders in some of the blue states (though frustratingly not D.C. where I live) talking about similar mandates for their workers.

The FDA even says they are putting “all hands on deck” to make sure the work of full licensure gets done as quickly as possible.

Of course, the vaccines first got their EUA in November of 2020. And since at least May, it’s been easy for anyone who wants a vaccine to get one. So why did we need to wait months until tackling this problem with urgency? Unfortunately, it’s the problem we see over and over again with infectious diseases — it’s better to tackle the problem early, but it’s very hard to get people to treat a crisis like a crisis until you’re already in its throes.

How Ron DeSantis lost the pandemic

Florida governor Ron DeSantis is an intelligent person with a keen sense of self-preservation, so he got vaccinated against Covid-19 early, which makes a lot of sense. But he’s also an intelligent person with a keen sense of self-preservation, so he then spent a lot of time engaging in showy anti-vax politics. It’s not just that he didn’t mandate vaccinations for any class of Floridians; he signed laws prohibiting private businesses from mandating vaccination. He went to battle with the cruise ship industry to stop them from requiring vaccinations.

And it’s really worth dwelling on how extraordinary that is.

Republicans are, after all, normally the party of property rights and free enterprise. They don’t oppose regulation in all instances, but they tend to have a default view that businesses should be allowed to do what they want. Yet DeSantis made an exception to this strong presumption in favor of capitalism specifically in order to stand up for the rights of unvaccinated people.

Which is really an extraordinary step. I’m not sure whether or not it would’ve been good for business for Disney World to require vaccination of its workers and visitors. But had Disney World decided to do that, there would have been benefits for all Floridians, including the unvaccinated ones. For a free enterprise party to break its own ideological precepts in order to prevent private business owners from doing something pro-social is extraordinary. But that’s where DeSantis was — eager to do everything he possibly could at the margin to discourage vaccination in his state, even while personally safeguarding himself.

Now Florida’s hospitals are filling up, which we know is really bad. If we look at non-seniors, we know that dying of Covid-19 is rare. But being hospitalized for Covid-19, though still rare, is much less rare than dying. That’s because they can treat you in the hospital. And the big de minimis policy goal throughout the pandemic has been to “flatten the curve” and make sure that every hospitalized person can get excellent treatment. Otherwise, you need to do triage where the least-promising patients get no treatment at all, and the case fatality rate skyrockets. Will it get that bad in Florida? I hope not. But it’s a risk.

And here’s the thing — suppose politicians outside of Florida had handled this better. In other words, suppose federal employees and blue state public sector workers started getting mandatory vaccinations back in June. And suppose the Department of Transportation encouraged airlines to require proof of vaccination to fly.

Ron DeSantis and other red-state governors would have postured against those politically controversial ideas.

There would have been higher uptake of the vaccine (including in red states) and lower levels of infection and hospitalization (including in the red states).

In other words, if Joe Biden and Andrew Cuomo and Jay Inslee had all acted appropriately, they not only would have taken shit for it from Ron DeSantis, but he would have claimed vindication based on the success of the political risks they took. That’s the shitty politics of infection control — if you take timely and effective action, that will be seen as vindicating your critics.

Exponential growth is hard

Underlying that difficult dynamic is the reality that exponential growth just presents really challenging problems for the human mind. You have one case, then two, then four, then eight, then 16, then 32, then 64, then 128, and after however many doublings, you’re still at half the acceptable threshold for action.

But then in a blink of an eye, you go from half the threshold to at the threshold, and even a tiny amount of delay becomes extremely costly.

This is why the FDA’s behavior with regard to the approvals strikes me as so egregious. I really do think that if Biden sent a missive over to the FDA during his first week on the job urging them to back-burner everything other than Covid vaccine work, there would have been plenty of political support for that. It was a form of timely hurrying that wouldn’t have required mass sacrifice or big political risks.

It wouldn’t have been costless, of course. Prioritizing Covid work would have meant delayed approvals for other promising new medicines. But most of the kind of stuff the pharmaceutical industry works on in the United States doesn’t have the exponential growth of infectious disease. Delaying a new cancer treatment by six months is sad, but speeding up Covid vaccinations by even a small amount has a much larger value.

But when it comes to stuff that does require mass action, you need to pick efficacious moves.

Mandate vaccines, not masks

I don’t personally have a strong view as to whether or not we should make school kids wear masks this fall. It seems like the public health benefits of doing this are low, but also the costs of compliance are low. To the extent that mandating masks makes it easier to force teachers to come back to work and force parents to send their kids back to school, then the benefits of that are large, and it’s worth engaging in a little theatre if it helps.

But what does make me mad is that DCPS is going to be requiring masks this fall but isn’t going to be requiring vaccinations.

Obviously, lots of school kids (including my son) are too young for the vaccines. But the youngest kids are also the people at the lowest risk. If you make all the adults in the school system get vaccinated, you have eliminated the vast majority of the risk of serious illness. And if you combine that with making all the teenagers get vaccinated, you’ve also accomplished something important for the broader community. Teenagers are at low risk personally and are also not the most conscientious people in the world, so they are a major risk for spreading the virus around. Forcing them to get vaccinated accomplishes a lot of good.

What’s more, we mandate vaccines in schools all the time. Earlier this week I got a text message from DCPS reminding me to make sure all my kid’s normal non-Covid vaccines are in order. But teachers, aides, staffers, and teenagers aren’t being forced to get their Covid vaccinations in order. If the reason you’re not mandating Covid vaccines is you’re like DeSantis and you’re committed to not caring about the pandemic, then fair enough.

But precisely because it’s so hard to get people to comply with preemptive measures, you should spend your political capital on things that are highly effective. Getting people vaccinated is much more effective at halting serious illness than sporadically enforced mask mandates. But unfortunately, a lot of the public health community seems to have a brainwork that says that a pharmaceutical intervention is per se more coercive than a non-pharmaceutical intervention, and we’ve got politicians who are following along. In the real world, though, getting two shots is a much smaller burden than wearing a mask day after day after day. That’s especially because at this point it’s not clear what a Covid endpoint would be. The virus is overwhelmingly likely to become endemic and new variants will likely keep evolving and spreading over time.

If we take vaccination as the solution, then we may need booster shots from time to time or we might not. If we take masks as the solution, then we’ll never be done.

And more to the point, whether you think SARS-Cov-2 was zoonotic or lab generated, the world has done approximately nothing to prevent a recurrence of either problem. When the next pandemic comes, we want to roll out a sound playbook for countering it. And that starts with focusing on improving what we’ve been able to accomplish on vaccines.

Don’t cheap out on pandemic preparedness

The Biden administration requested $30 billion in pandemic preparedness spending as part of the original draft of his American Jobs Plan. That didn’t make it into the infrastructure bill. And word on the street is that because moderates won’t let progressives spend as much as they’d like in a reconciliation bill, one of the things that’s likely to get cut is the pandemic preparedness request because it’s not really a “win” for any interest group or ideological faction.

But this is insane — the pandemic causes trillions of dollars in economic harm. If the preparedness money manages to reduce the odds of a recurrence by a tiny amount, then $30 billion will have been money well-spent.

For broadly understandable reasons, there is a lot of stigma against charging a market-clearing price (“price gouging”) for vital medical supplies in the middle of an emergency. One consequence of that is it doesn’t make sense for private companies to invest in redundant production capacity and stockpiling of supplies. If you did allow price-gouging of PPE then PPE producers would achieve windfall profits during crises, and it would make sense for them to invest in either extra capacity or else just giant warehouses full of supplies. I’m not a Slate guy anymore, though, so I’m not going to try to persuade people that price-gouging is #actually good. I just want to make the point that if we’re going to stigmatize price-gouging then we need a non-market mechanism for doing this.

That probably means not only public procurement of a stockpile but contracting with suppliers to build entire factories whose only purpose is to make stuff that gets warehoused and kept off the market.

And I would extend that logic from PPE to vaccines. There’s been a lot of media attention on the horrific global inequities in vaccine distribution, with poor countries going without despite the dual humanitarian and self-interested imperatives to vaccinate the world. But what’s honestly crazier is how stingy rich countries have been about vaccinating themselves. The United States paid $20/dose for shots that are obviously worth much more than that, and the European Union patted itself on the back for paying less than that. The rich Pacific Rim countries that did so well on non-pharmaceutical interventions got even more relaxed about vaccines.

If by spending more — would $500/dose really have been too much? — rich countries had been able to increase the pace of vaccine manufacturing, not only would the rich countries have been better off, but the poor countries would have benefitted too since once all the rich people get their shots, the marginal cost of continuing to roll doses off the line is low.

Timely investments are only going to get harder

Realistically, of course, I don’t think offering Pfizer $500 a dose would in fact have allowed them to triple vaccine output on a short timeline. I’m a little surprised we haven’t seen more rigorous inquiry into whether or not that’s true, but based on what people who know about vaccine manufacturing say, it seems like the logistical barriers really are too high.

But that goes back to the fundamental difficulty of timely action in the face of exponential growth. If it’s hard to invest in pandemic preparedness today, it’s not going to get any easier in 2022 or 2024, and then when disaster hits in 2027 we’re going to be really sorry.

We’ve learned two things about vaccines during the past year that are worth taking seriously. One is that mRNA technology is very promising and the actual development of mRNA vaccines can be done very rapidly. The other is that mRNA vaccine manufacturing is pretty challenging. This means that right now is an excellent time to invest tons of money in whatever it is we can do in advance to develop spare capacity for vaccine manufacturing. The United States should do this, but foreign countries should do it too — especially rich countries like Japan and Canada that don’t currently have any domestic vaccine manufacturing capacity at all.

It turns out that in “normal” times, making vaccines is not a particularly lucrative line of work. But the social benefits of vaccine manufacturing capacity are high, and big up-front investments in it are very valuable. So we should be in something like a “whatever it takes” mode now trying to scale that stuff up. It’s really hard to act today, but it’s only getting harder as we move into the future.