What We Need

The posts that I write on this blog can be classified into a number of different categories. There are quick takes, fiskings, long form essays, aggregations, and others. I used to post one aggregation post every day. I just don’t have the time for that now. This post is one I’ve characterized in the past as “riffing” from a term used in jazz—taking a theme and improvising and varying it a bit.

Bill Gates has written an op-ed, published in the Washington Post that is chockful of interesting observations. I agree with some and disagree with others. It’s pretty wide-ranging going from testing to contact tracing to a vaccine. Here’s how he enters into the discussion of testing:

It begins with testing. We can’t defeat an enemy if we don’t know where it is. To reopen the economy, we need to be testing enough people that we can quickly detect emerging hotspots and intervene early. We don’t want to wait until the hospitals start to fill up and more people die.

That’s certainly true but just how much testing that might be depends on the method in which testing is performed. Diagnostic testing alone won’t tell you that. Even testing every individual in the country won’t tell you that. Just to be clear on the enormity of that task, I would estimate that using current technology, you’d be talking about $10-20 per test for 330 million tests for each round. And that’s exclusive of labor costs. There will need to be at least two rounds and probably many, many more. For each test you’ll need, what? 50mL of viral transport medium? That’s millions of liters. I’d bet that most of that is being produced in China. It’s not that difficult but we’d need to gear up for it and that would take time that we don’t have. The Abbott test would be better but I’m disappointed with their ability to scale up.

Gates gets around to the labor cost issue:

Innovation can help us get the numbers up. The current coronavirus tests require that health-care workers perform nasal swabs, which means they have to change their protective gear before every test. But our foundation supported research showing that having patients do the swab themselves produces results that are just as accurate. This self-swab approach is faster and safer, since regulators should be able to approve swabbing at home or in other locations rather than having people risk additional contact.

That’s blithe but the reality is that would have to be approved by the states. There’s nothing the president, the CDC, or the FDA could do about it short of declaring martial law. The same is true of this:

Another diagnostic test under development would work much like an at-home pregnancy test. You would swab your nose, but instead of sending it into a processing center, you’d put it in a liquid and then pour that liquid onto a strip of paper, which would change color if the virus was present. This test may be available in a few months.

Here’s a clear indication that Mr. Gates believes it will ultimately be necessary to test everybody:

We need one other advance in testing, but it’s social, not technical: consistent standards about who can get tested. If the country doesn’t test the right people — essential workers, people who are symptomatic and those who have been in contact with someone who tested positive — then we’re wasting a precious resource and potentially missing big reserves of the virus. Asymptomatic people who aren’t in one of those three groups should not be tested until there are enough for everyone else.

He then turns his attention to contact-tracing but, sadly, I believe he’s thinking like a software developer:

The second area where we need innovation is contact tracing. Once someone tests positive, public-health officials need to know who else that person might have infected.

There’s an app for that:

An even better solution would be the broad, voluntary adoption of digital tools. For example, there are apps that will help you remember where you have been; if you ever test positive, you can review the history or choose to share it with whoever comes to interview you about your contacts. And some people have proposed allowing phones to detect other phones that are near them by using Bluetooth and emitting sounds that humans can’t hear. If someone tested positive, their phone would send a message to the other phones, and their owners could get tested. If most people chose to install this kind of application, it would probably help some.

He should try quantifying that. Contacts probably increase exponentially with the size of the population. How much compliance would you need for any of this to produce the desired effect? I submit that in the United States we will never achieve that level of compliance.

He then turns to the subject of treatment alternatives. Sadly, at this point supportive care is the state of the art. Improvements in supportive care and, importantly, sharing and spreading those improvements around will probably be the best we can depend on. Unless there’s some sort of breakthrough nature will have taken its course by the time an effective treatment option presents itself.

Unfortunately for all of us, I disagree with this statement:

If, a year from now, people are going to big public events — such as games or concerts in a stadium — it will be because researchers have discovered an extremely effective treatment that makes everyone feel safe to go out again. Unfortunately, based on the evidence I’ve seen, they’ll likely find a good treatment, but not one that virtually guarantees you’ll recover.

I think the more likely way that will happen is, as said above, that nature will take its course. Enough of us will have contracted the disease that we’ve become resistant or are just naturally resistant.

He then considers a vaccine. I think that’s a lot farther off than he seems to. If an effective vaccine for any coronavirus had been developed in the past, I would be more confident. But he does make this good observation:

Even before there’s a safe, effective vaccine, governments need to work out how to distribute it. The countries that provide the funding, the countries where the trials are run, and the ones that are hardest-hit will all have a good case that they should receive priority. Ideally, there would be global agreement about who should get the vaccine first, but given how many competing interests there are, this is unlikely to happen. Whoever solves this problem equitably will have made a major breakthrough.

I think the odds are that, should a vaccine be developed, it will be deployed in countries other than the U. S. before the U. S. if only for reasons of liability.

He concludes:

World War II was the defining moment of my parents’ generation. Similarly, the coronavirus pandemic — the first in a century — will define this era. But there is one big difference between a world war and a pandemic: All of humanity can work together to learn about the disease and develop the capacity to fight it. With the right tools in hand, and smart implementation, we will eventually be able to declare an end to this pandemic — and turn our attention to how to prevent and contain the next one.

That’s pretty good as a peroration but I think it misses the mark a bit. For one thing I believe that what defined his parents was probably as much the Great Depression as it was World War II and, for most his audience, it’s what defined their grandparents’ experience. Neither they nor their parents have faced anything like either of those events and this won’t be one, either. Nearly half a million Americans died during World War II. Let’s hope that COVID-19 doesn’t accomplish anything resembling that.