COVID Webinar Series: Transcript of session with Larry Brilliant, MD, MPH

Larry Brilliant, MD, MPH, Chair, Ending Pandemics
Recorded: Monday, April 27th
His session is available for viewing online.  This is a transcript of the Q & A:

KRIS REBILLOT:  Can we open things up?  You and others sent a non-partisan letter suggestion an option. Can you please talk to us about that?

LARRY BRILLIANT:  Thank you, Kristine. I’m very happy to be here, and I’ll use the goodwill that you’ve given me to embarrass Eric by wishing him a happy birthday.  I won’t hear the end of that.

So let’s just take a step back. What we’ve been through the last six weeks in California, and that much of the country has been through in the last month, and some of the states have not yet deigned to join us, this rolling social distancing… which I hope we would call physical distancing, because we all want to be together socially, even if it’s virtually… this has always been plan B or C. First, it’s weak tea if what we’re thinking about is quarantine. It’s a Swiss cheese kind of quarantine, if that. And it’s devastating to the economy, it’s emotionally crippling, and it’s… but we’ve… we’ve had to do it because we failed in the United States to put in motion plan A, which would have been to make a plan, to have a strategy, to try to find every case that was imported into the United States early on and their secondary cases, and then to follow that up with testing, and then to do what epidemiologists have always done, we’ve done forward and backward tracing, which are now called contact tracing, and we find all the contacts, we test them, and then we quarantine those who test positive, we isolate those who test negative,  just because they’re contacts.

That’s what we would have done. That’s similar to what was done in South Korea.  The virus landed on our shores, or we think it did, on the same day it first appeared in South Korea. The South Koreans responded slowly at first. They, too, wasted time. I think we wasted six weeks. Let me put it a different way:  We gave a virus that grows exponentially a six-week head start. Not a good strategy. South Koreans gave it a three-week head start. But then they responded by doubling-down, and in a time that it took us to do 15,000 tests, they did 350,000 tests. They responded with contact tracing systems that were computer-based, as well as human-based, and they were energetic in their use of isolation. As a result of that, early detection and early response, they vigorously defended their country, and they have really survived pretty much unimpacted as far as their economy and people who are… who don’t have the luxury that I have in Marin County, where I can sit here on a Zoom and talk to you, and think of myself as being on a kind of isolated island.

But we didn’t do that. We fumbled the test rollout at CDC, inexplicably, my beloved CDC that I trained at. We then didn’t allow people who actually had symptoms to get the test unless they had had face-to-face contact with somebody who came from China. These are crazy-making things. This is not the way epidemiology is done. These are political decisions. And, as a consequence, the virus reached all 50 of our states before we had anything close to an adequate testing regime. We don’t even have a test of the tests, a role always historically played by the FDA, which has now approved over 200 different tests… I shouldn’t really say ‘approved’ there. I should say it’s only approved five tests, but it has licensed, or allowed, another 200 tests under emergency use authorization. So do we really have? We’ve got the wild west of testing. 

KRIS:  What’s the game plan?  What have you folks suggested?

LARRY:  This letter that we sent this morning, which was sent by 12, as they say, former officials. I think they let me in because I chaired the National Bio Surveillance Advisory Subcommittee, but the others are real officials. And it is bipartisan and it an appeal to Congress to give us the tools that will let us approximate plan A. In other words, give us the funds to hire as many as 300,000 contract tracers. Give us the money, so that when you find a case and have tested the case and all of its contacts, you can then make life easy for the people you need to quarantine. Give them a free hotel for 14 days, and pay them $50 a day, the same as you would a juror, for giving what is really national service. Those three things will go a long way… and I think it’s about a $40 billion ask, which is, I think, small potatoes compared to the $5 trillion that we otherwise will have spent. You know, when I was a kid and my mom said to me ‘A stitch in time saves nine.’ This stitch would have saved 90. We really have made a serious mistake. We’re going to be paying for it a long time.

But there is good news, and if we can implement this plan and do it every time the wave crests and we get a little trough, and we can find cases, isolate the cases, trace all the contacts, test them, quarantine those who are positive, isolate those who are just contacts, even if they’re negative, we’ll go a long way to making sure that this terrible disease doesn’t do any further damage than it has to.

KRIS:  How long do you think it would take for us to get ramped-up to do that revised plan A?

LARRY:  I think we start on day one.

KRIS: Okay.

LARRY:  I mean, here we are in Marin County, and we’ve got a wonderful… two wonderful health officers here, Matt Lewis, and Lisa Santora. They’re wonderful.  But give them the ability to pay for a hotel for a contact, give them the ability to have the best contact tracing system and all the contact tracers that they need, and give them the ability to test everybody, and they will be even better. They’re an A-plus already, but… and we’re doing really well here, but let’s make it possible for everybody to do well with the tools and the resources that they need.

KRIS:  You focus on a term called the R nought and herd immunity. What’s R nought and how does it factor into R nought.

LARRY:  Well, historically, the R nought was envisioned as a new virus that emerges in a immunologically naïve population. So if small pox jumped form an animal to human 10,000 years ago, on that day how many secondary cases would it be? And all throughout history we have kind of calculated that for small pox every case gave rise to 3.5 to 4.5 new cases. So a rapidly spreading disease, small pox.

The R nought of influenza is probably about 1.2. Anything over 1 and the disease will continue. Maybe the R nought of the great influenza in 1918 was closer to 2. The R nought for Ebola is about 1.2, 1.3. However, the R nought for measles is 12 to 16. That explosive disease… which is why we worry so much about the anti-vax movement about measles, it’s such an explosive disease.

So what is the R nought for COVID-19? It was originally calculated to be four or five. The calculations by many scientists have brought it to 2.2 to 2.4. In most of the literature, the wonderful Harvard paper three weeks ago in science, they’re assuming it’s going to be 2.2 to 2.4. But there was another paper, it was carried out by a group from Los Alamos and published a week ago in the EID, the Emerging Infectious Disease Journal. It’s a CDC affiliated journal. They went back to Wuhan and traced all the cases who left Wuhan having been exposed to the disease and went to other parts of China. And they found the ones who had actually become positive, who had come down with the disease, and they put them back into the calculation. And they calculated the R nought as 5.7.

KRIS:  Yikes.

LARRY:  So I think it’s fair to think that the R nought is going to be lumpy. In some cases, like Manhattan, when you have a highly dense population, all of them naïve… or immunologically naive. I guess they’re not very naive in New York. But that idea that what drives this outbreak is the R nought… or the RE, the R effective, or the RT, at a particular time… what drives it is the number of secondary cases there are, it’s exponential growth—that’s the exponent—and the periodicity—that’s pretty much the incubation period or the intergenerational period—for COVID, that’s about six or seven days—and then the density of susceptibles, which is maybe even the most important, but we don’t talk about it very much because the word R nought assumes that everybody is susceptible. But, obviously, even if you had measles and 100% of people were vaccinated, it doesn’t matter that the theoretical R nought was 12. Nobody’s going to get it. So it’s really a practical R of zero.

So that’s a lot of math, but it’s important to understand that that goes on no matter what we do. Everything we do to… use a mask to wash our hands… is to remove ourselves from the number of susceptibles. Everything we do by social distancing is to remove the population from that list of susceptibles. It doesn’t stop or reduce the total number of cases. If you like calculus, you see that curve, you’re going to be pushing it far to the right. But the area under the curve, the integral stays the same, the number of cases doesn’t change. We’re hoping we can postpone it until the cavalry comes, and the cavalry is the vaccine. We’re hoping that we don’t get to herd immunity by everyone getting that case rather than vaccinate.

And let me explain why that is. To reach herd immunity, the formula is… I hope it’s okay that I do formulas.

KRIS:  Sure.

LARRY:  Of this group of all I must be able to do. So the formula for herd immunity, which I taught in Epidemiology 101 at the University of Michigan when I was a professor there, is, one, herd immunity must be greater than one minus one divided by R nought. So it’s simple math. When R nought is two, it’s one minus one half, or 50%. That’s the herd immunity. You got to get over 50% for the virus to stop, which means for the R nought to then… for R effective to be less than one.

But what if the R nought really is five? Then you have to have herd immunity of one minus one over five, or one minus 0.2 or 0.8.  Eighty percent of the population will have to get the disease.  Do we understand what that means? That means if we don’t push the curve, if we don’t do social distancing, if we do what Sweden proposed to do initially, and we just say, ‘You all get the disease and we’ll live with it.’ You get natural herd immunity. If you need to get 80% of people infected and our population is 8 billion, that’s 6.8 billion people. And no matter what the fatality rate is, if you multiply .1, .01 or 1%, if you multiply any of those numbers by 6.8 billion, you’re going to have tens of millions of people dying. I don’t think that we’re prepared for that. It’s not a good strategy.

So we’re stuck with plan A, find every case, draw a ring of containment, of quarantine around it. We have to have tests for that. Or plan B, postpone the big waves, the onslaught of disease until the cavalry comes, which is the vaccine.

But when the cavalry comes, what you get is not rainbows and unicorns. When the cavalry comes and the vaccine comes, what you’re getting is a vaccination program. And so we have to make our plan long enough to allow for some degree of pushing the curve to the right, social distancing, some effect of the vaccine arriving, and then some amount of time until we do what we call mop up. It’s a terrible term. But we go to 220 countries, to the most remote, the most vulnerable people in the world who have not been vaccinated and do a vaccination program like the polio eradication program or the smallpox eradication program. We should be thinking in terms of three to five years. It doesn’t mean you can’t have a love affair, you can’t work, you can’t go back to a park, we can’t open up business for three or five years. Of course not. We can do that the moment we have plan A in place and we have visibility into the disease by massive amounts of testing.

I propose something like 300 million tests that could be done at home with a fingerprint… with a finger stick, a blood drop, or a nasal swab, or urine, or spit, saliva. I don’t think we’re that far away from getting that. But first, of course, we’ve got to get the FDA to test the tests, we’ve got to make sure we have integrity in the tests, and we got to know what the sensitivity and specificity of those tests are.

So we have a road to go, but it’s not a… it’s certainly not hopeless. This is not a zombie apocalypse. This is not a mass extinction event. You know, when I do the math and I say, ‘Whatever the case fatality rate is going to be, it’s going to wind up being less than 2%. That means 98% of us are going to get out of this alive.’

KRIS:  So based on your current reading, do you have an estimate for when we are going to have a vaccine?

LARRY:  So we’re doing something that’s never been done in science, and I love it. It’s like Silicon Valley. Instead of doing things sequentially, we’re doing them with parallel processing. I mean, Bill Gates said he’s going to open up a six or seven vaccine assembly lines, factories for six or seven different vaccines that we don’t even know what they’re going to be yet. We don’t know what kind of vaccines are going to be. And he’s getting them ready no matter what kind of vaccine goes through the process. And the usual process for getting a vaccine ready to produce is in series, in sequence. We usually do safety trials, efficacy trials, and efficiency trials. And every one of those takes about six months, or whatever they take. That’s where the one year to 18 months to get a vaccine usually comes from. But we’re doing all those in parallel, too. Every suggested vaccine we’re doing safety and efficacy tests in parallel right now, which is just wonderful.

We actually have four vaccines where there is vaccine in people’s arms already today, shots being given, trials being done. I listened to the woman who runs the NIH Moderna vaccine trial, she says she expects to have vaccine ready, fingers crossed, this fall to be extended to the most risky group, the first responders. The Oxford group feels that they’re going to have vaccine in the field pretty soon. The J&J group. There are others. I don’t want to I don’t want to not include somebody and have that mistaken as a preference.

So I’m really optimistic that not only will we have a vaccine, but we will have a vaccine to which we found the right adjuvants to add to it. So the vaccine that I hope we’ll have in the field will be an adjuvant-enhanced vaccine that will provide more immunogenicity than the disease itself. And you saw perhaps over the weekend WHO made an unfortunate press release that made it sound like the virus itself did not confer immunogenicity. They didn’t mean to say that. They took it back. They reposted it. What they meant to say is we have no evidence on how much immunogenicity the vaccine… they were really intending to say, ‘Don’t bet your life on immune certificates until we know what immunity is.’ That’s what they meant to say.

So I’m confident… ‘optimistic’ is a better word than confident, I think. I’m aspirational… maybe that’s a better word than ‘optimistic…’ that we will have a vaccine that produces better immunity than the disease, and we will have it in the time period that Tony Fauci said, 12 to 18 months from now. I think we’ll begin to see enough… hopefully we’ll begin to get anecdotal information back from these trials that makes us feel more than aspirational, more than optimistic, and tending towards confident.

KRIS:  Do you think that folks who have had COVID-19 have developed antibodies? Do you think that there will be some protection conferred to those folks?

LARRY:  So there’s two ways to address that. One is with the lab tests that we’re having, or with the kind of test that we would normally do. What you would normally do is you would get college volunteers and you would pay them to be exposed to this virus. And then you expose them to a certain number of virus copies, and then you would see what the result was. And then you would give them the antiviral in case they got the disease. Well, we don’t have the antiviral. If you don’t have a cure, then it’s not moral to expose people to the virus.

So then you say, ‘Okay, well let’s look at the animal models.’ We don’t really have animal models. We haven’t in the United States used monkeys. China has done two animal model tests with monkeys. Their results are that the monkeys do get immune. We haven’t done that in the United States yet. But unless you have… and I’m pretty optimistic that convalescent serum will turn out to be a… if not a get out of jail free card, it at least will be a prudent and reasonable therapeutic. So maybe we’ll be able to do human trials to find out what the immunogenicity is.

But there’s another way of going about it, which is sort of looking at the epidemiology and history, and come back at it. And my friend and colleague, Arnold Monto from the University of Michigan, who is one of the most acclaimed influenza virologists, epidemiologists in the world, he published a paper last week, and his paper was to look at the six coronaviruses that have been circulating in human populations and ask, ‘What’s the immunogenicity of those six?’ This is another coronavirus. They’re all a little bit different, each one is unique. And he said, ‘Okay, well, we know that MERS conferred immunity for what looks like three years. We think that SARS, original SARS number one, conferred immunity for two years. Now let’s look at the other four.’  And these are four coronaviruses that have been circulating in human populations for a very long time. Let’s think of them as they once were SARS or MERS or COVID and now they’ve gone to the great coronavirus retirement community in the sky called colds. These are the viruses that cause colds. These four coronaviruses caused about 40- to 50% of all the cold we get. And they do circulate. Every year or two, you get a different one of them that is the preeminent virus that causes colds. And he looked at their periodicity and he looked at their conferred immunity, and he came to the conclusion that they confer about one to two years of immunity and that looks similar to the one to two years of periodicity that they go around the world. So that would make a lot of sense. Jus said a different way, if you want to get one year of immunity of the average person, then that virus is not going to come back and see you as a customer for another year.

KRIS: Okay.

LARRY:  Two years, you’re going to get two years between them. So looking at the family of coronaviruses and looking at one, two, or three years of immunogenicity, I think it’s reasonable to start off with the beginning assumption that this virus will provide immunity, something like that. Maybe it will only produce several months of immunity, but I think the fear that it will produce no immunity, there’s no real evidence I think to support that.

Why that’s so important is we’re going to need the people who have had the disease to be immune long enough to mount a vaccination program. If we are intent on ridding the world of this virus… I won’t use the term ‘eradicate’ because we know it’s a disease of bats, we know there are tigers and lions and other animals that have been infected with it. We know that it’ therefore’ has a reservoir. We can’t think of eradicating it like smallpox. But we can think of conquering it and throwing it in to the dustbin of history. If we’re planning to do that, we need to include the time that it will take to mount a global program like the polio eradication program in over 200 countries with sufficient vaccine. So we need people to be immune long enough for that. And, of course, we need it for them, for each of us to be immune long enough that we feel safe going back into society.

KRIS:  So what would you say to folks who live in states where the governors have opened them up for business? Should people still be staying inside? What’s your reaction to all these various semi policies that are happening around the country?

LARRY:  What would I say to people [yeah] that have a governor that opened up the state? I would say get a different governor.

KRIS:  And in the meantime, should they just keep staying at home?

LARRY:  No, I think they should be engaged in the political process. I think what Georgia has done is unconscionable. I think that the home state of the Center for Disease Control and Emory University, some of the top places in the world that have produced epidemiologists, the place that every epidemiologist thinks of when you think of going home for a minute or two, it’s going to be to CDC, 1600 Clifton Road. That state is at the very time that they are doubling the death count every two weeks, that they are in the top nine of all the states with cases in cases per capita and deaths, on that time, they’re opening up the state to make it safe for massage therapists and tattoo artists and nail salons. I have nothing against nail salons, tattoo artists or massage therapists. I love them, but it’s not safe for them to be allowed into this kind of… let’s just say non-social distance.

KRIS:  Do you think that there’s a possibility that the virus arrived earlier than and that there are people who have already had it?

LARRY:  Well, I don’t want to go into my family medical history, but let’s say people very close to me that are making the case that they should be allowed to get immunological testing because they had a very, very bad cough that kept them awake at night, racked their body, they felt that pressure in their chest, they couldn’t breathe. And while it was diagnosed with bronchitis, and I know, like you do, in Marin, at least dozens of people that have had that disease, and they had it late January and early February. So my index of suspicion is high. But I’m a scientist. I haven’t seen any data. I think we should be getting as many of those people tested immunologically as possible, and taking a look at it.

Look, we just found out last week that the first death in California, and in the country, was not as we thought it was, in the middle of March, it was March 5th. We only found that out because a woman living in the South Bay, her family had pushed hard to get an autopsy. And the… you know, the county didn’t want to do an autopsy. And she was never tested. Like many who had the disease at that time, and even now, they couldn’t get a test. It’s unthinkable in the United States of America, but that that was the case then, it still is now.  The autopsy was absolutely conclusive. She died of COVID. She died of COVID that actually affected her heart and caused massive heart failure. So we know that it was here March 5th. If she died on March 5th, we assume that she was sick for three weeks or four weeks, whatever that time would have been, we don’t know. But that means that it was here in February. So I think that people who feel that they had a disease at that time and want to know, they have a right to get an immunological test.

Now, I understand that we should be using tests very sparingly, but at the same time, we should be lobbying for having better testing, more testing, free testing, and safer testing that has been tested.

KRIS:  In this country, there’s a lot of nationalism. There’s a distrust of different governments. We used to work with other governments better than we do now. So if we’re really going to kick this thing and like you say, put it in the dust bin of history, that seems really hard to me based on the current sort of political atmosphere. Can you comment on that?

LARRY:  Yeah, I was privileged, blessed, honored to be able to see the last case of polio in India. And, in addition, I saw the last case of variola major, smallpox, killer smallpox, in the world. Other than a lab accident later on, she was the last case in the world. Her name was Rahima Banu. She lived in Bhola Island in Bangladesh.  And when I visited her just before Christmas in 1975, and the scabs from smallpox fell off of her after six weeks of illness and landed on the soil, and they were baked and they died, that was the end of an unbroken chain of transmission going back to Pharaoh Ramses V at least, thousands and thousands of years. That couldn’t have happened if we didn’t have Christians and Muslims and Jews and Buddhists and Hindus and Shinto and people of all faiths, people of all colors, all races, people who spoke a polyglot of hundreds of languages coming from a hundred countries to work together under the auspices of the World Health Organization to eradicate that disease. It couldn’t have happened if we didn’t have vaccine from Russia and Canada and money from Sweden and volunteers from the US and Africa all working together. That was for me a magical moment. And coming from Marin in the 70s, it had a doubly magical sense to me that we really were all in it together. This wasn’t some kumbaya kind of thing, this was the reality that we can work together. In the polio eradication program, it’s been even more. We had 150,000 people working in India. If the polio program has 4 million working in India, alone, think of how many they have had worldwide, all working together.

I can’t imagine a world in which we deal with a global threat without a global solution and global partnership. Whatever the virtues of nationalism, and I see few personally, but whoever does see virtues in nationalism, go back to our Constitution, our Declaration of Independence, ask ourselves why do we have a government to begin with, if not for this moment at this time for this pandemic? And because it has the ‘pan’ embedded in its name, which means everybody in the world, how can we possibly solve this? If we leave the virus in Wuhan, or in North Italy, or in Zimbabwe, or Venezuela, or Syria, or Afghanistan, and we say we’re going to erect walls, it doesn’t work like that. If this virus is anywhere, it is everywhere.

When I was teaching epidemiology, my favorite slide… and please don’t get me wrong about why it was my favorite slide… was a list of all the kings and queens and emperors and presidents who died of smallpox. I say don’t get me wrong about… I don’t promote regicide, but it was my favorite slide because it reminded me that when there is a novel virus, which smallpox was, and there was no vaccine, which there was no vaccine for smallpox, just like COVID now, all the money in the world will not protect you from dying from that disease. There are no walls, there’s no moats, any number of alligators or crocodiles in that moat is not going to protect you. It is in your best interest, oligarch, it is in your best interest, you know, billionaire, it’s in your best interest to make the world safe by a concerted global effort. We truly are all in this together. Anything less is unthinkable.

KRIS:  I’m going to take a question. Somebody wants to know, do you think it’s going to be safe to open the schools in the fall?

LARRY:  You know, in a funny way, there’s a couple of arguments in favor of doing that, in part, because we have no evidence that the kids of school-going age are either very often infected with a very serious form of this disease, or are carriers in any meaningful, epidemiological meaningful way. Historically, the reason that in a flu epidemic, the first thing you think about is close the schools, it’s because the seasonality of flu is usually, well, the kids have summer vacation, they go to camp or they go on outings. They mix it up with other kids. They exchange stories and they exchange viruses. Then they come back and they start school, and they exchange what they have learned or taken in the summer, and the viruses that they’ve exchanged, they now exchange it with their classmates. And a couple of weeks after school begins you see that there is a new season for influenza, and parents begin to get it and the elderly get it.  For most flu’s, we have… it’s a terrible way to say this, but we have a death curve that’s U-shaped. A lot of deaths in the young age group, infants and small children. A lot of deaths in the elderly. The influenza in 1918 and in 2008, you had a W-shaped death curve, with a high number of deaths in 20 to 40 group. This death curve looks J-shaped. It’s got one wing, just very age-dependent. So I think there’s an argument not to follow a practice that we correctly used because it was the correct epidemiological reason for it that we use for influenza and extend it for COVID. So I don’t… I think if other things are being opened, certainly schools should be opened, in my opinion.

That said, there are schools, and then there are schools. If you tell me that you’ve got 40 people, kids, all compressed into a one-room school house and that they don’t have any protective gear, or any opportunity to distance themselves, or wear masks, or wash their hands, or have gloves, or access to any of these things, then I would have a different answer. But if you’re saying, can we have schools, but be sensible about whether we reduce the classroom size, we provide outdoor time, we provide protective masks and gloves… and I would always add to masks and gloves, glasses and hat. Glasses because the virus can come in through the eyes, the hat because when you are out, you are like an inanimate object and there will be viruses landing on your hat, leave it outside your door, only wear one hat when you’re outside.

But those kinds of things with those caveats, safe attendance at a safe school, I don’t see a reason to single out children and their schools as something that needs to be closed in a reflex, knee-jerk way, the way it is for all influenza outbreaks.

KRIS:  But college would be a different kettle of fish, right? You have kids in dormitories and stuff.

LARRY:  You know, I think once you start getting into something that begins to look like mass gatherings, as opposed to the small gatherings in a local area, every time you get bigger and you get geographically more, and you put an airplane in the middle, now you’re dealing with increased risk. Every one of these things is a risk factor that will have to be weighed against the economic, moral, justice, equity, and practical issues. I think it’s going to be a while before anyone gets onto a closed metal cylinder, hermetically sealed with 200 or 300 people sitting close together when you don’t know their immune status. I think it’s going to be a while before that happens.

KRIS:  Based on our conversation about elementary schools, I’ve got a question, and you can tell people are desperate for changes. ‘Is it okay for me to see my grandkids?’

LARRY:  I can’t give you advice, because I don’t know who you are. So I don’t know what your preexisting conditions are. I’m not joking. You know, the reality is that it’s not just age. It’s a whole bundle of things that enter into the equation. And, today, no, I don’t think you should, because it’s against the rules that we’ve agreed to follow.

But when things are opened up, I’m afraid those rules may be vague and open to interpretation. And this is where we have to ask you and me to be the best version of our self that we could be. One of my highlights from this difficult time are the people who have a hashtag called #Imwearingthisforafriend and then a picture of a mask. I’m wearing this for a friend. I’m not wearing it for me. This mask is not intended to protect me. It’s intended to protect my friends who are older or in high risk categories.

And let’s not leave this without talking about social equity. I’m from Detroit, Michigan, a high African-American percentage. Fifty-six percent of the deaths in part of Detroit, Michigan are in African-Americans who are less than 30% of the population in that area. Here, in the Bay Area, we’re looking at 30% of the deaths in the African-American, compared to 10% of the population. These are round numbers, but they tell the story. Hispanic community, doubly affected. What about the homeless community? What about the nursing homes?

So when we ask these questions about ‘When can we open up?’ ‘Can I do this?’ It’s really important that we answer the question not just for what we can do, but what we should do.

KRIS:  So what should we do? It seems like we need to rejigger a whole lot of stuff if we’re going to really address this issue of social equity.

LARRY:  Well, we’re in Marin County. We are blessed by a…

KRIS:  Yes, we are.

LARRY:  …not only a beautiful god-given geographic environment, wonderful friends, wonderful people, but we’ve got really great government. The county government is wonderful. I live in Mill Valley. The Mill Valley city government is world-class. And our state government, I think Gavin Newsome is just doing a terrific job. He’s modeling the best behavior of what a governor should be. That isn’t necessarily the same at the federal level and in many of the states. So the question of what we can do, I think, will be adjudicated wisely in our particular circumstances. And I do expect actually in the next couple of weeks to hear more and more about how you balance the joblessness and the desperation that people are feeling, not just because of the physical confines, but emotional confines of this plan B or C.

I would beg that we not go to plan B or C without a tradeoff in doing plan A. I would beg us that when we barter when can we open, we simultaneously say, and when can we step our foot on the throat of this virus and double-down? Double-down on quarantine of those who should be quarantined. It’s a very small percentage. That’s going to be less than 1- or 2% of the population who should be quarantined for 14 days, so that others can be freer. If we’re willing to have an adult conversation and make that tradeoff… and I think that letter that was sent by 12 nonpartisan, bipartisan officials of the past three or four administrations, I think that letter is a part of the solution, but the best part about it was the first word, ‘bipartisan.’ If we’re going to get over the schism that has divided us and forced people into making dumb policy decisions because it’s consistent with something called their base, I would like them to think that the base in the United States is 330 million people. It’s not one less than that.

KRIS:  Best case scenario, where do you think we’ll be five years from now when we look back?

LARRY:  I think five years from now we’re going to have had two other pandemics by then, just personally, what I think. I don’t think they will be this bad. And I think they won’t be this bad because we will be prepared, vigilant, and act quicker. We will truly practice early detection and early response. And there will be outbreaks. There will be viruses jumping from animals to humans. There were 30 to 50 in the last three decades. Tony Fauci says that there will be one, two, or three every year for the next 20 years. But those outbreaks, they’re inevitable. But turning into a pandemic, that’s optional. It’s our option. If we find them quickly and respond to them quickly, they will not become pandemics.

So let’s always remember that this one is going to cost us millions of lives. It’s going to cost us trillions of dollars. It’s going to cost us untold hardship. This pandemic is going to do what all pandemics does. It’s going to rewrite history. It’s going to act like a river, going to rejigger the borders between countries, it’s going to topple some governments and bring in new forms of government, just as every pandemic in history has done. Let us learn the lesson from this one so we have only this one, and the next ones are prevented.

KRIS:  Let’s get back to vaccines, which is definitely a part of the larger solution. Do you think that we’ll be able to ramp up production? I think, for the flu vaccine, a lot of the companies that make them are in China, in foreign countries. Is there cause for concern now? Is there something that should happen now so that when there is a vaccine or vaccines, we’ll be able to move on it?

LARRY:  Yes. I think that what Bill Gates is doing, getting ahead of that curve… I don’t know if you saw his announcement yesterday, that the entire wealth of the Gates Foundation is going to be singularly devoted to the pandemic. This is an enormous commitment. And some of that is going to build vaccine production lines that will never get used, and some will have been bets on the wrong kind of a vaccine, but they certainly increase the probability of having a vaccine at quantity as fast as possible. So thanks, Bill Gates.

And let’s also look at another international organization besides WHO called GAVI,, which is the Global Alliance for Vaccines. And that’s run by a wonderful guy named, Seth Berkley. They are a quasi-monopsony. We know what a monopoly is, that’s a single provider of something that owns the market. A monopsony is the reverse, it’s an organization that’s the single buyer. So GAVI is the major buyer of vaccines around the world. Their business plan is they buy vaccines at about a dollar and they sell it at 10 cents, and they make up the difference with philanthropic dollars. That’s great for you and me, because it means the diseases that we worry about, and that we could get vaccines easily here, that those vaccines will now be available low cost all over the world, And GAVI is just doing a sensational job.

Between our scientists making the vaccine, Bill’s commitment to spend so much money developing and manufacturing vaccines, GAVI’s ability to deliver, and the experience that we have from the smallpox eradication program and polio eradication program, how to mount a global vaccination program, I’m pretty optimistic that our biggest problem is going to be logistical and it’s going to be time, it’s not going to be as much money as it would have been before. And I think the science, while problematic and uncertain, and there’s lots of reasons to worry, that if you look just at these four coronaviruses that are colds, and you look at the difficulty we’re having with not only immunological tests… the immunological test has got to tell you that you’ve had the disease, you’ve been exposed to the virus, you’ve seroconverted, which means you’ve waged a good fight against it, you are no longer shedding viruses. And then which immunoglobulin is it that’s responsible for doing that, and even later, how can we make a monoclonal out of that? Those are problematic for making one kind of therapeutic. They’re also problematic for getting the vaccine done.

So I understand the hesitation. My confidence comes from the incredible science that’s being done. I cannot keep up with it. I cannot read every paper that’s done any more. There was a time when I could read every paper on pandemics, and it would take me an hour a month. Now it takes me a month a day.

KRIS:  South Korea ramped up their testing, they started testing. That didn’t happen in this country. Given the current political state of affairs, is there a way where we can get on the same page in this country as far as which tests, how to test, what’s test? What’s that going to take?

LARRY:  As far as testing, the molecular test, or the test for copies of the virus or viral fragments, the genomic test, that part of the test, do you have the disease test, I don’t think that’s a technology question. I think that’s a political question. Because CDC fumbled at the gate, because this administration, for whatever reason, made decisions that reduce the quantity of tests that were available, even after we had a chance to use that same test that was used in South Korea, the test that was created in Germany, the test that WHO authorized for the world to use, even after those errors, we still didn’t have adequate numbers of tests, and the FDA made the decision to open up the flood gates to anyone regardless of how good their test was. We need to have a consumer report. We need to have a test of test, a good housekeeping seal of approval as to which of these virological tests, tests of do you have the disease, that we will all standardize on, and not worry about the free market, the cacophony, the wild west that has been created by the FDA not being, as it always has been in the past, the gatekeeper of excellence. We need it to be the gatekeeper of excellence, or somebody else has got to do it.

And I’m pleased that my friend Joi Ito, well-known to many people in Marin, Joi was kind of an extended member of the family, of the Whole Earth Community and rose to become the director of the Media Lab at MIT. Joi is now leading an effort to put together an ad hoc non-governmental, non-commercial test of tests, and he’s well into that process. And whether it’s Joi or somebody else, I hope that someone emerges as the tester of tests. I’m not talking now about an immunological test, I’m talking about the virological, and the test of acutely do you have the disease that we need to have so badly for deciding clinical treatments.

KRIS:  As far as tracking where this pandemic is going or where it’s been, how valuable will artificial intelligence be?

LARRY:  I think that was, in part, motivated by a study that was published in Science 10 days ago. The front page had about a hundred authors. The last name was Sam Scarpino, who is a phenomenal data scientist and epidemiologist at Northeastern University. And that paper used cell phone signals, mobile phone signals to test in China, the speed of the epidemic, the direction that it went. And then by using the actual data as truth data, they were able to train their model, and then they could extend their model and predict successfully. We did something aligned to that at Google when I was there. We used Google flu trends, and we used CDC’s data as truth data. But you can’t cantilever a house, you can’t… when you’re building a house you can’t cantilever your deck more than 12 feet. You can’t really cantilever a model that far beyond truth data to be the complete solution.

So I think it’s good to have a mobile phone tracking systems. Certainly, they did it in a way that we would consider intrusive, and invasive, and even South Korea, what the South Koreans’ response was, ‘This is wonderful, my government is trying to help us.’ We might have a different response here.

But in addition to all the AI, all the mobile phone testing, we should be looking at both non-stochastic processing and stochastic processing tests. What I mean by that, we use the word ‘random’ in two meanings in English. Random means haphazard. Well, that’s a random thought or a random idea, a random gathering, random meetup. But we also mean it mathematically to be a probability sample that is drawn with a rigorous protocol, so that every individual in that sample represents… is representative of that community from which the sample is drawn, and, therefore, we can take mathematically valuable inferential powers to that random sample. That’s the gold standard. That’s the University of Michigan Consumer Confidence Index. When we hear that consumer confidence has gone up by twice, we feel confident that we understand how consumers feel. That’s based on a history going all the way back to the father of survey sampling, Leslie Kish, who was one of my wife’s advisors, when she got her Ph.D. at the University of Michigan there. I’ll put in that plug.

But that kind of survey sampling is missing and desired and needed. We need a random sample tracking survey of everything related to COVID—opinion, fears, economic impact, symptoms, syndromic surveillance, testing, digital thermometers, partial pressure... PO2, oxygen saturations with those little things you put on your finger, all of those things. And we need to keep that going for three years, so we own, you and me, collectively, we own the science and the history of this outbreak. And we make that available in radical transparency for any scientist to work on, and I hope we’ll have some good news in that regard soon. But until we have that kind of a… and that’s a huge sample, that will be tens or hundreds of thousands of people individually sampled every week or month. That’s a long and a big sample 

But right now, we have great things. We have COVID Near You, which my friend, Mark Smolinski, started. It is now owned by Harvard. It’s at the Beth Israel Hospital in Boston. John Brownstein is running it. They have almost a million people who have opted in. There is How Are You Feeling that Pinterest is doing. There is the COVID Tracking System, also done by Harvard and MIT. These are part of a new field of epidemiology called participatory surveillance, where you try to put the public back into public health.

KRIS:  To the folks taking part in this seminar today, would you recommend people participate?

LARRY:  Absolutely. Sign in to COVID Near You. If you choose a different one, do that. But sign in to COVID Near You because then you will be able to see your dot on the map and know how many people around you... and as they get to bigger numbers, they will be able to refine the area that you need to worry about actual disease near you. That’s why it’s called COVID Near You, is there any disease near you?  But at the same time, you may be given an offer to get a digital thermometer and keep your temperature for a month. You may be offered a test kit. You may be offered a little oxygen saturation… but let this large cloud… crowd sourcing in the cloud, let’s use that, because it’s less expensive than building, right now, this stochastic process random sample tracking poll, which I hope we will do very soon.  But in the meantime, this is a really good thing. And I think I heard that, today, there will be an announcement that they may be doing something with Survey Monkey. So you may be able to get something from COVID Near You that has more extensive participation. I sure hope that’s the case.

These things are really valuable. I offer as an example not what we’re doing here, but one that is done in Thailand. It is also a derivative of the work that Mark Smolinski did a long time ago. It is based on opt-in to a government system, all voluntary, paid for by what the Thais call the Sin Tax. And that’s the taxes on cigarette smoking prostitution, and alcohol. The Thai Health Foundation is funded by those taxes. And that goes to support an app called Doctor Me. Look it up. Doctor Me is clever. It’s the best of, you know, mobile phone apps. And it is so valuable. If you see dead cattle, and you’re a farmer, or you see dead chickens, you just type in your location... or geolocation is captured, and you type in what you’ve seen, and the Thai Ministry of Health comes, and if they see 10 dead chickens due to bird flu, they will give you 15 chickens that are alive and healthy, and you’re not going to feel abused, and you’re going to be incentivized to report, and then you and I hear in Marin County will benefit because Thailand will not have bird flu and be exported it. But if you’re a local farmer and you have cattle, and you report a bovine disease, they can come and give you the medicine to treat the bovine disease or how to segregate the herd.

So it’s all part of this idea called One Health, that the animals we live with, the environment that we’re part of, and our fellow brothers and sisters are all part of One Health. We share so much of the same genomics. we share so much of the same vulnerabilities. Let’s start testing and looking at diseases where they begin in animals, and not waiting until humans get it or are sick.

KRIS:  Folks want to know if that letter that went out today, is that posted any place online? I’m assuming that folks are going to want to be in touch with their Congress people.

LARRY:  Yes, NPR released it this morning.

KRIS: Okay.

LARRY: It’s in the NPR website. It’s in my Twitter feed.

KRIS:  Okay.

LARRY:  I have… what I’ve actually done is since I was coming here in haste, all I did was retweet the NPR release of the letter. It will be everywhere by tonight, I hope. But, certainly, on the NPR… I think NPR was the original source last night.

KRIS: What do you find most heartening as far as what’s going on now?

LARRY:  I cried when I watched the fire fighters in Manhattan run into the buildings as they were burning and crashing. I’ve never felt more patriotic and... sorry. I never felt more American, I guess, or I never felt so proud of our species. I feel the same way about the public health officials in Marin and in Atlanta. I feel the same way about the ambulance workers, some of whom have been giving mouth-to-mouth respiration to people who may have COVID and they don’t know, to the nurses who want to keep coming to work even though they don’t have enough face masks or uniforms or gloves, to the firefighters who have become emergency first responders, to the policemen and women, and to ordinary individuals. Here in Marin, we have so many young people who volunteered to be drivers for Meals on Wheels, and to all the systems that we have to bring food for people who can’t get out, even if they wanted to. The rate of volunteerism has increased in this pandemic, I read just this morning, by 800%. Charities, while they’re having trouble raising money, they’re having far more volunteers than they’ve ever had before. I’m so proud of the people who are, whether they’re Republicans or Democrats, or left or right, are working in their communities, whether it’s with their public health officers, the governments, the non-profits. And look at the foundations. Jeff Skoll announced a huge amount of money for pandemics. Bill Gates announced something that’s never been done before. Every foundation is looking at its corpus and asking, how can we use not just the money that we give, the 4- or 5% every year, but how can we use this body of wealth that’s been put here to help stop this pandemic?

And I personally am very proud of WHO. I want to say that WHO is not perfect. I worked for WHO for 10 years. Everyone who has worked for WHO has a love-hate relationship with it. But by far, Tedros is the best Director General we’ve had of the last six. And WHO was slow in announcing a pandemic, putting that word on it, being watchful over its shoulder about what pandemic meant to China and to others. I think that it was slow in recognizing the public implications of the place that it had in a new world of social media. There’s a lot of things to say that can be improved about WHO, and I can say that because it’s WHO, themselves, that are saying this. The level of self-awareness in WHO, which I would have ranked as zero previously, has gotten much, much higher. I’m optimistic that this kerfuffle between the US government and WHO, which is being exacerbated by some for political reasons, will come to its rightful place. The US needs WHO more than WHO needs us. We cannot survive a pandemic that’s in 220 countries without the organization that represents the other 219.