Thread by @kesvelt

Let’s not fool ourselves. Containing an epidemic before it becomes a pandemic is difficult.

But CDC and FDA failed us. Their incentives aren’t suited to emergencies; politics made it worse. Lots of people died. The White House plan includes reforms. 1/20

https://twitter.com/kesvelt/status/1435974575196712964

@kmvnarayan14, Curran, Foege, and many others have suggested solutions, including a politics-resistant Federal Reserve model for pandemic preparedness and an independent advisory board to call out failures in real-time. 2/
jamanetwork.com/journals/jama/…

I’d go further: in a pandemic emergency, new leaders incentivized to act fast and at scale should take over. You don’t run clinical trials in a 30% lethality pandemic; you get shots into arms as they’re developed and track what happens. 3/

Evidently politics got in the way.

11. Regulatory Improvement: $1.6B. Efficient approvals for platform technologies, flexible and scalable clinical trial networks, and regulation that keeps pace with tech development. 4/

+ Acknowledges that regulatory improvement is desperately needed
+ Acknowledges that clinical trials took way too long
+ Streamlined approval of mRNA vaccines and other platforms 5/

- No mention of challenge trials that might have saved >100k Americans
- No mention of how to change FDA’s culture+approval process
- No mention of fixing CDC, or suggestion that it may need fixing 6/
1daysooner.org

Some say bureaucracies become sclerotic and need to be burnt down and rebuilt from scratch periodically. Perhaps. I’d settle for emergency directors for FDA & CDC, free of normal incentives and rules, who'd take over in a pandemic emergency. 7/

The American Pandemic Preparedness plan doesn’t reform FDA/CDC, but would at least give us a pandemic coordinator.

12. Manage the Mission: $0.8B. Establish a Mission Control for pandemic preparedness, including coordinating international efforts. 8/

+ Centralized hub for pandemic response
+ Overcome our scattershot response across agencies
+ Coordinate international containment efforts 9/

- Will the Mission Control director have authority to overrule FDA/CDC during pandemics?
- Will they be able to run city-wide drills, test stockpiles and distribution networks, etc when there isn't a pandemic? With what continuing budget? 10/

Putting the right person in charge of Pandemic Mission Control will be crucial. Above all else, I’d like to see someone who is humble. No matter who it may be, they won’t have a good picture of the threatspace, because nobody does. 11/

Moreover, Mission Control must be independent. Going along with the incentives & assumptions of the political, medical, and regulatory establishments killed an awful lot of people this time around. Next time, even more lives will be at stake. 12/

Overall grade for for the American Pandemic Preparedness Plan: A- (on a curve adjusted for probable political constraints due to establishment myopia)
Absolute grade: B
Congress should fund it all and frankly much more. 14/

What more would I have liked to see? More indications that we’re not just fighting the last war. Yes, we might get hit with another SARS-CoV-2 or 1918 influenza from a spillover or accident, but what if it’s worse, or even deliberate? 15/

Most important, we need concrete plans for what we’ll do given a >30% mortality pandemic with R > 6. How would we continue food/water/power distribution and maintain order? How many workers have to show up? Who’s in charge? Run drills to find out. 16/

We can build a metagenomic early warning system that will detect anything, comfortable near-perfect protective equipment for every essential worker, buildings that suppress transmission, & have millions of at-home diagnostics within 2 weeks of threat ID. 17/

All of these are included to some extent; all will work against any threat. Vaccines won’t, but we still need to make them asap when possible. We'll share these technologies with other countries: if they can stop it, we don't have to. 18/

Finally, let’s get serious about preventing deliberate pandemics. We can translate nuclear nonproliferation measures to bio, including laws against sharing blueprints. For security purposes, flagging a virus as pandemic-capable is worse than sharing nukes. 19/

Future pandemics could be much more lethal than SARS-CoV-2. We can save a tremendous number of lives by preparing. The White House plan is a very good start, better than anything else proposed. Let’s ensure Congress funds it. 20/20
whitehouse.gov/wp-content/upl…