What happens to Cassandras when their warnings become reality? If you are epidemiologist Larry Brilliant, you work to mitigate a situation that would not have been so terrible if people had listened to you in the first place. Pre-Covid Brilliant, along with many of his peers, had been ringing the alarm on pandemics in op-eds, a much-viewed TED talk, and a tragically prophetic horror movie he advised on called Contagion. In the last year, Brilliant—best known for his work in helping to eradicate smallpox—has been active in helping people understand Covid-19, as founder and CEO of Pandefense Advisory.
Now, along with noted epidemiologist Ian Lipkin and Pandefense Advisory colleagues Lisa Danzig and Karen Pak Oppenheimer, he has proposed a plan to help us avoid an unnecessarily lengthy recovery. Basically, Brilliant and his coauthors are instructing us to discard the panacea of herd immunity and gird ourselves for localized combat against a virus that produces ever more infectious variants. Ultimately, Brilliant envisions a framework that will not only get us to normalish but also position us to fend off pandemics to come.
This interview is my fourth pandemic session with Brilliant. The first one, just over a year ago, is the second-most-read article in WIRED’s history. Listening to him now is as urgent as ever.
Steven Levy: You and your colleagues just disappointed a lot of people by saying we can’t reach herd immunity. Why not?
Larry Brilliant: Herd immunity is fetishized now in society. It is envisioned as a magic moment when the ball will drop in Times Square and we’ll all be dancing, kissing and hugging, and marching our way into normality. Well, that’s never going to happen. That’s not how any pandemic ends.
Wait, didn’t we knock polio?
We haven’t knocked it yet! We’ve been working at polio for 70 years since you read that article on the front page of the newspaper saying polio is conquered. That’s my point. It doesn’t happen overnight, and it doesn’t happen the way people envision it. The threshold for herd immunity is when, on average, one case is able to infect fewer than one other case. It’s a math equation: Herd immunity means the effective reproductive number—R—is less than one. In that case, the pandemic fritters out. But with every new variant that is successful, R increases, crowding out the incumbent. Take a look at Brazil right now, where the P.1 variant has overrun hospitals. The city of Manaus announced some months ago it had reached herd immunity. They were very proud of it, even though they got there by people getting sick and many people dying. Then the P.1 variant appeared, and almost as many people got sick as before. They asked, if they had 76 percent herd immunity, how could that number get infected again? They were infected by the P.1 variant on top of having been infected by the original, because the P.1 variant was more transmissible.
But that was before the vaccine. Wouldn’t we prevent this if our herd immunity came from that?
Here in the US, 30 percent of people say they’re not going to get vaccinated. We don’t vaccinate children, but they’re part of the herd. We have immigration of people who haven’t been vaccinated. A lot of people get vaccinated and don’t take the second dose. But let me be clear—the response is extraordinary. I’m saying I want to hedge my bet, because I do not believe for a second that the success that we are having in the United States is replicable around the world. The whole reason we’re rushing to vaccinate everybody is to get people protected against this disease, so that when we do get variants that are more lethal, we will be able then to simply get booster doses. These vaccines clobber today’s variants, but they can’t clobber tomorrow’s, because we just don’t know where this wily virus is going to mutate and become a variant.
If you have half the population vaccinated, can we still have an incredibly destructive spike?
Of course. We’re all customers for the virus. There’s no wall that will keep the virus out. Think about the pandemic in year three or four. There will still be billions of people unvaccinated. Billions of people will harbor billions of viruses. Each one will be replicating. A certain percentage will mutate. A certain percent will become variants of those variants—some will be of high concern, and a percentage will be fucking nightmarish.
Is it an inevitability that a variant is going to come along that isn’t touched by the vaccine and is more deadly that what we’ve seen?
It’s not an inevitability, but it’s a non-zero probability.
Is it a double-digit probability?
I don’t know. How fast are we going to vaccinate the rest of the world? You tell me that.
Do have a contingency for when that happens?
Well, my dear friend, that’s why I’m doing this. We need a plan B.
We’re still losing over a thousand people a day—but we’re opening restaurants now. Wouldn’t it make a huge difference to hold off for six weeks or two months?
Of course, it’s insane. The cadence of spring break, Easter, Memorial Day, and Fourth of July can bring another spike that’s bigger than what we’ve seen before. That’s the reason that the Biden administration is working so hard and so quickly to get people vaccinated. If fewer people remain susceptible, the less likely a big spike is.
Well, I’m listening to you, Larry, and I’m thinking I might never see a Broadway show again. And if I go to a baseball game in five years, I’ll be wearing a mask.
That’s an overreaction. I’m saying that, because it’s a probability that we will never reach herd immunity, there will be places in the world and in the animal population that could produce variants that could continually reinfect us. Let’s plan for it and put aside enough vaccine, and enough money, so that we can find outbreaks quickly, respond to them just in time with the right vaccine, and keep outbreaks contained. I’m very optimistic about that. In the Cares Act, there’s money to pay people to be vaccinated, to be isolated, to give them food and to give them shelter. I think you’ll be able to go to a Broadway show. And I think baseball will happen again, not so much because people are vaccinated, although that’s critically important. Point-of-care diagnostics is also part of that. A year from now there will be $5, five-minute, at-home spit tests that are 100 percent accurate, and you can do one in the morning before you brush your teeth.
We’ve been hearing about those tests for a year now. Where are they?
We will have it within a year. You want a positive prediction? That’s my prediction.
That’s part of your plan B, what you call a comprehensive rapid-detection and outbreak-containment system.
We’re going to be testing, tracing, and isolating. I look at these digital notification systems, and I’m optimistic.
Those are the systems by Apple and Google that passively detect if you’ve been exposed?
I was not a fan of them in the beginning, I thought they were elitist, but now I understand their value. The biggest problem in contact tracing is finding the asymptomatic cases. These systems will find the asymptomatic cases. Also, they’re not invading privacy. Most of the data is anonymized. We don’t know someone’s name, but we can send them an appointment to get a test. Maybe you’re one or two degrees away from somebody who’s just tested positive. It will allow us to find cases that we haven’t found. If the system comes into effect, you might get a notice that you have been exposed to a new variant. It will tell you which vaccines clobber the variant and give you an appointment to get vaccinated. It’s so important that you vaccinate the person who is next to get the disease.
How realistic is your plan? At the moment, infection numbers are going up, even as states race against each other to open up more quickly. As I read your plan, I ask, what country are you talking about?
At least you didn’t say, What planet? Other countries have done it. Listen, the whole point of introducing both just-in-time vaccination and digital disease detection is that we don’t need much support from politicians to get the disease-detection part. More than 20 states have already accepted the exposure-notification systems that Apple and Google have created.
And we will be able to deliver specialized versions of the vaccine optimized to fight specific strains?
Our ability to do viral sequencing at low cost, speed, and scale is as astounding as our ability to deliver a brand-new-technology vaccine in a year. It’s the public health equivalent of personalized medicine, and we could do that. We have the just-in-time vaccine manufacturing now, and we have the just-in-time vaccine delivery. Now we need a just-in-time way to find the cases of tomorrow. We have to vaccinate where the virus will go. Also, let’s get a vaccine that works faster. And by the way, give it to me in a nasal spray. Because we’re Americans and we’re shitty at public health, we have to do things in a frictionless way.
Before this pandemic, would you have said that Americans are shitty at public health?
Five years ago, I probably wouldn’t have said it. Now it’s a shambles. We have dramatically underfunded public health. In the 1900s, we had an architecture for public health in the United States that was the envy of the world. We had public health directors at state levels who were empowered to arrest the governor if the governor was mentally ill. We had states that created their own vaccines. That’s almost unthinkable today. We have increasingly become more weighted to the private sector, and we have underfunded the public sector. And the stepchild of medicine is public health. This pandemic has exposed the crevices in our social system at every level, including medicine and public health.
It’s been a year since we first talked. What have you learned since then that you wish you’d known when we had that conversation?
I would go back further than a year. There’s a whole community of epidemiologists who have been saying just exactly what I’ve said and better than I’ve said it. The epidemiological part, we got right. Here are the things we didn’t get right: We expected a respiratory disease that killed because it created pneumonia. But this disease is systemic. It causes long-haul symptoms, it goes from nose to toes—you lose your sense of smell and your toes get swollen. In some cases, it increases the possibility of stroke. And so on. The second thing I didn’t anticipate was a totally AWOL government, a government that politicized, dismissed, minimized the disease that was the greatest medical challenge of our lifetimes. A high percentage of the half-million souls that have been lost would not have been lost with a competent government. And on the brighter side, I wouldn’t have ever expected that we would have a vaccine so quick that’s so good.
This pandemic clearly makes us rethink everything. The fundamental unfairness of always giving the short end of the stick to the African American community, in medical care, public health, and economics—that is our historic cross to bear. At one point in time, 80 percent of those hospitalized with Covid in Georgia were African Americans. And every country has a similar story. When Singapore was doing so well and thinking, “Well, we don’t have any cases,” they forgot about their immigrant community packed in close quarters. And they had to go back and rethink everything about how they were treating immigrants. The pandemic supposes and exacerbates the trends of the centrifugal forces in the world, the winners and losers. And we have to stop and think, who are we as a people?
But it’s not just for humane reasons that you want to get vaccines worldwide—it’s our own survival.
It is the ultimate act of selfishness to make sure that everybody in Bangladesh and Zimbabwe is vaccinated. And it’s the ultimate act of altruism.
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