Plan A for the coronavirus
As everyone can now see, the coronavirus is a test of every government.
This test — which the US is failing — is already a tragedy. It has barely begun. In the next few months, you or someone you love will drown of a cough.
Since some of us are still not sure Covid-19 is a thing, how that’ll go down:
It first struck me how different it was when I saw my first coronavirus patient go bad. I was like, Holy shit, this is not the flu. Watching this relatively young guy, gasping for air, pink frothy secretions coming out of his tube and out of his mouth. The ventilator should have been doing the work of breathing but he was still gasping for air, moving his mouth, moving his body, struggling.
We had to restrain him. With all the coronavirus patients, we’ve had to restrain them. They really hyperventilate, really struggle to breathe. When you’re in that mindstate of struggling to breathe and delirious with fever, you don’t know when someone is trying to help you, so you’ll try to rip the breathing tube out because you feel it is choking you, but you are drowning.
When someone has an infection, I’m used to seeing the normal colors you’d associate with it: greens and yellows. The coronavirus patients with ARDS have been having a lot of secretions that are actually pink because they’re filled with blood cells that are leaking into their airways. They are essentially drowning in their own blood and fluids because their lungs are so full. So we’re constantly having to suction out the secretions every time we go into their rooms.
Yet most of us will live. It would be more than a shame if we chose not to learn from this test. It would be a crime. Though the guilty will not be punished, and should not be punished — it is already a crime.
If we fail to act on what we learn — this too is a crime. If we act weakly, or erroneously, or worst of all slowly — a crime. In an exponential epidemic, all experts agree, the virus has to be hit as hard, accurately, and fast as possible.
The good news: the measures taken already should be enough to keep the fire from sweeping quickly through the American population. The bad news: they are nowhere near sufficient to put the fire out. And there is no realistic way to end the lockdown while the epidemic is still burning — at all. Ten sparks in the whole country are ten sparks too many.
And while the fire burns, our financial system — never made to be paused — is now melting into the water table. So is our economy, for finance and commerce are now inseparable. So is our society, now just an economy.
The terrible truth the virus has revealed is that the US and UK — as opposed to post-Communist Asia and post-Napoleonic Europe — are not even countries. They are free-trade zones. Our governments are not governments. They are bureaucratic anarchies with ceremonial elected monarchs. Pitting them against this ruthlessly objective virus is sending Don Quixote to Vietnam.
We thought we had the best government in the world. It is quite a shock to find we have the worst — outside the Third World, of course.
(Or do you think it’s doing great? While official authorities must be filtered no less skeptically than fringe sources, many still do excellent work. As of April 1, status of the epidemic, by the consistently reliable Marc Lipsitch, of Harvard; status of the response, from Science.)
Welcome to war. This essay outlines a broad strategy — “Plan A” — for winning World War V. Plan A is as strong and hard and fast as I can make it. And it thinks completely outside the box.
You probably think this is just a cliche. In fact, Plan A is so extreme that you are probably not ready for it. This is a pity. You can always change your mind and come back.
You will still find Plan A interesting as a thought-experiment. You are welcome to borrow it, or parts of it, without credit. If you want the whole thing, you’ll have to accept a couple of truths — one simple and one hard.
The simple truth is that the virus has tested our government and it has failed. France has fallen. It’s done. This is America’s Chernobyl — we can never again go back to believing that the government we have is wise and capable.
And it is neither the Republican politicians nor the Democratic civil servants who are to blame. It is both red and blue teams. It is not that one side of the government has failed. The whole machine has failed.
Our President, who should do the decent thing and resign, spent a month playing the Mayor in Jaws. Most conservative media followed him like a dog. Most progressive media spent the previous month talking about racism and the flu — though their private opinions seem to have varied. And if you still believe in the wisdom of our public-health experts, read this expose of how FDA slow-rolled high-speed RT-PCR testing for two and a half months — ostensibly because ethics, clearly to protect the sanctity of its hallowed turf. (Protip: if you know what you’re talking about, it’s “FDA,” not “the FDA.”)
Anyone repeating lines like “the Trump administration has failed” is spreading an Orwellian lie. There is no “Trump administration.” There is an elected showman and his cronies, fronting for an unaccountable permanent government. The celebrities are neither in charge of the bureaucrats, nor deserve to be. Anyone can be excused for thinking either team is worse than the other. No one can be excused for confusing the two.
The hard truth is that the virus is not just a test of our government. It is a test of our form of government.
The ultimate implications of this failure are irrelevant. Its proximate implication is that the strongest possible attack on the virus cannot use the organization, personnel, policies, or principles of the existing government. It is not any one of these aspects that has failed. It is all of them together.
Plan A will not happen. You are not ready for it. In fact, I’m posting it on Medium because no one else will publish it. My point is: if you lived here, you’d be home by now.
Conventional plans and existing structures
All kinds of conventional plans are being proposed. Let me link you to some of the best — like this one from former FDA commissioner Scott Gottlieb, or this one from Harvey Fineberg of Harvard via NEJM, or even this one from leading “rationalist” Roko Mijic. Read them all.
These inside-the-box plans — which do assume the organizations, personnel, policies and principles that got us here — are generally in the right direction. But they all suffer from two defects.
First: they are too weak and passive to succeed. Second: they are too strong and aggressive for the actual systems that would have to execute them.
They demand more state capacity than America has. They demand less than the problem needs. They are off by an order of magnitude in both directions.
For the essential step of tracking, testing and isolating needed to control and eradicate the virus, these plans all propose measures which are (a) voluntary, and (b) rely on scaling up and/or coordinating existing agencies.
These agencies have already shown themselves dysfunctional. A broken organization cannot expand or succeed. The American culture of civic responsibility, trust in government, and voluntary compliance with worthy suggestions and unenforced laws appears, in these plans, to be impeccable. And their 1950s process for developing biological protection remains identical to the creation of a new vaccine for acne, baldness, or toenail fungus.
Since their authors are not scientific idiots, they know that their weak plans for escaping from lockdowns will not be perfect. Since they are not political scientists, they seem unaware that they live in the most safety-conscious, risk-averse country on earth or in history.
The idea that any American decision-maker will approve a contagious activity, while it still creates the risk of drowning of a cough, is not worth taking seriously. Hyper-autistic plans for cyclic lockdowns — in which the epidemic is periodically allowed to restart, then promptly suppressed, then lather, rinse, repeat — will, when we can laugh again, seem grimly hilarious.
Macaulay observed that the amateur in political science designs constitutions for an ideal country — like a tailor who cuts all his clothes for the Apollo Belvedere. The real America needs a plan that works for the real America.
The real America does not want a plan that works for the real America. Most writers fudge this problem and split the difference.
Actually, the real America has an unprecedented opportunity to get over itself. It will not take that chance. It is the role of the writer to give it that chance — not to help it fail — not to tell it what it wants to hear.
Come with us if you want to live
The strongest possible response will come from a new agency, built as a startup. This Coronavirus Authority will scale up faster than any existing organization can execute. It will use the old agencies only where it finds them useful. And it will dissolve itself once the virus is beaten.
And all the CVA needs to do its job is plenary (unconditional) authority over all federal, state, local and private actors. In theoretical terms, its sovereignty is absolute — but both temporary (limited in time, to the end of the war) and partial (applied only to its specific mission or scope). A small thing!
(Or as Harvard’s Fineberg puts it, in JAMA: “This commander carries the full power […] and authority to mobilize every civilian and military asset needed to win the war.” Alas, the ellipses hide “of the American President.” A British Dr. Fineberg might have said: “of the Queen of England.” Political science, like epidemiology, is hard. Fineberg also says: “This is not a coordinator across agencies.” He then proposes… coordinating existing agencies.)
The CVA has zero time for any problem not related to the virus. Since plenary power must bound itself, over years or decades its scope would tend to creep. But before scope decay sets in, the CVA will die by succeeding (or be canceled for failing). Its absolute powers are no threat to our sacred Constitution.
Most Americans remember when Washington couldn’t build a website and Palo Alto bailed it out. They still think what Palo Alto brought to the table was computer science.
Actually, plenty of people in DC can code just fine. What Palo Alto brought was the ability to execute at scale. Back then, some website seemed important. Now we know what important means.
Do you want to start today? Or keep screwing around with the same clowns who got us here? Come with us if you want to live.
What will this CVA do? That’ll be up to it. But, just to illustrate what the right structure could do, let’s put forward a concrete plan.
There is no reason to have a financial or economic crisis at the same time as a pandemic. Putting both Wall Street and Main Street into suspended animation is a matter of paperwork — and maybe a bit of code.
The way to suspend Wall Street is not to suspend the stock market (which might end capitalism in America). Capitalism does not need to be ended. It does need a reset. The Fed can reset it by closing the whole market out for cash.
In this reset, the Fed monetizes all financial assets — trading them for new dollars at the last quoted price. If you had stocks or bonds, you sold them all to the Fed. Your portfolio is all cash. The number has not changed.
The Fed owns all public companies. Debts between them are debts to itself; they cancel. The companies operate as normal, not worrying about their P/L.
This state of affairs — literally the state capitalism of the Soviet Union — will, like the Soviet Union, slowly decay. But the epidemic is measured in months; the command-economy rot, in decades.
Once the virus is beaten, the whole economy goes public again and is again priced by the public, in essentially a giant IPO. The Fed receives the cash and cancels it. This is essentially a national bankruptcy and restructuring.
But wouldn’t it create inflation? Inflation is an increase in the general price level. Prices are set by supply and demand.
Your propensity to spend — to exchange dollars for goods — is a function of your personal net worth. It is not a function of the allocation of your portfolio between stocks, bonds, and cash.
If net worth does not change, the price level is not affected. Everyone keeps the chips they had when the casino was closed. Nothing else seems fair.
Most Americans have no stocks. They have jobs. Those jobs are burning down, right now.
Sending everyone random checks is lazy and ineffective. “Loans” (actually designed to be forgiven) to small businesses are already turning into a nightmare of paperwork and fraud.
Most Americans are paid through payroll processors, like ADP. The Fed has all the dollars it needs. The payroll companies have all the records they need. Just keep everyone’s check flowing.
Some people are self-employed. IRS knows how much they claimed to make last year. These claims are seldom overstated! It’s easy to continue their income on the same basis. There is no moral hazard, unless there is another pandemic next year.
Nor need these payments create debt. The deflationary impact of the crisis is already more than adequate.
Understanding “money printing”
These measures involve creating a lot of dollars. Intuitively, this seems both wrong and right. It is both wrong and right. Let’s relate it to your current theories of economics.
The three leading heterodox schools of economics today are Asian neo-mercantilism, “modern monetary theory” (MMT), and praxeology (Austrian economics). Each thinks little of the others, if it thinks of them at all. Each is right in its own way — as is post-Keynesian neoclassical macro, currently on the throne.
All four theories have the same relationship to reality as Newtonian physics or Ptolemaic astronomy. They are mostly true. Ptolemy had no trouble predicting eclipses. They work within a limited envelope. Outside this envelope, they are just wrong — and their advice can even be dangerous. There is no room here to reconcile them — just to present a plan which draws from all.
Issuing paper money is the 20th-century version of an old trick: debasing the coin (mixing base with precious metals). In the past, we see two kinds of regimes debasing their currency, for two different reasons: acutely by capable regimes (even Frederick the Great once diluted his money in a war), and chronically by incapable regimes (like most of the bad Roman emperors).
To an Asian neo-mercantilist, a government is a corporation; its balance of trade is its P/L. Financially, paper money is government stock. Just as the Fed can print as many dollars as it wants, Microsoft can print as many shares as it wants. These are worth more than a hundred dollars each! Free money! What’s the catch?
When Microsoft prints Microsoft shares, it’s the exact equivalent of confiscating a corresponding percentage of shares from all shareholders. It’s a tax — but easier to implement. And it is perfectly within Microsoft’s rights — very legal and very cool.
But Microsoft does not do this chronically. Only dying companies with mortal financial wounds try to fund themselves by continuously selling equity. A healthy company creates new shares for specific events — like mergers and acquisitions — in which the new shares are balanced by new assets.
Free money is financial fentanyl. It’s essential for surgery. It’s suicidal for recreation. It is both good and evil.
What happens to nations addicted to this fentanyl? No human endeavor can be free from discipline. The discipline of money forces any agent — person or company or government — to produce more than they consume.
When we relax this discipline chronically, everything goes slack and rots. Price inflation is the least of the problems. The real problem is that everything stops working — simply because it doesn’t have to work. MMT economists do not seem to understand this deadly power of the free lunch.
Yet the acute use of monetary dilution is as legitimate as any medical use of opiates. Undertaken in a controlled way, for a controlled and limited reason, debasement is a critical tool of sovereignty — for precisely these emergencies. Austrian economists do not seem to understand this at all.
One pathology of libertarian thinkers is their tendency to equate power with its abuses. We are coming out of a century of spectacularly bad and abusive government. The existence of child abuse is not a refutation of parenting.
Never in history has it been technically easier to control a communicable disease — even one without a vaccine or a cure.
Yet this technology does not work on its own. Here too we see a test not only of our government, but of our form of government. Nonmedical interventions have to work uniformly and perfectly. Our system of government is incapable of achieving this.
Here’s an analogy. Suppose you manage a wildlife reserve in Montana — stocked with ten thousand elk. Suddenly this herd is attacked by mad elk disease, for which there is no vaccine or cure. What can you do? Nothing.
So let’s change the rules. Every elk on your ranch is tagged. It has a number and a tracking chip. There is no vaccine or cure for mad elk disease — but there is a test. You also have a fleet of small, birdlike drones which can land on an elk, and test it — and big ones which can capture and transport live elk.
So your ranch has have four kinds of elk. Let’s label them by colors. You have naive elk (green); infected elk (red); possibly infected elk (yellow); and immune elk (gray). Any green elk that approaches a red or yellow elk becomes yellow.
You separate the red and green elk into two herds. You isolate yellow elk from all other colored elk until they resolve to either red or green. Gray elk can graze as they please. All you need is enough testing and transport drones, and stalls to isolate your yellow elk.
Elk are big and feisty. You can’t tell them anything. The physical barriers to testing and transportation of these large ungulates are considerable. Fortunately, we don’t care about elk — only humans, an intelligent, social and governable species.
China, Singapore, South Korea and Taiwan have used variants of this obvious design to contain the virus. Every adult in these countries is tagged and tracked by phone, and required to isolate if needed; kids just stay inside.
It is important to understand that lockdowns cannot end until the virus is either eradicated, or has passed through most people (creating herd immunity). An imperfect lockdown will reduce the death toll, but not eradicate the virus — or restart the economy.
While epidemiological models which portray humans as identical data points suggest that an infection ratio (R0) under 1 leads to exponential extinction, humans are not identical data points. Irregular and incomplete patterns of eradication — geographic or social — are not a path to zero.
In retrospect, population control should have begun as soon as the virus was discovered. Taiwan did this. In Taiwan, nominally a province of China, the virus has been little more than an inconvenience. Five people have died.
In America, at the start of February, there were probably only tens of cases in the country. A total lockdown was still necessary. The time a weak lockdown will take to get back to numbers this low might as well be infinite.
Our American values
Americans all have phones too. If they don’t, one costs $50. Why can’t we use this effective solution? Why haven’t we started full population control — with involuntary tracking, testing, and isolation — yesterday?
Because America is a democracy — or at least, has elections that its citizens still care about? Not so. The same is true of Taiwan and South Korea.
Here is the answer, without sugar. Americans are children. They are puerile, spoiled and arrogant. When they look in the mirror, all they see is a king or a queen. Can kings be managed? Like wildlife? A king is not an elk.
No king is he who bends the knee. To ask a king to wear a mask, so that a fountain of germs will not erupt from his mouth every time he breathes, coughs or sneezes — what an insult! A king’s breath is always sweet.
And if he can be ordered — he is no king at all. What king has another king to rule him? It’s nonsense. Any king would rather drown in his own pink juice. And he will. Who says there is no God? That pride goeth not before a fall?
I live in California. California is under “lockdown.” Leaving my house for “nonessential reasons” — including, but not limited to, scoring weed — is a misdemeanor, as serious as shoplifting.
But not to fear! Our governor, a custom suit with a snappy hairdo, reassures us that “social pressure” will “encourage people to do the right thing.” “I don’t believe the people of California need to be told through law enforcement.”
Indeed this order has succeeded in shutting down most businesses. Staying well away from anyone, I took a walk on the beach today. There were fewer people than usual — fifty, where I would have expected a hundred. Traffic, too, seems down. But this is a “nice area.” It is definitely true that California’s ruling class is civic-minded and responsible and likes to do the right thing, so long as that’s not too inconvenient.
But in general, this “lockdown” is to Wuhan — which was locked down at roughly the same point in its epidemic — as a tricycle to a Harley. Our suit-in-chief, perhaps extrapolating from his chic friends, seems to actually think California is a society. Like the rest of America but even more so, California is not a society. It is an economy.
Here and there across California and America are old, rotting pieces of our grandparents’ country. But Humpty Dumpty is done. We have no country; we have no society; we have no government.
We have a thing we call a government. It is big, officious, and expensive. When it needs money, it cannot be ignored. Some of its territory is controlled by informal armed groups, with about 300,000 members in California alone. They too cannot be ignored when they need money. Many pay both.
This official “government” does not even have a list of its residents. The United States does not even know, to within 8 figures, even the number of people within its borders.
South Korea has fought hard to control the virus. They have not quite won. But they started at their own 20. We are not even at the goal line. We are not even in the stadium. Of course South Korea has a list of who’s in the country. It even has full military control of its own territory!
All our pundits have ideas about what the government should do. My idea is: first, why not try having a government?
When we look at the responses to the virus around the world, they fall into four tiers. The first tier is Asia; the second tier is continental Europe; the third tier is the US and the UK; the fourth tier is the Third World.
The Continent has a Napoleonic tradition of government that goes well with emergency authority. In Italy you need a pass to be on the street. You really can get arrested. Wow! Is this freedom? Didn’t you think Italy was a free country? You were just wrong.
And still, a Chinese expert came to Milan and was horrified. People are still moving around; public transit is still running; not everyone is wearing a mask. “I don’t know what you’re thinking,” he said. He should check out San Francisco. Italy’s limp lockdown has not yet controlled the virus; at least it’s not a joke.
The one art Anglo-Americans must master to beat the virus is what Wyndham Lewis called “the art of being ruled.” We are as good as this art as a cat at painting — an average cat.
It is easy to read our history and see why. As Randolph Bourne said, war is the health of the state. All states are born in war. There are two kinds of wars: total wars of survival, and limited wars of choice. If your country is not seriously at risk of being subjugated, your war is a war of choice.
For America’s dominant New England core, the last total war was King Philip’s War, 350 years ago. That’s putting a lot of miles on the ol’ time machine.
A war of survival is a total war. Unless the population submits utterly to the government, unless the government can accept that submission and execute effectively enough to deserve it, that war will simply be lost — just as we are now losing World War V.
There are two ways to fight this virus: offense and defense.
Defense is about treating the people who show up at hospitals with ruined lungs. Offense is about finding infected people before they infect others and/or deteriorate.
Observing the different responses to the coronavirus, it seems clear that countries which play offense (like South Korea and Germany) have much lower death rates than those (like Italy and the US) which wait for walking corpses to show up at hospitals. This may be a statistical artifact; or early treatment may work better. But the best offense is still an effective vaccine.
Medical defense: drugs and equipment
The problems of effective defense are well-known. America needs ventilators; it needs protective equipment; it needs hospital beds; it needs antiviral drugs; it needs everything, and needs it now.
Two obstacles stand between us and these goals. One is just the technical implementation. The US has no shortage of engineers, chemists, contractors, or any other human skill. We are not even short of equipment. Our problem is just old pieces of paper — and the human beings who love them.
Consider one project to make N95 masks — not even a strictly medical product — domestically. The proper agency, a bunch of beautiful humans who call themselves “NIOSH,” told the team it would take 45 to 90 days to approve the factory — making the same product, with the same machines, that are already deployed. Meanwhile, ER docs are making their own masks out of bandanas. This is utterly mental and not even slightly surprising.
The law is clear. Everything is illegal unless it’s perfect. DC slow-rolled testing for two and a half months because it wasn’t sure the tests were perfect. It had to make its own perfect tests — which did not work, adding another month.
Imagine fighting World War II this way. It is unethical to send American boys to die in an unproven fighter plane. The new F-6 Hellcat cannot be deployed until it never crashes, no one can shoot it down, its engines never wear out, and it is tested against the F-4 Wildcat, the approved standard of war, in a randomized, controlled, double-blinded trial. If even the enemy pilots can tell the difference — your “evidence” is tainted — the study must be rejected.
The same applies to antivirals. Remdesivir probably works, and chloroquine might. A foolish person, ignorant of ethics, might think it would be okay to make as much as possible of both, right now, and let doctors make their own decisions as to what they think works.
Let the docs call the shots! This idea is illegal. It might even get you banned from Twitter. It reminds the ethical observer of Dr. Mengele, the Nazi — who also failed to seek proper FDA approval of his twisted “experiments.”
And synthesizing a molecule is even more complicated than making a mask. If the process is off, there might be contaminants. The dosage might be uneven. Everything has to be checked and checked and checked and checked and checked and checked and checked and checked. Dr. Mengele was not the only evil doctor in World War II — our good guys made penicillin without any such ethical safeguards. And they used it! On human subjects! Without any trials!
Everything is illegal unless it’s perfect. Since the perfect is the enemy of the good — ethics and the law are the enemies of the good. Relax! It may not be pleasant to drown of a cough. At least you’re dying legally — and your doctor is not a Nazi.
Medical offense: vaccination
Many observers assume that a really effective antiviral could get us back to normal life. No. As anyone who’s ever had the flu and asked for oseltamivir knows, a virus is not a bacterium and antivirals are not antibiotics.
Viruses work fast. A patient who shows up at the ER with ARDS is already hard to save. An antiviral helps to kill the virus — but it is no guarantee of survival. Not to mention intact lungs. Anyone for pulmonary fibrosis?
Even in a situation where remdesivir works and docs can get all of it they want, but the virus is still on the loose, fear is still quite rational.
And irrational fear is a thing, too. SARS-CoV-2 is the enemy of humanity — but fear is the enemy of the economy.
Which is not tanking because workers are dropping dead at their widget presses, and widget production has fallen off a cliff. It is tanking because people are afraid of SARS-CoV-2. And should be. Arguably they are still not afraid enough.
To cure fear without putting Xanax in the water supply, we either need a lockdown that really works, or a vaccine that really works. Or better yet — both. But as we’ve heard, vaccine development takes 12 to 18 months. It has to be proven safe.
Medicine is an art, not a science. Science is inductive, not deductive. The deductive concept of “proof” belongs to mathematics. In science it is a fallacy; in medicine, a fallacy squared. We have finally run head-on into this fallacy.
As a piece of marketing, this noble lie has long been helpful in persuading ignorant peasants to overcome their instinctive fear of being poisoned. So long as the p-value is under 0.05 (you have tortured a spreadsheet into confessing that there is less than a 5% chance of your results being pure luck), your result is proven — like the Pythagorean theorem, or something. This number, 0.05, is a fact of nature, like pi. In fact, it’s simply 3.1914 minus pi.
What are they doing for these 12 to 18 months, anyway? What does “development” even mean? Frankly, it is rude to ask. Your interlocutor may suspect that you too are one such peasant.
But such frankness, seldom found in journalistic interactions, tends to flower on social media. Here is a simple, true explanation I found on Hacker News:
As someone who works in the industry, you pretty much covered it. If you dose people with a new vaccine, you’ll need to monitor them 6 months at a minimum. 12 months would be better.
It takes 3 months to nail down the protocol and for all the sites to be ready. Then you start recruiting and for a vaccine, you’d want a large population (reflects usage). So assume 6 months to recruit 1000 people. They don’t all start at the same time, so if you’re tracking for 6 months, it will probably take 9 months for the last person to finish the trial.
Then you need to analyze all the data you collected, so another 3 months. Then the FDA takes 3 months to review and approve.
There is a TON of work that goes into running a clinical trial.
This would be funny if it wasn’t so stupid and evil. A “TON of work” — “6 months to recruit 1000 people” — to anyone who has ever gotten anything at all done, this is simply dark comedy. “12 to 18 months” is simply the result of taking this procedure as the word of God, but trying to do it twice as fast.
And yet, for a vaccine that would make life better but doesn’t rise to the level of a global emergency — perhaps for chickenpox, or papilloma, or even seasonal flu — this sedate, careful, and meticulous process may even be right and proper.
It is certainly right and proper for a civil servant whose career will be ruined by doing the wrong thing, but who cannot be held to account for doing nothing. It is certainly right and proper for a Hellenistic thaumaturge who may be strangled for harming his royal patient, but cannot be blamed for letting nature take its course.
Again, it is not just necessary to abandon the personnel and the processes that got us here — but also the principles. It is easy to see how the Hippocratic principle, 1500 years too old to be medieval, values the expected outcome of the doctor above the expected outcome of the patient. Physician, heal thyself!
We have our own century. We have our own problems. Suppose we abandoned the whole past — from 2400-year-old chestnuts of Hellenistic witchdoctor wisdom, to 75-year-old technocratic cathedrals of Potomac paperwork? Wow, is that even possible?
What would we do? What is the proper approach in our situation? What would be most likely to save the most lives? Note how different this results-based test is from the old principle — and how hard it would be to argue that we should not save the most lives, but instead… do the most science? Right. If this is science, science is a crime.
Making a candidate vaccine is easy. Modern molecular platforms (like those of Inovio and Moderna) produced vaccines in hours from the viral DNA. These vaccines probably work, and are probably safe. If I knew I was going to be exposed to the virus, and had no other protection, I would take one.
But this level of confidence can be considerably improved. It does take time to manufacture millions of doses. While this happens, a vaccine (this should happen in parallel for all plausible vaccines) can be tested in the most efficient trial form: the human challenge trial.
In a challenge trial, human subjects are vaccinated, then inoculated with the virus. We don’t even have to invent this: the top Google hit for “challenge trial” is this rant by a fringe group — based, like many cults, in Geneva — calling itself the “World Health Organization.”
These cowboys do acknowledge that a human challenge trial is crazy and may even be unethical. But they suggest that it may be appropriate in some cases — such as “emergency use of an investigational vaccine (e.g. in a pandemic).”
Take a vaccine that works on rhesus monkeys. Give it to a thousand humans, well distributed by age and sex and race. Spray coronavirus up their noses. See if they get sick. That’s a rough, effective human challenge trial. It could be done in a month. And if the subjects do get sick, we get to test antivirals in the best possible situation — as early as possible. (The ubiquitous Lipsitch, of Harvard, has a similar proposal.)
Who are these humans? Maybe they are altruistic volunteers. Maybe they are mercenaries, paid a million bucks each — cheap at the price. It is difficult to imagine much trouble recruiting either class. Ethicists, of course, will tell you that no one could give informed consent to this kind of dangerous Nazi-tier “experiment.” Surely the camps are just around the corner.
Go ahead and drown in your own pink juice — feeling very ethical. After all, isn’t ethics why our grandfathers invaded Germany? They were willing to die then. So we should be willing to die now. It isn’t easy to be a good person. Don’t try to pull the tube out — it won’t help.
We are at war. In a sane world, when you lose a battle, you switch generals. Sometimes you even switch armies.
Are some of the people you see at these press conferences okay? Well, some are better than others. What about Dr. Fauci? Calm, witty, wise, grandfatherly Dr. Fauci? A respected public-health leader since, get this, 1984?
On March 9, dear old Dr. Fauci said: “If you are a healthy young person, if you want to go on a cruise ship, go on a cruise ship.” In a sane world, this quote would be remembered as if he’d talked about “the blacks,” or addressed a journalist as “honey.”
In a sane world, anyone with a public record of minimizing the coronavirus would be cancelled — unfit for any further employment, let alone in this crisis. Old friends would edit their phonebooks and duck them in public, worried about being linked to a coronavirus minimizer.
If that’s going to far — benching the whole current team is not going too far. Their results speak for themselves. As Cromwell said: “you had sat too long here for any good you have been doing. Depart, I say, and let us have done with you. In the name of God, go!”
“A” is for aggression. Plan A chooses the most aggressive strategies it can copy or invent. It is as economically aggressive as Denmark; as socially aggressive as Korea; more scientifically aggressive than anyone. But the right strategy is wasted on the wrong generals. Who can run this thing?
Some suggest the military. Hopkins epidemiologist Tom Inglesby, perhaps having watched too many World War II movies, recommends centralizing the response under something called the “Defense Logistics Agency.” It really is remarkable when our best idea of an effective organization in 2020 is… the Pentagon. (If you want to see the Pentagon’s competence today, look at their ability to treat patients on a hospital ship.)
Why not put NASA in charge, because Apollo? The Department of Energy, because Los Alamos? Yes, the 1940s were awesome. But it’s 2020, and the fastest, most effective organizations America has today are called startups.
We call this world “tech.” This is a lie. Most startups are users, not creators, of technology. The same principles of scaling and execution apply to all problems. The secret of Palo Alto is not engineering, but management. Management is America’s problem right now — and America has the world’s best managers. But not in the Pentagon.
The right organization for a Coronavirus Authority starts with an experienced CEO who has taken a company from the garage to three commas. We are not starting from nothing — just from incompetent. Palo Alto has no idea how to reform incompetence. No one does. All we can do is replace it — starting, literally, with one person.
One common DC pathology is to take an effective leader from the private sector and put them in front of — not in charge of, since no one is in charge of anyone they can’t fire — the usual agencies. Such a frontman, in a cruel mockery of the Romanovs, is conventionally called a “czar.”
As a “czar” — a “coordinator of agencies,” in Dr. Fineberg’s terms — even the most capable private-sector CEO would be less effective than the usual bureaucrats. There is no manual for working the levers of Washington, only experience. We might as well ask a Tour de France winner to fly a 747, since transportation is transportation.
Our bicycle champion’s best move is to delegate to his experienced copilot. Why is he in the cockpit? People keep trying this; it keeps not working.
The CVA will not work unless it can hire and fire its own staff by its own rules — which means startup rules — which means no rules. Or as close as possible.
The current generals have to go. But the existing agencies — even including the Pentagon — are nowhere near universally and uniformly useless. Where they are useful, they must be used.
But if the CVA is to be useful at all, it needs unconditional and unlimited authority over all public and private actors. No one may resist it. Everyone must obey it. The White House must not micromanage it; Congress must not regulate it; even the Supreme Court must not overrule it.
Our founders were by no means perfect. Nor is their design. Nor were they fools or children. They had seen some sh*t. And when they granted Congress the right to suspend habeas corpus, it wasn’t for nothing.
But why is this safe? Because the CVA is limited and temporary, just like the emergency. While the emergency is happening, it doesn’t have time to care about anything else, like taking away your freedums.
Confiscating all the guns — enslaving all the poors — can we Americans, red or blue, white or black or yellow or mauve, just let go of all these stupid old nightmares? Can America, even for just a month or two while we fix this damn thing, abandon what Richard Hofstadter called “the paranoid style”?
But will it work? Is there any past precedent for something like the CVA? Sure. Just not in America.
We have a “Senate” because our founders were larpers. They were larping the Roman Republic — which, before the United States, was the most successful sovereign enterprise in history, lasting almost 500 years. It too saw some sh*t.
Yet there was one office of the Roman constitution that our founders didn’t clone: the tribune.
A tribune was a kind of temporary dictator. When danger threatened Rome — typically some war or other — she put all her powers under the command of one man, creating the most effective organization known now or then. When that danger was past — Rome went back to being a messy republic.
In the 500-year history of the Roman Republic, she appointed about a hundred tribunes. Some may have been unnecessary. Rome was so epic that she probably could have managed some of her wars by Senate debates. But… would Rome have had a 500-year history? The United States has only come half that far.
Have I made the sale? Just one little thing: I lied.
The Latin word for a temporary dictator isn’t tribune. The Latin word for a temporary dictator is… dictator. (The ancients would have called a 20th-century dictator-for-life a tyrant.)
Sorry. Are you going to let a word stop you? Come with us if you want to live.