Edit 1/29: Funding is back, baby!
Crossposted from my blog.
(This could end up being the most important thing I’ve ever written. Please like and restack it—if you have a big blog, please write about it).
A mother holds her sick baby to her chest. She knows he doesn’t have long to live. She hears him coughing—those body-wracking coughs—that expel mucus and phlegm, leaving him desperately gasping for air. He is just a few months old. And yet that’s how old he will be when he dies.
The aforementioned scene is likely to become increasingly common in the coming years. Fortunately, there is still hope.
Trump recently signed an executive order shutting off almost all foreign aid. Most terrifyingly, this included shutting off the PEPFAR program—the single most successful foreign aid program in my lifetime. PEPFAR provides treatment and prevention of HIV and AIDS—it has saved about 25 million people since its implementation in 2001, despite only taking less than 0.1% of the federal budget. Every single day that it is operative, PEPFAR supports:
> * More than 222,000 people on treatment in the program collecting ARVs to stay healthy;
> * More than 224,000 HIV tests, newly diagnosing 4,374 people with HIV – 10% of whom are pregnant women attending antenatal clinic visits;
> * Services for 17,695 orphans and vulnerable children impacted by HIV;
> * 7,163 cervical cancer screenings, newly diagnosing 363 women with cervical cancer or pre-cancerous lesions, and treating 324 women with positive cervical cancer results;
> * Care and support for 3,618 women experiencing gender-based violence, including 779 women who experienced sexual violence.
The most important thing PEPFAR does is provide life-saving anti-retroviral treatments to millions of victims of HIV. More than 20 million people living with HIV globally depend on daily anti-retrovirals, including over half a million children. These children, facing a deadly illness in desperately poor countries, are now going
A few minutes later, he said:
He also said wearing masks would be going overboard in response to a question if people should buy masks. He said he travelled internationally "yesterday" (which would have been February 9th if the video was uploaded the day of the lecture) and didn't wear a mask. He said he saw people wearing masks with their noses out or with masks around their neck (implying it wouldn't be effective to tell people to wear masks?) and also that it's uncomfortable to wear an N95 for too long, so he wouldn't recommend the general public to wear a mask unless sick (in which case "maybe" they should wear a surgical mask).
I think his prediction and advice should probably be judged negatively and reflect poorly on him / Center for Health Security, but I'm not sure how harshly he/ CHS should be judged.
Edit: Also, at 42:10 he said "I do think that it's not containable in any country, it just appears to be so now." I think this was also wrong, since clearly some countries have managed to avoid major outbreaks.
This seems totally okay to me, FWIW. In most places (e.g., London or the US), it would have seemed a bit overly cautious to wear masks before the end of February, no?
I generally agree with that, but it's worth noting that it was extremely common for Western epidemiologists to repeat the mantra "you cannot do what Asian countries are doing; there's no way to contain the virus."
It's actually worse than that. As I discovered when researching COVID giving opportunities for the FRAPPE donor group last year, Johns Hopkins experts explicitly recommended against wearing DIY masks in early March (a position reversed by the end of the month) and were not discouraging people from pressing ahead with travel plans as late as March 6. Sanjay had a phone call with them about a year ago in which he confronted them about these reversals, and they offered a sort of half-hearted defense.
I don't have any inside information about why CHS made the choices it did, but my naive view is that I agree with your comment that mistakes like these should reflect poorly on CHS. CHS's core competency may be more in the area of pandemic preparedness than dealing with the pandemic once it's already here, but their experts were quoted in the media a TON last spring and had significant ability (= responsibility) to shape the public conversation about COVID, particularly in the US. And yet lots and lots of people far less credentialed than CHS epidemiologists had correctly figured out by the first week of March that it was smart to wear a mask and to avoid being around others more than... (read more)
Fwiw, my vague memory is that some other people at CHS, including Tom Inglesby (the director) did better than Adalja. I think Inglesby's Twitter was generally pretty sensible though I don't have time to go back and check. I'd guess that, like most experts, he was too pessimistic about travel restrictions, though. Maybe masks, too?
I do think CHS should get some credit for arguing for taking pandemic response very seriously early on. For example, I think Tom had some tweets arguing for pulling out all the stops on manufacturing more PPE in January 2020.
Note - I'm a bit biased since I was working on biorisk at Open Phil the first time Open Phil funded CHS.
I think the key question for CHS, or even Amesh specifically, is whether they outperformed other organizations, and by how much - i.e. were investments in CHS positive contributions to response overall. And they / he could have done almost arbitrarily bad in February, and still overall have vastly outperformed the alternatives.
And I think that it's clear that CHS's work was impactful in increasing preparedness in the US, even if the level of preparedness was far short of what was needed.
(Note that I have personal biases about this, and know many of the people at CHS.)
To be fair, the Johns Hopkins Center isn't just Adalja. I'm not aware of the list of things they do, but for instance, they kept an updated database in the early stage of the virus outbreak that was extremely helpful for forecasting!
If you're referring to what I think you are, it was a different group at Hopkins
Adalja also confidently predicted the infection fatality rate for the rest of 2020 to be around 0.6% (on the Sam Harris podcast) despite thinking the virus can't be contained (if true, this would have led to more ICU beds and oxygen shortages in lots of places). In reality, the IFR was more like 0.9% or higher for countries like the US and UK. Probably it was lower for countries with younger demographics, but I don't even think Adelja was basing his estimates on that.
(TBC, this isn't as big a mistake compared to other statements or compared to Ioannidis who completely disgraced himself throughout 2020 and ongoing, but I find it worth pointing out because I remember distinctly that, at the time when Adalja said this, there was a lot of fairly strong evidence for higher IFRs, including published estimates. I thought 0.6% seemed [edit]hard to defend, though I don't remember how much he flagged that there's a substantial chance it's significantly higher. Importantly, it would have been higher than it actually turned out to be, if Adalja had been right about "the virus can't be contained.")
It's still unclear, and the developing world detection and survival rates are a bit uncertain. I think you could probably get a decent approximation by looking at test positivity rates and testing volume compared to death rates over time in different countries, but I'm not going to put together the model to do it.
We're doing something related with IFR estimates by age at 1DaySooner, but using seroprevalence data, i.e. only where there is really good data for the estimate. I don't have results of that yet.