There is a secret shame hovering over us all… I am referring, of course, to the conspicuous absence, in 2015, of flying cars. - David Graeber
The Great Stagnation Ends
Before the pandemic, it was commonplace for Western intellectuals to remark on the slow pace of general progress since the 1970s.
The post-war era up until then had delivered an embarrassment of riches to most of the Western world. You’ve probably heard that real wages grew steadily after the war before stagnating in the last fifty years, but the stagnation goes beyond economics. Just start listing the events of the decades following World War II and you’ll get a clear sense of why we call them the “Thirty Glorious Years”: television, commercial air travel, the civil rights movement, effective birth control, a massive expansion of highway infrastructure, and The Beatles all fostered a sense of a rich, dynamic society. More vividly, when I imagine 1945, I picture it in black-and-white, but 1975 is always in colour.
It was in contrast to this social miracle that the subsequent fifty years were labelled “The Great Stagnation.” In 2019, half a century after the swingin’ sixties, wages had flatlined, inequality had returned to nineteenth century levels, and the entire film industry was monopolized by an eighty year old cartoon mouse. On the other hand, we had the internet, the gay rights movement, and hip hop, but even they savoured somewhat of anti-climax. The internet had come to look like just another idiot box, the gay rights movement succeeded only after the mass suffering of the AIDS crisis, and hip hop never became the consciousness raising instrument of revolution that one might have expected from listening to Gil Scott Heron in 1971.
Ireland’s story is different, but only because we were still so far behind everyone else in the 1970s. The twenty years either side of the millennium may have been transformative, but by 2019 we were facing the same long-standing crises in health, housing, higher education, energy, and migration as everywhere else in the Western world. It was as if humanity had lost its sense of imagination.
The slowdown did not go unnoticed. By the end of the last decade, any economic commentator worth their salt had to have some explanation for the emergence of this new “secular stagnation”. Some even blamed this new malaise for the rise of populist politicians; the people knew that something had to give.
On the surface, the coronavirus pandemic looks like it could be just the shock we needed to jolt us out of our complacency. The unfathomable scale of the response to COVID-19 is worth putting numbers on. Last April, the International Labour Organisation estimated that 81% of the world’s workforce lived in countries undergoing full or partial lockdowns. At that same time, UNESCO estimated that there were 1.4 billion students out of education. These purely negative measures were complemented with radical proactive policies. In Ireland, the government took over the nation’s private hospitals, and other countries launched intensive R&D efforts to develop new vaccines. In the process, governments and central banks took on debt and released liquidity at rates unprecedented in economic history. It’s a testament to both the scale of the shock and the alacrity of the response that there was a global financial crisis last March and no one outside the world of finance remembers it.
But even in these disruptive times, governments around the world have been committing sins of omission. Public health officials dithered, regulatory systems failed to adapt, and world leaders failed to recognise just how high a priority immediate vaccination should have been. These failures are, to a unique extent, failures of the imagination. Coronavirus has no lobby group, and there is no politician who can pander to his base with promises of further contagion. Any government which has failed to contain the virus has done so despite its best intentions. Thus, this pandemic gives us a unique opportunity to understand the dynamics of the last fifty years. When will complacency feel like the only option? When does the unthinkable come to feel inevitable? What can we do to control any of this?
Three pandemic failures in particular are worth considering.
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Lockdowns: Too Late, Too Brief
Hindsight is 20/20, but the case for zero COVID is obvious in light of January’s case spike. There was little appetite for a Christmas lockdown, but if cases had been kept at their summer levels during autumn, we could have pushed down to zero in November and not have worried about exponential growth over Christmas. Instead, we allowed cases to rise for sixteen days after NPHET recommended a Level 5 Lockdown on the 4th of October, making it impossible to bring cases to zero before Christmas. Then, when Christmas did come, we took our foot off the pedal too much too fast, allowing ourselves to be blindsided by the new British variant.
In spite of all that, this might be the weakest example of complacency during the pandemic. At least lockdown hesitancy implies an eagerness to do more things rather than less. If we are trying to measure social dynamism, it seems inappropriate to give lower marks to Ireland than to those American cities where schools have been kept shut despite repeated expert advice that it’s safe to open them up. The other two examples of pandemic complacency are more straightforwardly neglectful.
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Human Challenge Trials: Risks Averted, Risks Accepted
Cast your memory back to last April, when Contagion became the most watched film on Earth.There’s a scene in that movie where a scientist self-administers her own untested vaccine to prove its efficacy, thus eliminating the need for a long vaccine trial process. The big plot hole there is that we saw earlier in the movie that some people are naturally immune, so she hadn’t actually proven anything.
But what if you did it properly, and got thousands of people to volunteer as guinea pigs, rather than just one? It would basically just be the normal vaccine development process, except you wouldn’t be delayed by the preliminary trials on animals. That way, you would have your vaccine ready months earlier and save countless lives as a result. Remember how the AstraZeneca vaccine was designed in one weekend in January? Imagine if they didn’t have to wait until the end of April to begin human trials.
This idea surfaced early on in the pandemic, but was dismissed out of hand in health policy circles. Anthony Fauci described HCTs as “not essential or ethically justified” on the grounds that, at the time, no effective medical treatment existed for COVID-19, so some of the test subjects might get very sick if the vaccine didn’t work. This reflected the general consensus within the medical community. Michael Rosenblatt, M.D. writes in STATNews,
“...human challenge studies with live virus are unlikely to save time. Moreover, there are ethical and practical reasons for not undertaking human challenge studies with this virus. [Advocates of human challenge studies] are well intentioned but wrong.”
Rosenblatt’s “unlikely to save time” comment refers to the fact that by the time he wrote the piece, the development process for some vaccines was already quite advanced. He also goes on to argue that since human challenge trials would have to be targeted at young people, they would not be effective at identifying winning vaccine candidates.
But these arguments don’t stand up to scrutiny. For one thing, at the time that Fauci made his comments, we were already letting people get infected with the Coronavirus for experimental purposes. Normal phase three trials involve vaccinating tens of thousands of people and then seeing if case rates are lower in the treatment group than in the population at large. Without high levels of transmission in the population there would be nothing to compare the treatment group to. So rather than letting people consent to infecting and isolating themselves to test a vaccine, we have let the disease spread throughout society for months and made the population at large into our guinea pigs, all in the name of ethics.
Rosenblatt’s failure, meanwhile, is not thinking boldly enough. If the proposed human challenge trials are too little and too late to make a difference, then we should have done them sooner and made them bigger. Members of at-risk groups who volunteered to test the vaccines would have made the world safer for those who share their co-morbidities and would also have received a potentially life-saving vaccine months before it became generally available. This approach would not have been risk-free, but it would have been unambiguously safer than the path of complacency we took instead.
In a further twist, HCTs have been allowed to commence as of last January, now that we have effective treatments for COVID-19. It’s too late for these experiments to bring us the first vaccines any sooner, but they still stand a chance of helping us understand the exact nature of the interactions between existing vaccines and the virus. It remains to be seen whether this embrace of pragmatic ambition will set a precedent for the future of our war on contagion.
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Stretching Vaccine Supply: A Failure of Experimentation
Before getting into the weeds on vaccine supply, it’s worth taking a moment to appreciate just how effective the vaccines are.
The Pfizer/BioNTech and Moderna vaccines are each approximately 95% effective at preventing COVID-19 symptoms. For AstraZeneca, it depends on your dosing regime, but if you give one half dose and then follow it up with a full dose one month later, the efficacy is 90%. All three of those regimens involve two shots, but the Johnson and Johnson vaccine is 66% effective after one shot, which is also pretty decent if you’re aiming for herd immunity.
But these headline numbers obscure the most important statistics of all: hospitalizations and deaths. Phase III trials of all four of the aforementioned vaccines found that no one who completed their full regimen of vaccinations died from coronavirus. Let me re-state that for emphasis. All four of the major coronavirus vaccines were found to be 100% effective at preventing coronavirus deaths.
We need to be doing much more to get these into people’s arms as soon as possible.
The most obvious failure on this front has been that spending on manufacturing and research has simply been too low. Rather than go into detail on this, I’ll just refer you to the first blog in this series and stress again the negligence of relying on the Bills Gates of the world to fund vaccine production in India.
But there are two much simpler measures which we have also been neglecting to implement. The first is dose spacing or “First Doses First.” As early as New Year’s Eve, the UK Joint Committee on Vaccination noted that both of the major vaccines which had thus far been approved reduced hospitalizations by over 85%, even after only one dose. Accordingly, they recommended including a space of twelve weeks between each dose of the vaccine in order to facilitate speedy distribution vaccine to as much of the at-risk population as possible. Ireland has followed the UK’s lead on the AstraZeneca vaccine, but the Pfizer/BioNTech vaccine, which constitutes 83% of our supply, is still being distributed two at a time.
One other way to stretch supply is to engage in “fractional dosing”, whereby half doses of the vaccine are given to each recipient. Studies show that smaller doses of the Pfizer/BioNTech and Moderna vaccine are enough to do the job. Given that halving the dose of any given vaccine would effectively be equivalent to doubling its supply, the ethically responsible thing to do here is experiment. Dose sizes are set where they are right now because that’s what was shown to work in trials, but there’s plenty of precedent for experimentation in other vaccine rollouts. Partial doses of a yellow fever vaccine were used effectively during a Yellow Fever outbreak in Brazil in 2018. As further evidence emerges about the frontiers of possibility, we should adjust our ambitions accordingly. That’s what science is all about!
Admittedly, implementing dose spacing and fractional dosing and human challenge trials at the same time would push us into uncharted territories and expose us to a certain amount of risk. But with the European vaccine rollout being what it is, almost any measure which boosts vaccine supply during these crucial early months would be worthwhile.
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The Limiting Factor
In all of the above examples, the common denominator has been a failure to take calculated risks. It’s not that there aren’t risks to experimentation, there always are. But the devil you know is still a devil. Even if you really believe that every bit of caution we have taken during the pandemic has been warranted, consider that the countries which now look most cautious were themselves seen to have been acting recklessly when they set the tone for the global response. If COVID-19 had turned out to be a big nothing, the Chinese government would have ended up with egg on their face after implementing their lockdowns in early 2020. Notably, Chinese society subsequently opened up right as the rest of the world was locking down, sparing them from making any of the risk calculations faced by Western governments over the last year.
Risk is unavoidable. The only question is whether we have the imagination to face up to those risks when the time comes.
The pandemic has been a revealing test of that imagination, illuminating our capacity for proactive adaptation, but also the limits of that capacity. Why did our imaginations expand so far in March? Why did they stop expanding after that? Perhaps the answer is an emotional one. The pandemic has obviously been a brutal experience for many, but I don’t think we’ve ever returned to the levels of shock and disorientation we were experiencing last March and April. Given that this was also the time of our most radical policy shifts, perhaps the lesson is that social failure will be tolerable to us so long as it’s predictable.
But that brings us back to the most persistent theme in these pandemic blogs – international variation. Few countries have had a perfect response to the coronavirus, but, like Tolstoy’s unhappy families, they’ve all been imperfect in their own way. The UK has done a poor job of containing the virus, but is leading the way on vaccine innovation. Japan is only now beginning to vaccinate its population, but it has also been a shining example of effective containment efforts. If there really was such a tight relationship between crisis and policy change, we wouldn’t have seen such a variety of responses in the months since last year’s shock.
It seems entirely possible, then, that ideas simply matter on their own terms. There is no set of circumstances which will reliably guide our hand towards the ideal set of policy outcomes - we have only ourselves to rely on. Time is running out for our ideas to make a difference to how this crisis plays out, but when the storm passes and the wreckage is cleared, we will have a chance to look again at the problems we faced in calmer times. Whether it’s to be another Thirty Glorious Years, or another half century of the Great Stagnation remains to be seen. It may be that the prospects for change in the aftermath of the storm look worse than they did when we were still in its eye. But whatever kind of world we find ourselves in, we can at least begin to imagine a better one.
FURTHER READING:
The Complacent Class: The Self-Defeating Quest for the American Dream – short 2017 book by Tyler Cowen – Argues against the notion that we live in an age of disruption and dynamism. The author has since acknowledged that things have changed somewhat.
What are we Waiting for? - Washington post essay by Alex Tabarrok – How to amend regulations to speed up vaccine supply.
Enough is Enough: How to Build a New Republic – book by Fintan O’Toole - written during the last recession about how to fix Ireland’s political system and address our social problems. The first book I would recommend to anyone interested in getting involved in Irish politics.
References
David Graeber quote from the beginning of chapter two of The Utopia of Rules: On Technology, Stupidity, and the Secret Joys of Bureaucracy
Other Western Intellectuals who have commented on the slowdown include Thomas Piketty in Capital and the Twenty-First Century, and Tyler Cowen in The Complacent Class
“...81% of the world’s labour force...”
“...1.4 billion students out of education...”
“...The government took over the nation’s private hospitals...”
“...intensive R&D efforts to develop new vaccines.”
“...there was a global financial crisis last march”
History of COVID-19 in Ireland
Vox Explainer on Human Challenge Trials
“Not essential or ethically justified”
Explanation of vaccine development process
Headline info about each vaccine
AstraZeneca 90% effective depending on dosing
UK Joint Committee on Vaccination
Ireland is dose spacing AstraZeneca but not Pfizer/BioNTech
Pfizer/BioNTech is 83% of our supply
All sources for the fractional dosing paragraph are taken from that Tabarrok piece