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Monday, March 27, 2023

Larry Brilliant on How Well We Are Fighting Covid-19

It seems like a century ago that I first interviewed Larry Brilliant about the novel coronavirus. But it’s been just a little over three months since I spoke to then-75-year-old Brilliant, an epidemiologist who aided in the eradication of smallpox, and who for years has been warning the world of a pandemic that looks very much like the one we have now. (One of the tools in sounding the alarm was the movie Contagion, for which Brilliant was an adviser.) In that interview, he was able to provide clarity, gravity, and even a measure of hope to our unique and terrifying circumstances. The response was tremendous; it was the second-most-read story in the history of WIRED.

Larry Brilliant talking

The Doctor Who Helped Defeat Smallpox Explains What's Coming

By Steven Levy

Brilliant’s vita includes roles with the World Health Organization, Google, and the Grateful Dead, but his life’s work has been anticipating and dealing with pandemics. (He is currently CEO of Pandefense Advisory, a team of experts assisting in responses to the coronavirus.) So it was vital that I return for a second conversation, to update what is both the biggest story of our time and the most baffling.

Brilliant reminded me that since our first conversation, he turned 76, an age, he notes, that provides unattractive odds should SARS-Cov-2, the virus that causes Covid-19, invade his cells. He wears masks, of course, and seldom ventures outside his Marin County, California, home. It was there that I reached him by phone to speak about the tragic course of the pandemic, what we’ve learned and haven’t learned, and how we still might be able to one day—eventually—recapture normality. I also learned about a possible curse of those who provided the science for Contagion. The interview has been edited for clarity and length.

WIRED: We talked 100 days ago. What is different about the pandemic now?

Larry Brilliant: A hundred days ago we didn’t really understand the pathophysiology—the way the virus and the human body interact, the illness as opposed to the epidemic. The unexpected things that it’s doing are not epidemiological—they are virological. In March, we were just beginning to see these horrific CT scans or x-rays of people with ARDS, acute respiratory distress syndrome, where they had these big circles of holes in their lungs, and we were thinking this is pretty much a respiratory disease. Since then we have learned that this virus attacks almost every organ in the body. The joke is that it’s from nose to toes, because you lose your sense of smell and you can get "Covid toes," the swelling of your toes and your fingers that look like frostbite. There is still a lack of clarity on how it chooses entry points in the cells.

It seems like the longer it goes, the less we know about it. Every week something new comes up that contradicts what we thought we already knew.

No, no—you know a lot more about it now than you did three months ago. Yes, there are absolutely more questions today than there were 100 days ago. But part of that is because we’re getting more sophisticated in our ability to ask questions. Three months ago, we had only had a couple hundred cases of this novel virus. We have now got over 11 million cases, and a half a million deaths globally. The virus has been speeding along at an exponential speed, but so has science. So now we can begin to understand that this virus attacks the circulatory system, it attacks the vascular and nervous systems, it attacks the respiratory system, it attacks our ability to bring in oxygen. That’s why people can go to the hospital and be on their phone, not in any respiratory distress, but have oxygen saturation in the 50s, which in the old days we’d think of as you’re near death. It also makes you understand why you can get these Covid toes, why you can lose your sense of taste or smell, why you can have a stroke. This virus attacks blood vessels, it creates blood clots. That is probably one of the reasons why it causes strokes. We have a very large number of deaths due to kidney failure, and we are having terrible results from the ventilators that we were so obsessed about early on, though lately it’s looking a little better, because we’ve learned more about how to use them for this disease. We have learned a tremendous amount about this virus, about how it infects people, how it kills, how it spreads, but the big surprise to me is the kind of pan-organ nature of its attack. It gives the lie to anybody who thought that a comparison with influenza was in the ballpark.

You paint quite a picture.

This is a big fucking deal. If I would not be excommunicated from the world of science, I would call this an evil virus, but I can’t do that because I can’t impugn motives to it. But if I could, I would call it that. It’s certainly pernicious. This is the worst pandemic in our lifetime. And it is the first time we have had a pandemic in the United States in which we have had such a total, abysmal failure of our federal government.

Yet you say we’ve made progress. How much better are my odds of survival than they were three months ago?

Number one, you’re better off because you’re three months closer to a treatment or a prevention. Number two, the treatments are getting better, so the outcomes in hospitals are getting better. We already have convalescent plasma [with antibodies from recovered Covid-19 patients] that’s doing an amazing job. And number three, depending on where you live, by flattening the curve, it is far less likely that you would have died in a corridor in a hospital because there was no room in an ICU, or there was no oxygen to give you. But I think now almost 100 percent of all the ICU beds in Phoenix are full.

So it’s not a second wave, but still the first one.

If you look at the case number graph from Arizona or Florida, you will see a vertical line for an epidemic graph. And it is because of the cavalier way in which those states dealt with this pandemic.

So all that work we did to flatten the curve was squandered?

It was absolutely not used as effectively as it should have been. To this day we do not have a federal pandemic plan.

You have experience dealing with populations suspicious of medicine. When we do get a vaccine, how much resistance do you anticipate?

When you get a vaccine, you get a vaccine campaign. We have around 160 vaccines today in various stages of trial or hypothesis or funding, with maybe a dozen candidates emerging. Several are from China. China is looking at its ability to rapidly produce a vaccine as a demonstration of modernity, scientific acumen, and a little bit of redemption, because they were the place at which Covid emerged. When one or two or three of those vaccines are declared workable and we have made sufficient quantities, you don’t get rainbows and unicorns. What you will most likely get is a food fight. If you were in the middle of a goddamned pandemic and you saw the first stirrings of possibility of a vaccine, you would hold a global meeting, bring all the countries and organizations together, and decide on a plan to divvy it up, I would hope, for equitable distribution. Others might hope for strategic distribution. Where will you put the vaccine so that it will stop the whole pandemic quicker? Some would lobby for an America-first, or a China-first, policy of the use of the vaccine. Others would argue, hey, whatever country makes it gets it first. But whatever, there would be that conversation among all the funders and the distributors, everybody in. You would expect that to happen, wouldn’t you?

You would hope.

It has happened, absent one player: the United States of America. We are not in these meetings.

Because we pulled out of the World Health Organization?

We haven’t pulled out of the World Health Organization. [laughs] It’s not even clear how you pull out of the World Health Organization. Distancing ourselves is probably a better word. It just makes us look like clowns. WHO is stronger than ever. The rest of the world has rallied to its side. The Trump Administration was not in the meetings where WHO was raising $8 to $12 billion just to help plan for the vaccination program. America’s money has been replaced by other countries donating it. And with it will come the inevitable soft power that comes with funding.

How influential is it that for months the president has resisted wearing a mask?

It’s incredibly influential. It is the reason why people can go to Palm Beach and accuse those who are wearing masks of stealing your God-given right to breathe oxygen. It’s the conspiracy theory that masks are impregnated with some secret virus that’s going to make you impotent. Most important, he gives license and cover to the governors in Georgia, Florida, Texas, and Arizona. They have been given permission and encouragement from Trump to say things like “It’s going to disappear in April, the virus is going to disappear when it’s hot.” Excuse me? We are now in the middle of the summer and this puppy is exploding.

[Note: Days after this interview, Texas governor Greg Abbott reversed course and issued a statewide mask order. Also on July 1, President Trump said “I’m all for masks,” though he did not wear one publicly.]

OK, we know to wear a mask. But should we still be swabbing everything with Clorox?

The virus does not exist very long in fomites. I mean you’re talking about a very small percentage of cases that are caused by the pencil, the toilet seat—asterisks on toilet seats, because if you don’t have a cover on the toilet seat, and somebody who’s got Covid takes a poop, you create an aerosol so that can spread. But if you look at the things that we worried about, like the Amazon box that comes to the door, the fact that the virus can do that doesn’t mean it does do that. I don’t scrub my groceries at all. If an Amazon box comes, I open it right away. I’m mostly worried about face-to-face transmission by somebody you have had a conversation with, or you’re stuck in an elevator with, or you’re seated next to somebody at a rock show or at a bar. I don’t go do any of those things. I don’t go to lectures, I don’t go out.

I hear that.

Yes. Two of my friends who worked on Contagion got Covid. Ian Lipkin, who, along with me, was one of the senior scientists on the movie, was in China investigating Covid in January, and then he came back to the US under quarantine. He did not get infected in China, but he got really, really sick in New York City. He is a month and a half recovered from it. And Scott Z. Burns, who was the screenwriter for Contagion, just got out of the hospital yesterday in LA.

So is there a curse of Contagion?

That’s what I said to both of them. I hope the pharaoh’s curse ends with two.

Speaking of ending the curse, how do we get out of this mess?

We can still get to that inverted V, but we have to do three different things. First, we have to develop a way to deal with the clusters—nursing homes, refugee settlements, immigrant workers, homeless encampments. We should look to Japan, which had similar problems, and they created a team which called the Cluster Busters. In an act of humility, we should be inviting the Japanese epidemiologists to come and teach us their techniques for being Cluster Busters.

The second thing that we should be doing is basic epidemiology 101. We should be finding every active case. You find someone who has symptoms of the disease, and a human being talks to them and identifies all the people they’ve been in contact with, looking backwards to try to find where the disease came from, what was their source of the disease. Those who test positive, you either treat them or you quarantine them for 14 days. Those who test negative, you isolate them for 14 days. You do whatever the hell you need to do, because you’ve got to stop the virus from walking into a bar. It’s not a joke. You’ve got to stop the virus from walking into a super-spreader event.

Some people say you can do that in a culture like South Korea or Japan, but that’s not how Americans behave.

We have to do this in a particularly American way—we have to pay them money! I am a cosigner of a bipartisan bit of prospective legislation. Our proposal is $50 billion out of a $2 trillion set of stimulus packages—$50 billion that will pay people who are contact-traced and who test positive or are suspected of having the disease. Pay them $50 a day for 14 days to quarantine, so they don’t spread the disease. We want to pay for their hotel lodgings. And we want to hire 150,000 contact tracers and pay for the software that does contact tracing.

Maybe we should have done that months ago. Isn’t it too late for that?

It's less effective, obviously, when you have 3 million cases and 130,000 deaths in the US than when you had 15. But it’s never too late to stop a virus from spreading.

What’s the third thing?

A sensible, nationwide requirement for those places where there are clearly going to be super-spreader events to stay closed: bars, indoor restaurants, churches, megachurches, the kinds of places that we know will spread the disease. Those places can’t be reopened.

Many people left the house for the first time to join in the Black Lives Matter protests. Did that concern you?

Of course, it concerns me. But the vast majority have been wearing masks, and we are not seeing the bumpettes that I would expect. Look, the numbers are pretty clear. What is fueling this explosion are the states that opened before Memorial Day, and it’s going to be the Fourth of July, and then it’s going to be Labor Day, and then it’s going to be the election. These are beads on a necklace of explosive disease.

Does it shake your faith in the United States that we failed so much?

It certainly shakes my faith in the Trump administration. We have 130,000 deaths. There is a really good possibility that the number will double before the election. And then what is Trump going to say? There could have been 2.5 million? The pandemic is not over yet. We have half a million deaths worldwide. I can’t imagine there’s not going to be over 2 million deaths worldwide.

Is there anything more optimistic we can leave with?

You can be really optimistic that science is moving at a pace unknown before. Just as the virus is growing exponentially, science is growing exponentially. MIT has recorded over 20,000 scientific papers that are on the virus. We have taken a page out of Silicon Valley, and we are exchanging money for speed. And we are doing things now in parallel instead of in sequence.

We are simultaneously testing the safety and the efficacy and the efficiency of vaccine candidates. You may begrudge the fact that it’s not days or months, but you have to be optimistic about creating a novel vaccine in the length of time that Tony Fauci is talking about, 12 to 18 months. I think that period of time was prescient when he said it. I think it is still true from the date that he said it. So 12 months from now, which is within the 12 to 18 months, I think we will have quantities of a vaccine.

In our first interview, you talked about the virus as an equal opportunity infector that could teach us about our shared human condition. But it seems that Covid-19 isn’t an equal opportunity infector—minorities have suffered more.

I don’t agree with that. It is an equal opportunity infector. It is not an equal opportunity killer. If you are old, you are going to have a reduced immune system. If you’re poor and you’re somebody who has hypertension and diabetes and is more obese, which is the African American community, you are in more danger. Or if you are living in a jail where you can’t social distance. I mean San Quentin has over a thousand cases right now.

In our last interview you were a little more inspiring.

I said I was hopeful that what will happen is what happened after the Second World War. We had peered over the brink of the abyss and decided that each of us would give up a little bit of our sovereignty in order to create the United Nations. That is happening today. But it’s happening without the United States of America.

Updated 7-9-2020 at 7:38 PM EST: This story was updated to correct Scott Z. Burns' middle initial.

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