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- [00:00]
A
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B
So most things have not gone very far, but they do illustrate that infections happen. Transmission can happen, as it did with sars, with one of the SARS releases by mistake in the mid 2000s. So it is a real risk.
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A
And now the good fight with Jasia Monk. Around the world, there have been, and to some extent still are, a lot of labs that engage in gain of function research. What that means is that they take a pathogen and they try to find other ways in which it could be more dangerous. Now, the purpose of this is to make sure that we are prepared for all kinds of possibilities that we can prevent terrible pandemics in the future. But there's also an obvious risk. What if one of these pathogens leaks from the lab? What if somebody working in those labs learns how to do them and replicates it for nefarious purposes of their own? There's all kinds of things that could go wrong. Arguably, that is what did go wrong at the beginning of a COVID pandemic. So should we ban gain of function research? Well, today I invited onto my podcast somebody who has argued that we should at the very least be much, much more cautious about gain of function research than we are. And he is a very senior figure in the field of public health. Mark Lipsich has taught at Harvard for a long time, just joined the Stanford faculty, where he's going to have any number of appointments from the School of Medicine to the Freeman Spogli Institute for International Studies, where our friend Fukuyama is also a faculty member. In the rest of this conversation, we talked about a whole bunch of other issues. We revisited the 2020 pandemic and looked into where there were failures in the public health community. We talked about how the Trump administration is trying to redress some general structural problems and why it is that what the Trump administration is doing is only going to make the problem much, much worse. Finally, in the part of this conversation which is reserved for paying subscribers, we talk about the reasons why the public health community so often is bad at communicating to the public. The reason Marx suggests maybe that they treat citizens a little bit like children that they are so afraid of admitting uncertainty, so afraid that people might take the wrong upshot from what they say, that they oversimplify, that they overstate the level of their confidence. And we also talked about whether the blind application of a precautionary principle is a real problem for public health. Why is it, for example, that during COVID we were so reluctant to do human challenge trials, which might have put a few people at risk in a way that they agreed to and could potentially have saved lots and lots of people through the faster development of vaccines? Should we make sure that the instinctive SMORC conservatism of the public health community doesn't get to determine the the kinds of ways in which we develop vaccines or roll out new experimental medical treatments? Could you potentially save a lot of lives in that way? To listen to that part of the conversation to support this podcast, please become a paying subscriber, go to writingdotiamonk.com I would be very grateful. Mark Lipsich welcome to a podcast.
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B
Thank you for having me.
- [04:16]
A
So there's many topics I'm excited to talk to you about, and we'll talk a little bit more broadly about the landscape of public health in the United States at the moment, which is interesting. But I asked you to be on the podcast because I've been trying to think through a subject that I find fascinating but don't have much expertise on, which is gain of function research. To start off with, what is gain of function research?
- [04:40]
B
Gain of function is a general term that means biological experiment that gives an organism a new function, a new ability to do something by a genetic change. Usually the type of gain of function research that has been controversial and raised concerns by many people, including me, is what's sometimes called enhancement of pandemic pathogens or dangerous gain of function or risky gain of function, or there are various other names. It's the small category but particularly concerning category in which the function that an organism gains is the ability to spread more easily or cause more disease in organisms we care about people or our crops or other organisms that we care about specifically. The most notorious example of it was when researchers took a strain of influenza flu virus that had been causing sporadic disease in people and was killing a large fraction of those that it was infecting and achieved the ability of that virus through genetic and evolutionary manipulations to transmit readily in the air. The specific experiments took strain of influenza or flu virus that had been causing sporadic disease in people, so called bird flu or H5N1 flu, and gave it the ability to transmit readily in the air, which is how flu pandemics transmit, how pandemic flu transmits. The reason why that's concerning is that if you, if you do that to a strain of flu, there's a risk that it actually becomes capable of causing a pandemic in people. A new outbreak. We've all experienced a pandemic recently of coronavirus and a flu pandemic would be equally, if not more, damaging. The idea of these studies is that the investigators are trying to understand what makes it possible for a virus to like flu to become pandemic.
- [07:00]
A
Yeah, so I was going to ask about that. Right. I mean, at first it seems like a crazy thing to do, right? Like you're taking a virus that's somewhat dangerous and you're deliberately making it more dangerous by making it more easily, more easy for it to be transmitted, or by making its properties worse. You know, that sounds like a kind of Bond villain, kind of crazy scientist thing to do. But the purported logic is that understanding these viruses, better, understanding what kind of pathogens we might face, might allow us to prepare better for pandemics, to prepare vaccines. Talk me in detail through what it is that scientists are hoping to achieve with this research, which in their mind is very well intentioned, right?
- [07:41]
B
Yes, I think that's right. I think that the goal of the research as described by the investigators is exactly as you say, to find ways to characterize viruses and say, this one is dangerous, this one might cause a pandemic that we might find in nature. This virus that we might find in nature is capable of causing a pandemic. This one probably isn't. If we do dry runs in the lab, then we are able to make a list essentially of the characteristics or the genetic properties of, of a virus that allows it to do that. So the critique from those of us who are skeptical of that is really both about the risks and about the benefits or the purported benefits. On the risk side, as you say, there's lots of reason to be worried about the possibility that a strain of virus could create it that way, could infect one of the lab workers and, and eventually transmit beyond the lab that it could be stolen and used for deliberate mischief to start transmission in people, or that it could enable people to figure out how to make a bad virus themselves. So it's sort of the information, the security and the safety that are all of concern in terms of the purported benefits. One of the arguments that I and others have made is that you learn potentially what's true about that strain of Flu. If you learn how you can take the strain of flu that they took and make it transmissible. But there's lots of reason to believe and even experimental evidence to show that if you do, if you do the same thing to a different strain of flu, you might not get the same result. You might even get opposite results that it becomes less transmissible or less able to cause widespread harm. So the generalizability of the information is very, very limited. And so that's been at the heart of the debate.
- [10:02]
A
I want to bring out one assumption that you have here, which I share, which is that the way to think about this seems to be as a trade off. Right? So there's potentially information that we can get out of doing this research, which is scientifically interesting in itself, but more importantly which could be helpful to us in trying to prevent a pandemic or trying to treat a pandemic. So there's a kind of side on the ledger of why we should be doing this for social benefit in the first place. And then there's the side of all of the risks, right? The risk that somebody gets infected and the virus we've created actually ends up infecting a lot of people. The risk that somebody might steal it. The risk that the kind of scientific knowledge we gain in the process of doing this research could get to somebody who's trying to create a virus for purposes of bioterrorism or something else. So let's go through each side of this in a little bit more detail. One sort of question is about how much benefit it really has. Right. And so you've started to talk about how this virus understanding sort of the particular ways in which the behavior of virus might change, might generalize, but you're kind of skeptical about whether it generalizes. What about the other perpetrate benefits that people claim for this? What is the strongest case that defenders of this practice would make for why we absolutely need to be engaging in this work in order to gain scientifically valuable research that might actually prevent bad pandemics in the future.
- [11:34]
B
I think that's it. I mean, that is the case. The case is if we can do it in the lab, then we understand what nature will do. Nature is trying lots of things out there with mutations happening and viruses spreading in animals and things. And if we can somehow predict what will happen, then we can prevent it.
- [11:55]
A
Walk me through the rest of the steps in this argument. Right. Because I'm not a scientist, I kind of can't evaluate whether or not it is accurate that doing experiments on one kind of virus tells us a lot about different kinds of viruses. It sounds like you're quite skeptical of that. Perhaps you can explain to layman why that is the case, but I so far find it hard to judge that. But I feel like there's a lot of other steps in that process that you also need to assume, which is if we figure out that the most dangerous potential viruses have X or Y shape, then our whole machinery of pandemic prevention is going to be able to take precautionary steps to prepare us for that kind of pandemic. Right. That they're going to be able to pre produce the relevant vaccines, or they're going to be able to plan for certain kinds of social interventions that would stop the spread of this kind of vaccine. And the part of it where I'm quite skeptical is that part. When you look at the experience of COVID there was certainly a pandemic that, roughly speaking, was in line with what we might have expected. Some of the specific characteristics of COVID were different from earlier coronaviruses, but we'd gone through H1N1 and other kinds of viruses that behaved in roughly similar shape. So it's not like we were totally surprised by the characteristics of this virus. But all of that prior knowledge doesn't seem to have helped us all that much in actually responding to that pandemic in a very rational way. So one of my forms of skepticism, and I wonder what you think about that, just comes from, even if we do know roughly, the most dangerous kind of pandemics are going to be roughly of this short form and roughly of this shape, and perhaps we have some degree of knowledge about that that we wouldn't have without gain of function research, is that realistically going to put us in a position to prevent that pandemic or to lessen its impact in a way that goes way beyond what we might have been able to do without that specific knowledge.
- [13:56]
B
Yeah, I largely agree with your skepticism and would push back on one piece of it, which I'll say at the end, I completely agree. And actually, recently with undergraduate student from Harvard, where I was working until this year, we published a paper looking at the claim that finding viruses in nature is an important way to create vaccines as countermeasures. What we found was that over and over again, viruses have been found in nature and little has been done about it. And then when there is a large scale human outbreak, usually in rich people in the west, especially in rich people in the west, and occasionally in other settings, then vaccine development begins in Earnest or when there's concern about it as a bioterrorist agent, then vaccine development begins in earnest. And, and simply finding it in nature, even with signs that it could be very dangerous, has not been enough to prompt significant development of countermeasures.
- [15:00]
A
So, so we can find in the lab, hey, you know, gain of function. Research has shown this kind of pathogen could be super dangerous. You know, that could be a huge problem for the world. You know, let's develop a vaccine. But actually that is unlikely to happen. And so the perpetrat benefits from, from the scientific practice aren't going to arrive.
- [15:21]
B
How are, Let me just make a distinction. So what we studied was when people find new viruses in wild animals rather than in the lab. So it's a, it's a slightly different point, but the broader point is that we are pretty good at mobilizing resources when there are significant numbers of especially developed world people at risk. And we are not very good at mobilizing resources historically otherwise.
- [15:50]
A
Now, part of this, right, is that vaccine development is an incredibly expensive, complicated and under usual circumstances, slow process. And so we can only develop vaccines about a relatively limited number of diseases. Now my understanding is that there's new technologies coming online, perhaps most importantly the RNA vaccines, but also other kinds of approaches that have a potential if a regulatory environment is reformed in the right ways to speed up vaccine developments hugely. Which way does that cut in this debate? You could say, on the one hand, if we are becoming much more skilled, much faster at developing vaccines, that then we need to know less about potential pathogens because what we should do is simply to wait for them to emerge and to have actual human outbreaks. And rather than having to have this five year head start to have a chance of responding to it with a vaccine, we can very quickly produce those vaccines. And what we should be investing in is just the capacities to adapt and roll out vaccines at scale when that happens. Now on the other hand, perhaps if vaccine developments become much easier, it is becoming more feasible to pre produce these defensive vaccines against a whole number of imaginary pathogens that haven't quite emerged yet, at least in real world outbreaks yet. And so perhaps sort of having that knowledge about what kind of pathogens could be more dangerous is now becoming more valuable in the past because we're going to be able to do more about it. So which way do you think does our progress in rapidly producing and adapting vaccines cut in this debate?
- [17:27]
B
One of the other things that we found in our study of existing vaccines and virus prospecting in nature was that there are numerous whole viral families, large groups of viruses that infect and cause widespread disease in humans for which we have no vaccines, no existing vaccines. It's not really at this point on the broad scale, if we go beyond pandemics and look more at just anything that infects humans and spreads, there are numerous viruses for which we have and groups of viruses for which we have no vaccines. So there's a whole menu of things that we could be doing to develop vaccines with the knowledge we have. That is not to say there's no point in getting new knowledge. To me, the question is, is the new knowledge? Is the best way to get that new knowledge by doing very risky experiments that tell us something narrow about a particular group of viruses, or are there alternative approaches to studying these viruses that will tell us something about which viruses to be concerned about, but are not, but does not involve creating viruses that are themselves dangerous?
- [18:46]
A
So just to understand this point, the claim by the people who defend gain of function research is we need to be able to understand all the potential kinds of pathogens there might be in order to develop vaccines against them and so on. What you're saying is we know there's a ton of existing pathogens which potentially could cause pandemics, and we haven't even developed vaccines against them. So how about we start by developing vaccines against these known dangers before engaging in a really risky practice to discover other kinds of candidates of pathogens for which, in a speculative manner, we could pre develop these vaccines.
- [19:21]
B
That's right. And even beyond that, there are many ways to study which viruses are potentially dangerous without creating new ones, without creating whole new viruses. So, for example, if you want to understand what makes a flu virus dangerous, we understand many of the components of that. We know what the major determinants of being able to transmit in people are in a flu virus. We can study individual proteins of the flu virus and ask how they work, how well different proteins work, and then look for those proteins, those variants of those proteins in viruses that we see. It is not the same experiment. It's not exactly the same result. But if you think about getting some large proportion of the information with none of the risk, it's a pretty good trade off. So one of the important points in thinking about which research to do in my mind is don't think of it as should we do experiment X or not do experiment X? Because there are hundreds of thousands of experiments that get lost on the cutting room floor every hour in science, every scientist is deciding, I'm going to spend My money and time on this project, not that one, or on this approach to the project, not that one. Most experiments that you could do that would be interesting never get done. It's just a question of where you allocate your resources. And if you think about allocating the resources that would otherwise be used for our gain of function experiment to the next most useful experiment that would give you similar information or similar ability to develop countermeasures, which is two different things. Because you can develop countermeasures with different kinds of information, then it becomes very hard to say, well, it's really worth marginal benefit. The extra benefit you get from this gain of function study is really enough to make it worth doing, putting the world at risk, in my view. And not everyone agrees with that view, obviously.
- [21:39]
A
So I think we've given a pretty fair hearing to some of the potential benefits from gain of function research. And I myself at least am convinced that those benefits are much smaller than some of the defenders of the practice claim. Talk us in a little bit more detail through some of the risks of this kind of research. The claim that defenders would make presumably is that this tends to happen in labs with high levels of security and that therefore, even though the pathogens they create may be dangerous, the risk of them getting out into the world are quite low. To start first of all with that claim, how confident can we be that these pathogens really would remain contained in safe research environments?
- [22:24]
B
Yeah, I think that it is true that many of the studies done in the west, at least, have been done in very carefully designed, highly skilled labs. There is a lot of global variability in, in laboratory standards of safety. And that's putting aside the whole issue of malicious use, but just the safety aspects. Much of the controversy that followed the discussion of Wuhan and the origin of the COVID virus highlighted whatever you think of that controversy, it highlighted the fact that there is that there have been at least much lower levels of containment for the same experiments in China than would be expected in the United States. And that in particular viruses where you really don't know the pandemic potential are not very well regulated. I think the idea that these gain of function studies, which tend to show up in the most prestigious journals because they're flashy, that phenomenon makes it more attractive for people around the world to do these studies to promote their own careers and to. And to get into the good journals, which is what scientists try to do, all scientists try to do, and, and that's appropriate, but. But we really don't want an incentive in which the more dangerous your experiment, the. The more prestigious the publication. And I think the amount of biology we learned from those gain of function studies which appeared in Science and Nature, the top journals in the scientific field, the amount of knowledge gained was comparable to many other papers that appear in much less prestigious places. But I would argue that it appeared in those places because it was so shocking what had been done.
- [24:26]
A
Just give us a little bit of a historical understanding of lab leaks. We can come back to the question about the origins of COVID and the research undertaken taken in Wuhan, but my understanding is that there's actually a long history of significant accidental lab leaks. I think in the 1970s, you had H1N1 escaping probably a lab in the Soviet Union. You had an outbreak of smallpox in the United Kingdom. And then more recently, you had escapes of satisfaction SARS in a number of labs across East Asia in I believe, Singapore and Taiwan and Beijing and other places. And you had some incidents at the CDC in the United States with serious biosafety failures involving anthrax and other kind of pathogens. I mean, historically, have we been really, really good at avoiding these kind of lab leaks, or is there a pattern that lab leaks repeatedly happen not just in one country, not just in one culture, not just in one political system, but some of those examples are just reeled off span from the United States to the Soviet Union, from North America to East Asia and so on.
- [25:42]
B
Yeah, well, you've made the list of the prominent ones. And there have been some bacterial pathogens. There has been a bacterial pathogen leak in China in more recent years. There's been one of the foot and mouth epidemics in animals in the UK resulted from a lab leak from their highest security lab. So humans are imperfect. And almost all of these leaks are not that some physical system failed, some of them are, but. But most very often the issue is that a person fails to inactivate a vial of pathogen but thinks they have or switches the inactivated vial for the, for the still alive vial. I mean, it's just human error, and that's the hardest kind of thing to prevent. And so the skill of the lab is of course important, but the record is, as you say, and underreporting is acknowledged by even the people who run these labs that the incentives to report if there is an incident or an accident is very low. And the Netherlands, for example, has published a paper assessing the risk of underreporting and saying it's quite high. So fortunately, putting aside Covid and the controversy over that, fortunately, most of These have not gone very far. The 1977 release of H1N1 flu being the other, the most clear exception. So most things have not gone very far, but they do illustrate that infections happen. Transmission can happen, as it did with sars, with one of the SARS releases by mistake in the mid 2000s. So it is a real risk. And because the consequences are so high, I think we're just not good at thinking about that risk. Biosafety is really a field about protect that's mostly dedicated to protecting individual lab workers and the people immediately in the area. And biosafety on the sort of population scale is a new phenomenon as we. A relatively new phenomenon as we deal with more dangerous pathogens.
- [28:12]
A
Yeah, that's very interesting. I mean, even from a philosophical perspective, that seems to make a difference. Obviously, we want to protect all scientists who work in labs and make sure that they don't get sickened and are exposed to serious danger. But at the limit, you can say that they agree to work in an environment with highly infectious pathogens. And even though we should obviously do what we can to protect them, they understand there's some kind of risk involved with that. They can make a decision for themselves. But here we're talking not about exposing individuals to risk who have knowingly taken on a job in which there might be some outside risk of a negative outcome. We're talking about thousands or tens or hundreds of thousands, perhaps millions of people dying as a downstream consequence of choices that they didn't make and that they didn't have a say in. Which I know about.
- [28:58]
B
Possibly. Yeah.
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A
Yeah. Which seems very different. So you fully convinced me. I find that when you look at trade offs, that's one of the hard things to do. It's one of the things that political scientists and commentators often fail to do. They sort of look at, look, here's a bad thing. Why aren't we doing anything about it? Well, because there's something on the other side of the scale and you have to actually compare them. When I look at this trade off, it seems to me that the potential dangers are very serious and very clear. The potential benefits are minor and questionable. And so we probably should be discouraging or perhaps banning this practice. Why is it that this practice is continuing despite how stark this trade off is? Why is it that there haven't, so far as I understand, been serious efforts to discourage or ban gain of function research?
- [29:49]
B
I don't think that's a fair characterization. Toward the end of the Biden administration, there was a large effort led by the National Science Advisory Board on Biosecurity, or the nsabb, and then became an executive order from the Biden administration in May of 2024 that laid out a framework for very careful review of this kind of research. It was comprehensive and very much applauded by people like me and, and colleagues who thought that it was a. It was a major step forward and it was not perfect. I think one of the major issues is that it's very hard for the federal government to regulate work that it does not fund. It's not impossible and it should be done, but it's much easier to regulate or to put the guardrails around work that the federal government is itself funding. But it was a very good policy. And then under the Trump administration, actually some of the same people were involved in developing an executive order that came out in May of 2025 that if it had come from an administration, Democratic or Republican, other than this one, I would have been 95% given a grade of 95% or so. It put quite strong restrictions on what it calls dangerous gain of function. It attempted to extend some of that rule that regulation beyond federally funded work did a lot of good things. And the reason that I put the asterisk about which administration it was is that even at the time, it was clear that regulation and discussions of research funding were much more complicated and much more destructive in many ways in this administration. And indeed, when the actual implementation happened of that executive order, a number of studies were stopped that were being funded by the federal government that had no reasonable risk. I mean, no reasonable person would say this is at risk of causing a pandemic. Some of them were types of studies that have been done for decades and really for various reasons, just were not what all of us have been concerned about. And then there were some that were stopped that might raise concerns. But I think there is actually, at the moment, it would be very hard to get funding to do dangerous gain of function research. But I think that the pendulum has swung in the direction of now collateral damage to other kinds of research that have no plausible risk, but that the Washington Post reported the administration just wanted more things banned because they hadn't banned enough. So let's ban some more or stop funding some more.
- [33:12]
A
And. And there's obviously a much broader attack on research funding from. From the administration that I'm also worried about, that we've covered before on the podcast. But give me a sense of the kind of risk that we're currently running for gain of function research worldwide. So you're saying that it's become much harder to get research for that in the United States. Is there still some dangerous gain of function research going on in naps in the United States? Has there been an international understanding to scale back this kind of research or is this ongoing in labs in, in China and Russia and perhaps Europe and other parts of the world? You know, to what extent have we actually, you know, been able to build a consensus that we should abstain from the most dangerous forms of this research?
- [33:57]
B
It's really hard to say what's going on because there's no central tracking and because the definitions are different in different places. I don't really have a good answer on that. I would say there is that the weight of. Well, there was a very good article by Tony Mills at the American Enterprise Institute about a year or so ago, maybe two years ago, called how the virologists lost the gain of function debate, which pointed, which made the point that the sort of leave us alone and let us do our science attitude that some virologists were taking was really self defeating and really not sustainable, particularly after people had experienced a pandemic in their own lives and seen what it really meant. So I think there, there is some significant shift of opinion and, and more attention going to the concerns about it in this country. I don't know really if that can, if the same can be said worldwide. China has a new, new ish biosecurity law that, that may represent some move in that direction, but I think, I think there are a lot of things on people's mind and this is probably not at the top, at the top of most people's list. So I think the sentiment is shifting to some degree towards seeing gain of function, dangerous gain of function as a, as a problem and something not to be done. But I don't think we've quite reached the point of everyone agreeing to that.
- [35:52]
A
It's amazing how complicated it still is to shop for things online. You find the product you want, you add it to your shopping cart and then it just takes putting in all of your credit card info, all of your shipping info, all of your billing address, and by that time you've half given up. That's why I'm always really elated when I see the purple button by Shopify at the top of the payment options because it just makes everything easier. You don't need to get your wallet out and look for that credit card and put in all of your address information. You can simply complete your checkout with a tap of one button. It's truly one of the best features in the chaotic world of online shopping. Shopify is the commerce platform behind millions of businesses around the world and 10% of all E commerce in the United States, from household names like Allbirds and Momofuku to brands Just getting started. Get started with your own design studio. With hundreds of ready to use templates, Shopify helps you build a beautiful online store that matches your own brand's style. Sealer's Cards Go Go Abandoned and more sales go with Shopify and the Shop Pay button. Sign up for your $1 per month trial today at shopify.com Good Fight Go to shopify.com Good Fight that's shopify.com Good Fight. So one of the elephants in this podcast, or in the room, whatever precise formulation of a metaphor you want to choose is about COVID early on in the pandemic, there was a pretty concerted attempt by public health officials and parts of the scientific community to rule out the hypothesis that this could have been caused by an accidental lab leak, which would likely be related to gain of function research going on in particular in the Wuhan Lab of Virology. Later, it seemed as though the consensus was shifting towards thinking that it had indeed been a lab leak. There was a number of assessments, for example, by American intelligence agencies and European intelligence agencies that strongly suggested that this was the most likely cause of a pandemic. My understanding is that perhaps some of the consensus shifted back again a little bit. There are some people who are now more skeptical of likelihood that this is a lab leak than they were a few years ago. What is your assessment of how likely it is that the most consequential pandemic in 100 years did stem from an accidental lab leak? And how should people who are not scientists think through this question?
- [38:39]
B
I think the best way to understand this discussion is that there is no definitive evidence either way, and therefore people who have strong prior beliefs, that's all they have, really. Because the evidence is so flimsy in both directions or so lacking in both directions, there is some circumstantial evidence in each direction. And so I am totally happy to have a honest discussion with somebody who thinks it's 99% either way. It's the hundred percent, which is a lot of a lot of the lab people think it's 100% roughly split between lab and zoonotic or animal origin. And that I think is just an implausible view of the evidence. The evidence is not compelling. I think people can interpret tea Leaves essentially, in whatever way their priors allow them to do. And that's totally fine. But I think anybody who's certain is just dismissing all the flaws in their evidence.
- [39:52]
A
That's a fascinating way of putting it. Let's take each side one by one. What is the strongest argument for believing that it's of zoonotic origin? That this is, you know, whether there was a bat in a cave somewhere that was brought to the Wuhan wet market or some other kind of transmission mechanism that this just in a natural way jumped from an animal host to humans.
- [40:16]
B
I really don't want to go into. Into this whole detail, if you don't mind. I think it's a. It's just a long. And I won't characterize either side very well because I think they're both. They're both a little overblown. Like, I just don't think the evidence is very strong either way.
- [40:36]
A
Yeah, I see that, but just how. I mean, I am just trying to figure out how to think about this. And I've talked to people who have strong conventions on one side or the other. I myself am very confused about what to think. So I guess I'm just asking, is there some way in which you can help? You know, how should somebody who's interested in that question? I think it's an important question. It's a relevant question. Right. Like, how should my listeners think about it? What's an intelligent way to think about this?
- [41:01]
B
Well, the way I think about it is that the evidence for a. For a zoonotic or animal origin is primarily the genetic evidence. I mean, I. I'm sorry, I really just don't. I'm going to get. I'm going to mischaracterize the people that I disagree with and probably also the people that I agree with. Wait, so who do you agree with more with? The lab origin side, but it's all circumstantial. Okay, yeah, I'm sorry.
- [41:34]
A
I understand. No, no, that's fine.
- [41:36]
B
I'm not up to having that conversation.
- [41:39]
A
That's fine. Happy to broaden the conversation about other things. I mean, to ask a broader question, I find myself also unsure about what to think about public health in the United States this juncture. Going back to the pandemic, it does seem to me that there was obviously a failure of public health. There's important things that public health did during the pandemic to keep the situation manageable. But on the whole, the Centers for Disease Control were built in order to prevent pandemics. And in order to coordinate a rational response to pandemics. They had an enormous budget that they spent on doing this. And in the first major pandemic in 100 years, there was all kinds of misfunction, from the difficulty of developing a reliable diagnostic test for Covid early in the pandemic, to the fact that they wouldn't allow private labs for a crucial period to step into the breach, to often conflicting guidance about masks, which changed very rapidly from one moment to the next and then changed back to any number of other things. So it seems to me, again, as an outside observer. But there's good reasons to think something seems to have gone wrong here, and there's probably serious need of reform on the other side. You look at the way in which the Trump administration is trying to blow up public health, in which it is changing guidance around vaccines for diseases like measles in ways that have already led to serious outbreaks of this highly infectious disease, the way in which they seem to mistrust all of science. That seems to me to be sometimes perhaps aiming at the right problems, but doing it in a way that is only likely to make those problems much, much worse. How should somebody like me, who sees the failings of some of our institutions, who takes the criticisms of them seriously, but who doesn't want to throw the baby out of the bathwater, approach this debate? What kind of reform do these institutions need, and why is it that the reforms that are currently being opposed to them by the Trump administration are, as I imagine you agree, by and large, going in the wrong direction?
- [44:02]
B
Yeah, I mean, I think as a first cut, I would say there are significant problems with how we did public health in the pandemic, and almost everything that's been done by the Trump administration would make it worse. The next time I heard someone say that the biggest threat to our biosecurity right now is undermining trust in vaccines, which most Americans very strongly approve of. And if you wanted to make it easier for an adversary to cause trouble in our country with biology, one of the best ways to do it is to undermine trust in the most beneficial public health innovation of the 20th century, which is vaccines. So, yes, there are problems, but shooting, not even randomly shooting holes in the best parts of public health is really a catastrophic way to address those problems. So, in my darker moments, my sense is that this is all simply shrink government down to the point where we can drown it in the bathtub, as Grover Norquist once said, and that it has nothing to do with reforming public health. It has to do with shrinking government and making it untrusted. I don't think that's the motivation of everybody involved. And I think there are some things that need to be done. And I think it is the diagnosis that we made major mistakes in the pandemic is correct. I would also point out that many of those early mistakes were under the first Trump administration and were partly due to trying to deny that this was going to be a problem when all the experts were saying very loudly, this is going to be a problem and we need to prepare. And we spent months, people talk about the value of early warning. We had warning in December of 2019 that this could be a problem. And certainly by January it was a three alarm fire. And we didn't really get into gear nationally fast enough because there was too much denial going on.
- [46:28]
A
I don't want to litigate the details of this, but it seems to me that the story of who is taking it seriously when was a little bit more complicated in the sense that I think there was a period in January and February where there was a kind of portion of a Republican Party that was taking it quite seriously. I forget it was Tom Cotton or some other senator who was really warning about it. And Nancy Pelosi was giving press conferences in Chinatown in San Francisco saying, anybody who's concerned about this is basically just racist against, you know, Chinese people and, you know, should continue to go out to restaurants and so on. That was in part a response to some genuine craziness where Asian Americans were being discriminated against and so on in a, in a, in a totally abhorrent way. But in my memory of it, the kind of partisan politics of this was like a little unclear in January and February of 2020, and those big parts of the Democratic Party who are really downplaying it. And then it was around March and April, that very dangerous dynamic and very bad dynamic where Trump kind of wanted to keep the economy going and downplay the dangerousness of the virus and Democrats became kind of more in favor of social distancing measures and closing things down really got set into place.
- [47:43]
B
Yeah, I don't remember all the details of what everyone said. There was a current of anti Asian racism at that time. And I attended an event in Boston's Chinatown in January or February that made some of the same points. But I think saying that this is not an occasion to express racism is a different claim from this is not an occasion that we need to be taking seriously as a threat to public health. And I think some of us were able to make that distinction. And if certain politicians couldn't, that's a, that's a failing on their part.
- [48:20]
A
And in general, we would all profit from politicians who are better able to make those kind of obvious distinctions which somehow don't seem to be.
- [48:27]
B
But I think the CDC is an institution that can benefit from reform. I was working there from 2021 until 2025 part time and saw a lot of great things and also saw that. I think the ability to explain ambiguity to the public is something that used to be there. I Remember from the 2009 flu pandemic there was really excellent examples of it from some of the top officials. I think that's been lost to some degree. I think there's a sense that being ambiguous is too hard and that you should just overstate certainty more often than is appropriate. So I think on the communication side, there's a lot to be done. I think that the same kind of conservatism is part of why the labs didn't get going and allow other labs to do some of the work to test for a while. It's a understandable impulse in public health, but not a good one to try to discourage people from drawing their own conclusions. So I think there's lots that could change at the cdc. But again, undermining vaccination, which is really the one thing that really doesn't need to change except to get even more widely used, is a sign of bad faith and really destructive impulses rather than reconstructing impulses.
- [50:17]
A
Yeah, and we obviously strongly agreed about that. The point about communication you're making is really interesting though. I never had the impression that there was bad faith involved in any of these failings. I certainly don't think that at any point important public health officials were either lying or were misleading the public, certainly out of commercial interest or because they're in the pocket of Pfizer or anything like that. I did often feel that they treated the public like children, that they thought, you know, for the good of a country we need to induce certain behaviors like staying at home or like not trying to buy up over masks that might otherwise be used by medical personnel when, you know, personal protective equipment. Eczema is unpredictable, but you can flare less with epglis, a once monthly treatment for moderate to severe eczema. After an initial 4 month or longer dosing phase, about 4 inches, 10 people taking MGLIS achieved itch relief and clear
- [51:23]
B
or almost clear skin at 16 weeks. And most of those people maintain skin
- [51:26]
A
that's still more clear at one year
- [51:28]
B
with monthly dosing Emplus Lebricizumab LBKZ a 250mg 2ml injection is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema, also called atopic dermatitis, that is not well controlled with prescription therapies used on the skin or topicals or who cannot use topical therapies. EBGLIS can be used with or without topical corticosteroids. Don't use if you're allergic to ebglis. Allergic reactions can occur that can be severe. Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with ebglis. Before starting Ebglis, tell your doctor if you have a parasitic infection.
- [52:03]
A
Ask your doctor about ebgliss and visit ebgliss.lilly.com or call 1-800-lilyrx or 1-800-545-5979. It was incredibly scarce in the early stages of the pandemic. And let's spike the football a little bit. Let's communicate in such a way that the outcomes that are going to be better for everybody are more likely to come about. But neither sort of reckoning with the fact that people can smell bullshit and that actually that is not necessarily likely to induce the behavior they were hoping it would induce. No reckoning with the second order effects of this, that if people feel misled about one thing, they're going to be much less likely to listen to you on the next thing. And so you're eroding TR over time. No reckoning with the ways in which you want to induce behavior that goes beyond the immediate response to this piece of information. One of the things in the debate about masks and the guidance early on that masks were not useful, that I think public health officials didn't think through was other disciplines of social science, like economics, like the fact that the earlier the market would get the signal that there's going to be a large and ongoing demand for masks, the faster factories producing other kinds of things could retrofit in order to produce more masks. And I just don't think that that is the sort of thing that sitting in Atlanta, somebody at the CDC would be thinking about. So is that a fair account of some of those communication failures? And how can these institutions do better than that? How can they warn citizens about real dangers, exhort them to engage in the behaviors that on the best judgment is most likely to save the largest number of lives, but do so in a way that actually takes citizens seriously as reasoning adults who can make decisions for themselves.
- [54:00]
B
Yeah, I mean, I think you're exactly right and I, I agree fully that this was not about corruption, financial corruption or something like that. I would add to the list of concerns about it that it's just fundamentally undemocratic to lie to the citizenry or anti democratic. And that's a problem too. So I've thought a lot about this and one thing I think is that we actually need more research on how to, how to effectively communicate in public health. I don't think that it's been. If there is good research, it's not being used because we see the failures. And my guess is that there is much more to be done. My hypothesis for such research would be that in any moment of time you are in an environment that you've set with your previous actions. So if you have been communicating with the population under normal circumstances in a way that is, that suggests that you always know exactly what's going on, that you're not going to revise your views, that science is all settled and so forth, then people will be really surprised when you say I don't know. But in fact, on many scientific topics and public health topics, there is uncertainty. Very few things that change as fast as a pandemic, to be fair, but there is uncertainty about what the best diet is. There is uncertainty about what the timing of flu is gonna be this year. There is uncertainty about a whole bunch of topics in public health. And I mean people deal with uncertainty in their lives all the time and don't think that the person who tells them that there's uncertainty as an idiot or is doing their job badly. Even if your doctor tells you this has a risk of helping you and a risk of not helping you. People can deal with that. I think. I don't like to use the word conditioning, but conditioning people to expect that public health, like all human endeavors, is one that has some science and it has some uncertainty and that especially in fast moving times, there's going to be changing guidance. And that's not because anyone was lying. It's because the best understanding changes and there's going to be disagreement. All of that I think is something that people could get used to, but it would be very hard to get used to in the moment of a crisis because people don't react well to, to crises. So I think it's a long term project.
- [56:50]
A
Yeah, I have two Thoughts about this. The first is that the slogan that most galled me during the pandemic was believe the science, because I do believe the science and I put great trust in science. But precisely the difference between science and systems of blind faith is that in science no point of view is sacrosanct and that you do have genuine debate about most propositions. And that when somebody comes in and says, I have a paper that challenges a long held assumption in the field, the right way to respond to this is neither to dismiss it nor to blindly believe it, but to probe how strong the evidence is that the paper is bringing to bear and then come to a conclusion about where we should revise our views. And so often the slogan believe the science was invoked precisely in a way that was actually against the spirit, spirit of falsifiability and rational inquiry, which is the reason why we should believe provisionally when there's a scientific consensus in the first place. The second thing just comes from my teaching practice. I imagine that there's many insecure teachers who hate to be asked challenging questions by students because they feel embarrassed or they fear loss of authority if they can't answer a question. I love it when a student asks me a question to which I don't have the answer. Because when I can genuinely say, authentically say, I don't know the answer to that question, do you want to look it up? Or I'll look it up and I'll come back next week and I'll tell you I can feel how the trust and everything else I say goes up because I've just signaled when I give you an answer, it's because I'm pretty sure I know the answer. And when you ask me something which I don't know the answer, I'm going to tell you. And that actually increases the trust that people have in a professor, in my classroom at least.
- [58:34]
B
Yeah. Some of the smartest journalists about infectious disease have the same thing. Helen Branswell, who's perhaps the smartest one that I know well and writes about infectious disease, said once that I don't trust anyone who never says I don't know. Yes, and so I think that's exactly right. I mean, going back to the believe the science part, I think the phrase that I heard more often was follow the science. And I think that's even more, even more problematic in the sense that science tells you what is, not what you should do, and there are consequences for what you should do of what is. But the science doesn't say, you should stay home the Science says if you don't stay home and other people don't stay home, then there might be a lot of bad consequences for disease spread. So my wife and I and a colleague wrote an article in the New England Journal. My wife's an educational ethicist and the colleagues and infectious disease pediatrician and I'm an epidemiologist. We wrote an article in the New England Journal in July of 2020 calling for schools to primary schools to be reopened. That was based on science. It was based on an emerging and imperfect understanding that children were not major transmitters. And it was based on the view that education is an important good that is not worth sacrificing on that scale to some benefit for reducing disease transmission, particularly given the other choices we were making at the time. But people could debate that. I mean, in fact, people did. Most people, most schools did not reopen in the fall of 2020, or many schools didn't. And, and it's not that the science says you must do that. The science says here are the consequences as best we understand them. And those were, those were changing.
- [60:39]
A
Yeah, I mean, I went through, through, through a version of this. You know, I think we probably had a somewhat similar set of public positions during pandemic. I wrote a viral article early in the pandemic encouraging the cancellation of a lot of large scale events at that point. This is, I think March 6, 2020, that article was published. We were still having mass concerts and mass political rallies and all those kinds of things. The debate wasn't yet whether there should be government restrictions on movement. It was just about whether we should be canceling a lot of these privately held events. And I got a very angry email from an old, you know, friendly, from an old friend who's also kind of a boss of mine for a little while, saying, you're not an epidemiologist. Why are you writing about this? Stay out of it. Right. And my answer to that was, well, I'm a political theorist and I'm basing the factual assertions I'm making on the best statements by people with expertise in virology and so on. I'm certainly not pretending that I understand something about the properties of this virus that they don't understand. But the question of what consequence to draw from that is an ethical question and it's a political question. And as a citizen I should be able to speak to that. And by the way, as somebody trained in reflecting about normative issues, I actually, insofar as that's relevant, which I think is very limited I have some professional expertise in staying that later on. I was among earlier people to say, now that a lot of people are vaccinated, and now that we know more about the properties of, of this virus, we should start reopening a bunch of social institutions. And so the people who like me the first time, dislike me the second time around. But that is one of the hazards of writing. I do have a question about that set of ethical attitudes. I mean, one of the interesting things about the field of public health is that there's a lot of ethical reflection in it and it often comes from one particular kind of disciplinary angle. And so a lot of attention, for example, is given to a precautionary principle in discussions of public health. And I wonder whether sometimes these ethical principles, which I think would be very controversial in philosophy departments, in which a lot of moral philosophers, I think, would be far less convinced that this is a black and white issue than the consensus in the field of public health seems to imply. And these ideas then guide public policy in ways that perhaps can backfire. So one example of this is that we might have been able to get a vaccine even earlier than we did. And it's an achievement how quickly we did get it through human challenge trials, but those were ruled out as being unethical, where if some people would have been willing to expose themselves to a pathogen which is dangerous, but didn't have a very high likelihood of killing any one individual, and as a result we might have been able to save hundreds, thousands, tens of thousands, hundreds of thousands of lives. It is not at all obvious to me that that would be unethical, but there did seem to be a relatively broad consensus within at least parts of a public health field that that is unethical. Or more broadly, there was a very interesting viral story of somebody designing a custom made vaccine of sorts of for the dog's tumor in Australia with the help of a number of AI systems. And they said that over 50% of the work they put into this miraculous way that they saved the dog was to fill out the enormous amounts of paperwork that were required to get the permission to inject a novel drug into a dog that had a likely lethal form of cancer in the first place, to give it this outside chance of possibly being able to survive. So do you think that in the field of public health, in some areas, like gain of function, we're continuing with really dangerous practices, at least in some places, even though you make a very convincing case if that's dangerous. But in other areas, like human challenge trials or like the bureaucratic burdens for getting drugs to, in this case, a dog, but I think often to humans who, you know, are at very high risk of harm. In any case, there are bureaucratic rules that are too strong to actually, you know, maximize the potential benefits of medicine.
- [65:02]
B
Yeah, there's a lot there. I mean, it's funny you bring up human challenge trials because with a moral philosopher, Nir Eyal, and another epidemiologist, Peter Smith, the three of us wrote one of the first articles advocating for human challenge trials early on in Covid of vaccines for exactly the reasons you say. I think in retrospect the benefit would have been pretty small because the United States, Brazil, South Africa and the uk, where vaccine trials turned out to be run, provided the world with a massive global public good, which is a huge epidemic to test, to test vaccines in. And we would rather have not provided that good, but we did.
- [65:49]
A
Right. So because in this particular case, so many people were infected in the first place, there was less need for the human challenge trial. But you could imagine lots of other circumstances where the human challenge trial can save a lot of lives.
- [65:59]
B
And I think actually there was some movement. I mean, there was at least one member of the US Congress who was quite interested in. And the UK did establish a human challenge model, although much a bit later. So I would say. But yes, the strong reaction in the bioethics community was do no harm. And this is not something we should be doing, but it moderated to some degree. So I think that's a much more complicated or it's a, it's a complicated example. But I do think that the, the field of research ethics as a whole is, is very precautionary and very much more concerned about avoiding a harm than about doing good. And some people have begun to push back about that. Alex London wrote a book recently, about two years ago, three years ago, on this topic that I think pushes back in the right direction. So I think it's been recognized, but I think that the level of reflection, as you would expect in an applied field, the level of reflection about basic principles of ethics is not that high. It's more how do we apply what we've been taught? And what we've been taught is largely non maleficence, beneficence and, and justice. And those are interpreted in the standard interpretation to mean better to miss the opportunity to do something great than to, than to cause harm. So yeah, I think the conservatism is, is a real thing.
- [67:50]
A
Pandemics have unfortunately been in the news again over the last days and weeks. We also asked Mark to come back for an update to tell us about how worried we should be about that outbreak of Hunter virus on a cruise ship and the very large outbreak of Ebola that has just been detected in Congo. How can we tell over the next days and weeks whether or not these might turn into much larger pandemics? What is the characteristics of each of those diseases? And in keeping with the rest of the conversation, do we still have the collective agency and the trust in public health to respond appropriately if these turn out into genuine global emergencies? To listen to that part of a conversation to support this podcast to make sure that you get all full episodes ad free into your favorite podcasting feed every week, twice every week. Go to writing.ashamonk.com listen go to writing.dashamonk.com listen and if you already are a paid subscriber, make sure that you click on Set up podcast and check that your icon for the podcast has a little premium feed field SA.