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Gates Package, p.1154 · gates:exh:00564
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Page 194, para 5: this brings to mind the devastating book by Chinua Achebe: "Things Fall Apart", in
which he explains that because of high childhood mortality many parents won't name a child until it
reaches its 8th birthday, but then will say that "he or she has come to say".
Chapter 9
Page 208, para 3: once again, readers may ask, yes, but HOW do we do these things when lack of
international cooperation is a roadblock to so many things (e.g., climate change, territorial water rights,
trade wars, etc.)
Page 209, bottom para: this really touches on the old but very important question of investigatorinitiated v. managed or directed research, and what role these two approaches should play in going
forward to prevent pandemics. The book seems to assume that directed research is the way to go (e.g.,
"let's all try to make a universal coronavirus vaccine"). But this may be short-sighted. In many cases,
scientists don't have very good clues about how to proceed, in part because of lack of basic knowledge.
For example, we know that influenza can result in fatal viral pneumonia but, shockingly, in a typical
influenza infection that might or might not go on to be fatal, we don't know where the virus is, how and
where the immune system encounters it, and why that infection, even if it's a severe one, fails to elicit
long term protective immunity. Without these clues, how can we hope to make a successful universal
vaccine?
Moreover, most of the momentous breakthroughs have come NOT from directed research but from
serendipity in the hands of scientists curious about arcane stuff: PCR, monoclonal antibodies, CRISPR
cas9, mRNA immunogenicity, even the discovery of the "double helix", all came about because unknown
scientists were studying obscure things with little or no funding and few expectations of success. So,
where in the big picture of pandemic prevention do these two different approaches to science fit? This
was a question faced successfully by Basil O'Connor in the 1940s, as he hoped the NFIP could come up
with a polio vaccine. It did.
Page 210: para 3, sequencing more genotypes is good but not sufficient, because "genotype does not
equal phenotype", meaning that looking at a genetic sequence, even if modeled to guess its protein's
tertiary structure, tells us very little other than epidemiology of viral circulation. Ideally, sequencing
should lead to study of the infectious virus in animals and in some situations, if safe, even in people,
including pathogenesis studies and what has been called pejoratively "gain of function" studies. In this
era of genomics, we seem to have forgotten the importance of the biology of infection. It is worth
repeating that if we had had the entire genome of the 2009 pandemic H1N1 flu virus beforehand, we
wouldn't have been able to predict that it had a chance of becoming pandemic. Had we grown it up into
live virus and studied it in the lab, we might at least learned that it was highly transmissibly and not
prevented by population H1N1 immunity, derived from infection with highly drifted H1N1 viruses. That
would have allowed us to surveil for it and identify a pandemic at its earliest stages.
Page 211, para 4, re vaccines against viral families, this is a great aspirational goal, but all attempts have
failed so far, and few if any have good ideas about how to proceed. Can this goal be made realistic, and
how?