Gates Package — page 1146

GATES BOOK COMMENTS General comments, to be followed by chapter-specific comments. This is a powerful book that is very well written, to be understood by average people. It is well organized, clear, conversational, sometimes folksy, and it respects its readers and engages in an intimate way. The science is explained at a level that is probably optimal, "not too hot, not too cold", and the opinions reflect serious understanding of the scientific, public health, and societal issues associated with trying to prevent and control pandemics. Many of my comments relate to addressing the complexities of the challenges. While I am sure that some problems can be solved by money, organization, and an entrepreneurial spirit, there are other challenges that currently seem, and may well prove to be, intractable. This might be addressed in a sober way. In this vein, many of the stated goals, in Chapter 9 and elsewhere, are aspirational, but readers may wonder: OK, yes, but how do we get there? This is most apparent in the several discussions of the GERM force. It's a great idea that many have already floated in the past 5+ years, but the key question is: HOW DO WE ESTABLISH IT? Some specific ideas about this would be very helpful. Such a force must be international, cooperative, collegial, and with broad national and public buy-in. In an era in which international squabbling and non-cooperation is more notable than international cooperation for the common good (see for example, climate change), how to proceed with this idea? Introduction Page 16, bottom para: a 5-year time frame seems far too optimistic for respiratory pathogens Page 17, top few lines: an issue here to be addressed is that many pandemic pathogens probably spread silently for many weeks or months before the first detection (e.g., pandemic flu, SARS and SARS-CoV-2), so how do you find something like this before a single case of symptomatic or out of the ordinary disease is detected? It is worth noting that had we been doing extremely enhanced viral surveillance in 2009, detecting multiple genomes of the pandemic flu virus, we would have had no way of recognizing it as such, because we have no way of recognizing viral properties such as pandemic transmissibility from the genomes alone. Page 17, para 6, approval of drugs and vaccines requires a minimal time frame rarely less than 6 months, even when the recipe is agreed on, as with seasonal flu vaccines. There isn't much that can be done to lessen that time frame short of approval based on incomplete data that might miss catching serious problems. Page 18, line 7, the time frame was LESS than 12 months, I think closer to 11 months Page 18, general, I think it desirable to pull back a bit on implying that success with the two mRNA vaccines provides lessons for future pandemics. The mRNA success, while real, may be a one-off thing, since other mRNA vaccines haven't worked. Moreover, the short-term protection, easy breakthrough, and need for boosters, makes that vaccine more of a quick interim solution, not an ultimate solution for pandemic disease control. Even successes have important limitations that should be appreciated. This