Gates Package — page 1155

Page 11, para 5: re creating transmission blockers, it's worth remembering we have great ones now: N95 masks. In pursuing the high tech it's worth remembering the low tech "first lines of defense". Page 213, para 4: again, the idea of drug combinations could be stressed, see comments above Page 214, para 3: speeding up clinical trials would be great, but there is a real limit to how much time can be saved. This is for biological reason such as the fact that it takes time to see whether you have a protective immune response that isn't transient, and to look for late side effects. There is a limit to how much "fat" can be trimmed. Page 215, para 3: again, viral isolation is the real gold standard, and many will argue we should be doing much more of it, as it provides important data we don't get from PCR and, to reiterate, genotype does not equal phenotype Page 216, para 1: not only incidence but also prevalence and transmissibility. That is, rather than models we need to be doing more "shoe leather" on-the-ground population epidemiology in real time, including population prospective studies which are expensive, but which yield critically important data. Page 216, para 2: as above, genome sequencing should lead to study of the live virus in experimental animals so we know what all of these genotypes can do. Page 216, last line. The GERM team idea is so important that one wishes it could be fleshed out with more specifics. Most importantly, how to set it up so that it will work collaboratively and be "owned" and valued by every country. I don't think something like this will just happen spontaneously, just because it's a good idea. How to birth it? Page 217, first two paras: more fleshing out of the details would be good. Page 217, para 3: in addition, we need to try to get a census of the viruses circulating in "non-patients", those who are infected but don't know it, and may nevertheless transmit. This is probably a significant, if unknown, component of pandemic spread. It may be worth reviewing the classic "Virus Watch" studies of the mid-1900s, which intensively surveilled whole large open communities. Can this be done in the modern era? I think it can, although it's expensive. Page 222, para 2: here, a lot more international scientific exchanges including workshops and training exchanges would be helpful. Science thrives on lots of in-person contact, and more so with international collaborative science. Page 222, para 3: but as noted, WHO has no money and few staff, it is basically an organizing entity with a staff of bureaucrats. This raises again the question of how to set up the GERM idea. Afterword While this chapter is really interesting, it seems to be independent and not closely related to the rest of the book. I worry it might detract from the powerful impact of the previous 9 chapters.