Getting to scale

In his newsletter, author Steven Johnson shared a thought provoking post on the topic of “Getting to Scale.”

A lot of what I’ve written about the pandemic has focused on the things that we have managed to get right, compared to past outbreaks: the speed with which we identified and sequenced the genome of the virus, the miraculous development of safe and effective MRNA vaccines, the fact that billions of people around the planet made profound adjustments in behavior to flatten the curve.

But the rise of Omicron and the imminent FDA approval of the Pfizer antiviral Paxlovid are, in slightly different ways, reminders of something that we should get much better at—namely, the hard logistical and operations work of scaling. We have miraculous vaccines, but the longer it takes us to vaccinate the entire planet, the more opportunities there will be for new variants to emerge.

And while Paxlovid looks to be the most significant new advance in the fight against COVID since the vaccines, its production ramp is not going to be fast enough to have any real impact on the Omicron wave.

As Matt Yglesias wrote a few weeks ago: “Pfizer says it’ll have about 180,000 packs of Pavloxid by the end of 2021 and then a very rapid ramp up to 21 million in the first half of next year. Those are large numbers, but they are not that large relative to a world population of seven billion or even the 630 million people worldwide who are over 65.”

In last week’s post about serendipitous discovery, I wrote a little about the classic story of Alexander Fleming, accidentally discovering penicillin after leaving a petri dish exposed on his desk during a two-week vacation. I briefly touched on the Fleming story in the book version of Extra Life, and my co-host David Olusoga did a wonderful recreation of it in the TV version. But in both the book and TV show, we emphasized a completely different part of the penicillin story, one that generally gets far less coverage than Fleming’s Eureka moment at the workbench: the extraordinary multinational and multidisciplinary effort to scale production of penicillin in time to get it to soldiers on the frontlines of WWII.

I’ll spare you the details of the story, but suffice to say that it was a far more complex and heroic task than simply stumbling across a curious mold in a petri dish. It involved creating crazy, jury-rigged production systems to test the drug on a single subject; a daring flight across the Atlantic with most of the world’s supply of penicillin in a single briefcase; squads of soldiers dispatched around the world to find other molds that might reproduce more efficiently; a team of agronomists in Illinois who were experts at growing mold in corn steep liquor; and Pfizer’s mass production facilities in Brooklyn. All leading up to one extraordinary result: In 1941, there wasn’t enough penicillin in the world to keep a single human suffering from a bacterial infection alive; and yet just three years later, when Allied soldiers landed on the Normandy beaches on D-Day, they were carrying penicillin packets as part of their standard gear.

It’s an amazing story, and one of the things that struck me researching it is how strange it is that the Fleming narrative is vastly more familiar to most people. And I think that’s because we romanticize—and thus invest in—discovery, and tend to ignore—and thus underfund—scaling.

I thought it was striking that Operation Warp Speed—which did a superb job at developing effective vaccines, and a terrible job of actually getting them to people—was originally dubbed MP2, shorthand for Manhattan Project 2.0. According to Politico, then HHS Secretary Alex Azar rallied the troops by saying, “If we can develop an atomic bomb in 2.5 years and put a man on the moon in seven years, we can do this this year, in 2020.”

As is so often the case, when we reach for examples of heroic scientific achievement, we turn to the familiar legends of military breakthroughs or space travel, and not the far more relevant example of actually making a drug that saved millions of lives. If they’d code-named the vaccine crunch P2, after the penicillin project, it might well have reminded them that inventing a life-saving medical invention is only half the job; you need to get it into people’s arms or mouths on the scale of millions for it to make a difference.

So to my mind, one of the lessons of this pandemic is that we need as much innovation in the approval/production/distribution side of the equation as we do in the lab science that conjures up mRNA vaccines or antivirals like Paxlovid. There are many potential ways of doing this, from challenge trials during the early days of development, to a more aggressive use of the Defense Production Act, to investing in excess production capacity that can be switched on for future crises—to other ideas that no one has thought of yet.

And if we’re going to have role models for what we’re trying to do, much better to lean on stories where we mass produced millions of drugs, instead of making a handful of bombs or sending three guys to the moon.

Steven Johnson makes a powerful point about the importance of scaling. As more new data about Omicron trickles in (confirming (a) its insanely fast spread, (b) lower severity, (c) strong booster protection), I find myself feeling grateful for the creation of the vaccines.

Clearly, I need to be just as grateful for all the work done to scale production and distribution.

Operation Gratitude. :-)