The future of pandemic preparedness, with Joshua Morrison

This week I had a conversation with Joshua Morrison, CEO of an advocacy non-profit (1DaySooner) focused on increasing the uptake of challenge trials and other mechanisms to better fight infectious diseases. We discussed the history of Operation Warp Speed, some of the unfortunate and complicated political economy of vaccines in the U.S., and the future of improvements to the built environment to decrease exposure to respiratory diseases.

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Timestamps

(00:00) Intro
(00:56) The role of challenge studies in vaccine development
(09:24) Understanding vaccine platforms
(18:33) Sponsor: Check
(19:46) Regulatory system insights and future improvements
(20:41) Lessons for our regulatory system
(29:55) First doses first debate
(37:35) The surprising nature of COVID-19
(39:30) Vaccine hesitancy and public communication
(42:08) Political influence on vaccine distribution
(58:28) Indoor air quality and disease prevention
(01:06:52) Future of public health initiatives
(01:12:27) Wrap

[Patrick notes: As always, I have included commentary below, set out in this fashion. This transcript has been massaged by an LLM and is designed for readability rather than for being a court stenographer.

I make some points with an unfortunate amount of political valence, and must therefore disclaim that I am only speaking for myself and not on behalf of VaccinateCA, Call The Shots, Inc., or anyone else affiliated with the effort, including team members, funders, partners in government or industry, etc.

And, as always, Complex Systems is a personal project of mine, and not everything said by myself or guests is endorsed by e.g. advertisers or other organizations I may be affiliated with.]

Transcript

Patrick McKenzie (patio11): Hideho, everybody. My name is Patrick McKenzie, better known as patio11 on the Internet. A quick disclaimer before we dive in—I have strep at the moment, so I might not sound as great as usual. Not that I normally sound great! I hope you can power through and join me for a conversation with my friend Joshua Morrison, who leads 1Day Sooner.

1Day Sooner is an advocacy organization focused on advancing scientific progress in the fight against infectious diseases. Joshua, thanks for coming on. I’ve given the brief overview, but can you delve a little deeper into 1Day Sooner’s work? After that, we’ll talk about the recent history of infectious diseases—a story that’s both traumatic and inspiring.

The role of challenge studies in vaccine development

Joshua Morrison:Thanks for having me, Patrick. 1Day Sooner started about four and a half years ago, at the height of COVID in March 2020. Our initial focus was on promoting challenge studies to help develop COVID vaccines and learn more about the disease.

A challenge study is when participants are deliberately infected with a disease under controlled medical conditions, often in quarantine, to either learn about the disease or test vaccines. Early in the pandemic, there was significant public interest in participating in such studies. In fact, about 40,000 people from 165 countries signed up on our website to volunteer for these trials.

Our goal was to accelerate COVID vaccine development. However, for various reasons—scientific readiness, ethical debates, and timing—challenge studies weren’t conducted before the first vaccines showed efficacy in November 2020 or were approved in December 2020. That said, COVID challenge studies did eventually take place in England, starting in May 2021, and they’ve provided some valuable insights.

At its core, 1Day Sooner represents people who are willing to take calculated risks by participating in studies that push the frontier of infectious disease research. Our focus is on combating diseases that disproportionately impact people in poorer countries, such as tuberculosis, hepatitis C, and group A strep—the very thing that’s giving you trouble today. We’re also concerned with diseases that can lead to pandemics, like COVID or pandemic flu.

Our work spans several areas, from supporting individual clinical trials to advocating for broader technologies, such as malaria and hepatitis C vaccines. We also promote innovations like indoor air cleaning with far-UVC light. Alongside these efforts, we engage in policy development to enable and advance these critical interventions.

Patrick McKenzie:We’ll come back to indoor air cleaning in a moment—it’s one of my personal weird interests—but let’s start here:

It was the best of times; it was the worst of times. The pandemic is still fresh in everyone’s memory—unless someone was literally born yesterday. On the one hand, there were massive failures across nearly every axis: political, scientific, pharmaceutical, and societal. Underperformance happened at almost every level.

On the other hand, we witnessed a world-historical success: vaccines were brought to market faster than any medicine in history and distributed to an unprecedented number of people in under 12 months from development. That is extraordinary.

A significant part of that success is attributable to a government initiative called Operation Warp Speed. For the benefit of anyone who hasn’t geeked out on this topic—or who thinks vaccines might fall off trees—can you explain what Operation Warp Speed was and how it came to be?

Joshua Morrison:Yeah, so basically, Operation Warp Speed represents what the U.S. government—or really, humanity at large—does when you absolutely need a vaccine and are willing to throw immense resources at the problem to get it as quickly as possible.

What does that look like in practice? With COVID, it was essentially a combination of a few key strategies. First, there was what’s called “push funding.” The government selected about half a dozen vaccine candidates, assembling a diversified portfolio of bets. The idea was that if these bets panned out, there was a high likelihood of having an approved vaccine by the end of 2020.

This wasn’t the traditional approach of one pharmaceutical company working on one specific candidate. Instead, they operated at the level of the entire field, effectively hedging bets across multiple approaches.

But that’s only part of the story—there were two other critical pieces to the puzzle, which I—

Patrick McKenzie:Let me just elaborate on that briefly for anyone unfamiliar with this field, and please correct me if I’m off base. This isn’t my area of expertise.

When a pharmaceutical company talks about a “candidate,” they’re usually referring to a molecule or a combination of a molecule and a delivery system. In the case of the COVID vaccine effort, we weren’t searching for just one molecule out of all possible molecules. We were looking for any viable combination of a molecule and a delivery system that could safely and effectively prevent COVID.

There were also sub-goals involved—things we can dive into in a moment—but the overarching idea was to identify and support a portfolio of six likely candidates that could lead to an efficacious vaccine. So, once those candidates were identified and the government provided significant funding up front, what happened next?

Joshua Morrison:So, once the government gave companies significant funding up front, they also introduced an innovative mechanism called "pull funding," or "demand funding," through advanced purchase agreements. Essentially, the government guaranteed that if a company’s vaccine received FDA approval, it would purchase a set number of doses—often a couple hundred million—at a pre-agreed price, something like $20 per dose.

This created a clear and substantial demand for the vaccines, ensuring there would be a purchaser. That was a huge incentive for companies to invest heavily in development.

At the same time, the FDA operated differently than it usually does. No corners were cut, and all the same rigorous steps were followed, but everything happened much faster. This was achieved through a surge in regulatory capacity and advanced guidance to companies. The FDA explicitly communicated what they expected from the vaccines. For instance, they stated they wouldn’t approve a vaccine that was less than 50% effective, among other criteria in the target product profile.

This clarity helped companies understand exactly what they needed to achieve. Additionally, the FDA worked around the clock. In a typical scenario, if a company wanted to run a trial, they’d submit paperwork and wait 30 to 60 days for a response. Under Operation Warp Speed, submissions sent at 5 PM might be reviewed and returned by 9 AM the next day because the FDA staff were working overnight in shifts.

Another critical component of Operation Warp Speed was the involvement of the Department of Defense (DoD). The DoD handled much of the contracting, procurement, and hands-on coordination with companies. They were also heavily involved in the logistics of vaccine distribution, which added a significant level of operational expertise to the initiative.

Patrick McKenzie:Right. I won’t rehash everything I’ve semi-expertly absorbed about the distribution story, especially the hiccups after the baton was passed to the rest of civil society. But setting that aside, I think it’s important to underline a couple of things.

[Patrick notes: In 2021 was the CEO of an initiative (VaccinateCA) which attempted to patch holes in our distribution strategy, mostly around no one having an actual understanding of where the vaccine was presently available. If you were able to successfully Google for the vaccine, you were very likely downstream of our work. For more on that subject, see the Story of VaccinateCA or the previous episode with Dave Kasten, who was a volunteer on the project.] 

Patrick McKenzie:First, we should be profoundly thrilled that this effort was even possible and that we ended up in a world where a successful vaccine existed by the end of the year. That wasn’t guaranteed—there were certainly possible outcomes where no vaccine materialized on that timeline.

Second, while the FDA brought extraordinary competence and regulatory capacity to this effort, it’s fair to say they don’t typically operate with the same level of urgency or enthusiasm for quick results in a normal year, for a standard drug or disease.

[Patrick notes: In describing the FDA as being extraordinarily competent in 2020 I am grading it against a curve composed of “The FDA” and not “institutions which I broadly believe are competent.” You can take the salaryman out of Japan, but you can’t take the salaryman out of the salaryman. There were some decisions by the FDA in 2020 which I consider to be on the spectrum from “extremely suboptimal” to “outrageous.” We will discuss some later in the episode.]

That said, there were still gaps in this process. Can you talk a bit about where those gaps were?

Understanding vaccine platforms

Joshua Morrison:Before I get to the gaps in Operation Warp Speed, I think it’s important to talk about the prehistory that set the stage for its success. You mentioned luck earlier, and there was definitely an element of that, but there was also a tremendous amount of groundwork laid before the pandemic that allowed us to develop successful vaccines so quickly.

One major factor was the development of the mRNA vaccine platform. This was a long-term effort involving academia, private industry, and government funding. Private companies like BioNTech and Moderna were instrumental in innovating on the platform, but they stood on the shoulders of academic pioneers like Katalin Karikó, who, despite not always being treated well, made groundbreaking contributions.

Government funding also played a critical role, particularly from agencies like DARPA and the NIH. For example, DARPA, led by people like Dan Wattendorf (now at the Gates Foundation), supported foundational work, while the NIH funded Moderna’s phase 1 studies for pandemic flu using the mRNA platform.

There was also important work done on viral vector platforms, like those used by Johnson & Johnson and AstraZeneca. While these turned out to be less effective in the U.S. compared to mRNA vaccines, they were still a crucial part of the global vaccine effort.

Patrick McKenzie:Let’s pause for a quick timeout to explain the difference between these vaccine platforms, particularly for anyone who hasn’t been immersed in the topic.

The mRNA platform represents a completely novel way to create vaccines—an enormous scientific advance in the history of humanity. It works differently from the live virus or weakened virus vaccines you might remember from high school biology. For example, take the cowpox vaccine, which was key to eradicating smallpox. The idea there was to infect someone with cowpox, a virus similar to smallpox, but far less dangerous. The immune system would then develop immunity to both cowpox and smallpox without the deadly risks of the latter.

mRNA vaccines, however, don’t involve any virus at all. Instead, they stimulate the immune system in a way that teaches it to produce antibodies without requiring live-fire exposure to an actual virus. To oversimplify a bit, the vaccine delivers instructions—messenger RNA, hence “mRNA”—that prompt your body to produce a harmless piece of the virus, like the spike protein on COVID-19. Your immune system learns to recognize and attack that protein, so if it ever encounters the real virus, it’s ready to fight it off.

By contrast, weakened virus vaccines work by giving the immune system a deactivated or incomplete version of the virus. Imagine the virus is like a ball with a distinctive shape. A weakened virus vaccine might break that ball into pieces and show those to your immune system. Your immune system learns to recognize the shape and can respond if it encounters the whole virus later.

Quick refresher on high school biology complete—back to you, Joshua.

Joshua Morrison:Can I be a bit pedantic about a couple of small things?

Patrick McKenzie:This is the pedantry podcast!

Joshua Morrison:Okay, so, yeah, the explanation about smallpox was great. But for Operation Warp Speed, there were actually three different types of vaccines that received funding.

First, there were the mRNA vaccines, which we’ve already discussed. Then there were viral vector vaccines, which are a bit different. And finally, there were protein-based or protein subunit vaccines.

The protein subunit vaccines are closest to what you described earlier—a vaccine that uses part of the virus to stimulate the immune system. Viral vector vaccines, though, use a different approach. Instead of simply giving you a piece of the virus, they use a harmless virus as the delivery mechanism.

For example, with Oxford’s vaccine, they used a chimpanzee adenovirus—a virus that causes colds in chimpanzees but isn’t dangerous to humans. They modified it to include the spike protein of SARS-CoV-2. So, it’s more like mRNA vaccines in terms of being a novel platform than it is like the traditional weakened-virus approach.

There were also two traditional protein-based vaccines funded by Warp Speed: one from Sanofi and another from Novavax. Novavax has finally become available in the U.S., but it wasn’t approved for manufacture during the initial rollout.

Patrick McKenzie:Am I remembering correctly that Takeda Pharmaceutical’s vaccine was also a traditional virus vaccine, or am I just confabulating that?

Joshua Morrison:I don’t have any specific memory of Takeda’s COVID vaccine, but you’re probably remembering it correctly.

Patrick McKenzie:I’ll look it up later and include it in the show notes. 

[Patrick notes: Takeda ended up doing a technology transfer / licensing agreement with Moderna and distributing it domestically. I had a recollection that they had a candidate prior to that agreement but that it was withdrawn due to poor efficacy, but 2020 was a bit of a trying time, and I may be entirely confabulating that recollection, which I cannot conveniently substantiate via searching.] 

Patrick McKenzie:The relevance of Takeda Pharmaceuticals here is tied to the fact that the world isn’t coextensive with the United States. Different nations made different political and economic choices when running their crash programs to develop COVID vaccines.

Many countries understandably prioritized their own national interests. A common decision was to nominate a "national champion" company to lead vaccine development rather than taking the portfolio approach we saw with Warp Speed.

Takeda Pharmaceuticals was, to my understanding, the national champion of a country near and dear to my heart. While Warp Speed pursued multiple parallel shots on goal—knowing that some vaccines might fail, but confident that at least one would succeed—Takeda seeeds to have been one of those firms that got unlucky. Unfortunately, the country didn’t have six companies in the running; they relied on a much smaller pool.

[Patrick notes: The Japanese government then bought about 150 million doses from foreign manufacturers and administered them expeditiously, FWIW.] 

Similarly, many of our friends in Europe took a different approach. They saw Warp Speed and thought, “This seems likely to produce a vaccine eventually, and we’d like to buy that.” But they didn’t allocate enough funding to prioritize early delivery of doses.

Joshua Morrison:Yeah, they ended up getting their vaccines later as a result. There are definitely lessons to be learned from that. Another interesting example is China. They developed several vaccines that worked "well enough" initially but weren’t particularly protective in the long term.

China also faced a dynamic of national pride—they weren’t eager to rely on Western vaccines. What’s notable, though, is that nearly all the successful Western vaccines—except for the Oxford-AstraZeneca vaccine—used the same spike protein construct. That construct was developed in the U.S., primarily through work funded by Barney Graham at the NIH and led by Jason McClellan at UT Austin.

The construct was designed to “jam” the spike protein into a fixed shape, ensuring it was presented to the immune system in the most effective way to generate a robust response. This approach addressed a key challenge: the spike protein naturally shifts between two states—extended when it’s trying to enter a cell, and folded when it’s not. Fixing it in the extended position made it far more effective as a vaccine target.

This work didn’t happen overnight. It was part of a long-term effort after SARS-CoV-1 and MERS, other severe coronaviruses, to prepare for future pandemics. The same strategy was used for RSV, a virus that causes colds in adults but can be severe in infants and the elderly. Recent RSV vaccines, which appear quite effective, also benefited from this forward-thinking NIH-funded research. This kind of groundwork was crucial to the ultimate success of Operation Warp Speed.

Patrick McKenzie:One of the most stunning aspects of this effort was how quickly we moved from sequencing the virus to synthesizing the first vaccine candidate. I believe it was two or three days from the point where the virus was fully sequenced to when the first candidate was ready.

On one hand, that’s a world-historical achievement for Science (with a capital “S”). It’s the kind of breakthrough that feels closer to magic. On the other hand, it’s a testament to standing on the shoulders of giants. Science didn’t just “discover” viruses in 72 hours.

We got there because of decades of prior work—like the perseverance of Dr. Katalin Karikó, who was treated very poorly for a long time, but ultimately succeeded in advancing the mRNA platform. [Patrick notes: Reading the history of how the scientific establishment and her own university treated her is positively enraging.] 

Her contributions laid the groundwork for mRNA vaccines to be productionized quickly and, fortunately, she’s now receiving the recognition and accolades she richly deserves. But none of this was guaranteed—it required an extraordinary convergence of preparation, talent, and opportunity.

Regulatory system insights and future improvements

Patrick McKenzie:So, with that context, let’s shift gears. What have we learned about our regulatory system from this experience? Under extreme pressure and stress, the system achieved something remarkable. What changes should we consider to improve it going forward?

Joshua Morrison:Yeah, so I think the first takeaway is that we should build on this experience to create a framework for testing high-priority technologies in the future. Can we develop this capacity “off the shelf” and repeat what we achieved with COVID vaccines for other critical advancements?

For example, let’s say we want to develop a highly effective gene therapy for sickle cell disease. We could provide additional regulatory capacity, offer faster responses, and give developers advanced guidance so they understand exactly what they’re aiming for. This would reduce uncertainty for the developers and investors, which could accelerate progress.

If we can prove this approach works in a few high-value cases, we could refine it and expand it to other contexts.

Now, to give a real-world example, the FDA is already experimenting with this idea. Peter Marks, who runs the Center for Biologics Evaluation and Research (CBER)—the part of the FDA responsible for biologics like vaccines, blood products, and gene therapies—has initiated a pilot program called the START program. It’s essentially a “Warp Speed” for rare disease treatments involving stem and gene therapies.

Interestingly, Peter Marks was also the one who came up with the name "Operation Warp Speed." While the FDA often has a reputation for slowing things down, Marks exemplifies a progressive mindset—small “p” progressive—in trying to improve and modernize FDA processes.

Beyond targeting specific high-value technologies, there are broader lessons we can take away. One of the most important is the value of advanced guidance. Normally, the FDA operates reactively—they wait for a company to bring them an application and then decide.

This creates a lot of uncertainty for companies and investors. If you don’t know what the FDA wants, you’re less likely to invest heavily. And if a company submits an application and has to wait 60 days—or longer—for approval to start a clinical trial, it slows everything down.

During COVID, we saw much greater flexibility and willingness to adapt. For example, vaccine trials began before we had animal study results. Phase 1 trials started quickly, which could make sense in other contexts, especially when volunteers are well-informed. That’s an area my organization works on—ensuring volunteers understand the risks.

We also saw Phase 1 and Phase 2 study designs combined. This made sense because vaccine safety incidents typically occur within the first 30 days of vaccination. If you’re 30 days into Phase 1 and haven’t seen issues, you don’t immediately jump to vaccinating 10 million people, but it gives you a strong basis to progress.

These are the kinds of innovations—like reducing the gaps between trial phases—that could be adopted more broadly to make the regulatory process faster and more effective without sacrificing safety.

Patrick McKenzie:For the benefit of people who might not have caught the earlier episode with Ross Rheingans-Yoo, or who haven’t worked in clinical trials, could you briefly explain the difference between Phase 1 and Phase 2 trials? Why do we have those distinctions in the process?

Joshua Morrison:Yeah, so in a vaccine context, it’s a little different because you’re administering it to a healthy population. For most drug trials, Phase 1 focuses on safety: is it safe to give to humans at all? It also explores some basic biochemical effects—what does the drug do in the body, and how do different dose levels affect it?

In a typical drug trial, Phase 2 is when you start looking at efficacy: does the drug actually treat or prevent the condition it’s targeting? For vaccines, that sometimes happens in Phase 2—often referred to as Phase 2b—but usually, Phase 2 focuses on measuring the immune response in a larger population.

For example, a Phase 1 vaccine study might involve 20 to 30 participants, while Phase 2 might scale up to around 100. By this point, you’re looking at how safe different doses are and what kind of immune response they generate. If things look promising, you might conduct a Phase 2b study, which starts gathering some efficacy evidence, but not on a large scale.

In a Phase 2b trial, you might observe outcomes like 30 cases over several years in a high-risk population. For instance, with a hepatitis C vaccine trial, researchers found 15 cases in the vaccinated group and 15 in the placebo group—showing no efficacy. On the other hand, if a Phase 2b trial shows promise, like a tuberculosis vaccine funded by the Gates Foundation and others, which was 50% effective, it can move to Phase 3.

Phase 3 vaccine trials involve tens of thousands of participants because you need enough cases to assess efficacy in a real-world setting. This is different from most drug trials, which typically require smaller populations.

Patrick McKenzie:One of the non-obvious consequences of this system is that we, as a society, sometimes operate under assumptions about drugs or vaccines that aren’t necessarily capital-T true. These assumptions often stem from the constraints of the trials we’ve run, rather than immutable facts about the world.

Take COVID vaccines, for example. We treat them as if they lose efficacy after being out of the freezer for 12 hours and cannot be refrozen. But these aren’t laws of nature; they’re artifacts of what we were able to test under time constraints. No trial was run to measure the effects of refreezing or extended time at room temperature, so we simply agreed on the paperwork that the vaccine is unusable after 12 hours and cannot be refrozen.

If we could improve how we run trials and reduce their costs, we might be able to explore more edge cases like this. That knowledge could translate into significant real-world benefits.

Here’s another example—one that sparked unnecessary controversy in some places. 

[Patrick notes: The below numbers are made up, but the unwillingness to combine doses was entirely real. A related issue: we were inconsistent about using so-called “overfill”, where a bottle labeled as containing five doses physically contained six. The six dose, chemically indistinguishable from the first five, was routinely discarded due to some combination of Seeing like a Pharmacy and uncertainty that using it would be blessed by regulators (despite the FDA, at least, publicly blessing its use on a temporary basis due to the emergency). Another related issue: “low dead space syringes” could increase the effective number of doses per vial by reducing waste, but some nations failed to procure them, despite them being abundant in the world relative to vaccine doses.]

Patrick McKenzie:Eventually, the drug leaves the trial phase and enters the physical world, where it’s in a vial in someone’s hand. Imagine a scenario where you have 3 milliliters of vaccine left in one vial and 2 milliliters in another. You need 5 milliliters to dose a patient.

Are you allowed to combine the 3 from the first vial and the 2 from the second into the same syringe to make a full dose? The answer to that question depended a lot on where you lived. In some jurisdictions, 3 plus 2 equaled 5. In others, it didn’t.

This kind of variability highlights how our regulatory systems construct “reality” in ways that don’t always align with logic or practicality. Addressing these inconsistencies would be another way to improve outcomes in future public health efforts.

Joshua Morrison:Yeah, and it gets to your earlier question about some of the failings or areas where Operation Warp Speed could have been improved. It did an excellent job getting that first generation of vaccines out—vaccines that were developed within days of having the SARS-CoV-2 genetic code—and scaling up production.

However, where it fell short was in what came next: optimizing the initial vaccines or developing better ones. One example is the question of how to administer doses efficiently.

First doses first debate

There was this debate around the idea of “first doses first.” Should we give two doses to the highest-priority populations first, then move on to the next groups, and so on? Or should we give the first dose to twice as many people more quickly, protecting a larger population initially but with somewhat weaker immunity until the second doses could be administered?

Patrick McKenzie:This is a perfect example of how our paperwork constructs reality. A lot of people understood the COVID vaccine to require two doses to be effective, but that’s not strictly true. There’s no cell in your body thinking, Ah, I got the blue part of the dose, now I just need the red part and bam, immunity.

Both doses are the same liquid. What happens is that the first dose generates a certain immune response, and the second dose boosts it further. Early testing showed that one dose didn’t quite get the response to where we wanted it, so we tried spacing out two doses. That worked well, and we settled on that as the standard.

But we didn’t have time to test whether, say, three or six doses would work even better. So, the paperwork says, Requires two doses. And that became the guiding principle.

The tradeoff is this: with a limited supply of vaccine vials, you could either give a lot of people—indicative numbers here—a 70% effective single dose, or give half as many people 95% effective two doses. Mathematically, two times 0.7 is greater than 0.95, so you’d think the choice would be obvious. But it wasn’t to many nations.

In the U.S., civil society had to badger decision-makers into adopting the first doses first strategy. Alex Tabarrok, an economist rather than an epidemiologist, wrote a blog post advocating for it. That post eventually circulated in the right places in Washington, helping drag the policy into place.

The UK had its own intense debate about this. I believe Dominic Cummings and others were involved, but I don’t recall how the UK ultimately resolved the issue. Sorry, I interrupted you—please continue about first doses first.

Joshua Morrison:No, no, that’s a great point. But yes, my understanding is that the UK implemented a version of first doses first, which likely saved thousands of lives. I don’t have the exact numbers handy, but the evidence strongly suggests it was a net positive.

In contrast, I don’t think the U.S. really ended up doing it, at least not systematically. That’s where having better trials or a more robust system for evaluating real-world evidence could have made a significant difference. A better surveillance system to track real-world outcomes would have allowed us to adjust strategies more effectively and optimize the rollout.

Patrick McKenzie:Brief interruption—this is such a key point. One challenge in discussing the U.S.’s COVID policy is that we had so many policies happening simultaneously, often contradicting each other.

Specifically, in the early days of vaccine distribution, the allocation process worked like this: to schedule someone for vaccination, a healthcare provider needed to have two doses allocated upfront. They needed one vial to open on Day 1 and another vial already in their possession to be opened on Day 21. This was treated as a hard constraint initially.

Eventually, once sanity prevailed and we recognized that the U.S. still had a functioning logistics system—vials of vaccine were constantly in transit around the country—the policy shifted. Providers could schedule a vaccine appointment if they had one dose in hand, without needing the second dose physically present yet.

[Patrick notes: Indeed, some healthcare providers began to advise callers at VaccinateCA things which rounded to: “We are doing first doses only at this time. Second dose? You’ll have to find it yourself, but we don’t expect that to be too hard in a month or so.”]

The updated understanding was that it would be fine to give the second dose as soon as it arrived, whether that was on Day 21, Day 35, or later. Even if someone never received the second dose, they’d still be better off with the first.

This insight trickled through the American regulatory and healthcare systems at varying speeds, from around January 2021 to May 2021. It wasn’t announced in a coordinated, high-profile way—like the president going on national TV to explain the change. Instead, it emerged piecemeal as different officials and healthcare providers adapted their processes.

And, as listeners of this podcast may know, my organization was deeply involved in calling up pharmacists during that time to ask, Why can’t you give out the COVID vaccine today? [Patrick notes: We, obviously, did not phrase it like that. Publishing positive results, even when limited by e.g. eligibility criteria, was the goal; developing the list of perceived blockers was bonus points.] So, I’ve seen firsthand how these changes played out on the ground.

Sorry for jumping in with that bit of context—please continue.

Joshua Morrison:Yeah, it’s fascinating—and frustrating—because after the initial development of the vaccines, it feels like we stopped having a coherent plan.

One major gap was the failure to develop better vaccines. It’s remarkable that the same vaccines we’re receiving today are essentially the ones developed within days of sequencing the COVID virus. Despite all the subsequent research on COVID and vaccines, we haven’t significantly advanced beyond that first generation.

It’s hard to call this a failing of Operation Warp Speed itself because it was largely a result of decisions made after the Biden administration took over. They ended Operation Warp Speed, rebranded the effort, and brought in new personnel. While there were efforts to create a successor—like Project NextGen, which was called for by Republican senators like Senator Burr and Senator Hoffer—it wasn’t launched until 2023.

Project NextGen is being run very differently from Warp Speed, and while there has been some progress on second-generation vaccines, they’re still far from becoming viable products. For now, the best vaccines available remain the ones developed at the beginning of the pandemic. These vaccines are good—great, even, for ending the pandemic—but they’re far from perfect.

Patrick McKenzie:Right. And unfortunately, the pandemic didn’t end after everyone got their first dose because the virus itself had certain advantages.

Unlike us, the virus can’t communicate or coordinate between its individual instances. But it does have massive distributed computational capacity to evolve and optimize for infecting humans. It was running “upgraded releases” in the form of new variants—Delta, Omicron, and so on—competing them against each other with literally hundreds of millions of “shots on goal.”

The variants that could “punch through” our existing vaccines—meaning they were better at evading immunity—became much more widely distributed than earlier versions of the virus. Our vaccines, which were designed to combat the initial strains, were less effective against these new variants. [Patrick notes: The jargon word for this is “immune escape.”] 

The result was a kind of ongoing equilibrium. On one hand, the best academic research credits vaccines with saving millions of lives worldwide. On the other hand, the peak of daily deaths in the U.S. occurred well after we had started vaccinating many of the most vulnerable people. [Patrick notes: This was a mis-recollection; the CDC has the peak early in the vaccination campaign, when the delta variant was hitting hardest. The omicron peak in early 2022 didn’t quite hit the delta peak.]

That’s both impressive and sobering. Vaccines were undeniably effective, but they didn’t achieve everything we might have hoped for. This nuance is often lost in political debates. Critics on certain parts of the political spectrum, particularly those skeptical of vaccines, point to these outcomes and say, “See? It was all nonsense in a bottle.”  [Patrick notes: For what it is worth, vaccine hesitancy has historically been quite bipartisan in the U.S.—one reason it is such a live issue in deep blue California communities—but to the extent there was sustained organized vaccine skepticism in the political establishment, it mostly now comes from the side of the aisle that I’m usually on.]

But the reality is more complex. Vaccines can be effective—saving millions of lives—and still fall short of delivering an ideal outcome, especially when facing a rapidly evolving opponent like covid.

The surprising nature of COVID-19

Joshua Morrison:Yeah, one thing I found fascinating was talking to Matt Memoli, an NIH scientist and a leading researcher on challenge trials, particularly for flu. He really wanted to conduct COVID challenge trials, but Anthony Fauci didn’t allow it.

What stood out in our conversation was when Memoli said how surprised he was by how typical COVID was as a respiratory virus. This was back in 2020, and his perspective was interesting—respiratory viruses mutate frequently, so from his lens, it wasn’t surprising to see variants like Delta and Omicron emerge.

As someone without formal scientific training, I found it surprising—and I think many people did—just how significant those mutations turned out to be and how quickly they emerged. But Memoli viewed it as an expected characteristic of respiratory viruses.

He was also an interesting figure in his own right. For example, he opposed the NIH’s COVID vaccine mandates for its employees, even though he was actively developing a universal flu vaccine and exploring a universal COVID vaccine. It was an unusual position for someone in his role.

I think this ties into a broader issue with the political and public health system. There’s often a merging of descriptive truths—what is factually accurate—and normative truths—what should be true, especially from a political standpoint. That blending creates challenges in maintaining a clear understanding of reality and predicting what’s likely to happen next.

Vaccine hesitancy and public communication

Complicating matters further was the sheer volume of new information coming in constantly. Public health officials were overwhelmed, dealing with a firehose of data and trying to solve huge problems in real-time. Mistakes were inevitable, and one of the most significant areas where we fell short was public communication, especially around vaccine hesitancy.

Patrick McKenzie:Can I make one point about vaccine hesitancy that I think is broadly underappreciated?

Consider the Pell Grant program in the United States. Pell Grants are essentially free money for college. Despite that, we never hear about “Pell Grant hesitancy,” yet every college knows it has to do a sales job to explain this to prospective students.

For example, they’ll say: "There are various ways to fund college. A loan you have to pay back. A grant, like a Pell Grant, is free money you don’t pay back. Here’s an application you need to fill out, and then the money will arrive." Even though it’s free money, colleges still invest in explaining and promoting it because people don’t automatically understand the program. [Patrick notes: You can understand why people are skeptical, too! “As if the federal government would give me tens of thousands of dollars, for free, with basically no checking. That certainly hasn’t matched any other experience in my life!”]

Now think about the COVID vaccine rollout. A lot of people, particularly in the professional-managerial class, assumed the vaccine was the most anticipated product release in human history. After a year of lockdowns and trauma, it seemed obvious that no one would need convincing to take it. But that assumption was wrong.

Much of what was perceived as vaccine hesitancy wasn’t driven by anti-science or deep-seated opposition. It was more like, No one has sat me down and explained why this benefits me. Many people assumed, If the vaccine were truly important, someone—my doctor, a public health official—would have told me by now.

This wasn’t well-calibrated to the reality of the U.S. healthcare system, which, for better or worse, didn’t believe it needed to sell the vaccine to individuals. [Patrick notes: Pharmacies were the primary site that the vaccine was physically delivered at, and pharmacies are not specialized in demand generation for drugs. The pharma industry expects physicians to do that; that is why the physicians get visits by attractive people explaining the benefits of the new things on offer.] 

Now, of course, there was a partisan and politicized element to vaccine hesitancy. And it wasn’t a straightforward left-versus-right issue—it had a bit of a horseshoe effect, pulling in groups from across the spectrum. But a significant portion of the hesitancy stemmed from a lack of direct, clear communication, not outright opposition.

If we’d approached vaccine rollout like a college explains Pell Grants, we might have done better at closing that gap.

Political influence on vaccine distribution

Joshua Morrison:Yeah, if you look at what the people who ran Operation Warp Speed say in hindsight, they often point to the lack of a communications strategy as the biggest mistake. Paul Mango, who was Deputy Chief of Staff at HHS during that time, wrote a memoir about this, and he identifies it as the single greatest failure of the initiative.

There were some vague attempts at communications under the Trump administration, but those efforts were quickly criticized. There was skepticism and concern that any public messaging would come off as the administration using government money to promote itself, which was politically controversial. As a result, those efforts were essentially abandoned.

If you’re trying to defend the Trump administration’s approach to public communication, you could argue that when they initially floated the idea, it was shot down due to political backlash. But the reality is that there wasn’t the same "Warp Speed" urgency applied to public messaging as there was to manufacturing, procurement, and regulatory coordination.

When the Biden administration took over, there were opportunities to address this gap, but they made similar mistakes. For one, there was still no large-scale, clear, and coordinated public communication effort.

Another interesting angle from early 2021 was the widespread concern about vaccine hesitancy among minority populations. There was a lot of focus on whether Black and Hispanic Americans would be reluctant to take the vaccine. But when you look at the data, those groups ended up being vaccinated at similar rates to others.

The bigger story of vaccine hesitancy played out along political lines. If you want to frame it cynically—and critically of Democrats—you could say that a Democratic administration succeeded in vaccinating Democratic constituencies but failed to reach Republican ones.

Patrick McKenzie :I’ll neutrally observe that in California and many other jurisdictions in the U.S., we explicitly prioritized the delivery of life-saving healthcare using proxies for race. That is an absolutely gobsmacking fact about the American political system.

[Patrick notes: This is inescapably true, and absolutely maddening to me. Many people I respect would strongly prefer I not bring this up. And I’ll make the usual disclaimer: this is just little old me talking, as a witness for the dead.

In some parts of the nation racial preferences in vaccine administration were explicit. California laundered it through extensive use of the Healthy Places Index, allocating 2X the doses to communities low on that index (40% allocation to bottom 25% of index leaving 60% for top 75%; state authorities unable to crunch the math are welcome to consult a fourth grader of their choice). California also pervasively instituted residency restrictions at the county and zip code levels, designed to prevent disfavored-but-otherwise-eligible patients travelling to doses that had been earmarked for favored patients. 

That index is, as a quick perusal of their homepage or deep dive into their technical papers will both suggest, designed to be intentionally used to proxy for race. California et al will swear blind that they had a medical rationale for this. They are lying. It’s very carefully designed flimflam. Prioritizing by medical necessity would prioritize old people, they're disproportionately white, that was considered politically non-viable during the racial reckoning, and thus gestures to a million policy documents, emails, meeting notes, press conferences by the governor, etc.

This is certainly not the only way that California prioritized vaccine delivery based on political expediency (see Story of VaccinateCA for further discussion and the paper trail), but it is one way which is considered to be a monstrous crime against the Constitution, laws, and deeply held moral principles of the U.S. We intentionally blocked access to lifesaving medical care, on the basis of race, at the direction of the state.

This would be an ongoing political scandal but for the quirky valence of vaccine politics in the U.S., where the party that considers penalizing people of disfavored races to be uncontroversially bad does not presently consider vaccine access to be a priority. The other party is enduring a struggle for its soul between one faction which thinks discrimination by race is presumptively illegal and immoral, and another faction which thinks it is functionally mandatory. The second faction was ascendant in halls of power in 2020/2021.]

What’s even more striking is that the people who implemented these policies will openly defend them—unless you frame it with the exact valence I just used. In that case, they’ll deny it. But we absolutely did it.

Joshua Morrison:Yeah, and there’s an argument that prioritizing certain groups was justified because they were the most vulnerable and needed it most. I don’t think that’s inherently wrong. But if you want to critique the Biden administration’s approach, you could point to their discomfort with anything associated with Donald Trump.

This aversion extended to scrapping the Warp Speed branding entirely. They didn’t want to be tied to Trump’s name or legacy, even when it came to something as successful as Operation Warp Speed.

Patrick McKenzie:Fun fact: while I was running VaccinateCA, we also had to navigate the political sensitivities of the time. We were very careful to brief anyone speaking to the media—myself included—not to use the words Warp Speed, even if the intent was just to convey urgency or speed.

Why? Because while Warp Speed is a fantastic metaphor for moving quickly, it had become so politically charged that it could make some people immediately defensive. The moment they heard it, they’d metaphorically put their shields up and set phasers to maximum.

Joshua Morrison:Yeah, and that’s an excellent point. Alex Azar made a similar observation when I spoke to him before the Warp Speed Conference we’ve hosted for the past three years. He suggested that the Biden administration could have brought in figures like Mike Huckabee or Ben Shapiro—people with influence in conservative circles—to champion the vaccine.

There wasn’t much effort to engage those voices, though. If you want to critique the right, you could point out that Republican leadership, including Donald Trump, also didn’t do enough to promote vaccines effectively within their constituencies. Counties that voted Democrat saw proportionally fewer COVID deaths than Republican counties, which could be read as a failure of Republican political leadership to address vaccine hesitancy among their voters.

I imagine the Biden administration would argue that it wasn’t their job to convince Republican voters or leaders, but either way, the vaccine rollout became deeply politicized, and communication was ineffective across the board.

Patrick McKenzie:If I may jump in with an example of how explicit politicization happened—and how implicit politicization likely shaped decisions—here’s one mechanism that played out during the vaccine rollout.

There’s a website called vaccines.gov that still exists today, allowing people to see where COVID vaccines are available. Back in 2021, approximately 50% of vaccine doses were allocated to the federal government and the other 50% to state governments, counties, local healthcare providers, and NGOs.

The federal doses were primarily distributed through the Federal Retail Pharmacy Program—meaning locations like Walgreens and CVS—though some state doses also went through those channels. Now, here’s where the politics get messy.

The federal government wanted to display vaccine availability on a national map at vaccines.gov. The question arose: should the map display all doses (federal and state) or just the federal doses? The obvious answer is to show all doses—that’s in the best interest of the public.

[Patrick notes: The below speculation as to the political economy of display on this system owes to some people who have spent a lot more time in Washington than I have, rather than from our discussions directly with the VaccineFinder initiative or another privileged source.]

But in the U.S. political system, cooperation from state-level authorities is often necessary to make something like this happen. There was a strong perception in Washington that some governors, particularly those from the opposing party, might object to the president claiming credit for making all doses visible. Governors might feel their state-level efforts were being overshadowed, especially if the president is from the other party.

The fear was that governors in Republican states might refuse to cooperate, leading to a map that showed vaccine availability in some states but not others. Optically, that would have been disastrous, as it could be interpreted as the federal government intentionally withholding vaccine data from Republican states. The narrative could have escalated to something as extreme as accusations of the Biden administration targeting Republicans for extermination.

To avoid this, the federal government decided not to display state-allocated doses on the map at all. As a result, vaccines.gov only showed federal doses, even though this decision likely made it harder for people in some areas to find vaccines near them.

This is an example of how expectations about partisan politics shaped decisions that directly impacted public health. The Biden administration made what they considered a rational calculation based on their model of political actors, but the outcome was a system where life-saving doses were harder to locate because of fears about negative optics and news cycles.

This kind of complexity—where a system makes seemingly rational decisions that lead to absolutely insane outcomes—happened repeatedly during the vaccine rollout. It’s maddening to think about how many lives could have been saved if not for these layers of political and systemic dysfunction.

Sorry, I get a little wound up about this one.

Joshua Morrison:Yeah, absolutely. To me, this underscores two key challenges. First, it’s incredibly difficult to implement effective vaccine policy—or really, any policy—in a politically polarized and low-trust country.

The second challenge is that distrust tends to cluster along political and educational lines, particularly in the U.S. With educational polarization, lower-trust populations increasingly align with one political party. That dynamic makes it harder to craft a vaccine policy that works for everyone, because one side of the political spectrum harbors more skepticism about vaccines.

So the question becomes: how do we design a functioning vaccine policy going forward? Movements like "Make America Healthy Again" or figures like RFK Jr. tap into that distrust, responding to the skepticism many people feel.

I’ve thought a lot about this, and I believe we need a twofold approach. First, we must improve verifiability. That means building systems that provide real-time data transparency. People should be able to go online and see how many doses of a vaccine have been administered, what safety incidents have occurred, and what outcomes are expected.

Second, we need to adopt a more freedom-oriented approach for new vaccines. For vaccines that haven’t been given to hundreds of millions of people, we should emphasize individual choice. Let people decide whether to take them, while providing clear, transparent evidence about the risks and benefits.

However, we can’t afford to throw the baby out with the bathwater. Childhood vaccination schedules—things like the measles, mumps, and rubella (MMR) vaccine—are critical. These vaccines have been administered billions of times and protect against diseases like measles, which can spread explosively in unvaccinated populations. One measles case in a naive population can infect 20 others, so maintaining high vaccination rates is essential.

I think the backlash against COVID vaccine mandates stemmed from a combination of distrust in new mRNA technology and resentment over being forced to take it. That backlash risks undermining public confidence in long-established vaccination programs, which would be disastrous. The goal should be to provide more transparency, evidence, and freedom for newer vaccines, while preserving the critical gains we’ve made in public health over the past century.

Patrick McKenzie:There are so many directions I could go with a critique of our communication strategy in 2021—or, more accurately, our lack of one.

Let’s focus on one specific example: the messaging around the vaccine being “safe, effective, and free.” Those are three key product characteristics that any marketing department would hammer home. But oddly enough, in the U.S., it’s almost illegal to advertise vaccines.

Even when messaging existed, it was undermined by unnecessary complications. Take the word free. If you walked into a pharmacy in 2021, you might see signage saying, Get your COVID shot here—it’s free! But there’d be an asterisk. And if you’ve lived in the American healthcare system for long, you know that free with an asterisk actually means not free.

The asterisk was there because legally, the vaccine wasn’t technically free. If you were insured, your insurance would be billed about $40. If you were uninsured, the state covered the cost. So, while it was free to the individual, money was changing hands behind the scenes. Legal departments insisted on the asterisk, and that tiny detail created confusion and mistrust.

We literally allowed people to die over that asterisk because we prioritized pedantic healthcare economics over clear, simple messaging.

Joshua Morrison:I’d argue that’s because no one had the job of marketing the vaccine as a whole. Pfizer’s job was to market its vaccine. Moderna’s job was to market its vaccine. But no one owned the overall responsibility of convincing the public to get vaccinated.

That’s one of the lessons from Warp Speed. In the height of an emergency, you can accomplish incredible things—sometimes even superhuman things—if you bring in outside expertise and create a focused, mission-first organization.

Warp Speed succeeded because it wasn’t tied to any one agency. Leaders like Moncef Slaoui emphasized that everyone was part of the team, not representing their individual agency—whether that was BARDA, the Department of Defense, or ASPR. That mission-first approach was crucial.

Warp Speed also had a clear, time-limited objective: deliver a working vaccine by the end of 2020. But you can’t maintain that level of focus indefinitely. Once the distribution phase began, there was no single entity tasked with maximizing vaccinations or communicating effectively to the public.

That lack of ownership and coordination during the rollout is one of the most important lessons to carry forward.

Patrick McKenzie:In January 2021, when VaccinateCA came together—just a handful of us geeks in a Discord—we assumed that eventually we’d meet the United States National Vaccine Location Information Czar. We figured we’d hand them our CSV file, say, “Here’s what we’ve got,” and be done.

[Patrick notes: I remember a meeting at which I told the team: “I have some good news and some bad news. … Bad news: we are the cavalry.”]

It turned out the U.S. didn’t have someone whose job it was to know where the vaccine was. That was one of the many gobsmacking things we learned.

Practically speaking, history repeats itself. VaccinateCA, like Warp Speed, was a mission-driven organization. We pushed ourselves into the red zone for six months, operating in sprint mode. That’s sustainable for a short period, but eventually, we had to pass the baton to the rest of society—people had to return to their jobs, and in my case, I ended up in the hospital after many sleepless nights.

[Patrick notes: Very briefly, but yeah, that happened.]

So, without offering excuses, I’ll say this: extraordinary efforts done under sprint-mode conditions can’t continue indefinitely. They need to be integrated into existing systems—the apparatus that handles the boring, everyday work of governance.

Indoor air quality and disease prevention

I could talk about Warp Speed for days, but we’d be remiss if we didn’t discuss something else during this conversation. Here’s a question I often get asked: if you could take one piece of technology from the present back in time—without knowing what year in history you’d end up in—what would it be?

I have a five-word answer: boil water before you drink it.

Explaining this to as many people as possible would dramatically reduce mortality. Boiling water kills pathogens, and humanity’s all-cause mortality would drop substantially. You could even give contextually appropriate flavor text, like, “There are evil spirits in the water. They scream when you boil them. That’s why steam rises.” If you make their death cries audible, your kids won’t die.

Now, here’s the parallel: we don’t boil air before we breathe it. Very plausibly, our grandkids are going to mock us for recirculating dirty air without doing anything to clean it.

Joshua Morrison:Exactly. Two things in the air can harm you: particulate matter (tiny particles, like PM2.5) and pathogens that cause infectious disease. Removing either of them improves health outcomes.

Even if you focus solely on pollutants, clearing the air of tiny particles would significantly benefit public health. My expertise is infectious disease, so I’ll focus there, but the problems are interconnected.

Think of infection as a probabilistic event—your likelihood of getting sick depends on how much of a pathogen you’re exposed to. If you remove 50% of pathogens from the air, your risk of infection likely decreases, although it’s not a simple linear relationship.

The good news is that transmission operates as an exponential function. Reducing pathogen levels by 50% might reduce disease spread by much more than 50%, particularly in a pandemic context. Slowing transmission dramatically alters outcomes.

For instance, my organization worked with Rethink Priorities and biostatistician Vytal Vychek on a report modeling indoor air interventions. Vytal showed that reducing transmission by 50% could stretch the time for a pandemic to grow from one case to a thousand cases from a few weeks to several months. This slows the spread enormously, buying critical time to respond.

Patrick McKenzie:And this presumably isn’t just about pandemics. We deal with seasonal flu, strep throat (speaking from current experience), and other illnesses every year. Society pays an enormous cost for these “normal” diseases, just as our ancestors paid a high price for cholera before realizing they could boil water. [Patrick notes: Not the only widely endorsed method for reducing cholera risk, but I'm being handwavy to be evocative.]

The idea that we can engineer our built environments to reduce these costs—costs we’ve passively accepted for centuries—is incredibly compelling.

So, what are the actual engineering improvements we could make to our buildings to improve indoor air quality?

Joshua Morrison:Yeah, there are three basic approaches to cleaning the air: ventilation, filtration, and disinfection.

• Ventilation involves bringing fresh air in from outside.
• Filtration means running the air through filters like HEPA filters to remove particles and pathogens.
• Disinfection targets pathogens specifically, often using UVC light to kill them.

For disinfection, UVC light is especially promising. It’s not the same UV light we get from the sun, which can cause cancer and other issues. UVC is a safer wavelength for indoor use. The concept is similar to the old adage, “sunlight is the best disinfectant,” except this is engineered UV light that can be deployed indoors.

To put things in perspective, the air in an average U.S. room gets exchanged about once per hour—one “air change per hour.” A new standard for communal settings aims for the equivalent of six air changes per hour, which significantly reduces particulate matter and pathogens.

• Ventilation alone might bring air changes up to 5 per hour.
• Filtration could add another 5 to 10 air changes per hour.
• Upper-room UV systems—an older technology where UV light is directed upwards to avoid harming people—could provide the equivalent of 30 to 40 air changes per hour.
• Far-UVC, a newer technology safe for direct exposure, might achieve 80 to 200 air changes per hour in practice.

These interventions, combined, could dramatically reduce airborne pathogens and particulate matter. However, to scale them broadly, we need better systems for measuring and predicting outcomes. For example, models could predict how interventions like filters or UV systems would reduce sick days in workplaces or transmission rates in schools.

Right now, companies like Google, Stripe, or Citadel might consider investing in air quality improvements to reduce employee sick days. But without precise data quantifying the benefits, it’s hard to make the case. Similarly, governments might hesitate to roll out large-scale interventions in schools, daycares, or federal buildings without clear evidence.

Patrick McKenzie:Indicatively, I’ve heard that retrofitting HVAC systems across the U.S. built environment might cost tens of billions of dollars. [Patrick notes: I didn't say "to hundreds of billions" in the live conversation but FWIW that is closer to the range.] That sounds like a lot, but we already pay an enormous cost in lives and resources every year due to poor air quality and infectious diseases.

The advantage of technologies like UVC light is that they’re relatively mature and inexpensive to produce. We can manufacture them at scale, and they’re effective against a broad range of pathogens. [Patrick notes: By "we" here I mean Shenzhen more than I mean the U.S., though I'd be happy to purchase them wherever they are made. Geopolitical rivalries aside, it's all team humanity against team virus, and I want us to win, regardless of who makes a dollar or gets the credit for it.]

Unlike the constant evolutionary race against new viral variants, pathogens share certain vulnerabilities—one being that they all “hate light.” [Patrick notes: Please excuse this exaggeration. Some microorganisms are extremophiles, etc etc. But to a first approximation they really don't like being boiled.]

This might not be the final chapter in humanity’s fight against airborne diseases, but it could be a significant leap forward.

Future of public health initiatives

Joshua Morrison:Absolutely, and it ties back to what we discussed earlier: what could the future of “Operation Warp Speed” look like?

At One Day Sooner, we’ve thought about a “Warp Speed 2.0” focused on a strep vaccine, which I’ve written about. But I don’t think Warp Speed needs to be limited to vaccines. A Warp Speed initiative for indoor air quality could be incredibly impactful.

Even something as simple as better filtration could make a huge difference, especially if paired with evidence generation. For example, imagine a focused goal: reduce airborne infections in military housing or barracks by 50% by the end of the next administration. That’s a clear, time-limited objective, and it’s technically achievable with better filters and monitoring.

If such an initiative proves measurable reductions in disease, the private sector will likely adopt these interventions where cost-effective—and even cost-saving. This could extend to schools, daycares, nursing homes, and cruise ships.

Rather than thinking of this as requiring a $100 billion overhaul of HVAC systems, the focus should be on demonstrating results. Once we establish evidence of the benefits, markets and governments can handle much of the scaling.

This approach aligns well with themes championed by both RFK Jr. and the Make America Healthy Again movement, while also honoring the Trump administration’s Warp Speed legacy. 

Patrick McKenzie:I’m extremely bullish on this, partly because, as you said, once we have solid data to back it up, it will likely become immediately incentive-compatible for organizations. Even ignoring the public health benefits, reducing employee sick days is a direct financial win for companies.

The optics of air-cleaning technologies are also significantly better than vaccines—sorry for the pun, folks. With current vaccine delivery mechanisms, there’s [almost] always going to be a needle involved, and a lot of people have a visceral dislike of needles.

This was something we encountered repeatedly [at VaccinateCA]. [Patrick notes: The feedback from early users was so strong that we changed icons and similar to avoid representing the shot as a shot.]  

By the way, shot blockers—devices that reduce pain from injections—should probably be standard of care for vaccine delivery, but that’s a separate discussion. [Patrick notes: “Standard of care” is a bit of medical/legal jargon. Essentially, there exist certain accepted practices where you’d need to exercise (and justify) your medical judgement to deviate from them. I’m saying that not using one of these devices for a vaccine should require a physician to affirmatively make that choice, as opposed to simply defaulting to the traditional method.]

Contrast that with Far-UVC lighting or other air-cleaning technologies. I’ve yet to meet someone who passionately hates electric lights. We’ve had them for over a century. No one turns on a light and experiences stabbing pain in their shoulder. These technologies, even if novel, are analogous to something everyone already accepts, which hopefully means they won’t become politically polarized.

Joshua Morrison:I agree, and it’s interesting how long we’ve known about the potential for air-cleaning technologies. For example, upper-room UV systems were studied almost 80 years ago. At the time, however, the momentum shifted toward antibiotics.

Jake Swett at Blueprint Bio has explained to me that while air-cleaning methods like UV worked in some cases, they didn’t always show dramatic effects. Meanwhile, antibiotics like penicillin ushered in a pharmaceutical revolution, capturing much of the focus and investment.

Part of the issue is that our market mechanisms are better at supporting products that help individuals than those that benefit communities. That makes this a very RFK Jr.-aligned concept. His broader themes around community-focused solutions and pollution fit well with advancing indoor air quality initiatives.

Patrick McKenzie:The economy and infrastructure we’re working with today are also vastly different from when penicillin was introduced. Imagine trying to explain to the first doctors using penicillin: “In the future, we’ll have container ships—uh, you don’t know what those are—filled with LED—uh, you don’t know what those are—which produce light of any wavelength for pennies on the dollar or satoshi on the Bitcoin—uh, you don’t know what those are.” [Patrick notes: I was really reaching for a third invocation of parallel structure.]

There are reasons to be optimistic about scaling these technologies now. Humanity has made extraordinary progress in its fight against infectious diseases, and with continued scientific advances, we can make significant strides here as well.

For folks who want to follow what you and One Day Sooner are doing, where can they find you online?

Joshua Morrison:You can visit our website at 1daysooner.org—We’re also on X (formerly Twitter) at x.com/1daysooner, and my personal handle is @JoshCMorrison.

If you’re interested in participating in challenge studies or other research, we’d love to hear from you.

Patrick McKenzie:Josh, thanks so much for joining the program today. For the rest of you, we’ll likely be off next week in observance of Christmas, but I’ll see you around the Internet soon. Thanks for listening!