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The Great Vaccine Race: Deutsche Bank’s Updated Primer

Deutsche Bank Returns With Updated Primer On Global Race For COVID-19 Vaccine



This article was originally published by ZeroHedge.

Deutsche Bank Returns With Updated Primer On Global Race For COVID-19 Vaccine Tyler Durden Wed, 11/11/2020 - 10:20

With all the vaccine-and therapeutic-related developments already this week (the Pfizer-BioNTech announcement, Novovax's new deal with the federal government, with the Eli Lilly antibody treatment earning FDA emergency-use approval, news of Brazilian authorities halting a trial involving a leading Chinese vaccine candidate etc.) it's not surprising that a team of analysts at Deutsche Bank have just released a follow-up to a comprehensive summary about the global race for a COVID-19 vaccine that was apparently popular with both clients and readers of financial blogs.

In the preamble to the research, the analysts note that there are now 12 vaccine projects that have reached 'Phase 3', the most expansive and final stage of testing. Of those, 6  - 4 Chinese and 2 Russian - have already received some limited form of emergency approval (also: Vladimir Putin claimed that his adult daughter tried the Russian vaccine during the trial, and was fine).

As DB has noted in the past, some 80% of vaccines are typically approved after reaching Phase 3. But that's hardly a guarantee that the optimistic timelines for a vaccine (in the US and Europe, at least) offered by Pfizer, Dr. Fauci, the leaders of Operation Warp Speed and others will pan out.

Read the rest of the report below:

Vaccine Developments:

More than 170 vaccine candidates were in development in November 2020. These efforts are being tracked by the WHO. Twelve vaccines are currently in phase 3 trials, including six already approved for emergency use and three additional vaccines (by AstraZeneca, Pfizer, and Moderna) that could receive similar validation by the end 2020. Of all clinical drug trials that reach phase 3, about 60% gain approval for widespread use. This suggests that there is a very high chance of a vaccine approval soon.

Given the pressured timeline to end phase-3 testing, adequate results could begin to be released in the first quarter of 2021. The first successful candidate(s) could be fully approved in H1 2021. If AstraZeneca’s and BioNTech/Pfizer’s testing were halted and trials delayed, full approval could get pushed to H2 2021.

Vaccine candidates, such as those being developed by AstraZeneca, BioNTech/ Pfizer, J&J, and SinoVac, are being tested in various countries. They could be more readily accepted because their phase-3 trials are being conducted on populations with diverse ethnicities, nutrition intakes, immunity levels, and ages.


Once a vaccine is approved, the next important milestone will be production and distribution. The WHO does not expect widespread vaccination until the middle of next year, and even that looks optimistic.

In total, the world will need at least ten to fifteen billion doses. That’s because most Covid-19 vaccines will require people to receive two-doses by injection. It’s fairly obvious to state but that means this is going to be one of the biggest logistical challenges ever known to humans. By comparison, in 2018 ten billion 1 doses globally across all vaccines and inoculations were injected. Global distribution will face a bottleneck because there are only four-to-six facilities in the world that can reliably mass produce vaccines. Other issues include technology transfer, intellectual property protection, and temperature-controlled distribution (called “cold chain”).2

Our baseline scenario involves a gradual post-vaccine normalization of economic and social activity occurring in advanced economies over the second half of 2021 and into the first half of 2022. For other parts of the globe, normalization will likely emerge through 2022 and well into 2023. Vaccine production should pick up enough to advance this schedule but getting enough doses to adequately cover a billion people in advanced economies by mid-2021 and 6.5 billion people in emerging economies by end 2021 seems overly optimistic.

According to recent announcements about the vaccine candidates in Phase 3, seventy eight million doses could be ready by the end of next year. Assuming a stable annual production and increased production capacity later on, the world could be covered in 2022. Though it's worth highlighting that the vaccines are all for adult use.

Earlier we noted that, assuming a 75% vaccine efficiency rate and a full vaccination of the population (very unlikely), three-quarters of the world’s population could be vaccinated by mid-2023. That should be enough to curb the spread of infection, but not enough to eliminate the virus. However, now with Pfizer’s reported efficiency of over 90% based on early data from Phase 3 trials, it is on par with highly effective childhood vaccines for diseases such as measles. Assuming an R0 of 2.5, it would take just over 60% vaccination coverage to achieve herd immunity. That may be feasible over the course of 2021.

Because the best vaccines will inevitably be in short supply, many advanced economies have started signing bilateral supply agreements with manufacturers. The UK, US, Canada, Japan, EU, and Australia will have secured enough diversified doses from leading candidates for their populations.

If the Oxford/AstraZeneca vaccine is successfully rolled out, the benefits would be distributed symmetrically across regions because most governments around the world have secured significant quantities. Emerging economies will likely benefit more than G10 economies from a Chinese vaccine.

Distribution & Price:

According to Northeastern University’s Mobs Lab, which assessed a scenario in which doses were distributed globally based on each country’s population, a vaccine would have prevent 61% of total deaths. In a second scenario, in which 50 high-income countries monopolised the first two billion doses of the vaccine, nearly twice as many people would die and the virus would spread more widely.

To ensure a ”fair” distribution and to avoid ”vaccine nationalism,” 172 countries and multiple vaccine candidates are engaged in the Covid-19 Vaccine Global Access Facility (COVAX initiative) with the aim of having enough vaccine doses to treat at least 20% of the participating countries' populations, with a goal of two billion doses by the end of 2021.

“Fair distribution “also means three tier prices. Advanced economies would pay back a lot of the fixed costs, whereas middle-income countries would pay some of its costs, and the poorer countries would pay a true marginal cost.

Very few vaccine development companies have “officially” set their prices. We should expect a wide variation in pricing. Moderna indicated that its prices are likely to be around $37 per dose maximum. Media reported that AstraZeneca sold its dose at about $3 or $4 to the EU. The vaccines developed by J&J and Sanofi/GSK are expected to cost about $10 per dose. The mRNA-based vaccine (e.g. Moderna and BioNTech/Pfizer) are likely to be costlier as they are most expensive to manufacture. China’s Sinovac started selling its vaccine in some cities at $60 for two shots as part of an emergency use program. COVAX has an agreement with Serum Institute of India to deliver doses of candidate vaccines licensed from AstraZeneca and Novavax to low- and middle-income countries at a maximum of $3 a dose.

Efficacy, Herd Immunity, and Vaccination:

Vaccines currently in phase-3 trials are only meant for adults, including the elderly and early data from Pfizer/BioNTech has suggested an efficiency of over 90%. Next we should likely hear from Moderna and AstraZeneca over the coming weeks. Early stage vaccine trials currently in phase 3 have been largely effective in individuals between age eighteen and fifty-five. Additional early stage trials from both AstraZeneca and BioNTech/Pfizer have shown that their vaccine candidates are effective in elderly people as well.

Most vaccines currently in phase 3 will require two shots. An exception is the vaccine by Johnson and Johnson, which is expected to be a single-shot vaccine. Early research shows that any immunity is likely to be time-bound, which means that people might need injections at regular intervals as is the case with flu vaccines. A study from Imperial College London highlighted that the proportion of people in England with antibodies dropped by more than a quarter in the space of three months. The roles of mucosal immunity, biological antibody activities (e.g., antibody-dependent cellular cytotoxicity), and T cells in the protection offered by natural infection or passive immunisation are still unclear.

Tests on vaccinated primates showed reductions in pathology, symptoms, and viral load in the lower respiratory tract, but they failed to elicit sterilising immunity in the upper airways. Sterilising immunity in the upper airways has been claimed for one vaccine, but without peer-reviewed confirmation.

Assuming that development and production bottlenecks are cleared, population willingness to receive a vaccination remains a question. Our proprietary survey showed that between 35% and 53% of people in various countries will choose to be vaccinated—a much lower number than we found in August. This leads many to debate whether vaccination should be mandatory.

Due to limited vaccine supply, and because vaccines could be less-than-fully effective, and because many people won’t accept vaccination, herd immunity probably won’t be reached in advanced economies until the first half of 2022 and more globally in 2023. And if vaccine candidates’ trials were to be delayed, herd immunity would probably be reached in early H2 2022 for advanced economies and mid-2023 globally. Full normalization of economic activity could take even longer.

Historically, there has been resistance to vaccines. Many believe that diseases are disappearing due to better sanitation and hygiene, not because of vaccines. This has been proven false by the resurgence of previously eradicated infectious diseases. An example is measles, which was declared eradicated in the United States in 2002 and then reappeared in 2014 with six hundred cases). Some people think that the risks of vaccines outweigh the benefits. For example, many think that vaccines can cause autism even though the CDC has clarified that vaccine ingredients don’t cause autism. People often distrust science and the government, or they believe that pharmaceutical companies want to sell a product regardless of harmful consequences.

As a result of these false notions, more than a tenth of one-year-old children globally are not immunized against tuberculosis and hepatitis B. Less than half of one-year- old children globally are vaccinated against pneumococcal disease or the rotavirus. The WHO listed “vaccine hesitancy” as one of the top-ten threats to global health in 2019. According to our proprietary survey, a third of the people surveyed were vaccinated last year for the flu. In Europe, only half of the population agreed that “vaccines are safe.”

An extreme scenario to ensure full vaccination coverage would be make it mandatory. Of course, it is difficult to define mandatory. Public policy might involve incentives, punishments, or a combination of the two. Medical exemptions will be needed for various groups. Governments will need to acknowledge the impossibility of determining the long-term side effects of a newly developed Covid- 19 vaccine at this time.

In our proprietary survey, we asked people if they believed that governments should mandate Covid-19 vaccination. In October 2020, only a third of the Americans and French, and half of Italians and British, were in favor of mandatory vaccination. This could be explained by: (i) the politicization of vaccines during the US elections, and (ii) recent reports about adverse effects of a few candidate vaccines during phase 3 trials (e.g. AstraZeneca and J&J), which resulted in temporary pauses in the trials. (These trials have since resumed, or will resume after medical agency reviews.)

Meanwhile, without herd immunity, cheap and fast tests could be a solution:

We might need to learn to live with this virus. Many scientists believe a resurgence in SARS-CoV-2 could persist until 2025.8 During the coming winter months in the Northern Hemisphere, people could see the virus spread at an accelerated pace because they spend more time indoors where virus transmission is more prevalent.

On the positive side, a few countries have started to implement cheap, fast tests. These tests would allow people to return to work quickly and they could be a game- changer for the travel and hospitality industries. It may only be a question of time before these tests are offered at schools, universities, companies, airports, and pharmacies. As with masks, the rapid test could soon be universally available.

Most tests require specialised equipment to read results, limiting widespread use. Recent antigen tests (e.g. Abbott and Innova Medical Group) have shown promising results with an accuracy above 90%. Health care professionals are administering antigen tests. In addition, companies are developing self- administered kits that use saliva samples. None of these self-administered tests have received regulatory approval yet.

Only a few countries have started implementing cheap, fast tests. Italy began trials with coronavirus swab tests in hospitals in July and, later, at major airports to screen high-risk passengers. Plans are underway to screen all passengers at all airports. Spain, in April, began using these tests in elderly care homes and hospitals. The US will use 100 million tests from Abbott in schools and “other special needs populations.” Some US airlines have started to offer pre-flight rapid coronavirus testing. The UK is planning to roll out two tests ahead of winter to NHS hospitals, elderly care homes, and labs. Rapid antigen tests are being used as screening tools for sports, such as professional basketball and football. Results can take fifteen to thirty minutes.

These tests are expected to improve the situation in African countries, where the testing ability is limited to large cities and often take two to ten days to obtain results.

The WHO says that these new tests will be used in addition to PCR tests and will be more effective when used on patients who show symptoms, have a high viral load, or high concentrations of the virus in upper respiratory tracts. The WHO recommends that these tests be used in remote and rural areas. The organization has rolled out about 120 million rapid tests to low- and middle-income countries.

Conclusion: Vaccine Side Effects

Most vaccine side effects are well-identified. They are mainly caused by adjuvant, which is an ingredient used in some vaccines that helps create stronger immune responses. Adjuvant vaccines are known to cause more local reactions (redness, swelling, and pain, etc.) at the injection site, and more systemic reactions (fever, chills, and body aches) than non-adjuvant vaccines, according to the CDC. Most vaccines developed today are not adjuvant-based and include just small amounts of germ components, such as proteins, rather than the entire virus or bacteria. Among vaccine candidates that have reached phase-3 trials, the only adjuvant- based vaccine is Novavax, which uses a proprietary saponin-based MatrixMTM adjuvant. Recently, Bharat Biotech announced that its novel coronavirus vaccine will use adjuvant Alhydroxiquim-II to boost immune response and longer-lasting immunity.

Thimerosal, a form of mercury, is used in some vaccines in small quantities as a preservative, mostly for flu and a few multi-dose formulations. The CDC denies any causal relationship between Thimerosal and autism. The CDC states that the mild side effects include redness and swelling at the place where the shot was given.

Anaphylaxis is a severe allergic reaction to ingredients such as gelatin, which is sometimes in vaccines. It can cause life-threatening breathing and/or circulation problems. It is always extremely serious, but reactions can be treated with adrenaline. Influenza and yellow fever vaccines mostly contain egg protein; therefore, people with severe egg allergies are recommended to get the injection under medical supervision. Based on data from the UK between 1997 to 2003, the overall rate of anaphylaxis is around 1 in 900,000.

Common side effects, in early trials, from Covid-19 vaccine candidates have included tenderness and pain. Less-common systemic side effects have included headaches, fatigue, and myalgia (achiness). However, these are general side effects which one might experience after taking any vaccine.

* * *

Source: Deutsche Bank

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Glimpse Of Sanity: Dartmouth Returns Standardized Testing For Admission After Failed Experiment

Glimpse Of Sanity: Dartmouth Returns Standardized Testing For Admission After Failed Experiment

In response to the virus pandemic and nationwide…



Glimpse Of Sanity: Dartmouth Returns Standardized Testing For Admission After Failed Experiment

In response to the virus pandemic and nationwide Black Lives Matter riots in the summer of 2020, some elite colleges and universities shredded testing requirements for admission. Several years later, the test-optional admission has yet to produce the promising results for racial and class-based equity that many woke academic institutions wished.

The failure of test-optional admission policies has forced Dartmouth College to reinstate standardized test scores for admission starting next year. This should never have been eliminated, as merit will always prevail. 

"Nearly four years later, having studied the role of testing in our admissions process as well as its value as a predictor of student success at Dartmouth, we are removing the extended pause and reactivating the standardized testing requirement for undergraduate admission, effective with the Class of 2029," Dartmouth wrote in a press release Monday morning. 

"For Dartmouth, the evidence supporting our reactivation of a required testing policy is clear. Our bottom line is simple: we believe a standardized testing requirement will improve—not detract from—our ability to bring the most promising and diverse students to our campus," the elite college said. 

Who would've thought eliminating standardized tests for admission because a fringe minority said they were instruments of racism and a biased system was ever a good idea? 

Also, it doesn't take a rocket scientist to figure this out. More from Dartmouth, who commissioned the research: 

They also found that test scores represent an especially valuable tool to identify high-achieving applicants from low and middle-income backgrounds; who are first-generation college-bound; as well as students from urban and rural backgrounds.

All the colleges and universities that quickly adopted test-optional admissions in 2020 experienced a surge in applications. Perhaps the push for test-optional was under the guise of woke equality but was nothing more than protecting the bottom line for these institutions. 

A glimpse of sanity returns to woke schools: Admit qualified kids. Next up is corporate America and all tiers of the US government. 

Tyler Durden Mon, 02/05/2024 - 17:20

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From Colombia to Laos: protecting crops through nanotechnology

In a recent breakthrough, DNA sequencing technology has uncovered the culprit behind cassava witches’ broom disease: the fungus genus Ceratobasidium….



In a recent breakthrough, DNA sequencing technology has uncovered the culprit behind cassava witches’ broom disease: the fungus genus Ceratobasidium.

Credit: Alliance of Bioversity and CIAT / A. Galeon

In a recent breakthrough, DNA sequencing technology has uncovered the culprit behind cassava witches’ broom disease: the fungus genus Ceratobasidium.

The cutting-edge nanopore technology used for this discovery was first developed to track the COVID-19 virus in Colombia, but is equally suited to identifying and reducing the spread of plant viruses. The findings, published in Scientific Reports, will help plant pathologists in Laos, Cambodia, Vietnam and Thailand protect farmers’ valued cassava harvest.

“In Southeast Asia, most smallholder farmers rely on cassava: its starch-rich roots form the basis of an industry that supports millions of producers. In the past decade, however, Cassava Witches’ Broom disease has stunted plants, reducing harvests to levels that barely permit affected farmers to make a living,” said Wilmer Cuellar, Senior Scientist at the Alliance of Bioversity and CIAT.

Since 2017, researchers at the Alliance of Bioversity International and CIAT have incorporated nanotechnology into their research, specifically through the Oxford Nanopore DNA/RNA sequencing technology. This advanced tool provides insight into the deeper mysteries of plant life, accurately identifying pathogens such as viruses, bacteria and fungi that affect crops.

“When you find out which pathogen is present in a crop, you can implement an appropriate diagnostic method, search for resistant varieties and integrate that diagnosis into variety selection processes,” said Ana Maria Leiva, Senior Researcher at the Alliance.

Nanotechnology, in essence, is the bridge between what we see and what we can barely imagine. This innovation opens a window into the microscopic world of plant life and pathogens, redefining the way we understand and combat diseases that affect crops.

For an in-depth look at the technology being used in Laos and Colombia, please explore this link.

About the Alliance of Bioversity International and CIAT

The Alliance of Bioversity International and the International Center for Tropical Agriculture (CIAT) delivers research-based solutions that harness agricultural biodiversity and sustainably transform food systems to improve people’s lives. Alliance solutions address the global crises of malnutrition, climate change, biodiversity loss, and environmental degradation.

With novel partnerships, the Alliance generates evidence and mainstreams innovations to transform food systems and landscapes so that they sustain the planet, drive prosperity, and nourish people in a climate crisis.

The Alliance is part of CGIAR, a global research partnership for a food-secure future.

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Public Health from the People

There are many ways to privately improve public health. Such responses make use of local knowledge, entrepreneurship, and civil society and pursue standard…



There are many ways to privately improve public health. Such responses make use of local knowledge, entrepreneurship, and civil society and pursue standard goals of public health like controlling the spread of infectious diseases. Moreover, private responses improve overall welfare by lowering the total costs of a disease and limiting externalities. If private responses can produce similar outcomes as standard, governmental public health programs—and more—perhaps we should reconsider when and where we call upon governments to improve public health.

Two Kinds of Private Responses

Following Vernon Smith and his distinction between constructivist and ecological rationality, private actors can engage in two general kinds of public health improvements. They can engage in concerted efforts to improve public health, and they can engage in emergent responses through myriad interactions.1 Three stories below—about William Walsh, Martha Claghorn, and Edwin Gould—indicate concerted efforts to improve public health.

Walsh, a Catholic priest and President of the Father Matthew Society in Memphis, Tennessee, used the society to organize a refugee camp outside of the city and helped hundreds of people avoid yellow fever during the 1878 epidemic—one of the worst yellow fever epidemics in the country.2 Shortly after learning mosquitos carried diseases prior to 1901, Claghorn chaired the Civics committee of the Twentieth Century Club in the Richmond Hill area of Long Island and led a community-wide anti-mosquito campaign, which rid the area of potentially infectious mosquitos.3 After realizing that many of his employees were sick with malaria, Gould—president of the St. Louis Southwestern Railway—used his wealth and business firm to finance and develop an anti-mosquito campaign throughout Texas.4

These stories show how individuals recognize a public health problem given their circumstances and use their knowledge and available resources to resolve the problem. More recently, we might all be familiar with private, constructivist responses to Covid-19. We all made plans to avoid others and produce our desired amount of exposure. Many people made facemasks from old clothes or purchased them from facemask producers. Businesses, retailers, restaurants, and many others adapted in various ways to limit exposure for their workers and customers. My favorite example, albeit not relevant for most, is the so-called bubble that was implemented by the NBA, which housed teams, encouraged play, and limited infection. The NBA finished their season and crowned a 2020 champion only because of the privately designed and implemented bubble solution. The key is that the bubble pursued all of those objectives, not just one of them. All of these responses indicate how private interactions among people can minimize their exposure, through negotiation, discussion, and mutually beneficial means.

In addition to privately designed solutions, emergent public health responses are also important, perhaps even more so. Long-term migration and settlement patterns away from infectious diseases, consumption to improve nutrition, hygiene, sanitation, and the development of social norms to encourage preventative behavior are all different kinds of emergent public health responses. Each of these responses—developed through the actions of no one person—are substantial ways to improve public health.

First, consider how common migration operates as a means of lowering prevalence rates. As soon as people realized that living near stagnant bodies of water increased the probability of acquiring diseases like malaria, they were more likely to leave those areas and subsequently avoid them. Places with such features became known as places to avoid; people also developed myths to dissuade visitors and inhabitants.5 Such myths and associations left places like the Roman Campagna desolate for centuries. These kinds of cultural associations are also widespread; for example, many people in North and South Carolina moved to areas with higher elevation and took summer vacations to avoid diseases like malaria. East End and West End, in London, also developed because of the opportunities people had to migrate away from (and towards) several diseases.6

While these migration patterns might develop over decades, movement and migration also help in more acute public health crises. During the 1878 yellow fever epidemic throughout the southern United States, for example, thousands of people fled their cities to avoid infection. They took any means of transportation they could find. While some fled to other, more northern cities, many acquired temporary housing in suburbs, and many formed campsites and refugee camps outside of their city. The refugee camps outside of Memphis—like the one formed by William Walsh—helped hundreds and thousands of people avoid infection throughout the Fall of 1878.

Second, more mundane public health improvements—like improvements in nutrition, hygiene, and sanitation—are also emergent. These improvements arise from the actions of individuals and entrepreneurs, often closely associated with voluntary consumption and markets. According to renowned medical scientist Thomas McKeown, that is, rising incomes encouraged voluntary changes in consumption, which helped improve nutrition, sanitation, and lowered mortality rates.7 These effects were especially pertinent for women and mothers as they often selected more nutritious food and altered household sanitation practices. With advancing ideas about germs, moreover, historian Nancy Tomes argues that private interests advanced the campaign to improve house-hold sanitation and nutrition—full of advice and advertisements in newspapers, magazines, manuals, and books.8 Following Tomes, economic historians Rebecca Stein and Joel Mokyr substantiate these ideas and show that people changed their hygiene, sanitation, house-hold cleaning habits, and diets as they learned more about germs.9 Such developments helped people to provide their desired exposure to germs according to their values.

Obviously, there were concerted public health improvements during this time that also explain falling mortality rates. For example, waterworks were conscious efforts to improve public health and were provided publicly and privately, with similar, positive effects on health.10 The point is that while we might be quick to connect the health improvements associated with a public water system, we should also recognize emergent responses like gradual changes in voluntary consumption.

Finally, social norms or rules that encourage preventative behavior might also be relevant kinds of emergent public health responses. Such rules identify behavior that should or should not be allowed, they are enforced in a decentralized way, and if they follow from the values of individuals in a community.11 If such rules pertain to public health, they can raise the cost of infectious behavior or the benefits of preventative behavior. Covering one’s mouth when sneezing is not only beneficial from a public health perspective, it also helps avoid earning disapproval.

The condom code during the height of the HIV/AIDS epidemic is another example of an emergent public health rule that reduced infectiousness by encouraging safer behavior.12 People who adopted safer sexual practices were seen to be doing the right thing—akin to taking care of a brother. People who refrained from adopting safer sexual practices were admonished. No single person or entity announced the rule; rather, it emerged from the actions and interactions of individuals within various communities to pursue their goals regarding maintaining sexual activity and limiting the spread of disease. Indeed, such norms were more effective in communities where people used their social capital resources to determine which behaviors should be changed and where they can more easily monitor and enforce infractions. This seems like a relevant factor where many gay men and men who have sex with men live in dense urban areas like New York and Los Angeles that foster LGBTQ communities.

Covid-19 provides additional examples where social norms encouraged the use of seemingly appropriate behavior, e.g., social distancing, the use of facemasks, and vaccination. Regardless of any formal rule in place, many people adapted their behavior because of social norms that encouraged social distancing, the use of facemasks, and vaccination. In communities that valued such behaviors, people that wore face masks and vaccinated were praised and were seen as doing the right thing; people that did not were viewed with scorn. Indeed, states and cities that have higher levels of social capital and higher values for public health tend to have higher Covid-19 vaccine uptakes.13

Improving Public Health and More

“Private approaches tend to lower the total costs of diseases and they limit externalities.”

While these private approaches can improve public health, can they do more than typical public health approaches cannot? Private approaches tend to lower the total costs of diseases and they limit externalities. Each aspect of private responses requires additional explanation.

Responding to infectious diseases and disease prevention is doubly challenging because not only do we have to worry about being sick, we also have to consider the costs imposed by our preventative behaviors and the rules we might impose. Thus, the total costs of an infectious disease include 1) the costs related to the disease—the pain and suffering of a disease and the opportunity costs of being sick—and 2) the costs associated with preventative and avoidance behavior. While disease costs are mostly self-explanatory, the costs of avoiding infection warrant more explanation. Self-isolation when you have a cold, for example, entails the loss of potentially valuable social activities; and wearing condoms to prevent sexually transmitted diseases forfeits the pleasures of unprotected sexual activity. Diseases for which vaccines and other medicines are available are less worrisome, perhaps, because these are diseases with lower prevention costs than diseases where those pharmaceutical interventions are not available. Governmental means of prevention also add relevant costs. Many readers might be familiar with the costs imposed by our private and public responses to Covid—from isolation to learning loss, and from sharp decreases in economic activity to increased rates of depression and spousal abuse.14 Long before Covid, moreover, people bemoaned wearing masks during the Great Flu,15 balked at quarantine against yellow fever,16 and protested bathhouse closings with the onset of HIV.17

Figure 1 shows the overall problem: diseases are harmful but our responses to those diseases might also be harmful.

Figure 1. The Excess Burden of Infectious Diseases

This figure follows Bhattacharya, Hyde, and Tu (2013) and Philipson (2000), who refer to the difference between total costs and disease costs as the excess burden of a disease. That is, excess burden depends on how severely we respond to a disease in private and in public. The excess burden associated with the common cold tends to be negligible as we bear the minor inconvenience of a fever, a sore throat perhaps, or a couple days off work; moreover, most people don’t go out of their way to avoid catching a cold. The excess burden of plague, however, is more complicated; not only are the symptoms much worse—and include death—people have more severe reactions. Note too that disease costs rise with prevalence and with worsening symptoms but eventually decline as more severe diseases tend to be less prevalent. Still, no one wants to be infected with a major disease, and severe precautions are likely. We might shun all social interactions, and we might use government to impose strict quarantine measures. As disease severity rises along the horizontal axis, it might be the case that the cure is worse than the disease.

The private responses indicated above all help to lower the total costs of a disease because people choose their responses and they use their local knowledge and available resources to select cheaper methods of prevention. Claghorn used her neighborhood connections and the social capital of her civics association to encourage homeowners to rid their yards of pools of water; as such she lowered the costs of producing mosquito control. Similarly, Gould used the organizational structure of his firm to hire experts in mosquito control and build a sanitation department. These are cheap methods to limit exposure to mosquitos.

Emergent responses also help to lower the total costs of a disease because such responses indicate the variety of choices people face and their ability to select cheaper options. People facing diseases like malaria might be able to move away and, for some, it is cheaper than alternative means of prevention. Many people now are able to limit their exposure to mosquitos with screens, improved dwellings, and air conditioning.18 Consider the variety of ways people can limit their exposure to sexually transmitted diseases like HIV. If some people would rather use condoms to limit HIV transmission, they are better off doing so than if they were to refrain from sexual activity altogether. Similarly, some people would be better off having relatively risky sexual activity if they were in monogamous relationships or if they knew about their partner’s sexual history. That people can choose their own preventative measures indicates lower total costs compared with blunt, one-rule-for-all, governmental public health responses.

Negative and positive externalities of spreadable diseases indicate too much infectious behavior and too little preventative behavior, respectively. Hosting a party is fun, but it also incurs the internal costs of the drinks and appetizers and, more importantly, perhaps the external costs of raising the probability that people get sick. Attending a local cafe can be relaxing, but you have to pay for a cup of coffee and you might also transmit a disease to other coffee drinkers. The same could be said for many other public and social activities that might spread diseases like attending a class or a basketball game, transporting goods and people, and sexual behaviors. Our preventative behaviors from taking a vaccine to covering your mouth and from isolation to engaging in safer sexual practices emits positive externalities. If left unchecked, negative and positive externalities lead to higher rates of infection.

Overall, we should continue to think more critically about delineating how private and public actors can improve public health and overall welfare. More importantly, we should recognize that private actors are more capable than we often realize, especially in light of conscious efforts to improve public health and those efforts that emerge from people’s actions and interactions. These private efforts might be better at advancing some public health goals than public actors do. Individuals, for example, have more access to local knowledge and can discover novel solutions that serve multiple ends—often ends they value—rather than the ends of distant officials. Such cases and possibilities indicate cheaper ways to improve public health.


[1] Smith (2009), Rationality in Economics: Constructivist and Ecological Forms, Cambridge University Press.

[2] For more on Walsh, see Carson (forthcoming), “Prevention Externalities: Private and Public Responses to the 1878 Yellow Fever Epidemic,” Public Choice.

[3] For more on Claghorn, see Carson (2020), “Privately Preventing Malaria in the United States, 1900-1925,” Essays in Economics and Business History.

[4] For more on Gould, see Carson (2016), “Firm-led Malaria Prevention in the United States, 1910-1920,” American Journal of Law and Medicine.

[5] On the connection between malarial diseases, dragons, and dragon-slaying saints, see Horden (1992), “Disease, Dragons, and Saints: the management of epidemics in the dark ages,” in Epidemics and Ideas by Ranger and Slack.

[6] For more on migration and prevalence rates, see Mesnard and Seabright (2016), “Migration and the equilibrium prevalence of infectious disease,” Journal of Demographic Economics.

[7] The American Journal of Public Health published several commentaries on McKeown in 2002:

[8] Tomes (1990), “The Private Side of Public Health: Sanitary Science, Domestic Hygiene, and the Germ Theory, 1870-1990,” Bulletin of the History of Medicine.

[9] Mokyr and Stein (1996), “Science, Health, and Household Technology: The Effect of the Pasteur Revolution on Consumer Demand,” in The Economics of New Goods, NBER.

[10] See Werner Troesken’s work on public and private waterworks in the U.S. around the turn of the 20th century. See Galiani, Gertler, and Shargrodsky (2005), “Water for Life,” Journal of Political Economy.

[11] Brennan et al., (2013), Explaining Norms, Oxford University Press.

[12] For more on the condom code, see Carson (2017), “The Informal Norms of HIV Prevention: The emergence and erosion of the condom code,” Journal of Law, Medicine and Ethics.

[13] Carilli, Carson, and Isaacs (2022), “Jabbing Together? The complementarity between social capital, formal public health rules, and covid-19 vaccine rates in the U.S.,” Vaccine.

[14] Leslie and Wilson, “Sheltering in Place and Domestic Violence: Evidence from Calls for Service During Covid-19.” Journal of Public Economics 189, 104241. Mulligan, “Deaths of Despair and the Incidence of Excess Mortality in 2020,” NBER, Betthauser, Bach-Mortensen, and Engzell, “A systematic review and meta-analysis of the evidence on learning during the Covid-19 Pandemic,” Nature Human Behavior,

[15] On the great influenza epidemic, see CBS News, “During the 1918 Flu pandemic, masks were controversial for ‘many of the same reasons they are today’.” Oct. 30, 2020.

[16] On yellow fever quarantine in Mississippi, see Deanne Nuwer (2009), Plague Among the Magnolias: The 1878 Yellow Fever Epidemic in Mississippi.

[17] On these closures, see Trout (2021), “The Bathhouse Battle of 1984.”

[18] Tusting et al. (2017), “Housing Improvement and Malaria Risk in Sub-Saharan Africa: a multi-country analysis of survey data.” PLOS Medicine.

*Byron Carson is an Associate Professor of Economics and Business at Hampden-Sydney College in Virginia, where he teaches courses on introductory economics, money and banking, health economics, and urban economics. Byron earned his Ph.D. in Economics from George Mason University in 2017, and his research interests include economic epidemiology, public choice, and Austrian economics.

This article was edited by Features Editor Ed Lopez.


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