Larry Brilliant on Covid Rapid Antigen Tests and Public Health

This was the year that Larry Brilliant got Covid. In May, he traveled to Davos, Switzerland, to attend the elite global gabfest that had been postponed from its usual January staging. The 78-year-old epidemiologist had gotten through the first years of the pandemic virus-free.

But, he now believes, traveling through a crowded Zurich airport exposed him to a recent variant of the disease that has infected over half a billion people worldwide and killed a million people in the United States alone. It was further proof that this virus spares no one, not even a disease fighter who helped eradicate smallpox and had been warning the world about a potential pandemic for years. He had even advised Davos organizers on their Covid protocols .

But Brilliant, of all people, knows that with ever-more virulent variants of Covid-19, even the most meticulous virus-avoider might get sick. And thus the multiple-boosted founder and CEO of Pandefense Advisory went through 17 days of testing positive and two rounds of the Paxlovid treatment. Now recovered, Brilliant is once again speaking about what we might expect with our ongoing global crisis.

I began interviewing Brilliant about the coronavirus in March 2020, and our first session was one of the most-read stories Condé Nast (which owns WIRED, the New Yorker, Vogue , and other publications) ran that year. This is the fifth installment of our ongoing conversation . We touched on how variants evolve, the humbling of the CDC, and why he thinks that rapid antigen tests are a menace.

Brilliant makes predictions reluctantly—he distinguishes glimpses into his “crystal ball” from actual science, which proceeds on empirical trials and experiments. But if he’s right, we’ll still be talking Covid for a very long time. This interview has been condensed and edited for clarity.

Steven Levy: How are you feeling? Larry Brilliant: I think I’m 110 percent recovered, after 17 days of positivity. Do you know about the Rockefeller Foundation retreat in Bellagio, Italy, where people go to plan conferences? I think that all the variants of Covid got together there with a list of all the people who spoke bad about them and decided: “Enough of this shit. Let’s go after those people.

” It certainly seems that tons of people who had been boosted and masked have gotten Covid recently. Fauci and Biden have gotten it, too. Why are careful people getting it now? Even the most careful person will get the most transmissible virus in history.

Also, mRNA vaccines are based on the formulations from the original strain . Every evolution produces a more evasive variant—it won’t win the race unless it’s the fastest pony. So instead of only finding new customers in the unvaccinated population, this BA.

5 variant increases its market by being able to infect people who’ve had three doses of the vaccine, or people who have had Covid a month ago. In addition, this puppy might be infectious earlier and later than when you first have symptoms. The CDC has guidelines of ending isolation—or going back to work—after five days.

With BA. 5, that’s ridiculous. You were one of those people with four doses.

That’s right, and I was also able to get a prophylactic monoclonal antibody. That’s probably why I think I got a relatively mild disease. But it persisted for 17 days, and I had to have two courses of Paxlovid.

By the way, I don’t think we should call this a rebound. A better way to say it is that we don’t have the dosing schedule correct. It’s possible that Paxlovid probably requires a course of seven or 10 days.

So if I get Covid, I can ask my doctor to give me seven or 10 day’s worth of Paxlovid instead of five? [Note: The official guidance is that Paxlovid should be administered for five days, though some physicians have spoken out about the need for clearer guidance . ] Not yet. When people say they’re following the science, what they should be saying is they’re following the published science, which is always based on a study done on something that happened before.

You’re always behind. Sometimes it seems like politics, not science, is determining policy. Biden said that he’d remain in isolation longer than the recommended five days if he kept testing positive.

Who’s right? Biden is modeling very good behavior. That’s really refreshing since the last president modeled the worst. Sure, but it’s strange that the president has to disregard his own agency to do the right thing.

[Note: After this interview, Biden ended up leaving isolation after five days when he tested negative, then reentering isolation after experiencing a rebound case . ] In part, this is because when Trump was president, he attacked the CDC. There was so much political interference that there was an exodus of the CDC’s top people and a loss of its institutional memory.

But there’s also been a failure of the CDC to communicate well and update their recommendations. Also, the CDC is slow. In some ways, you’d like that to be the case—you like your doctor to be deliberative.

But not too slow. Even though their advice may have been perfect a year ago, it’s not perfect now. So now the administration is talking about shifting pandemic preparedness to what used to be a small agency— ASPR [Administration for Strategic Preparedness & Response].

Why does that make sense? The CDC’s mandate is much more than pandemics. It works on health promotion, prevention. It’s responsible for looking at heart disease and diabetes, international relations with other countries doing all health programs—all the public health units of all the different counties.

But of course right now we’re necessarily focused on the pandemic and infectious diseases, and we’re really dealing with Covid and monkeypox. I was going to mention monkeypox . What’s going on there? Let’s go back to 1967.

The WHO had the idea that the whole world should work together to eradicate smallpox. But what about other poxes? The smallpox vaccine protects against monkeypox, too. If you eradicate smallpox, and subsequently you stopped vaccinating, what happens to the other poxes that were held in check by continuing to vaccinate? We could have kept vaccinating.

But we didn’t, and now no one under the age of 40 has a vaccination scar. It was certainly justifiable to use that vaccine against the disease that killed one out of three. But monkeypox is relatively mild, killing very few people.

It’s understandable that people would say, ‘Well, what’s the fuss?’ Well, there’s two reasons. First, we got over 20,000 cases. The people who are affected the most by this outbreak are men who have sex with men—but it’s also people who have sex in general, or anybody who rubs bodies with each other for any reason at all, or, of course, anybody who’s immunocompromised is at greater risk of getting it, giving it, and maybe having the bad side effects of it.

That’s one reason. But there’s another reason. If we had acted sooner—when there were 100 cases, 1,000 cases—we could have eliminated it as a significant problem.

We could even do this now by identifying every case and vaccinating all the contacts. We could stop this outbreak. The United States is not doing it.

Because it would require identifying every case and the complicated issues around who’s getting it. We don’t want to stigmatize the gay community; we did that with HIV/AIDS, with horrific results. Monkeypox is not a disease of gay men.

It’s also not a disease of monkeys. We are not the natural host of this virus. This is primarily a disease of rodents, but it was first identified in monkeys, and that’s where it got the name.

If we don’t act right now to contain the spread of monkeypox—if it’s subjected to the same laissez-faire epidemiology, “let it rip” ideology we are using with Covid—how far are you going to let it go? A hundred thousand? Two hundred thousand? A million? Speed is critical. If we quickly work to contain monkeypox, we don’t have to worry about 20 years of having urban rodent pox that spreads to humans. That’s why I’m unhappy about what we’re not doing now.

I’m unhappy about letting the cat out of the bag when we still have a bag. [Note: After our conversation, the World Health Organization declared monkeypox an emergency . ] Back to Covid.

You just used the term “laissez-faire epidemiology. ” Do you feel that our approach now, based on individual choices, is misguided? Yes. Remember Trump’s Covid advisor Scott Atlas, who promoted the idea that we should do away with lockdowns? When he said that, we didn’t have vaccines.

Millions more people would have died, certainly. In the United States, hundreds of thousands more people would have died. The death rates are down now, but it’s still very bad, for a hundred reasons.

When you say, “Everybody’s on their own,” we’re forgetting that we have a duty of care. At least 20 percent of our population are either over the age of 65 or immunocompromised. They are at high risk of dying if they don’t get vaccinated and they’re not careful, they’re not wearing masks.

… So if you just say, “OK, well, everybody’s gonna get it,” you endanger the people who are most vulnerable. That’s where the death rate is. That’s where the hospitalization rate is.

Second, the longer this virus continues, the more variants we’re going to have. We don’t know exactly what forms a variant, but for sure one factor is immunocompromised people who have the virus puttering around longer in their system—not for 17 days like me, but for months. The body can’t clear the virus completely.

You’ve created ideal circumstances for reassortment, recombination. Another issue is that we don’t have a good handle on numbers because we never got testing, right? What if I said to you that antigens, those rapid at-home tests we all use now, were bad for our public health? It’s stupid that antigen tests were approved without the requirement to report positive cases. How would you enforce that? Through technology.

It’s not that hard to build the technology to do automatic reporting. There’s now a class of at-home molecular tests that can already do that. They’re almost as good as PCR tests.

Aren’t those more expensive? The only thing that makes them expensive is the lack of scale. Right now we can get antigen tests for as little as $5. If you’re doing a billion molecular tests, you can bring the cost down as well.

When those molecular tests go to the FDA for approval, they say that all positives should be reported. That makes them much better than antigen tests, which are great at the back end of the disease when you’re trying to determine if you’re still infectious. But they’re terrible for the first two days, when the rate of false negatives is so high.

Between the false negatives and the fact that they don’t report into public health, antigen tests are dangerous to the public health. Would you ban them? I would regulate them. On to vaccines.

The one we have works against the original version of Covid, which no one gets any more. So why didn’t we have a “warp speed” effort for a specific vaccine directed toward the newer variants? We sort of did. Both Pfizer and Moderna are about to release vaccines specific for Omicron.

You seem to be asking why we don’t have a warp speed for BA. 5? We call that process whack-a-mole. So the new vaccine will do a better job protecting us from getting it? I hope so.

You will have more immunity to Omicron. But BA. 5 itself doesn’t necessarily honor a previous infection with Omicron.

The vaccine will, though, better prevent you from being hospitalized or dying. But we should start talking about BA. 2.

75 . It seems to be the next car in the train. And it’s coming on really quickly.

We’re already on to the next one? It’s already been detected in several states. We’re just getting more variants. There’s a controversy over whether people who are due for a booster should take it now or hold off until this new vaccine shows up in the fall.

I’m very cautious. I don’t want anybody to get Covid in the next two or three months before you can get the new vaccine. [Note: White House officials have said that anyone immunocompromised or over the age of 50 should get a second booster if they haven’t done so already.

] If you went back to our first conversation, in March 2020, it seemed unlikely we would be talking two and half years later and still facing huge numbers. Why are you surprised? I wrote an article called “ The Forever Virus . ” Will we ever get back to Before Times? When we don’t have to be careful and we can eat indoors and go to a Broadway show without a mask and feel safe? That’s two separate questions.

Will we ever get to a point where there’ll be no Covid? No. There will always be Covid. Will we ever get to a point where we go to a Broadway show without a mask? Yes.

We’ve probably had coronaviruses infect the world in a pandemic-like way before. And then the virus went into the retirement home for coronaviruses, and we called it a “cold virus. ” And they kind of rotate.

That’s why you can get two or three colds a year. They feel the same to you, but they’re different viruses. And that’s because the immunity that they give you is only good for about a year or two.

This Covid will eventually look like that. “Eventually” is the key word here. Over time, as the human population becomes more and more immune through a combination of vaccines and prior infection, repeated infection, then the coronavirus will sort of settle for being transmissible and it won’t be dangerous.

It won’t take you to the hospital. It doesn’t seem that way now. These variants are still getting lots of people super sick.

History does not move in a straight line. Has getting Covid changed the way you thought about this? Of course. I had begun to buy into the idea that for most people Covid was really like a cold or like a flu, and wasn’t that big a deal.

But it is a big deal. It’s a terrible effing disease. For a quarter of the population or even more, it’s a very serious disease.

And for the fifth of the population that’s not vaccinated at all, BA. 5 is an extraordinarily dangerous disease. I thought I was compassionate.

But having Covid has ratcheted me up to a much higher level of compassion for people who are having it or who are at high risk, because I know how bad it could be. And I don’t even have long Covid. Update 4-5-2022 11:45 PM ET: The headline for this story was updated to clarify that Brilliant is a a critic of Covid rapid antigen tests, not all Covid rapid tests.

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