Corona Crisis: The View From The Valley (w/ Balaji Srinivasan)

Balaji, thank you for joining us at Real Vision.

Hey, thank you for having me.

Balaji, we have so much to talk about today. You're such an interesting person. You've led such an interesting life in so many different domains as an angel investor, as an operating executive, and also as an academic at Stanford. We're going to get to all of that, but first tell us a little bit about your background and how you came to be where you are right now.

Parents came over from India, and I grew up on Long Island, New York. You say on Long island, not from Long Island. Came out to Stanford as an undergrad and was there for quite a while. Got my B.S. mS, Ph.D. in electrical engineering, Ms. in chemical engineering. Then I taught computer science, stats and bioinformatics at Stanford for a few years. My PhD work was in microbial genomics, and I also did genetic circuits, clinical genomics, systems biology, basically everything in genomics. I had a finger in that. And then after that, I started a genomics company with some of my colleagues from Stanford that ended up eventually selling for $375 million, basically a diagnostics company that tested for Mendelian diseases like sickle cell 6, fibrosis, Tay Sachs, stuff of that nature. What I was able to do after that is I became an angel investor. I invested in, you know, as early investor in Bitcoin, Soylent, Superhuman, Lambda School, Cameo, Ethereum, zcash, a bunch of things that have done well, some things your audience may have heard of. I was a general partner at Andreessen Horowitz, multibillion dollar venture capital firm where some of my portfolio companies ended up becoming the basis of our bio and then also our crypto funds, which are now large independent funds. I taught a MOOC course, a massively open online course with 250,000 students online. So very large online course. And then most recently, I took over one of our portfolio companies at Andreessen Horowitz, turned that around, messy situation, which I fixed. So I had to be a turnaround CEO, turned that around, sold it to Coinbase, which is an $8 billion cryptocurrency company. I was CTO of Coinbase until last year. And then I took some time off. Then starting in January, basically right about when I was about to do my next thing, I started paying attention to this coronavirus and tweeted about that and I think helped, among many other people, raise the alarm on that, especially in Silicon Valley and the West Coast. And that brings us to the present day.

Yeah, you were very early on coronavirus and many People know you now from your Twitter feed. The things that you've been tweeting, your analysis and the framework that you've brought to that, the sort of academic rigor and the background in biotech kind of converging to give us a bit of a sense of the way you think about the world.

That's very kind of you. I basically, I have a few filters that I was putting on it as a diagnostics person also, certainly as like a vc, as a biotech entrepreneur, as an academic who had studied this kind of stuff for a long time. I mean, the space is very interdisciplinary. Right. There's nobody who's an epidemiologist and a pulmonologist and a cardiologist and this and that. Right. But from a bioinformatics and genomics and diagnostic standpoint, I think, at least on those angles, I think I was qualified to comment.

Right. And there were certainly no COVID 19 experts as recently as six months ago.

Yeah, that's right. That's right. And I think one of the things about this is it's so broad. Everybody has to have some. If you're doing any kind of economic planning, you're basically going to have to be an amateur epidemiologist in the sense that you have to have your personal forecast of how bad the thing is going to be. And you simply can't just trust experts because enough experts disagree with each other that there isn't a obvious consensus, number one. And number two is in such a high stakes situation you probably want to do your own diligence to some extent. So it's something where I don't think anybody can possibly be an expert in everything. There's a great article and actually BMJ recently which said, hey, we need to create experts, not hoard expertise, not pretend that there's a finite pool of it because that person was at one point just an undergrad, read a textbook and leveled up in the space. And you might be able to do that in a day, but in a month you can actually get reasonably conversant with some of these terms. I'm not saying expert, but I am saying conversant. I think that's actually a valuable thing to do. Everybody's been talking about serology and ifrs and all this type of stuff. The vocabulary is filtered out there and I think it's actually generally good. We can get into that. Yeah.

So set the stage for us a little bit where you were in January, how you came to be aware of it and what your first exposure to.

It was yeah, so Twitter is a hobby of mine, like it is for many people who enjoy wasting time in the Uber or whatever. I was basically following this virus, like 20 other things you might follow in your peripheral vision. It just kind of pops up on your radar because when you're an investor or something like that, this is what you do. You're tracking a bunch of trends and many of them fizzle out before they get anywhere. But this one in particular, what was obviously a huge deal, was the lockdown of Wuhan on January 23. And the thing is that the Chinese government is not known for committing economic harakiri. It's not known for committing economic suicide. There's a lot of other things it does that we might disagree with, and I might well agree with you in that disagreement, but it's not dumb or self destructive in quite this way. And for it to do that, that was an unfakable signal to the world that something very serious was going on that endangered the regime's legitimacy to a greater extent than potentially causing a huge economic crash could. And so that got my attention. I mean, the other thing is some of my friends here in tech, we were talking about this. But in Silicon Valley, in technology, you're dealing with folks, Chinese entrepreneurs, who are very competent and often, frankly, will defeat you, certainly in China and often abroad, because they just execute really, really fast and they work very hard and they're smart and they can clone your stuff really fast. But now they've also been able to innovate. We have a healthy respect for them as peer competitors and folks who we have to give our A game with, I mean, it's possible to win. I think, for example, Facebook and Google have done well against Tencent and Alibaba. Internationally, it's possible to win. They're not unbeatable, but you have to give your A game or your A plus game. And when we saw that China was having trouble with this, not just trouble, but overturning society to control it, that made us very concerned because we don't have the model of them being a third world country. This is a very sophisticated, very technologically advanced country that's ahead of the United States and the rest of the world in many ways, especially things like WeChat or what have you. For them to struggle with. This really had to pay attention. So that was a big trigger. And then I started digging into the literature.

Yeah, that's such an interesting frame. The notion that the Chinese were certainly not about to shut down a city in such a key industrial area. If they did not absolutely have to. So when you begin to see that, at what point did you begin to understand the biology of it and what was happening in terms of the actual disease itself?

Well, so the first thing I did after I saw what was going on there is I went to pubmed and I went to nejam, New England Journal of Medicine and Lancet and just started reading every article I could on it. I mean now this space is gigantic. There's thousands and thousands and thousands of papers. It's actually awesome from a research standpoint in that sense you can't keep up on all of it. There's actually a good site like I think it's covid19primer.com that that is like an automated natural language processing review of the whole thing. So you kind of keep on the latest research that way so you don't have to hand filter it. But I went to New England Journal of Medicine and the Lancet and read the early case studies on the patient zeros and so on and some of the stuff was very concerning. Like the first study of somebody who had gotten the coronavirus in the US healthy 35 year old who was knocked to the ground in Washington State and basically was going to die until he was put on Remdesivir intravenous and then he suddenly bounced back. By the way, that prescription was to the best of my knowledge of what I can reconstruct from public sources and I'm open to correction on this, but appears to have been done via right to try laws since it looks like they just worked with state regulators and only notified the FDA rather than actually going through the fda. And that's a very big deal because it means that maybe the first case in the US was treated with right to try laws as opp to going through a traditional pathway. That's a theme we can come back to what I call the decentralized response as opposed to the centralized response of bottlenecking through the federal government, for example.

Yeah, I think it's so interesting to have you talk about this because you bring what I think of as kind of a west coast perspective to this, a west coast thinking, a framework where the centralized authorities are not the ones who are controlling solutions. It's very entrepreneurial and experimental, which is really an interesting view.

Yeah, I mean I think like to linger on that for a second. I actually think we're now about to actually snap to a new like realignment slash political alignment of the US that the north south divide is I think much less relevant. And what Actually matters is kind of, you know, broadly east coast versus west coast, centralized versus decentralized, modern monetary theory versus Bitcoin, the state versus the network, politics versus technology. And I think that is really where things are going to shape up. And that's kind of the emerging axis. And what's interesting is I'd sort of put myself in some ways dead center on that, even though I'm a West coast person. Because right now I think the emerging political axis in the US and probably the world is not traditional left, right, but antivirus versus pro market. And you know what I mean by that. Maybe that's obvious, but let me just drill into that for a second. Antivirus means the total state, the unlimited government. Because you're talking about a government that's able to put you under house arrest for doing nothing wrong. Not just you, but an entire town, an entire city was unprecedented in China on January 23 is now common practice in the west, right? Hundreds of millions of people under so called lockdown. So okay, house arrest for anybody. No due process. And I am saying that these extraordinary measures may actually hold back the virus, but they will not be given up by governments at the end. The first lockdown may be to protect you from the virus and the nth lockdown may be to protect you from each other. Especially if a huge chunk of people are out of work, there's civil unrest or something like that. I can't say it's 100% probability, but there's some percentage probability of that. So you have the total state, you have lockdowns, you have price controls, you have border controls, you have the ability to tell people that they need to get tested. For example, in China that you have to have forehead thermometers and all these scans repeals effectively on search and seizure. So lots and lots of due process goes out the window because you're basically in a wartime situation against a virus. I think people have been talking about this, is this a recession, Is this a depression? And I think those are fundamentally bad metaphors for what this is. This is the first successful invasion of the United States of America in modern times by a virus. Or really by anything. But really an invasion is probably the best metaphor because tens of thousands of people are being killed, millions are being sickened. Actual physical production is being shut down involuntarily, not due to fully for economic reasons, but to physical reasons. People are getting sick and dying and leaving their posts or getting sick enough that, for example, meatpacking plants want to shut down. So on the one end is this total state. And on the other end is the kind of the market. And that's where the kind of anti lockdown protests and a lot of that sentiment comes from. Very understandably. You've got 25 million people out of work. And so this is a reaction to price controls, to seizures of masks, to bailouts, to all of this type of stuff. And that's kind of the libertarian ish end of the spectrum, the freedom end, the privacy end, the don't tread on me end, et cetera. That's kind of the axis. I think that's there not just in the U.S. but the whole world. And I think that's kind of dead center of where east versus west coast is.

And where do you see yourself on that continuum as you look at this problem?

My preferred strategy. So it's interesting, a lot of people are thinking about this as a trade off between how many cases you get with the virus and how long your lockdown is. And with the implication being that you'd get fewer cases for the virus the longer your lockdown, or vice versa, that economic damage and viral damage were inversely correlated with each other. But I actually, I don't think that's the case. I think that when all is said and done, the countries that have the short, sharp, competent lockdowns will have much less economic, less economic damage and less viral damage. So New Zealand or actually China, I think on net is going to turn out to have a relatively better outcome than many other countries, potentially. So certainly Taiwan, South Korea, etc. Even these Asian countries that are having second waves are jumping on top of it very aggressively. And I think that model of aggressively jump on this thing, don't just let it get to 100%, drive new cases to zero and then gradually open up with testing, tracing, isolating, such that you don't just let a case happen until you've got a cure or a vaccine. Then you deploy that. That's a New Zealand strategy. That seems to me to be a smart strategy. The opposite of that is just kind of what I call let it rip. And my friend from Twitter, John Stokes, calls it the great yolo. And that's what we're defaulting into, which is this disorganized thing where we do a halfway lockdown. People, people understandably yell. I don't want to make light of them yelling. They're losing jobs and livelihoods. But then what they're going to find, I think, is they come back and half, half the business isn't there already because people will social distance Even without a lockdown. And then more business will disappear because people will get sick and then they'll stay home at home. And now you've got kind of both the virus and the economic destruction and kind of worse of both worlds, unfortunately. I think that's where countries in the west, many of them are headed.

Right. You know, and to pick up on that. Where do you think we are now? We're recording here at the end. Where do you think we are in terms of the state of play with this virus right now in the United States and globally?

There's a really good site called Covid. There's two sites that I look at. The first is COVIDTracking.com and all the sites that use that data. COVIDTracking.com is looking at tests, cases, deaths, et cetera. It's a really good project by Alexis Madrigal and company. Basically they were just finding that the CDC wasn't able to track tests, so they went and did it themselves. Massive props to them. And that site is updated very frequently, very labor intensive effort, and it's pulled by a bunch of other folks. And then if you go to a website called covidcharts.com, basically you have to wait till the end of the day. But the new cases per day and new deaths. So looking at April 27, it does look like it's down, at least as of this morning or whatever. But you have to wait a few days to see that. In general, it doesn't look like we have massively decelerated yet. It doesn't seem like the deaths or cases have come down. People are like, oh, it happened in New York City and so on. Well, actually it happened in New York City and it came down in New York City, but then it's in 49 other places. Right. 49 other states. So I think we're just at the beginning of this thing, unfortunately. And I think that people who think, oh, the pandemic is over, oh, it only happened in New York City, it's going to come to their town potentially.

And how do you think about the trajectory of the virus right now in the United States just from a disease impact standpoint?

Yeah. So one thing that. So a few things I think are clear and let me at least give you my worldview on it because there's some very big variation in people's thinking on this. First is I'm pretty skeptical of the serology work that came out of Stanford and USC and others. I wrote a long medium post critiquing it and so did a bunch of other people, because I think the false positive rates of those assays are very high. Why is that important? There's basically being this thesis that, oh, a bunch of people have already gotten it because they've already gotten. It's already spread a lot. That means we're close to the end. We're already at 20% or whatever, 30%, just a little bit more, and we're almost done with this. And the reason I think that's unlikely is it would mean that this virus is way more contagious than other pandemics like H1N1 or the Spanish flu. Took more than a year to get around the world. H1N1 was in the age of modern jet travel. And so this would have to be spreading really fast. I think that's unlikely. And I also think that those kinds of calculations don't really contend with the second major metric that I think is important, which is this guy. His name is John. I think it's John Burns something from the. John Burns Murdoch from the Financial Times. J. Burn Murdoch. B U R N not B U R N S. So that guy has a very useful set of graphs that is something I'd been talking about since March or April. And they went, took that next level and they've created graphs of the spike in death rate over the historical average. So the spike in all cause mortality. Okay, across a dozen countries. And the thing is that, you know, I start from the premise that this is the best test. Unfortunately, COVID 19 has now gotten to the scale that it is a very significant cause of death in more than a dozen countries around the world. Actually way more than a dozen, but at least a dozen for which we have good data. And because it is at that scale, that means that you can compare it to past years and you can see how many excess deaths there are. And the reason that's important is death is. Well, from a diagnostic standpoint, I don't mean this in a callous way, but death has high test retest reliability. It can be diagnosed outside a laboratory. You don't really have false positives and so on and so forth. Right. So lots of the issues that bedevil other kinds of diagnostic tests are not there with death. Right. And it's also something where you have probably the best records that you might have. You know, if you talk about, oh, does somebody have pneumonia? Right. The diagnosis of pneumonia will probably differ from country to country in terms of how much, you know, like what a doctor would call pneumonia. But death doesn't differ from country to country. So it's the most consistent across space and time. It's easier to diagnose. So it's really the best statistics, unfortunately. And those stats are showing just a pileup of bodies. There's a huge surge of mortality in not just Italy, but Spain and a bunch of other countries including New York City. And Jburn Mardock has that. So that's the second set of charts that I look at, the all cause mortality charts.

This was something that came into sort of the broader consciousness I think yesterday where effectively there were some articles saying that all cause cause mortality seem to suggest that the death rate from COVID was twice as high as was being reported from other diagnostic criteria, which is obviously an enormous gap.

Well, yeah, so I was just saying though that definitely not to thumb my own chest, but if you look at my Twitter, we've been talking about this since March and pulling up analyses that were kind of. There's a guy, Dell Analuca, who's doing these analyses in Italy. There's another guy, David Bessier, so kind of tech, Twitter or whatever has been digging into this for a while now. We had already had the numbers to show that spike in all cause mortality a month ago. But great credit to John Burton Murdoch because he's taken it next level and actually gone and pulled it for even more countries and gotten the government stats in a bunch of different places to solidify the analysis. Let's call that basically just anchoring the severity of the disease. Now who is it severe for? The short answer is it's very severe for A, old people and B, meaning like you know, 65 plus in particular, but as you get older, just risk increases and B, people with pre existing conditions. Okay, but the second bit is, should not be that reassuring, especially to Americans because they have a pretty high rate of obesity and heart disease and you know, so on and so forth. It's a, it's an amazing like number unfortunately of Americans who have one or more of those of those comorbidities. So people who are like, oh, you know, like that's not me. And they're 53 and overweight, well, they're kind of in a relatively higher risk category. And you can look at the stats on it, it differs from study to study, but the CDC had some numbers on this and they did a whole demographic workup. The other thing though is that it's not that people are immune when they're younger. You know, something like, if I recall correctly, 25% of hospitalizations were for those under 50. So 75% were over 50, but 25% were under 50. And that's not zero percent. And so there's some of the stats. Other stats I've seen is something like 13% hospitalization rate for people 18 to 44. And I know people who've been very sick from it. Just kind of qualitative evidence to buttress that. And by the way, on the topic of anecdote, by the way, people say, well, the plural of anecdote is not data. And I would agree, except qualitative feedback often allows you to formulate a quantitative hypothesis. And that's why it's actually super important in tech startups just to digress for a second to talk to customers as well as look at your dashboards because you talk to a customer and they say, oh, I had trouble logging in. Then you put up a new dashboard, see how many people had trouble logging in. You see 1,000 people had trouble logging in. So the quote anecdote led you to collect data. So we should never discount the value of a patient study. That's actually really, really important because it lets us maybe look at things from an angle we weren't considering and then collect data to see if that observation is real. So point basically being A I think it's quite severe, B it's severe in the elderly and people with pre existing conditions, C that doesn't mean the younger people have clean ceiling of it. And D, something else I'm concerned about is folks who were so called asymptomatic. Many of them appear to be not asymptomatic but pre symptomatic, meaning that you do follow up on them and suddenly you're seeing CT scan of their lungs is actually showing evidence of viral damage and now they start coughing or they have other kinds of symptoms. And so for at least some people the virus is like a slow burn which is bad because kind of hiding. And so there's other things where the sheer number of different kinds of symptoms this thing is causing in folks, we're still kind of getting the table on this. People are reporting strokes, they're reporting weird lesions in the toes. Whether this is due to simply just the scale of it causing lots of rare cases, whether it is due to it actually mutating and there being different strains during different things as some people have speculated, we don't really know yet. But I just treat this thing as being fairly severe and not something you want to mess with. I think the strategy of a Singapore or New Zealand is probably right. I know there's a Long answer, but go ahead.

I'm so glad you brought that up. The two things that I was trying to reconcile from yesterday was the report of the double all cause mortality based on some of the analyses that we were just discussing. The second point was there was a study coming out of the state of Ohio, I believe, about testing prisoners, showing that 96% of the prisoners they tested were in fact asymptomatic. And trying to reconcile those two propositions. On the one hand, something that would suggest the disease is much worse on the surface than it appears, and then the second suggesting the opposite. And it is a very complex problem to get our heads around.

Yeah. And I think my speculation is that those asymptomatic prisoners, many of them will develop symptoms. I tweeted this a little while ago, but in a follow up study of the different kinds of follow up studies of asymptomatics, like 27%, 54% in different studies develop symptoms at some point. Yeah, I think that's what's going to happen with those prisoners, that they're not going to remain asymptomatic indefinitely. Not all, but many of them.

So one of the things that you talk about on Twitter is the viral funnel. Can you explain that a bit?

Yeah. So I tweeted about this in March, but basically there's lots of different efforts flying around. And where do you want to help? Ideally where it saves the most lives, given your skills. The funnel model comes from startups. You've got a bunch of leads at the top of the funnel. These are people who might be out there, and then some of them click and land on your website and some of them click a little bit more and they end up in a cart. And then some of them all the way convert and so on. Maybe they renew a subscription or they churn. It might seem like trivial startup lingo, but you can apply the same thing to the virus. You've got this group of healthy people out there, then they're exposed, then some of them get infected, some of them get sick, some of them actually die or recover. That's similar to the SCIR models, epidemiological models and so on. You can think of interventions at different portions of the viral funnel. For example for healthy people, masks, social distancing, lockdown, vaccines, tests, those kind of things you can do on healthy people. When you talk about if someone's exposed, you do more tests. You do CT scan, you do not just pcr, but you might do sequencing or whatever. If you think they're being exposed to a strain that you want to know about. If they're infected, then you'd actually isolate them. You need, now you need hospital beds or some kind of quarantine area. You're going to potentially need drugs. If they're really sick, then hospitalization, PPE for MDs and nurses, and if they're recovered, maybe serology tests. And so now once you kind of have that funnel, when you say, okay, I'm doing ppe, okay, you're actually at like stage four of the funnel. Right. Because you're helping sick people, because you're giving PPE to MDs and nurses. Oh. But maybe you might help at the top of the funnel as well, because some of those masks could go to people who are healthy. So in this fashion, you can kind of think about where you want to allocate resources. And really the best thing you could do is stop healthy people from getting sick in the first place. So that's why for the last few weeks of March and early April, I was helping out Jeremy P. Howard, who launched Masks for All, which is very effective in basically shifting policy on this, where the surgeon general was at first saying, oh, people, you shouldn't wear masks, and then literally recorded himself making a video wearing a mask. Which is good. Glad they turned around on this. Right. But essentially that common sense intervention is something that we think will significantly reduce the spread of the disease. So that's the idea of the viral funnel, is to prioritize different things, interventions based on the impact on the funnel.

You know, I mean, the frightening thing about hearing you discuss that is it sounds as though that sort of thinking hasn't broadly taken place at scale yet. It sounds as though the basic sort of staging and framework of this is still at the position where it's a novel idea.

Yeah. So the thing that has been concerning to me about this, this whole way is this whole thing is rear wheel drive, where the folks with scientific, technical, mathematical management backgrounds are not in politics and they're generally not in the media either, at least as writers. And, you know, so what that means is the folks who are talking about what to do and the folks who are responsible for making the decisions are just not. There's. There's not a critical mass of folks, you know, who know what a virus is, for example. Right. And so, like, you know, you just have. I mean, it's not a partisan thing, by the way. It's the federal bureaucracy. It is the mayor of New York and the White House. It is the FDA and the CDC is, you know, like both, you know, all major media outlets have had just the flu type stuff, and that's just the flu. But you know, masks don't work and then masks work just face plan after face plan on this. So I think, yeah, I'm pretty concerned about the fact that folks who I think of as competent are outside of the loop on making decisions on this or are doing kind of rear wheel drive. Right. You're tweeting frantically to try to get the attention of somebody as opposed to just being in the position to make decision yourself.

Another suggestion that's getting a fair amount of traction is this notion of immunity passports. This is something that's opened out into the mainstream media at this point. Could you explain that concept and tell us where we are with regard to being able to actually execute on that?

Yeah, that's something basically immunity passports are proof of health that could help reopen the world. Whether it's based on serology testing, which is, hey, do you have antibodies like immunity in that sense or some other kind of test. Essentially, for example, in Asia, people have forehead thermometers and they stand outside of buildings and they kind of scan people as they walk by. And that's not a perfect test because people can be asymptomatic and still pass and so on, but it gives you sub signal and so you can start thinking about defense in depth. Right. You have, for example, wearables like your Fitbit, your ura. There's studies going into whether that gives you signal. There's your forehead thermometers, there's certainly your self report. There is the digital diagnosis of whether you're close to somebody else. Contact tracing where you're close to another positive. Can we send you a signal on that basis? Which smartphone manufacturers can do. Now, I know it's Orwellian, but they can. Another test is these kind of thermal scans from afar. There's these really high throughput CT scans that the Chinese have where it's really fast and they can do a bunch of them quickly. There's obviously pcr, there's sequencing and so you start to have defense in depth. Something I tweeted about, I said, China's going to build the third Great Wall as a function of this. There's a great Wall, the great firewall. They're building the great bio wall of China, like a gigantic biodefense wall of testing and other kinds of things. Eventually, vaccines just fortify themselves in many different ways. So the virus breaks through one fortification, it doesn't break through another, and yet another. And so that's I think a good mental model also for proof of health or these immunity passports where you have a series of tests that are done on somebody and in China, the way they're doing it is green, code, yellow code red code. Your WeChat has either green, yellow or red corresponding to your current virus status. Green is you're fine, yellow, you've been exposed and need to be quarantined, you can't travel between cities and so on. And red, you're known to be infected. And so that digital status is contagious, just like the virus is. If a red walked into a crowd of 20 greens, it would all turn yellow, for example. Right. At least that's my, you know, that's one's understanding of it. So that's the kind of stuff that all goes into something like this immunity passport. And frankly, in a sense it already existed because you need vaccination certificates to immigrate to a country. Right. The U.S. has needed that for a long time. If you Google vaccination certificate. So this is kind of like that. A vaccination cert is are you going to bring a deadly virus into our shores? That's the same reason to ask, are you bringing in snails, Are you bringing in animals and stuff like that? They'll always ask those kinds of questions, the agricultural things, because they want to know, are you bringing something that can reproduce of its own accord and maybe get out of control of something that has no natural predators, all the type of stuff, unbalanced ecosystems. And I think that's what this is. It's like a vaccination cert. It's one of those questions about whether you're bringing in animals, except it's applied to a virus. And it's also done obviously in much more intrusive and real time way.

And on the treatment side of this equation, you talked a bit about the expanding the ripe tribe. Tell us a little bit about what that is and why it's relevant for getting the kind of treatments that we need to see.

Yeah, so you know, what the FDA did in February was basically catastrophic. It's now known that they prevented emergency use authorizations for tests and in so doing turned a containable epidemic into a catastrophe. You know, they basically what essentially happened was labs that could have run tests that would have shown that the coronavirus epidemic was actually spreading. They were prevented from running tests by the FDA for a critical 28 day period and only really allowed to run on the 29th once the test actually started to run. It was clear that we had a massive outbreak on our hands. And so where things might have been nipped in the bud because what happened was the lack of testing gave everybody a false sense of security over the course of February, when the fire was still at a relatively early stage. That's my point. My point is that was, you know, that's potentially the greatest failure in the history of not just the fda, maybe the greatest, one of the greatest failures ever in the history of the United States, cost the country trillions of dollars, tens of millions of jobs simply because bureaucrats didn't approve tests fast enough. And that's just something that's perceptible to people. It's a, it's a, it's a catastrophe on such a scale that's perceptible. Most of the times that something is denied for multiple sclerosis or, or like colon cancer, it's not visible on that scale. It's not something where everybody has a stake in it, where it's super. There's lots of eyes on it. It's more deniable with respect to the fda. There's been paths to route around it in the past. And critically, those paths don't say no regulation. They just say a different regulator to put some competitive pressure on this regulator. So some of them, for example, compounding pharmacies are one where pharmacies, pharmacists have some discretion in order to kind of mix drugs together to get a new drug off little prescription by mds, you can have a drug that's approved for purpose A, that a doctor in their own discretion can prescribe for purpose B. There's been CLIA and clinical labs where you can basically go and have individual labs that are not necessarily FDA regulated, but they're regulated by a different agency also under hhs, under cms. So HHS is apparent. It's got FDA and it's got cms. And CMS is something called clia. And CLIA works with state regulators to approve clinical labs which can roll out tests. And then of course, there's other countries. And so each of these are pathways that are outside of the fda, and the FDA wants to shut them down. Usually. They've been kind of waging a war against lab tests and compounding pharmacies and so on for a while. Right. To try is yet another pathway outside the fda where basically people have, as it sounds like, the right to try a drug, and they just have state regulators sign off on it and then under some circumstances give notice to the fda, because the procedure for actually getting approval to use a drug is Actually extremely bureaucratic normally, and the person is dying. And so now you just give a notice to the FDA rather than going through that whole rigmarole. One thing also, by the way, a lot of the FDA stuff, when it blocks things, it causes failure to apply rather than necessarily failure to get approved. And those are similar in outcome. But failure to apply is less measurable because it's top of the funnel. It's such a complicated and time consuming process that people don't even put in an application. And therefore it's harder to detect the full impact of what it is they're doing, if that makes sense. Because many of these companies and labs that were turned down for these authorizations, EUAs made out of file formal applications. They just got informal feedback that, you know, okay, they can't get one at a time. So what does this have to do with expanded right to try? So right now there's all these different pathways outside the FDA for drugs via off label, for labs, via clia, for drugs again via compounding pharmacies, for pretty much everything via going internationally like medical tourism. An expanded right to try would basically just expand all of this. And one model would be something where, for example, this Western states compact, California, Oregon, Washington, and now also Colorado, Nevada have joined this Western states compact now could basically say, look, we're going to have Stanford, uw, Berkeley, UCSF and Cedars Sinai, which are all very legit, you know, basically on the west coast, right? Maybe throw in, you know, uc, Boulder, you know, something like that. And those are universities that will work with state regulators to approve drugs, diagnostics, you know, and vaccines and what have you. You do the same thing for this upper Midwest compact where the Mayo Clinic is working with, you know, the local regulators to approve things. And same thing in the Northeast you have Harvard and mit, and the same thing in the New York Triceria Compact, you have Columbia and Cornell. And by doing this now, Suddenly you've got 4, 5, 6, effectively regulators. Each of these regions has like 80 million people or something fairly big, right? They're like essentially European countries. But now there's competition for the fda. And you're not giving up on safety, you're not giving up on quality. What you've got though are folks who have an incentive to balance quality with speed and with cost, which really, really matter in a pandemic very obviously. So. But it's also true at other times. It's just not something where everybody's eyes are on it.

Are you optimistic about our ability to actually execute on this in a reasonable time frame in a way that can get actual results for this particular crisis, or is this something that we're going to look at for potentially mitigating future issues?

Expanded. Right. To try would be, if not a silver bullet, certainly a very, very, very useful bullet that could be tried right now that would unlock a lot of biomedical innovation. And I think, frankly, it's the only way. Yes, the horse has left the barn in some ways. You know, the fire is going to burn for quite a while. But it's, you know, we need to. Even if this fire burns the US more than it burns other countries, and it looks like it will, we still need fire hoses. So we have to unlock that biomedical innovation. Even if, you know, I shouldn't say too little too late because, you know, it would be great if this had been done five years ago. You know, five years ago, for example, the Apple Watch had a bunch of diagnostic grade stuff in it that the FDA forced them to either take out or nerf this report in the Wall Street Journal, for example. And so had that been in there, had, for example, 23andMe the FDA ran a campaign against them. If we had 100 million people with genome sequences, maybe we'd know the pharmacogenomics and immunogenomics of this thing. Right. So, yes, it would have been much better had we done this five years ago, 10 years ago, but today is better than never. And that'll at least give us the technology where in six months we'll be. In a very, even a few months, we'd be in a very different place. If you have right to try, expand your right to try.

Yeah, it seems as though there's demand for change right now. Maybe that's the one sort of opportunity that we can come to, that there is a sense of needing to do things differently, of finding new solutions. I think that when people look at the efficiency with which China has handled some of their containment efforts, obviously we're talking about very different cultures with very different views of individual liberty and human rights. But I still think there is a sense of that there is just the technological solutions that are being applied, the speed of innovation. It seems as though we have a way to go on this.

Yeah, I mean, 1950s America had higher state capacity than 1950 China, but 2020 China is, has better, has higher state capacity than 2020America. That's obvious to everybody on the world stage, at least for something like this. If you're familiar with the, with the Maginot line, right from World War II, you know, that was something where the French developed it for World War I, or rather after the experience of World War I, you know, to, you know, stop the Germans from coming in in the same way you now the trench warfare that have fortifications. And the Germans said okay. And they just went around it with, with the Blitzkrieg. Right. And in the same way what we are learning is that the two oceans, the Atlantic and the Pacific, that protected the US the aircraft carriers and the F16s and this extraordinarily expensive and gigantic and well trained and equipped military just got completely bypassed by the virus. The virus is ultimate asymmetric threat. Now to be clear, I'm not saying it's engineered or anything like that. I'm just saying that it just completely invalidated all those defenses and has literally basically taken out aircraft carriers. I don't know if you saw that report from earlier this month, but that captain of the aircraft carrier is like, hey, all of my sailors are getting sick from this. Some of them will die if they don't get treatment and let's take them off, otherwise everyone's going to get sick. So that's to my knowledge the first thing that has taken down aircraft carry. And I saw another follow up report that says something like 40 naval warships have had this problem. So, so that's a really big deal because it means that in a sense the US military is like this giant Maginot Line versus the virus. And for all the talk of WMD heroin had focused on nuclear weapons or like Assad with chemical weapons. Looks like every, I mean not every regime in the world is nice. A lot of folks are looking at this and looking at, okay, well the biological stuff really seems to bypass US defenses. So that's like a dangerous two or three or four year out consequence of a lot of this.

Yeah, it's interesting. It feels as though it's not just software that's eaten the world as your colleague Mark Andreessen has suggested, but also the framework of software development, the framework of competitiveness that's brought to us more broadly from the software world is eating the world.

Yep, that's right. I think basically the only kinds of states that survive, I think it all converges on something I call the network state, where so for example, over the last 10 years or so, every company had to become a software company or die, frankly. Actually that's actually happening now in a way that I didn't expect it to happen. But the way it happened over the last 10 years was okay, Blockbuster Video, you don't go online okay, Netflix kills you. Okay, Hollywood, you don't go online. Well, itunes and again Netflix and so on kill you and, and so and so forth for industry after industry like taxis, hotels, whatever, right. And now it's something where restaurants that didn't get with doordash are dead. Right? You know, like higher ed. Any college that didn't invest in Coursera and Udacity and so on is really out of luck and so on. Essentially what happened was anybody who didn't invest in the future doesn't even have a leg to stand on because it was just all Internet or die. I think that that's now going to happening at the level of countries. And this is something where I think of as what I think of as the network state. Basically you either have countries that are run by basically people who I consider the ability level of a top tech CEO. For example, Li Hsien Loong of Sing Singapore, he was like a mathematician at Cambridge, was the wrangler there, like top his year. In Estonia there's a guy, Tomas Ilves, who isn't running the country and was actually president, so he's never to my knowledge, prime minister, but he was a computer scientist out of Princeton and responsible for Estonia's adoption of Internet technologies, one of the bigger influences on it, and helped modernize them and make them into the force that they are today. Very high strength to weight ratio in Israel. Netanyahu, he has political issues now, but he is MIT graduate and certainly an intelligent person. I think if you go down the list, the folks who are kind of like this, who are tech savvy enough to use software and engineering, are the ones who will do well on the other side of it, I think. So that's kind of a state getting the qualities of a company. The flip side is a company getting the qualities of a state. And so now, for example, companies can issue digital currencies or trying to. Facebook's trying to do Libra. And what I think is going to happen with Facebook and Google and Amazon and YouTube and so on and so forth is they're basically going to step into the gap where the WHO and UN and so on, those are kind of fading and leaving the stage in many ways because there's a loss of international confidence in them. And so the trustworthy multinational institutions are going to be these giant tech companies because they have billions of users around the world, they have the balance sheets, they're kind of in this sort of diplomat kind of role where they have to maintain relations with lots of different countries and they're frankly, more competent than who or UN who would you trust to implement contact tracing? Is it going to be Apple or Google? Not really. The UN Maybe who, but they're not going to code it or ship it On a billion iOS devices or Android devices.

Let me just push back a little bit on this. We all love big tech companies, those of us who are passionate about technology. But the question is, look, the counterargument could be, look, these are not states, these are not organizations that have the consent of the governed. They are there to make money for their shareholders. And some might say even more cynically, they're there to make money for management. And look, these do not have, the argument would go, the interest of the broader population at heart. There's a reason that we have governments and not private corporations that run the world. One could have made this argument in the 19th century and certainly in the 20th century about corporations being more effective, more nimble, more technologically savvy. And the history there is not a very strong one when you look at things like environmental pollution and those sorts of things. Why should we have trust that big tech companies have the interest of the broader population at heart?

Three points there. First is, I don't think one should have implicit trust. I'm a big fan of crypto and decentralization and end to end encryption and so on and so forth. I definitely think we need to check on the power of large tech companies, which can do censorship, deplatforming, demonetization. Yes, certainly abuse power for management. Let me put that on the table first. Second is, I do think that with that said, big tech companies are actually in many ways more accountable than let's say the UN or who, because first of all, you are a shareholder. Yes, you could become a shareholder of those. You can't become easily a shareholder of the UN or the who, number one. Number two, you're often a customer of these companies and a large customer can raise a stink or what have you. Number three is I actually feel that it's more transparent in the sense of the process by which a WHO bureaucrat is appointed is not how much democratic accountability really is there. You vote for a president who appoints somebody who appoints somebody, it gets pretty dilute at that point. You're talking 1 over 300 million of a vote for this, for that, it's effectively zero. Right. Whereas I think that if you actually want to affect that process, you actually go join the WHO or write about it. And then it's similar to your influence on Apple where you just join Apple and write about it. So in terms of practical influence from that standpoint. And then finally there's the aspect of just competence. Ultimately, the proof is in the pudding. I'm not saying, and I should be clear about this, I'm not saying that centralized governments are necessarily incompetent. In fact, there was a period from 1933 to 1969, roughly Hoover Dam, Manhattan Project, Apollo Project, where in that period the United States government got all the best talent and all the best scientists and was able to do things that no private sector company could do. I think I would argue that's because technology in the mid 20th century greatly favored centralization. It was mass media and it was mass production. It was mass society. And you basically couldn't make something unless a bunch of people were in a factory all working together. So, you know, you needed ideologies that supported those technologies. And then if you go both forward and backward in time, you go more and more decentralized. Like 1950 is kind of like a mirror moment and where you have. So for example, 1950, you have one telephone company and you have two superpowers and you have three television stations. So it's like the centralized century. And then you go forward in time and you get cable television and then you get the Internet and you start getting the explosion of things after the Internet. It's like the Internet's reopening the frontier. You go backwards in time from 1950, pre World War I, and then you go to 1890 and the frontier reopens. As you go backwards in time, then you get robber barons. And so I think in many ways our future is like our past. This has been something I've been writing about for a long time, and it's jumbled. It's not necessarily in exactly the same order. But guess what? We just kind of replayed this. We're replaying the Spanish flu. It's a little bit out of order. Robber barons, Spanish flu. There's other things. By the way, in the 1830s there was a whole thing about private banking. Do you know about that?

Yes, of course.

Private banking era. So that's come back too, with crypto. Essentially, it's almost like you have this.

Sinusoidal wave of centralization and decentralization that continues to alternate. I'm curious about what you think about the potential to do in some of these in an open source way, perhaps in a way that is not as proprietary and that doesn't belong to pick the large tech company of your choosing.

Yeah, so that's actually what I do care about that a lot. And I think that what blockchains allow us to do, and it's not just blockchains, but let's just say decentralized technologies. Okay, give us a humor on what.

That means for people who aren't as familiar.

Totally. So most people probably who are listening to this are familiar with the concept of open source, which is source code that you can download and inspect and look at and replicate and usually modify and what have you. The fact that you can do that gives you more confidence in its correctness and so on and so forth. Right.

Actually, I'm going to say something. I'm not sure that most people are familiar with the open source movement. I think most people who are passionate about technology are familiar with the open source source movement. But this is a very different model than most people who have iOS or Android phones, for example, are used to thinking about. So explain a little bit about that. Yeah, sure, sure.

So it's funny because. Okay, well, first, iOS and Android are very heavily based on open source technologies. Android itself is essentially Linux, though they have closed up pieces of it effectively over time. It's basically like copyright almost. You know, if you can just take content, images, music files and mix them together freely, it's easy to make something cool and creative in a mashup. If you have to go and get a bunch of license agreements from people, that's massive friction and it means you're just not going to do it because it's so hard to do it that you just don't do it. Right. So that's kind of what open source is like. It's basically something where you can look at code, take snippets, be inspired by it, understand what's going on, get smarter, and then share it with others.

One metaphor for this might be, we were talking earlier about bmj, the Lancet, the New England Journal of Medicine. One metaphor might be the idea of peer reviewed journals are open source in the sense that the information is freely shareable. You can comment on it, you can replicate or attempt to replicate, you can analyze it.

Right. Though not all of those journals, there's a whole movement for so called reproducible research. So not every journal article is reproducible research, but it's getting better over time. Okay, so now this may be for an audience that is new to open source. The following, what I'm about to say may be too much of a leap, but I'll just go there anyway. So what blockchains give you is kind of the next step after open source, which is open state and open execution, open state means you don't have the source code. You also have the database that's publicly visible. Now, open execution means you don't just have the source code and the database. You can trace through every single step that's happening. Let me give you an example. People wonder whether Twitter is filtering their searches, am I getting filtered or what have you. If Twitter is, and it's not possible today, but it might be possible, it probably will be possible in like 10 years, maybe sooner. If Twitter was based on a blockchain like back end, you could inspect it for yourself or get a developer to, to confirm that, oh, your searches aren't being filtered. Right, okay, so that's actually really interesting where it's a stateful application that millions of people can write to and read from at the same time, yet it operates in a low trust way where essentially you can use computation to confirm that it's not biased against you and in fact that it cannot be biased against you because it's cryptographically guaranteed to not be able to biased against you. And that's like a really, really powerful construct where essentially what we do is we trade computational time for trust because computational time has become cheaper. You do essentially math that your CPUs can crank out to replace or reduce the need for human trust.

This has been an incredibly wide ranging discussion.

We've talked.

We began with your background in technology and business, we shifted over to the virus. We've talked now about these broader philosophical issues. Looking back on this, I'm not sure we could have done it any differently because you really are framing a different approach to management, a different approach to governance, a different approach to the way that we think about challenges in the, in the health and medical domain, but also more.