Vaccine hesitancy, UK (79%) would take vaccine

Source: https://www.weforum.org/agenda/2020/11/fewer-people-say-they-would-take-a-covid-19-vaccine-now-than-3-months-ago

Source: https://www.weforum.org/agenda/2020/11/fewer-people-say-they-would-take-a-covid-19-vaccine-now-than-3-months-ago

Vaccine hesitancy, the ‘reluctance or refusal to vaccinate despite the availability of vaccines’, was listed among the World Health Organisation’s top ten threats to health in 2019.

In an August 2020 poll around one in four (26%) adults globally disagreed that they would take a vaccine for COVID-19 if it were available, with worry about side effects, followed by perception of effectiveness being mentioned most frequently as reasonsfor not getting a vaccine. This slipped further down in October. The November report from Ispos here. And WEF link here.

COVID vaccines, timeline update

Short update on COVID vaccine timelines. US/EU timelines have slipped by 1 -3 months, but China has held up since my August estimates. Treat all estimates with caution etc.

I thought I would update on my speculative COVID vaccine thoughts given the moving timelines here. There are >100 vaccine projects and COVID treatments in motion, and although recent vaccine timelines have slipped, it looks ;like we will have a vaccine at some point. When? is a key debate. Given the challenges around public health interventions, (lockdowns etc.) in EU/NA - one way we can cut the knot is to go fast on the vaccine. This is one reason why (althoguh not without some downsides) I support the UK challenge trials starting in early 2021. That said we have some decent chances of vaccines by very late this year / Jan 2021. Below is a moderatel positive scenario of how the US could be vaccinated in 2021.

Oct 2020, estimates. Treat with caution.

Oct 2020, estimates. Treat with caution.

I think China will have a vaccine starting to distribute to the public by Dec 2020. Chinese officials have indicated data is positive and they are willing to approve.

The UK has an 80% chance (IMO) of a vaccine in Dec/Jan for at risk populations (AZ/Oxford, timelines, newspaper leaks) under emergency approval. The early data is promising and despite the delays, if there were serious safety issues I would have expected to have had more negative news here.

The US has a chance for an emergency vaccine approval late Dec (slipping) or Jan, there are two shots on goal here (Moderna and Pfizer), and I rate the chances around the 70% level (although 40% and dropping for before year end as both have slipped, but still at 70% or so in Q1 2021 time frame). (This is down slightly from earlier due to challenges in the trials). Again early data is promising and no catastrophic safety events seen. Full approvals are more debatable than emergency (as hurdles different, but mixed messages from FDA makes this uncertain). The AZ trial stalled for longer in the US, so is more likely a Q1 2021 event as US don’t seem to want to recognize the UK/EU regulators view here.

Antibody treatments (Regeneron/Roche, Lilly) have a 90% chance of emergency approval before year end, but are only available in limited doses of around 5m to 10m doses pa. Data has been positive especially in the mild-moderate pateients.

12 Oct, 2020 Source: Gallup for Sep survey.

12 Oct, 2020 Source: Gallup for Sep survey.

There are a lot of variations on scenarios here, and supply and distribution as well as anti-vax movements are all other factors to consider. Some polls but vaccine willingness only at or so 50% in the US. Debates  arise are on (1) Willingness to vaccinate (2) Regulatory caution around durability as well as efficacy (3) social-political pressures.

It is of note that China is more advanced here seemingly than NA/EU and generally the countries outside of EU/NA are potentially faring better.

15 Leading vaccine projects, Source: Milken, press releases

15 Leading vaccine projects, Source: Milken, press releases

Life changing love of a world changing physicist

This was fascinating on Paul Dirac (by Richard Gunderman for the Conversation based on Graham Farmelo’s biography, The Strangest Man: The Hidden Life of Paul Dirac, Mystic of the Atom)…

…Born in Bristol, England, in 1902, Dirac became, after Einstein, the second most important theoretical physicist of the 20th century. He studied at Cambridge, where he wrote the first-ever dissertation on quantum mechanics. Shortly thereafter he produced one of physics’ most famous theories, the Dirac equation, which correctly predicted the existence of antimatter. Dirac did more than any other scientist to reconcile Einstein’s general theory of relativity to quantum mechanics. In 1933 he received the Nobel Prize in Physics, the youngest theoretical physicist ever to do so.

At the time Dirac received the Nobel Prize, he was leading a remarkably drab and, to most eyes, unappealing existence….

….Dirac was socially awkward and showed no interest in the opposite sex. Some of his colleagues suspected that he might be utterly devoid of such feelings. Once, Farmelo recounts, Dirac found himself on a two-week cruise from California to Japan with the eminent physicist Werner Heisenberg. The gregarious Heisenberg made the most of the trip’s opportunities for fraternization with the opposite sex, dancing with the flapper girls. Dirac found Heisenberg’s conduct perplexing, asking him, “Why do you dance?” Heisenberg replied, “When there are nice girls, it is always a pleasure to dance.” Dirac pondered this for some minutes before responding, “But Heisenberg, how do you know beforehand that the girls are nice?”

Love finds the professor

Then one day, something remarkable entered Dirac’s life. Her name was Margit Wigner, the sister of a Hungarian physicist and recently divorced mother of two. She was visiting her brother at the Institute for Advanced Study in Princeton, New Jersey, where Dirac had just arrived.

Known to friends and family as “Manci,” one day she was dining with her brother when she observed a frail, lost-looking young man walk into the restaurant. “Who is that?” she asked. “Why that is Paul Dirac, one of last year’s Nobel laureates,” replied her brother. To which she replied, “Why don’t you ask him to join us?”

Thus began an acquaintance that eventually transformed Dirac’s life. Writes Farmelo:

His personality could scarcely have contrasted more with hers: to the same extent that he was reticent, measured, objective, and cold, she was talkative, impulsive, subjective, and passionate.“

A self-described "scientific zero,” Manci embodied many things that were missing in Dirac’s life. After their first meeting, the two dined together occasionally, but Dirac, whose office was two doors down from Einstein, remained largely focused on his work.

After Manci returned to Europe, they maintained a lopsided correspondence. Manci wrote letters that ran to multiple pages every few days, to which Dirac responded with a few sentences every few weeks. But Manci was far more attuned than Dirac to a “universally acknowledged truth” best expressed by Jane Austen: “A single man in possession of a good fortune must be in want of a wife.”

She persisted despite stern warnings from Dirac:

I am afraid I cannot write such nice letters to you – perhaps because my feelings are so weak and my life is mainly concerned with facts and not feelings.

When she complained that many of her queries about his daily life and feelings were going unanswered, Dirac drew up a table, placing her questions in the left column, paired with his responses on the right. To her question, “Whom else should I love?” Dirac responded, “You should not expect me to answer this question. You would say I was cruel if I tried.” To her question, “Are there any feelings for me?” Dirac answered only, “Yes, some.”

Realizing that Dirac lacked the insight to see that many of her questions were rhetorical, she informed him that “most of them were not meant to be answered.” Eventually, exasperated by Dirac’s lack of feeling, Manci wrote to him that he should “get a second Nobel Prize in cruelty.” Dirac wrote back:

You should know that I am not in love with you. It would be wrong for me to pretend that I am, as I have never been in love I cannot understand fine feelings.

Yet with time, Dirac’s outlook began to change. After returning from a visit with her in Budapest, Dirac wrote, “I felt very sad leaving you and still feel that I miss you very much. I do not understand why this should be, as I do not usually miss people when I leave them.” The man whose mathematical brilliance had unlocked new truths about the fundamental nature of the universe was, through his relationship with Manci, discovering truths about human life that he had never before recognized.

Soon thereafter, when she returned for a visit, he asked her to marry him, and she accepted immediately. The couple went on two honeymoons little more than month apart. Later he wrote to her:

Manci, my darling, you are very dear to me. You have made a wonderful alteration in my life. You have made me human… I feel that life for me is worth living if I just make you happy and do nothing else.

Full essay here.

COVID Vaccine coverage estimates

An assessment of COVID vaccine coverage in 2020 - 2022

—> 80% (*) chance of a US vaccine approval by year end 2020

—> 60% chance that the US will have enough supply of vaccine to cover the country by mid 2021

—> 60% chance significant part of world is covered by early 2022

(* This estimate dipped in Sep but has rised by Nov, and should probably now nudge 90% for Dec/Jan approval due to both Pfizer and Moderna vaccines hitting)

Table 1. Source: Milken Institute, Press Releases, Author estimates. No approvals are certain. One vaccine in Russia and one vaccine in China have been approved for certain use.

Table 1. Source: Milken Institute, Press Releases, Author estimates. No approvals are certain. One vaccine in Russia and one vaccine in China have been approved for certain use.

I estimate an 80% chance of a vaccine approval by year end 2020 and a 60% chance that the US will have enough supply of vaccine to cover the country in first wave by mid 2021. (Although note as counter point on the safety risk you can note this article on the 1976 Swine flu).

The base case uses the public announcements of the large sophisticated UK and US groups. (See Table above). 

Downsides are from (1) negative data and (2) negative regulators; other possible downside are from (3) manufacturing constraints and (4) distribution constraints; and (5) vaccine hesitancy (certain anti-vaccine sentiments). Note (1) and (2) are separate risks as there may be data positive enough for patient choice (or developers to submit) but not enough to convince (risk averse) regulators. 

Upsides are from (a) China developers and possibly  (b) Russian development although I do not see those vaccines coming to Europe or the US but may well go to Asia and LatAm in H2 2021. A detailed overview of the developer groups is available from the the Milken Institute (link end) and WHO. I select a highlight below to give a sense of (i) the variety of technology mechanisms in play here and (ii) the colloborative group nature of the development even while there typically is a lead group.

Source: Milken Institute, slight author edits.

Source: Milken Institute, slight author edits.

Further upside would be positive data from manufactured antibody studies (eg Regeneron/Roche) which are due Q4 2020. The two major studies due in Q4 2020 are (a) Regeneron/Roche and (b) Lilly/AbCellera. If these are positive, then the Regeneron collaboration would add 4m to 8m prevantative doses to the calculations below.

I am less worried about distribution because:

—>vaccination during the flu season routinely reaches 50% of the population, thus distribution efforts are likely surmountable (cf US wholesaler deal with McKesson which is an experienced organisation). Also fill/finishers (packing the finished product) such as Catalent are already involved.

—> some nucleic-acid based vaccines may be distributed frozen, but appear stable for several days in regular refrigeration

The leading makers are also fully flying on manufacturing and there is expertise from flu vaccine and animal vaccines and outsourced makers (eg Lonza). I have toured vaccine plants (which are typically under utilised compared to chemical plants) and the technology and expertise from the leading makers is competent at scale, although this current speed is much faster than before - in my view, it’s not been out of reach for biopharma.

There are previous papers on biopharma probability of success. And while certain technology is new eg mRNA-based vaccines, much of the expertise on coronavirus and vaccine understanding has a high degree of understanding. Severe side effects (or long-term side effects) are risks (particularly from our understanding of side effects from previous RSV vaccines) but current data from multiple trials are not yet picking up a nasty effect. Although the trials are small, and many are across different products, the fact that there are multiple trials running across different geographies and populations gives statistical strength to the net probability of success. (Link end, see my primer on forecasting).

Some vaccines will fail. Some supply bottlenecks will materialize. New bottlenecks, so far undiscovered will appear.  But the net effect of so many shots on goal is that a first wave of vaccinations can be done in the US by mid 2021 and quite likely globally by end 2021 / early 2022. The stated capacity up to 1bn doses of many of the possible successes balances out those vaccines that will fail.

Source: Author estimates, Company Press releases, transcripts of managment calls. This table looks only at US, however similar calculation can show reasonable global coverage by mid 2022. Note, vaccination = 2 x doses in most cases as two doses requ…

Source: Author estimates, Company Press releases, transcripts of managment calls. This table looks only at US, however similar calculation can show reasonable global coverage by mid 2022. Note, vaccination = 2 x doses in most cases as two doses required.

There will need to be boosters (maybe every 2 years, possibly every year) and possibly - like flu - new strains will have to be made yearly if the virus ends up mutating and still being lethal, but my view is that we now are looking pretty likely to be on track to solving this one.

Source: Milken Inst, Press releases, Author estimates. Note: Private funding may not be but have not assertained. DOD = Dept of Defence, HHS = Human Health Services. BARDA = Biomedical Advanced Research and Development Authority. CEPI = Coalition fo…

Source: Milken Inst, Press releases, Author estimates. Note: Private funding may not be but have not assertained. DOD = Dept of Defence, HHS = Human Health Services. BARDA = Biomedical Advanced Research and Development Authority. CEPI = Coalition for Epidemic Preparedness Innovations . EC = EU Commission. EIB = EU Investment Bank. GAVI = Vaccine Alliance. GAtes = Bill and Melinda Gates Foundation.

While there will be many debates on the public health responses of various countries, it’s notable that the US, China and the UK are the geographies where the developing makers are concentrated with honourable mentions to a few countries such as France (Sanofi) and maybe Germany (CuraVax). Adjusting for population keeps UK in the spotlight (note Tyler Cowen has highlighted this in his column, link end).

Understanding this is insightful as the observation centres around historic expertise in vaccines and biological manufacturing capability from GlaxoSmith Kline, AstraZeneca and the Jenner Institute (Oxford University).  There is a learning here too for the unfortunate circumstance of much of biopharma closing down antibiotic research (in reality because of lack of commerical markets arguably due to inability to be able to price effectively as generics for old drugs are cheap and systems won’t pay enough for novel antibiotics).

After arguably a slightly slow start US government, the BARDA programme, looks fairly effective and the US biopharma response across the spectrum has been pretty good (I’d also include most global biopharma where they have expertise eg Roche partnered with Regeneron as well as executing on diagnostics, Novartis where it had technology (hydroxychloroquine). 

China is hard to assess sitting at a desk outside China, but impressions also seem favourable given they have many shots in the leading group and the sheer number of smaller biotechs working in the area (see Milke Institute tracker) is large at earlier stage. 

Overall, this to me looks like a win for science and innovation and perhaps shows we as humans can still build things (fairly fast) when needed.

Background assumptions to consider:

Vaccine developers will begin delivery of vaccine at the earliest possible date of approval and deliver the purchased amount over 6 months. The exception to this logic is AstraZeneca where the purchase volume is significantly greater (although the terms of the agreement are unclear).

There is an adjustment from 'doses' to 'vaccinations' based on whether each vaccine will require a second dose (booster). Immunogenicity data from Pfizer, Moderna, AstraZeneca and Novavax all suggested that that a booster will likely be required. 

Limited EUA (emergency use authorisation) will likely prevent supply shortage even early on. If vaccines were approved for the entire US population in late 2020, there would be shortages until March 2021. Still this seems unlikely. The initial market entry based on EUA will be based on convincing efficacy data. In contrast, safety data will be broad (10,000s  patients) but of relatively short duration, as the trials are expected to accumulate events (infections) quickly. 

Given political pressures, historic risk aversion when full data lacking (also note recent complete response letters to novel treatments eg gene therapy haemophilia, JAK inhibitor, in Q2 / Q3 2020)  FDA would limit the use to high-need groups (essential employees, high-risk comorbidities). If this is the case, then pre-approval manufactured amounts will be sufficient to satisfy demand.

I would still support informed patient choice in this scenario (see my previous paper) but I doubt we will have it. 

Links:

My forecasting Primer including on drug probabilty forecasting.

Milken Institute Data

My early vaccine use idea based on patient choice.

Tyler Cowen on UK COVID response.

Jeff Besos Statement on Amazon to US House of Rep

I found this statement by Besos insightful also offering a little family history and what a “Day One” mentality means. While a little advertorial, Besos makes the case for positives that Amazon has brought - worth pondering.

Statement by Jeffrey P. Bezos, Founder & Chief Executive Officer, Amazon before the U.S. House of Representatives Committee on the Judiciary Subcommittee on Antitrust, Commercial, and Administrative Law, July 29, 2020 (Link here)

Thank you, Chairman Cicilline, Ranking Member Sensenbrenner, and members of the Subcommittee. I’m Jeff Bezos. I founded Amazon 26 years ago with the long-term mission of making it Earth’s most customer-centric company.

My mom, Jackie, had me when she was a 17-year-old high school student in Albuquerque, New Mexico. Being pregnant in high school was not popular in Albuquerque in 1964. It was difficult for her. When they tried to kick her out of school, my grandfather went to bat for her. After some negotiation, the principal said, “OK, she can stay and finish high school, but she can’t do any extracurricular activities, and she can’t have a locker.” My grandfather took the deal, and my mother finished high school, though she wasn’t allowed to walk across the stage with her classmates to get her diploma. Determined to keep up with her education, she enrolled in night school, picking classes led by professors who would let her bring an infant to class. She would show up with two duffel bags—one full of textbooks, and one packed with diapers, bottles, and anything that would keep me interested and quiet for a few minutes.

My dad’s name is Miguel. He adopted me when I was four years old. He was 16 when he came to the United States from Cuba as part of Operation Pedro Pan, shortly after Castro took over. My dad arrived in America alone. His parents felt he’d be safer here. His mom imagined America would be cold, so she made him a jacket sewn entirely out of cleaning cloths, the only material they had on hand. We still have that jacket; it hangs in my parents’ dining room. My dad spent two weeks at Camp Matecumbe, a refugee center in Florida, before being moved to a Catholic mission in Wilmington, Delaware. He was lucky to get to the mission, but even so, he didn’t speak English and didn’t have an easy path. What he did have was a lot of grit and determination. He received a scholarship to college in Albuquerque, which is where he met my mom. You get different gifts in life, and one of my great gifts is my mom and dad. They have been incredible role models for me and my siblings our entire lives.

You learn different things from your grandparents than you do from your parents, and I had the opportunity to spend my summers from ages four to 16 on my grandparents’ ranch in Texas. My grandfather was a civil servant and a rancher—he worked on space technology and missile-defense systems in the 1950s and ‘60s for the Atomic Energy Commission—and he was self-reliant and resourceful. When you’re in the middle of nowhere, you don’t pick up a phone and call somebody when something breaks. You fix it yourself. As a kid, I got to see him solve many seemingly unsolvable problems himself, whether he was restoring a broken-down Caterpillar bulldozer or doing his own veterinary work. He taught me that you can take on hard problems. When you have a setback, you get back up and try again. You can invent your way to a better place.

I took these lessons to heart as a teenager, and became a garage inventor. I invented an automatic gate closer out of cement-filled tires, a solar cooker out of an umbrella and tinfoil, and alarms made from baking pans to entrap my siblings.

The concept for Amazon came to me in 1994. The idea of building an online bookstore with millions of titles—something that simply couldn’t exist in the physical world—was exciting to me. At the time, I was working at an investment firm in New York City. When I told my boss I was leaving, he took me on a long walk in Central Park. After a lot of listening, he finally said, “You know what, Jeff, I think this is a good idea, but it would be a better idea for somebody who didn’t already have a good job.” He convinced me to think about it for two days before making a final decision. It was a decision I made with my heart and not my head. When I’m 80 and reflecting back, I want to have minimized the number of regrets that I have in my life. And most of our regrets are acts of omission—the things we didn’t try, the paths untraveled. Those are the things that haunt us. And I decided that if I didn’t at least give it my best shot, I was going to regret not trying to participate in this thing called the internet that I thought was going to be a big deal.

The initial start-up capital for Amazon.com came primarily from my parents, who invested a large fraction of their life savings in something they didn’t understand. They weren’t making a bet on Amazon or the concept of a bookstore on the internet. They were making a bet on their son. I told them that I thought there was a 70% chance they would lose their investment, and they did it anyway. It took more than 50 meetings for me to raise $1 million from investors, and over the course of all those meetings, the most common question was, “What’s the internet?”

Unlike many other countries around the world, this great nation we live in supports and does not stigmatize entrepreneurial risk-taking. I walked away from a steady job into a Seattle garage to found my startup, fully understanding that it might not work. It feels like just yesterday I was driving the packages to the post office myself, dreaming that one day we might be able to afford a forklift.

Amazon’s success was anything but preordained. Investing in Amazon early on was a very risky proposition. From our founding through the end of 2001, our business had cumulative losses of nearly $3 billion, and we did not have a profitable quarter until the fourth quarter of that year. Smart analysts predicted Barnes & Noble would steamroll us, and branded us “Amazon.toast.” In 1999, after we’d been in business for nearly five years, Barron’s headlined a story about our impending demise “Amazon.bomb.” My annual shareholder letter for 2000 started with a one-word sentence: “Ouch.” At the pinnacle of the internet bubble our stock price peaked at $116, and then after the bubble burst our stock went down to $6. Experts and pundits thought we were going out of business. It took a lot of smart people with a willingness to take a risk with me, and a willingness to stick to our convictions, for Amazon to survive and ultimately to succeed.

And it wasn’t just those early years. In addition to good luck and great people, we have been able to succeed as a company only because we have continued to take big risks. To invent you have to experiment, and if you know in advance that it’s going to work, it’s not an experiment. Outsized returns come from betting against conventional wisdom, but conventional wisdom is usually right. A lot of observers characterized Amazon Web Services as a risky distraction when we started. “What does selling compute and storage have to do with selling books?” they wondered. No one asked for AWS. It turned out the world was ready and hungry for cloud computing but didn’t know it yet. We were right about AWS, but the truth is we’ve also taken plenty of risks that didn’t pan out. In fact, Amazon has made billions of dollars of failures. Failure inevitably comes along with invention and risk-taking, which is why we try to make Amazon the best place in the world to fail.

Since our founding, we have strived to maintain a “Day One” mentality at the company. By that I mean approaching everything we do with the energy and entrepreneurial spirit of Day One. Even though Amazon is a large company, I have always believed that if we commit ourselves to maintaining a Day One mentality as a critical part of our DNA, we can have both the scope and capabilities of a large company and the spirit and heart of a small one.

In my view, obsessive customer focus is by far the best way to achieve and maintain Day One vitality. Why? Because customers are always beautifully, wonderfully dissatisfied, even when they report being happy and business is great. Even when they don’t yet know it, customers want something better, and a constant desire to delight customers drives us to constantly invent on their behalf. As a result, by focusing obsessively on customers, we are internally driven to improve our services, add benefits and features, invent new products, lower prices, and speed up shipping times—before we have to. No customer ever asked Amazon to create the Prime membership program, but it sure turns out they wanted it. And I could give you many such examples. Not every business takes this customer-first approach, but we do, and it’s our greatest strength.

Customer trust is hard to win and easy to lose. When you let customers make your business what it is, then they will be loyal to you—right up to the second that someone else offers them better service. We know that customers are perceptive and smart. We take as an article of faith that customers will notice when we work hard to do the right thing, and that by doing so again and again, we will earn trust. You earn trust slowly, over time, by doing hard things well—delivering on time; offering everyday low prices; making promises and keeping them; making principled decisions, even when they’re unpopular; and giving customers more time to spend with their families by inventing more convenient ways of shopping, reading, and automating their homes. As I have said since my first shareholder letter in 1997, we make decisions based on the long-term value we create as we invent to meet customer needs. When we’re criticized for those choices, we listen and look at ourselves in the mirror. When we think our critics are right, we change. When we make mistakes, we apologize. But when you look in the mirror, assess the criticism, and still believe you’re doing the right thing, no force in the world should be able to move you.

Fortunately, our approach is working. Eighty percent of Americans have a favorable impression of Amazon overall, according to leading independent polls. Who do Americans trust more than Amazon “to do the right thing?” Only their primary physicians and the military, according to a January 2020 Morning Consult survey. Researchers at Georgetown and New York University found in 2018 that Amazon trailed only the military among all respondents to a survey on institutional and brand trust. Among Republicans, we trailed only the military and local police; among Democrats, we were at the top, leading every branch of government, universities, and the press. In Fortune’s 2020 rankings of the World’s Most Admired Companies, we came in second place (Apple was #1). We are grateful that customers notice the hard work we do on their behalf, and that they reward us with their trust. Working to earn and keep that trust is the single biggest driver of Amazon’s Day One culture.

The company most of you know as Amazon is the one that sends you your online orders in the brown boxes with the smile on the side. That’s where we started, and retail remains our largest business by far, accounting for over 80% of our total revenue. The very nature of that business is getting products to customers. Those operations need to be close to customers, and we can’t outsource these jobs to China or anywhere else. To fulfill our promises to customers in this country, we need American workers to get products to American customers. When customers shop on Amazon, they are helping to create jobs in their local communities. As a result, Amazon directly employs a million people, many of them entry-level and paid by the hour. We don’t just employ highly educated computer scientists and MBAs in Seattle and Silicon Valley. We hire and train hundreds of thousands of people in states across the country such as West Virginia, Tennessee, Kansas, and Idaho. These employees are package stowers, mechanics, and plant managers. For many, it’s their first job. For some, these jobs are a stepping stone to other careers, and we are proud to help them with that. We are spending more than $700 million to give more than 100,000 Amazon employees access to training programs in fields such as healthcare, transportation, machine learning, and cloud computing. That program is called Career Choice, and we pay 95% of tuition and fees toward a certificate or diploma for in-demand, high-paying fields, regardless of whether it’s relevant to a career at Amazon.

Patricia Soto, one of our associates, is a Career Choice success story. Patricia always wanted to pursue a career in the medical field to help care for others, but with only a high school diploma and facing the costs of post-secondary education, she wasn’t sure she’d be able to accomplish that goal. After earning her medical certification through Career Choice, Patricia left Amazon to start her new career as a medical assistant at Sutter Gould Medical Foundation, supporting a pulmonary medicine doctor. Career Choice has given Patricia and so many others a shot at a second career that once seemed out of reach.

Amazon has invested more than $270 billion in the U.S. over the last decade. Beyond our own workforce, Amazon’s investments have created nearly 700,000 indirect jobs in fields like construction, building services, and hospitality. Our hiring and investments have brought much-needed jobs and added hundreds of millions of dollars in economic activity to areas like Fall River, Massachusetts, California’s Inland Empire, and Rust Belt states like Ohio. During the COVID-19 crisis, we hired an additional 175,000 employees, including many laid off from other jobs during the economic shutdown. We spent more than $4 billion in the second quarter alone to get essential products to customers and keep our employees safe during the COVID-19 crisis. And a dedicated team of Amazon employees from across the company has created a program to regularly test our workers for COVID-19. We look forward to sharing our learnings with other interested companies and government partners.

The global retail market we compete in is strikingly large and extraordinarily competitive. Amazon accounts for less than 1% of the $25 trillion global retail market and less than 4% of retail in the U.S. Unlike industries that are winner-take-all, there’s room in retail for many winners. For example, more than 80 retailers in the U.S. alone earn over $1 billion in annual revenue. Like any retailer, we know that the success of our store depends entirely on customers’ satisfaction with their experience in our store. Every day, Amazon competes against large, established players like Target, Costco, Kroger, and, of course, Walmart—a company more than twice Amazon’s size. And while we have always focused on producing a great customer experience for retail sales done primarily online, sales initiated online are now an even larger growth area for other stores. Walmart’s online sales grew 74% in the first quarter. And customers are increasingly flocking to services invented by other stores that Amazon still can’t match at the scale of other large companies, like curbside pickup and in-store returns. The COVID-19 pandemic has put a spotlight on these trends, which have been growing for years. In recent months, curbside pickup of online orders has increased over 200%, in part due to COVID-19 concerns. We also face new competition from the likes of Shopify and Instacart—companies that enable traditionally physical stores to put up a full online store almost instantaneously and to deliver products directly to customers in new and innovative ways—and a growing list of omnichannel business models. Like almost every other segment of our economy, technology is used everywhere in retail and has only made retail more competitive, whether online, in physical stores, or in the various combinations of the two that make up most stores today. And we and all other stores are acutely aware that, regardless of how the best features of “online” and “physical” stores are combined, we are all competing for and serving the same customers. The range of retail competitors and related services is constantly changing, and the only real constant in retail is customers’ desire for lower prices, better selection, and convenience.

It’s also important to understand that Amazon’s success depends overwhelmingly on the success of the thousands of small and medium-sized businesses that also sell their products in Amazon’s stores. Back in 1999, we took what at the time was the unprecedented step of welcoming third-party sellers into our stores and enabling them to offer their products right alongside our own. Internally, this was extremely controversial, with many disagreeing and some predicting this would be the beginning of a long, losing battle. We didn’t have to invite third-party sellers into the store. We could have kept this valuable real estate for ourselves. But we committed to the idea that over the long term it would increase selection for customers, and that more satisfied customers would be great for both third-party sellers and for Amazon. And that’s what happened. Within a year of adding those sellers, third-party sales accounted for 5% of unit sales, and it quickly became clear that customers loved the convenience of being able to shop for the best products and to see prices from different sellers all in the same store. These small and medium-sized third-party businesses now add significantly more product selection to Amazon's stores than Amazon's own retail operation. Third-party sales now account for approximately 60% of physical product sales on Amazon, and those sales are growing faster than Amazon’s own retail sales. We guessed that it wasn’t a zero sum game. And we were right—the whole pie did grow, third-party sellers did very well and are growing fast, and that has been great for customers and for Amazon.

There are now 1.7 million small and medium-sized businesses around the world selling in Amazon’s stores. More than 200,000 entrepreneurs worldwide surpassed $100,000 in sales in our stores in 2019. On top of that, we estimate that third-party businesses selling in Amazon’s stores have created over 2.2 million new jobs around the world.

One of those sellers is Sherri Yukel, who wanted to change careers to be home more for her children. She started handcrafting gifts and party supplies for friends as a hobby, and eventually began selling her products on Amazon. Today, Sherri’s company employs nearly 80 people and has a global customer base. Another is Christine Krogue, a stay-at-home mother of five in Salt Lake City. Christine started a business selling baby clothes through her own website before taking a chance on Amazon. She has since seen her sales more than double, and she’s been able to expand her product line and hire a team of part-time employees. Selling on Amazon has allowed Sherri and Christine to grow their own businesses and satisfy customers on their own terms.

And it is striking to remember how recent all of this is. We did not start out as the largest marketplace—eBay was many times our size. It was only by focusing on supporting sellers and giving them the best tools we could invent that we were able to succeed and eventually surpass eBay. One such tool is Fulfillment by Amazon, which enables our third-party sellers to stow their inventory in our fulfillment centers, and we take on all logistics, customer service, and product returns. By dramatically simplifying all of those challenging aspects of the selling experience in a cost-effective way, we have helped many thousands of sellers grow their businesses on Amazon. Our success may help explain the wide proliferation of marketplaces of all types and sizes around the world. This includes U.S. companies like Walmart, eBay, Etsy, and Target, as well as retailers based overseas but selling globally, such as Alibaba and Rakuten. These marketplaces further intensify competition within retail.

The trust customers put in us every day has allowed Amazon to create more jobs in the United States over the past decade than any other company—hundreds of thousands of jobs across 42 states. Amazon employees make a minimum of $15 an hour, more than double the federal minimum wage (which we have urged Congress to increase). We’ve challenged other large retailers to match our $15 minimum wage. Target did so recently, and just last week so did Best Buy. We welcome them, and they remain the only ones to have done so. We do not skimp on benefits, either. Our full-time hourly employees receive the same benefits as our salaried headquarters employees, including comprehensive health insurance starting on the first day of employment, a 401(k) retirement plan, and parental leave, including 20 weeks of paid maternity leave. I encourage you to benchmark our pay and benefits against any of our retail competitors.

More than 80% of Amazon shares are owned by outsiders, and over the last 26 years—starting from zero—we’ve created more than $1 trillion of wealth for those outside shareholders. Who are those shareowners? They are pension funds: fire, police, and school teacher pension funds. Others are 401(k)s—mutual funds that own pieces of Amazon. University endowments, too, and the list goes on. Many people will retire better because of the wealth we’ve created for so many, and we’re enormously proud of this.

At Amazon, customer obsession has made us what we are, and allowed us to do ever greater things. I know what Amazon could do when we were 10 people. I know what we could do when we were 1,000 people, and when we were 10,000 people. And I know what we can do today when we’re nearly a million. I love garage entrepreneurs—I was one. But, just like the world needs small companies, it also needs large ones. There are things small companies simply can’t do. I don’t care how good an entrepreneur you are, you’re not going to build an all-fiber Boeing 787 in your garage.

Our scale allows us to make a meaningful impact on important societal issues. The Climate Pledge is a commitment made by Amazon and joined by other companies to meet the goals of the Paris Agreement 10 years early and be net zero carbon by 2040. We plan to meet the pledge, in part, by purchasing 100,000 electric delivery vans from Rivian—a Michigan-based producer of electric vehicles. Amazon aims to have 10,000 of Rivian’s new electric vans on the road as early as 2022, and all 100,000 vehicles on the road by 2030. Globally, Amazon operates 91 solar and wind projects that have the capacity to generate over 2,900 MW and deliver more than 7.6 million MWh of energy annually—enough to power more than 680,000 U.S. homes. Amazon is also investing $100 million in global reforestation projects through the Right Now Climate Fund, including $10 million Amazon committed in April to conserve, restore, and support sustainable forestry, wildlife and nature-based solutions across the Appalachian Mountains—funding two innovative projects in collaboration with The Nature Conservancy. Four global companies—Verizon, Reckitt Benckiser, Infosys, and Oak View Group—recently signed The Climate Pledge, and we continue to encourage others to join us in this fight. Together, we will use our size and scale to address the climate crisis right away. And last month, Amazon introduced The Climate Pledge Fund, started with $2 billion in funding from Amazon. The Fund will support the development of sustainable technologies and services that in turn will enable Amazon and other companies to meet The Climate Pledge. The Fund will invest in visionary entrepreneurs and innovators who are building products and services to help companies reduce their carbon impact and operate more sustainably.

We recently opened the largest homeless shelter in Washington state—and it’s located inside one of our newest headquarters buildings in downtown Seattle. The shelter is for Mary’s Place, an incredible Seattle-based nonprofit. The shelter, part of Amazon’s $100 million investment in Mary’s Place, spans eight floors and can accommodate up to 200 family members each night. It has its own health clinic and provides critical tools and services to help families fighting homelessness get back on their feet. And there is dedicated space for Amazon to provide weekly pro-bono legal clinics offering counsel on credit and debt issues, personal injury, housing and tenant rights. Since 2018, Amazon's legal team has supported hundreds of Mary’s Place guests and volunteered more than 1,000 pro-bono hours.

Amazon Future Engineer is a global childhood-to-career program designed to inspire, educate, and prepare thousands of children and young adults from underrepresented and underserved communities to pursue a computer science career. The program funds computer science coursework and professional teacher development for hundreds of elementary schools, introductory and AP Computer Science classes for more than 2,000 schools in underserved communities across the country, and 100 four-year, $40,000 college scholarships to computer science students from low-income backgrounds. Those scholarship recipients also receive guaranteed internships at Amazon. There is a diversity pipeline problem in tech, and this has an outsized impact on the Black community. We want to invest in building out the next generation of technical talent for the industry and expanding the opportunities for underrepresented minorities. We also want to accelerate this change right now. To find the best talent for technical and non-technical roles, we actively partner with historically Black colleges and universities on our recruiting, internship, and upskilling initiatives.

Let me close by saying that I believe Amazon should be scrutinized. We should scrutinize all large institutions, whether they’re companies, government agencies, or non-profits. Our responsibility is to make sure we pass such scrutiny with flying colors.

It’s not a coincidence that Amazon was born in this country. More than any other place on Earth, new companies can start, grow, and thrive here in the U.S. Our country embraces resourcefulness and self-reliance, and it embraces builders who start from scratch. We nurture entrepreneurs and start-ups with stable rule of law, the finest university system in the world, the freedom of democracy, and a deeply accepted culture of risk-taking. Of course, this great nation of ours is far from perfect. Even as we remember Congressman John Lewis and honor his legacy, we’re in the middle of a much-needed race reckoning. We also face the challenges of climate change and income inequality, and we’re stumbling through the crisis of a global pandemic. Still, the rest of the world would love even the tiniest sip of the elixir we have here in the U.S. Immigrants like my dad see what a treasure this country is—they have perspective and can often see it even more clearly than those of us who were lucky enough to be born here. It’s still Day One for this country, and even in the face of today’s humbling challenges, I have never been more optimistic about our future.

I appreciate the opportunity to appear before you today and am happy to take your questions.

Elon Musk on dynastic wealth (against)

"Elon Musk: “…(Laughs.) Ah, oh, man. (Laughs some more.) Ehhh, Mark Zuckerberg has some issues, we all have some issues. My concern with Facebook is that he just has absolute control over Facebook with the way the voting shares are structured. And it’s also structured such that the Zuckerberg dynasty will have control over Facebook and his great-grandkids will control the thing. So I think we ought to be careful of creating dynastic wealth in the U.S. Just generally, an aristocracy of wealth is a cause for concern…”

From NYT interview (2020).

UK all cause death below 5 year average

UK all cause death now below 5 year average. (Still some COVID deaths offset by fewer non-COVID deaths).

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You can see the approx trend (ofc certain problems with data) on UK COVID deaths here from World in Data.

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Around 1200 to 1500 people die in the UK a day. As of end July around 60 of those deaths are COVID-realted. This suggests about 80 - 100 non-COVID deaths are currently not happening (although some of this is likely pull through where sick elderly died a little earlier in the year but were still likely to pass in 2020).

This - at least in the short term - suggest lockdown and perhaps certain areas of (lack of) activity are positive for death rate eg accidents, maybe drugs + alcohol ? I wonder about long-term eg diet and exercise? But, actually enforced home stay --> more home cooking --> healthier ? And maybe exercise is possibly over-rated??? (Maybe wishful thinking here).

In England and Wales you can see some COVID/Non-COVID splits here: (England/Wales were running below average in the early part of the year pre-COVID, so it’s possible there’s been a slight positive structural trend on a 5 year view eg via wealth and health effects, I’m unsure)

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Link to UK ONS here.

Link to World in Data.

Addendum: Turns out the Imperial team have looked at this. They note this:

Possible interpretations of excess non-COVID-19 deaths

If excess non-COVID-19 deaths are higher than expected deaths: First, it is possible that deaths actually caused by COVID-19 are incorrectly attributed to other conditions. This could be due to lack of a diagnosis, nonspecific symptoms before death, multimorbidity making attribution of death difficult, lack of knowledge by the reporting medical staff, or stigma-related concerns of family members. Non-COVID-19 related deaths could be genuinely higher during the pandemic. First, the pandemic has caused disruption to healthcare provision. Hospitals have cancelled elective surgeries in some weeks, possibly resulting in increased mortality in those patients. Second, even critically ill patients may be reluctant to access care, for fear of hospital-acquired infections. Both inability and reluctance to access care may have led to patients’ death, when they would have survived in the absence of the pandemic.

If excess non-COVID-19 deaths are lower than expected deaths: This finding could be due to irregularities in reporting. Second, the reduction in mobility and travel associated with control measures, particularly stay-at-home orders, may result in a reduction in accidents and associated deaths. Third, it is also possible that COVID-19 disease may cause mortality displacement, a short-term forward shift in mortality whereby a certain proportion of deaths due to COVID-19 occurred in patients that would have died of other conditions in the following weeks or months. This implies that over time, COVID-19 deaths that are higher than expected all-cause deaths are followed by lower than expected non-COVID-19 deaths in the following weeks and months, resulting in a deficit in excess non-COVID-19 deaths. In addition, hospitals have increased their capacity over time to treat non-COVID patients or patients changed their behaviour and started visiting hospitals again resulting in a reduction in deaths in line with expected levels.

Variations in deaths: The figures show steep increases and declines for COVID-19 deaths and unexplained deaths in some regions and for some ages over the weeks since March 2020. In some regions and weeks, excess non-COVID-19 deaths are even lower than expected deaths. These findings could have several explanations. First, case numbers vary over the pandemic, leading to variations in hospitalizations and deaths with a 2 to 3 weeks delay on average. Second, there may be irregularities in reporting. For example, in the first weeks of the pandemic, deaths due to COVID-19 may have been wrongly attributed to other conditions instead of COVID-19 but and in later weeks, non-COVID-19 deaths may have been wrongly attributed to COVID-19.

More details and splits here from the Imperial Team.

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