Stopping the Next Pandemic

Transcript

Archive Recording: Israel is on track to lift all social-distancing restrictions in the coming months thanks to a world-leading rollout of COVID-19 vaccines.

Archive Recording: The UK has expedited vaccination plans, aiming to vaccinate all adults with their first dose by the end of July.

Archive Recording, President Joe Biden: We’re now on track to have enough vaccine supply for every adult in America by the end of May.

Archive Recording: We hear some people saying, well, this is a once-in-a-100-years event. It is absolutely not.

Archive Recording: This pandemic has been very severe. It’s spread around the world extremely quickly and it’s affected every corner of this planet, but this is not necessarily the big one.

Jennifer Nuzzo: Hello?

JN: Hi Elmira, how are you?

JN: Yeah, you too.

JN: I am at home near Baltimore, Maryland.

JN: Yes, that’s true. You know, people often say to me, it feels like we’re hearing about more and more of these deadly outbreaks occurring in the world, you know, is it just the news? But the reality is it’s not just the news. I mean, we are living in probably what you could call, you know, an age of epidemics where new viruses, new pathogens are emerging and, you know, they have the ability to get into humans. And if they’re suited to humans, global conditions are such that they can spread pretty widely. And so, there’ve been some studies that have looked at this and, you know, even when we account for the fact that there’s more surveillance now, that there’s new tools to find pathogens now, the frequency with which new pathogens are emerging has been increasing. And really, I think probably, you know, the emergence of HIV or the discovery of HIV in the eighties, I think really sort of signals the beginning of that era, where we see more and more of these sorts of events starting to happen. In particular, just looking at the past decade, I mean, you know, thinking about the things the world has lived through: multiple very serious epidemics of Ebola, we had a flu pandemic in 2009 that a lot of people have forgotten about. MERS is another coronavirus that emerged – fortunately it didn’t have the ability to spread between humans in a sustained way like the novel coronavirus. So really just a number of these pathogens that we have seen countries struggle with.

JN: Yeah, it seems to be the trend where there are pathogens that are in animals, usually mammals, that somehow are able to spill over into human populations that can occur and just sort of stay within, you know, the few people who are directly exposed, or the pathogen can mutate in such a way that it then can be passed easily between humans and certainly that’s clearly the most worrisome situation.

Archive Recording: Fifty percent of the world’s population live in urban areas, but that will grow to 70% by the year 2050, according to the United Nations.

Archive Recording: A new United Nations report says nature is essential for our existence and a good quality of life, but points to a stark warning. Humans are transforming the planet’s natural habitat at an unprecedented rate.

JN: Yeah, so people who study spillover events have undertaken various different modeling exercises to try to understand drives spillover. And my understanding is that the result of that finds that above all, land use change seems to be a particularly important driver. It can be land use change in two directions: it could be the sudden deforestation of an area, or it could be a reforestation next to, you know, perhaps a place where humans are living. So that, I think, is important. So first we need that environmental trend, which basically, you know, means are we putting people in contact with species that they may not have had contact with because of that change? And then once that contact is established, you know, I think urbanization can play another role, which is just when you have a density of people living next to each other that potentially facilitates spread. Those are really the situations. It’s not cities per se, but it’s if we have rapid changes that we haven’t accounted for in land-use change, rapid increases in crowding, and decreases in sanitation, that those are particularly worrisome traits for the spread of pathogens.

Archive Recording: Mystery surrounds the high-security lab at the Wuhan Institute of Virology that handles the world’s most dangerous pathogens, making it the target of conspiracy theories about the origin of the virus.

Archive Recording: A team of international experts investigating the origins of COVID-19 have all but dismissed a theory that the virus came from a lab. The conclusion was made by a WHO team on a visit to Wuhan, the Chinese city where the virus was first detected.

Archive Recording: Bats and pangolin have long been suspected as the origin of coronavirus, but other species, including cats and minx, will now be investigated.

JN: You know, there is, I think the possibility of both. In the course of legitimate scientific work, there could be an accidental release of a pathogen that could cause harms. And then there’s also the possibility that somebody with malintent could engineer or even just release a pathogen for the purpose of doing harm. Now, I can’t tell you what the probability of those occurrences are, but recognizing that it is a possibility and recognizing that, were any of those events to happen, they would have considerable consequences, that then suggest that we just should prepare for them and figure out what we would do. Were those events to occur, regardless of the cause, we need to be prepared to respond. And fortunately, much of what we need to do to respond to those events are comparable and you know, would be cross-cutting. And so the goal of preparedness is to be ready, regardless of the cause, but to be ready for the event.

JN: Yeah, so I think when we say experimenting on these viruses, it sort of gives the impression that we’re just kind of out of curiosity tinkering with them, when reality is, much of the experimentation is really for purposes that advance health. You know, trying to better understand how we develop diagnostic tools, how we develop vaccines and therapeutics, trying to understand how we are susceptible to these viruses and what makes one bad and one not. And so the real challenge is that, although there is concern about the potential for this research to have unintended consequences, there also, very much, is a need for the research for beneficial purposes. And it’s really hard to draw the line between the two. There is no clear way, or at least many groups have looked at this in a variety of different ways, and the fact that we haven’t come up with a solution yet is, in part, because it is quite hard to say, “that experiment is bad, but that experiment is good” because, you know, there are, there are risks and benefits involved.

JN: Yeah, I mean, I think there were a lot of mistakes. First of all, I think now with the benefit of hindsight and some information that has come out, it was clear that there was a more obviously worrisome situation happening in China for longer than it was publicly disclosed. And that obviously is not a good situation to have, but also, you know, even if you took that off the table, even if you took when things were disclosed off the table, there still is always going to be, unless we’re prepared, a challenge to figure out what’s happening. I mean, when new pathogens emerge, it can be difficult to tell how much of a public health threat they are at first. Part of being able to do that is making sure we have in place appropriate surveillance systems, that the doctors and nurses who first see the patients are astute enough to recognize that something unusual may be happening, that they know how to report it, that we have diagnostic tools to help us figure out what’s causing it, that we can do enough diagnosis and testing in order to be able to figure out how many people have it and how many don’t.

So there’s this whole kind of cascade of responses that have to kick in, some of which are just simply to describe for us the problem and to understand how big of a threat it is. And some of it is just to try to contain it so that, you know, if a new pathogen emerges and causes an outbreak, that we don’t let it grow to an epidemic and then let it grow beyond that to a pandemic. I have been so struck by the fact that, you know, our first understanding of the threat that the virus posed was, in part, from investigations done by other countries that also saw cases. To me, this is always going to be a global endeavor that requires participation by multiple countries.

JN: Yeah, that is a really big problem that I don’t think we have solved as a global community and I think people are very quick to dismiss it as a problem. I mean, it is so frequently the case that when new disease events happen, countries’ first response to protect themselves is to ban travel or trade from the country that’s struggling. And I understand those tendencies and why it can feel appealing. But if the effect of those tendencies is to have a chilling effect on countries, to make countries not be willing to report emerging events that they are struggling with for fear that they will be slapped with economic penalties, which is what travel and trade restrictions are, you know, that’s not going to benefit any of us.

Really, we need to figure out how both to incentivize countries to report these events early and also figure out how to eliminate disincentives. So by incentivize, you know, I think one of the challenges is that when countries report, there’s not really much benefit to them. It’s not as though there’s some, say, global fund that could provide resources to help them combat the problem that they may be facing within their own borders that has the potential to spread across, or outside of their own territory to other countries. If there were some resources that could then be summoned or marshaled to help those countries in a guaranteed way, you know, perhaps countries might be more willing to report because they know they can gain help by doing so. The reality of what happens now is that countries can report and we don’t ever truly know if help will arrive. We don’t ever truly know if the global community will sort of pitch in and donate resources to help. Usually the WHO often winds up having to kind of beg and plead for global assistance. And that really doesn’t help encourage countries to be forthcoming with events.

Archive Recording: There is word from US intelligence that China vastly understated its own death toll in the pandemic.

Archive Recording: Russia’s coronavirus death toll has been revealed to be three times more than originally reported.

Archive Recording: Data sent to the BBC by an anonymous source claims the death rate in Iran is triple official figures.

Archive Recording: We’re following a major setback on the road to recovery for New York City.

Archive Recording, Bill de Blasio: We do need to close our schools for the coming days.

Archive Recording: This came after the city’s seven-day positivity rate reached 3%.

Archive Recording, Andrew Cuomo: So the mayor saying it hit 3%?

Archive Recording, Andrew Cuomo: When is 3% not 3%? Because nothing is easy.

JN: Yeah, that’s been one of the biggest challenges in this pandemic, that we clearly have a need to understand how countries are being affected by COVID. We also have a need to understand how regions within countries – states, US states, for example – are being affected. And in order to know, we need to have some common agreement for how we’re going to measure impact. So it’s common to talk about cases, but the reality is not all places are looking for infections, diagnosing infections, and calling them cases in the same way. Some of that is capacity-dependent. So if you’re a country and you don’t have much by way of testing infrastructure, it’s going to be very hard for you to go out and look for infections. And in fact, a number of the countries that seem to be relatively spared in terms of impacts, COVID, when you look at who they’re testing, they may be largely only testing travelers, people who arrive via airplanes, because those travelers pay for those tests and so therefore there are resources to conduct the tests, but that’s quite different than other countries that are being quite aggressive in their surveillance and going out into the communities and looking for infections in an effort to try to truly characterize the burden that they may be experiencing.

So that’s a problem, right there, even something simple as deaths. I mean, in order to be counted as a COVID death, for the most part, someone has to have been tested. And if countries aren’t testing people who’ve died, then we don’t know how many deaths there have been. A lesson for me is that, you know, early on, we need to have some kind of global consensus about how we are going to count cases. How should we, as a matter of ideal practice, be looking for infections? How should we be reporting deaths? It’s very clear that the impact of COVID is being under-counted in many places, including the United States. And one way that we can tell is if you look at something called excess deaths. And so excess deaths are, you look at a period of time and you see how many deaths occurred during, say, the pandemic and then you compare that to the same period of time in other years. And the delta, the difference, gives you a sense of, perhaps, additional deaths that were either directly caused by the virus or, perhaps, caused because people maybe didn’t get care during that time, because they were concerned about the virus.

Different countries have different ways of counting excess deaths and looking at excess deaths and so even if you are able to get a list of excess deaths from different countries, you’re not truly comparing apples to apples either. So we need some global consensus on how to do that, so that we can do those apples-to-apples comparisons.

JN: Yeah, so I think the goal here is to prevent pandemics. And I think that is a possible goal, but when I say prevent pandemics, what I mean is that, you know, it is likely that new pathogens are going to continue to emerge and potentially spill over into humans. And it may cause an outbreak, but whether that outbreak is going to grow in geographic scope and size to become an epidemic, or a spill across borders and affect multiple countries at once and become a pandemic, really depends on how we respond and how quickly we recognize the events that are happening. But unfortunately, much of our preparedness has really kind of stopped at the outbreak or epidemic level.

What we saw play out in COVID is that once you get into a situation where nearly every country is affected at once, it really changes the game in terms of what a response looks like because whatever global resources you have now need to be spread out among basically everywhere. You also have a situation where essentially countries are competing against each other for access to resources. And we very much saw that in COVID, where the first thing was personal protective equipment. Every country wanted it, but they were only made in a few places and there wasn’t enough of it. It’s certainly playing out now in terms of the rollout of vaccines. And we see huge disparities in countries have vaccines and which don’t and those disparities are well-aligned with income.

So this is the problem with a pandemic: we know that the global response and global coordination is essential. We know that we need to share information about cases in a standardized way. We know that it probably makes sense to pool our resources and to be able to distribute them a bit more evenly than what’s happening now, because if we leave pockets of the world unprotected, that’s not going to be good for everyone. There is a clear benefit to global cooperation in a pandemic for the goals of trying to end it earlier. But essentially what winds up happening is it’s almost every country for itself and no real mechanism to get countries to work together as much as we need them to in order to bring an end to the pandemic.

JN: Well, so, I mean, the first hope is that we can have a framework that at least spells out the expectations of how we should act. And unfortunately, we don’t really have that. The existing framework that we have, the international health regulations, don’t adequately address these issues. They basically create the expectations that countries are going to report cases, but they don’t create the expectation of what communal response will follow. I think there are some promising examples that have been stood up in the course of COVID-19 that I think we should consider as more of a permanent features, things like the COVAX facility for trying to improve access to vaccines. I think, you know, it hasn’t been perfect, but I think it’s making some important progress and we need to figure out how better to support those efforts in the future. I think some of the global clinical trials that have been happening are other important examples of what we can do collectively, but we need to negotiate this and accept the expectation of what should happen so that when the next event happens, we’re not just kind of making it up on the fly.

Archive Recording, António Guterres: The health catastrophe makes it clear that we are only as strong as the weakest health system. Global solidarity is not only a moral imperative – it is in everyone’s interests.

JN: So we looked at all sorts of traditional public health capacities, things like laboratories and surveillance systems. We also looked at capacities within their health system, so things that may fall out of the purview of public health agencies, but more in the purview of health clinics and things that may not necessarily be government entities. We looked at the risk environment in countries. So things like factors that we know may facilitate the spread of pathogens, as well as cross-cutting factors that could influence a country’s ability to use the capacities they have, so things like economic resilience and social and political factors. So that’s in our risk environment. And then we also looked at countries’ adherence to international norms and the extent to which they have financed health security as an imperative. And although the exercise wasn’t really meant to rank countries, inevitably, when you create an index and you give every country a score, you create a ranking of it. An unfortunate outcome is that some of the countries – many of the countries, in fact, that scored highest on the index in terms of having the most resources are, unfortunately, those that have been hardest hit by COVID-19.

JN: Yeah, so I mean, one of the things we’re trying to do right now is to understand of all of the factors that are in the Index, which seem to be most linked to COVID-19 outcomes. It’s a little bit challenging because as we talked about earlier, not every country is reporting COVID outcomes in the same way. So we don’t really have a standardized set to compare it to, but, from some analyses that have been done to date, it seems like trust in government is an important dimension of how well countries have responded. And you can imagine if a government’s in power and they tell their people to do one thing, and they don’t believe the government, they’re not going to do it. And so you could see how that could play out as being challenging, but in the case of the United States, I mean, I think the story is a bit more complicated than just a trust in government issue.

There were also some other warning signs in the US’ scores on the Index. One of the places where we lost a fair amount of points was on the robustness of our health sector and, in particular, access to care. We are seeing enormous challenges in terms of access to care in the response to COVID-19. People not able to get tested, people not able to access vaccines as quickly as they are eligible. So I think there are a number of places where the United States had some warning signs. And then there were a number of places where we have capacities on paper that we just simply chose not to use. I think a particularly good example: the United States had a strategic national stockpile that, on paper, was supposed to have things like personal protective equipment for contagious, infectious disease emergencies. It was supposed to have ventilators and other things. But what happened was that it became obvious in the beginning of the pandemic that much of those supplies had been depleted and never replaced for reasons I don’t fully understand. I think there are probably other dimensions to the US response, like just poor governance or poor leadership of the response.

The Index measures whether a country has a fire alarm, like let’s just put a fire analogy on it. You know, we all know that if you’re worried about the threat of fires, you know that having a fire alarm is important, and you probably also know that it’s important to test your fire alarms a couple of times a year. The Index measures those two things: whether you have a fire alarm or whether you’ve tested it. What we don’t measure is whether you’re going to decide to ignore the fire alarm and not run out of the building when the fire alarm goes off.

Archive Recording: Even as countries race to vaccinate their populations, the COVID-19 death toll continues to rise at an alarming rate.

Archive Recording: With a troubling new report on widening economic inequalities in the wake of COVID-19.

Archive Recording: A majority of American public students are now well into a virtual school year and data from around the country is starting to show that middle- and high-school students are falling behind.

Archive Recording: The Europe head of the World Health Organization says the agency is deeply troubled by reports of increasing domestic violence and are sounding the alarm.

JN: Well, so I think it depends on where you live. And I will say, speaking from the perspective of someone living in the United States, I am a bit more hopeful for the future, in part because of our access to vaccines. We are so extraordinarily fortunate to have access to multiple vaccines that have proven themselves to be incredibly helpful in taming this virus, you know, that it can take off the table the threat of “if you get infected that you will wind up in the hospital or that you will die from it.” I really think that that is putting us on a faster path back to normalcy than we would have been on. I do worry though, because, you know, as we’ve seen this virus continues to mutate and there is, of course, the potential for these mutations to result in traits that we do not want to see. Things like increased transmissibility or increased severity or, you know – and we fortunately haven’t seen too much of this yet – the potential for virus to mutate such that vaccines and therapeutics no longer protect us. There is really an urgency for us to figure out a way to protect the globe from this virus, even if living in the United States, I am slightly more hopeful that life will begin to return to normal in the coming months.

I do think the long-term worry is that we could see a new mutation occur because we’ve left parts of the world unprotected. So it’s really, I think, an urgent situation for governments to not only think about, you know, what’s happening within their borders, but to be looking ahead to what’s happening out there in the world. If the goal is to return to a state of normalcy in a way that makes us really sure of our futures, then that necessitates global cooperation for ending this pandemic.

JN: Thank you so much.