Pandemics and Hunger:  Part 2 of Our Interview with Dr. Ron Waldman

Exclusive content from the World Hunger Education Service.  June 2020.  Dr. Ron Waldman reflects on lessons of pandemic preparedness and response, the roles of the USG and UN and recommended references.

Hunger Notes editors Peter Morris and Steve Hansch interviewed pandemic expert Dr. Ron Waldman (RW), Professor of Global Health at George Washington University’s Milken Institute School of Public Health, Board President of Doctors of the World, author,  and long-time point person for international health in emergencies for USAID and the Centers for Disease Control and Prevention (CDC).  This article continues the interview begun at:  www.worldhunger.org/pandemics-crisis-and-hunger-an-interview-an-interview-with-dr-ron-waldman1

What, if anything, most surprises you about how this COVID-19 outbreak has played out? 

RW:   What surprises me is that people seemed to have under-estimated the importance of political leadership when a serious problem affects societal functions as a whole.  Frankly, it surprises me the degree to which this turns out to be important.  When you look at Germany or New Zealand, you see that it was really the ability of those governments to make decisive, intrusive decisions like restricting movement, and to do so with a battery of public health measures instituted simultaneously, that led to reasonably good results.  In those countries where leaders were reluctant to make those decisions at all, or where they made them incrementally, like “Oh-I-don’t-really-want-to-do-this” next step implementation; those countries are getting hit hard.  Those countries that are more decisive have done much better.

Australia made this sort of firm decision ahead of the curve.  Austria is another example of that.  It’s not liberal or conservative, it’s decisive.

It is really interesting how wrong “the experts” were.  For instance, some of the more prominent ranking of countries in regard to their preparedness for an event like this had the US, UK, and France way up at the top of the charts.  That’s because they left out some of the important criteria that comprise preparedness and tended to focus on health-specific, technological factors.

Have any recent public communications concerned you?

RW:   I think there are things that seem to be logical things to do that don’t necessarily have the best science or evidence behind them.  Such as all the calls now for wearing masks in public places.  At the start of the outbreak scientists were saying that it is silly to wear masks or that it’s really the people who are sick who need to wear masks.  But now it has sort of become a given that if you’re outside in a crowded place, you should wear a mask.   It’s come about because it seems to be a logical thing to do.  And now the scientists are saying that the science supports it, although exactly the opposite was true at the onset.  It’s really a bit Brave New World-ian, isn’t it? That’s one mess-up of communications.

All of these times that the scientific experts reverse themselves, it makes science look bad.

And now, the science doesn’t really seem to matter because everything, including masks, has become political symbols.  Republicans aren’t wearing masks, so Democrats condemn them.  What does viral transmission dynamics have to do with political affiliation?  Only in America (and maybe a few other countries).

President Trump has been saying there are States that are just locking down too much.  I don’t know what the evidence basis is for making this conclusion.

There still is a lot of confusion, obviously about testing.  I was upset when they were first talking about “testing, testing, testing”.  The goal is not merely to test.  It’s not like the country that does the most testing wins.  It’s just a shorthand for identifying cases as early as possible by diagnostic means.  They could have said people who meet this case definition should be presumed positive.

The series of events cannot stop with testing – it needs to continue with contact tracing, any of the contacts exhibiting symptoms need to be isolated.  And the others should be quarantined for one incubation period.  That has not been communicated to the public well. Testing, contact tracing, isolation, quarantine.  Now people are starting to understand that, but the WHO Director-General went on about “testing, testing, testing”, as shorthand, and a lot of people picked up on that.  They didn’t understand the broader implications so they didn’t prepare for them

I don’t think people understood there are two completely different kinds of tests:   Diagnostic and antibody tests tell you different things and are useful for different decisions.  This is another bad element of risk communication.

What about Communications related to a vaccine and about herd immunity?

RW:   There seems to be a feeling out there that there is going to be a vaccine in 18 months.   Because scientists said it would take at least 18 months. There’s no vaccine for SARS or MERS (another coronavirus disease).  That’s been one of the holy grails. There’s no guarantee there’s going to be a vaccine, ever!  If it doesn’t happen, there’s going to be a lot of disappointment and rebellion against the scientific community.  The scientific community does not understand how the public takes the pronouncements from scientists.  There are encouraging signs but vaccine development is one thing.  Mass production and equitable distribution are different ball games. Certainly we all hope it can happen.  But we should have modest expectations and not put all our eggs in the vaccine basket (perhaps not as apt a metaphor as in the past).

Another area that is murky is whether or not immunity develops.  Everyone and their brother now can opine.  All the TV doctors are now experts, using words like antibody testing, reproductive number and herd immunity, which many of them don’t understand well. The economists also.  People say that whenever you see an economist on television, they tell you all about the transmission dynamics and the development of immunity.  But whenever you see an epidemiologist, they say “I don’t know”.  That’s what I say in all of my interviews and it should be made clear here:  the starting point is “I don’t know”.  How could anyone know?  The whole point is that this is a new virus that we have never seen before.  It has been in humans for about 5 months. How much can we be expected to know?  Of course we can make inferences from past experiences with similar viruses and other pandemics, but we need to do so modestly and with the expectation of being proved wrong.

There’s this idea now that the so-called strategy of herd immunity is to open early and let the virus run its course, so then everyone will be infected and become immune.  That’s not actually the way it works.

Sweden is more or less pursuing this strategy now, in fact, if not in theory.  Although the Sweden case is complicated and there are other, political and regulatory, reasons why they are only suggesting public health measures to their population, not prescribing them.  Unlike people in many countries, such as the one in which this interview is being conducted, Swedes tend to behave like responsible adults.  But what they are doing is somewhat dangerous.  Some of the smaller studies in Washington State, and other places, and even in Stockholm have found that antibody prevalence in the community is much lower than what was initially predicted.  The virus seems to spread very heterogeneously.  Chris Murray’s data [at the University of Washington University] suggests that by the time this initial wave of transmission has run its course, maybe sometime in mid-August, there will be only about 4-5% antibodies prevalence in the population.  Meaning 96% of the population will remain susceptible to another outbreak next winter.

Can you comment about the kinds of planning and preparedness that you worked on for many years for exactly this type of outbreak?  

RW:   Most of the planning that I was involved in was done in conjunction with a dedicated UN agency, or unit, called the UN Secretariat for Influenza Coordination (UNSIC).  It was chaired by Dr. David Nabarro, had a staff of about 10-15, and received $125 million from USAID and had a number of other donors. As a whole, the pandemic preparedness business began in the 2000s, when the world was facing the threat of the avian influenza virus, also known as “H5N1,” a virus that appeared in 1997.  It was very threatening because almost every human who contracted the virus would die, an 80% case-fatality ratio.  Though, it was not very transmissible, and mostly moved within families.  When an outbreak occurred that year in Hong Kong, because of the spillover threat from animals, the director of the Hong Kong health department gave the order that all the chickens in Hong Kong should be culled.  She is given credit for eliminating the threat.   That Hong Kong health director at that time was Margaret Chan, who later became the Director General of the WHO.  As it turned out, that virus receded and did not pose an immediate threat, though it was still out there.

Then in the early 2000s, Avian influenza cases began to appear again, in Egypt, Indonesia, Africa, China, Vietnam, Cambodia, and elsewhere.

A concurrent trend was that the number of spillover events began to number in the hundreds.  And it became clear to everyone that whether it was H5N1or another virus, the question of a widespread, potentially lethal pandemic became “when, not if.” Consequently, interest grew in preparedness.  The UN created this little unit and the US began to invest in preparedness:  Sending large amounts of money to FAO, WFP, and WHO.

One track was to fund UNSIC and another to fund NGOs to reach the more peripheral parts of countries.  The major donor was the Division of USAID that was headed by Dennis Carroll.  And the State Department also began a pandemic preparedness operation.  John Lange was the U.S. Avian Influenza and Pandemic Ambassador in charge, and he had regular weekly meetings with representatives from USDA, Homeland Security, USAID, State, CDC.

At the same time the CDC began ramping up its own pandemic preparedness.  This must have cost hundreds of millions of dollars.

The USAID program, one that included the NGOs, became H2P, or Humanitarian Pandemic Preparedness, and that’s what I headed up.  There was a lot of procurement of PPE that has lasted to this day, stationed around the world.

USAID’s Office of U.S. Foreign Disaster Assistance [OFDA] had a big hand in that.  We in the USAID Global Health Bureau worked closely with OFDA as well, recognizing that OFDA’s mandate is principally for response, and that their involvement in preparedness was a reach.  It was very frustrating to us working in global health, working on the preparatory aspects that we could never quite get OFDA to deviate from its strict response mandate.

There is one report, the culmination of H2P, that grew to be a small movement, Towards a Safer World.  [http://www.towardsasaferworld.org/?q=content/what-tasw ] There is a monograph with that title that formed the basis of a large meeting held at WFP in Rome which culminated in a large multi-sector meeting in in 2009.  It remains available on a website with the same name.

What are five or so books about pandemics you would recommend?

RW:  I think that the best one would be Camus’ The Plague “La Peste:”   A perfect achievement.

I would also recommend John Barry’s “The Great Influenza”; Pale Rider (The Spanish Flu and How it Changed the World) by Laura Spinney; Sonia Shah’s “Pandemic: Tracking Contagions from Cholera to Ebola and Beyond”; Jonathon’s Quick’s “The End of Epidemics”; and David Quammen’s “Spillover,” which focuses on zoonoses and how pandemics can start.

 

 

Pandemics, Crisis and Hunger: An Interview with Dr. Ron Waldman Part 1

June 7, 2020

       Hunger Notes editors Peter Morris and Steve Hansch interviewed pandemic expert Dr. Ron Waldman (RW), Professor of Global Health at George Washington School of Public Health and long-time point person for international health in emergencies for USAID and the Centers for Disease Control and Prevention (CDC).

What should the World Health Organization’s (WHO) role be in pandemics, given all the recent controversy about WHO?

RW:  WHO should always be in charge at the start of a pandemic.  They need to be the one to identify the pandemic, to begin to issue guidance on a variety of aspects of control including prevention of transmission, diagnostic means, and treatment, and they should start and coordinate the R&D effort for vaccine development, production, and distribution.  But we saw how quickly a pandemic touches all sectors of society.  There needs to be a whole-of-society response that goes far beyond the health sector alone.  There should have be plans in place for when schools should close and when to close and re-open businesses.  What to do about travel shutting down, and so on.  There needed to be a clear safety net for low-income countries.  As we are seeing, it is really not all about health.  The economy is important and this cannot be a fight between averting COVID-19 deaths and averting deaths due to increased poverty, including increased food insecurity.  But there won’t be that kind of across-the board, whole-of-society preparedness if only WHO is in charge – they won’t always be able to effectively move from “their” lane, which is focused almost exclusively on technical aspects of health and its determinants, but not sufficiently on its broader consequences.

What is the relevance today of the International Health Regulations (IHR)?

RW:  SARS was the impetus for the revised International Health Regulations (IHR).  We know what a political organization WHO is.  Its policies and decisions are very much influenced by politics.  The governance is political, being that it is comprised of Ministers of the Member States.  That’s not necessarily a good way to do science.  Most of WHO’s budget is funding tied to “extra-budgetary” programs that are dictated by governments like the US, or by the Bill and Melinda Gates Foundation.

But this is part of the criticism of WHO because they did not declare an international emergency of public health concern.  I think this whole public health emergency of international concern concept has become somewhat meaningless and devoid of teeth.  The IHR has not lived up to its potential. Polio is now part of it.  Ebola was not before, but then it was.  Even for COVID-19, the declaration was delayed and WHO did not even declare it to be a “pandemic” for quite some time because they did not want to scare people, I guess.  If you look at those things that have happened.  I guess people don’t feel the IHR has the chops.

There are the IHRs, and they do call for early reporting.  And there is a lot of controversy about the degree to which China complied in their reaction to the outbreak of COVID-19.  They delayed excessively.  They declared the first cases on the 31st of December, though the first cases had occurred at least 3 weeks before.  The origin story of this pandemic will remain shrouded in mystery.  The Wuhan Seafood Market is not particularly convincing as the origin because there were cases prior to the ones that were first announced that had no connection there.  But I don’t think it’s of great importance.  I know a lotof people like to speculate about whether the virus escaped from a laboratory.

The point is that the bio-safety of those laboratories that deal with highly pathogenic organisms has to always be a major priority.  It was, it is, and it shall always be.  I don’t see what an escape would change in regard to the amount of care that has to be accorded, and certainly the BSL-3/4 labs in Wuhan are among the world’s best.  In addition, looking at the genomic sequences of the SARS-coronavirus-2, virologists feel it is unlikely that the lab was the origin.

If something should be done about it should be done on a multilateral basis.  Pointing fingers drives the problem underground.  It’s a good way to make sure the truth never comes out.

What is your view of the current tension over lock-down versus opening the economy?

RW:  There’s a lot of wishful thinking out there in the non-virology community.  Everyone knew that opening early, or May 1, as the President had wanted, or even earlier, by Easter, was a pipe-dream.

It’s kind of sad in a way to see the kind of leadership we are getting and the divisiveness it has caused.

The only way this epidemic is going to stop is if there are serious limitations to individual liberties.   From a strictly public health point of view, you can’t let people decide what to do.  You have to be instructive and enforce implementation of the right things.  You can’t let people just walk into supermarkets and cough on the produce.  When I say “you have to …” I mean from the public health point of view.  But societies can choose for themselves.  They certainly can choose “liberty over lockdown,” but they then have to be able to accept the public health consequences of that decision”.

The late Dr. Jonathan Mann was a champion of “health and human rights”.  I know it’s sounds terrible, but at times it is a question of health or human rights.  But, in any case, draconian measures should be in place for only the shortest time necessary.  You can’t ask people to not die of COVID-19, but to be driven into poverty and food insecurity through unemployment.  Quality of life counts too.  Not to mention that there are many other causes of death out there that are ignored if the singular focus is on COVID-19. Lockdowns need to be compassionate and sympathetic, not punitive.  Again, it requires unusually smart leadership, and very enlightened follower-ship, to do it right.  We have been shown by some countries, such as South Korea and New Zealand, that it can be done right.

In public health we’ve proposed or done this for a long, long time.  Now people are saying “you can’t do that; you can’t restrict m
ovement.”   But we’ve always done that.   It is how the word “quarantine” came into our language.

The traditional treatment of tuberculosis was to put people into what effectively were p

rison.   We called them sanatoria.   In the second half of the 19th century one of the leading sources of revenue in Colorado was renting out little gazebos that people would construct in their backyards for TB patients.  People with Hansen’s Disease [aka leprosy] were plucked out of society and put into special “reservations”.  People with mental health issues were locked up.  That what Thomas Szasz meant when he titled his book, The Myth of Mental Illness, not that there is no such thing as mental illness, but that it is a myth that we treat it as an illness as opposed to treating it as a crime.

How do you foresee this outbreak hitting in developing countries?

RW:  The outbreak in India (and now S. America) is more advanced than in other places.  The pandemic will also affect how other health problems are addressed.  It will have a devastating effect because the consequences of any lockdown undertaken will affect a much greater proportion of the population in places where people need to be out and about on a daily basis to have money and food.  Specific strategies have to be designed for those places – it does not seem right that those policies that were developed and implemented in China and Singapore should be transplanted to Peru or Zambia.  And the best strategies will be those that are designed locally, and with the participation and compliance of the affected population.  It’s a tall order.

From all your past research and planning, what do you anticipate may be the secondary impacts in terms of people no longer receiving treatment or hospital care for other conditions, for example in Africa or Asia?

RW:  In fact, I would go a step further.  I would expect the secondary impacts to be greater than the immediate health outcomes.  I would say there is extremely little vaccination taking place right now because of the pandemic.  I would expect to see new outbreaks of measles as a result.  There may be outbreaks of meningitis, and so forth, down the line.  I think in terms of maternal mortality, we will see an increased proportion of babies born at home and not in facilities, with the neonates not getting adequate attention.  Domestic violence is undoubtedly going to increase.

These extra health problems are further neglected as donors, such as Mr. Gates and others, are both urging and acting to transform everything they do and fund to be COVID-19 specific.  Some public health experts are concerned or very critical of this trend.

So, companies like Abbott are no longer making malaria diagnostics, as they focus instead on COVID-19.   HIV testing is grinding to a halt as those companies are moving to COVID-19 technologies.

What are your thoughts about how the pandemic is being measured?

RW:  It’s a problem with COVID-19 reporting.  I can’t get very excited about the numbers coming out.  The distribution is heterogeneous.  There are places within countries that are not represented at all by the numbers.   The US has had for the last few weeks a plateau of about 30,000 cases a day.  But that obscures that it’s growing in 30 states.

Even in Portugal, on the downside of the curve, most of the cases are in the country’s north.  Although the whole place is on lockdown.  The distribution is uneven.  You can’t say one place is like this and another like that.

How well might the Red Cross Movement – the IFRC in particular – contribute?

RW:  There is a reasonable model for pandemic preparedness and control, which is a major thrust of the International Federation of Red Cross and Red Crescent Societies (IFRC).   IFRC is implementing in 8 countries in Africa, and now they are going to expand their community Pandemic Preparedness Program (CP3) which is, by the way, funded for the most part by the US Government.   It’s in Mali, Guinea, Sierra Leone, Cameroon, Kenya, and a few others.  It’s an effective model because the Red Cross works at multiple levels, including the existing volunteer component at the village level, and each level up from there with the governments.

They have volunteers in every village.  They can take and apply a broad strategy from Geneva and adapt to the local level.  It needs to be passed on from generation to generation.

What do you think may be new problems in international health in emergencies that could arise, such as in malnutrition?

RW:  I would be waiting to see whether under-nutrition increases as a result of job losses and other impacts on income generation (self-employment, remittances, etc.).  The biggest problem with nutrition is if it is an underlying risk factor for severe COVID-19.  There are a number of publications that indicate that obesity is a clear risk factor for severe disease, independent of diabetes and age.  There is literature, and anecdotes about that.  But it isn’t known yet whether under-nutrition is in any way a contributing factor to severe disease.

Above that, how much of the immune reaction to this virus, especially in children, is hyper-immunity, so-called cytokine storm, in which case malnutrition may even be protective, in that it would blunt a hyper-immune event.

The social consequences of the COVID-19 outbreak may be greater than in other places.  India has major nutritional problems, exacerbated by COVID-19.

The nutrition problem in Yemen was so dramatic before COVID-19, it can only be made much worse.  Yemen is a good case in point about COVID-19, which is that a lot of the national strategies for control seem to be more or less cut and pasted from a generic WHO approach, with a focus on case management, expansion of intensive care facilities, and the procurement and distribution of mechanical ventilators.  The other side is testing, isolating, and quarantining contacts of cases.  It makes no sense to me that countries like Yemen should be adopting that kind of approach.  A modified approach should address an active war zone facing famine.