A Biblical Surge of Miscommunication

On Language:

In the popular media, including otherwise-intelligent talking heads and world leaders have invented new pretentious, uses for words that have little actual meaning.  Chief among these are:  “surge,” “spike”, “epicenter” and “biblical proportions.”

For example: the head of large United Nations agency has been prolific about how this pandemic might lead to famines and food shortagesof biblical proportions.   The biblical proportion part has subsequently been repeated by many journalists and in headlines.  In fact, this pandemic has certainly led to dramatic increases in malnutrition across the world, associated with the collapse of livelihoods and jobs of income-earners.  But what about this is of proportions that are “biblical?”  The Bible refers to famines and food shortages on a number of occasions, but never defines how many people were malnourished or died.  In other words, there are no proportions described or implied.  The populations in Biblical times numbered in the tens of thousands or hundreds of thousands, much smaller than those affected today (hundreds of millions).  So, if anything, “biblical proportions” under-plays the extent of death and excess malnutrition occuring today.

Many journalists liked to spruce up their reporting by referring to pockets of Covid-19 cases as “epicenters.”   One anchorwoman referred multiple times to parts of New York as the “epicenter of the epicenter.”  Actually, epicenter is not a term defined to say anything about diseases; it is defined for earthquakes where it refers specifically to the source of the release of the quake waves, i.e. the origin.  So it is untrue, misleading and surely unintended for our media to suggest that the current pandemic began and spread outward from Brooklyn or the Bronx.  Nor from most of the other places called epicenters in this pandemic.  It would be more useful and accurate to say simply “areas of high caseload.”

The most abused terms have been spike(an abrupt rise followed by a fall) and “surge.”  Spike was used early in the outbreak to refer to any spread of the disease, or increase in cases.   Mostly, it was misleading as the increase in cases was not followed soon after by a decline, but instead by continued, gradual increases.   Because the word “spike” may have sounded mathematical, it allowed those reporting to sound dramatic while avoiding saying anything specific about the extent of increase, or the rate of spread.  Better to just say “increase.”

“Surge has been used the most consistently, at times interchangeably with spike but, now, much more often.   “Surge” has grown in use in 2020 to serve as the all-purpose noun, verb and adjective for Covid-19.  In almost all instances it is undefined, without meaning and another way to avoid reporting anything specific.  Based on the context, surge has displaced terms with clearer meanings such as “increase”, “wave”, introduction into a new area, “outbreak”, “plateau,” and “cumulative caseload.”  Some people think it means acceleration, others simply “spread.”  In most cases it means nothing more than “the disease continues to spread from person to person”, which, after all, is what communicable diseases do.  When the first few cases hit Washington, DC, in the same short speech, the Mayor used the word “surge” several times but each in a different way to mean:  “any new cases”, the overall curve, the cumulative caseload, an eventual “plateau” and a growing epidemic.  As another example:  on August 2, the New York Times ran a headline that “Britain had Europe’s Worst Surge in Deaths.”  The article used surge to mean several things at once:  the cumulative deaths over many months, the extent of geographic spread, and the duration of the outbreak.   Where “surge” sometimes means nothing more than “increase”, it is also now referring to everything else that happens including  to the sum total of the disease’s effects.

The word surge has historic usage connoting a “wave.”  But consistently talking about Covid-19 spread as a wave distracts from the reality that it moves from a single person to another single person at a time.  It does not drop from the sky in one big wave onto a lot of people at once.

We do have simple yet specific terms that journalists have become too lazy to use, such as “spread,” “increase”, “caseload”, “outbreak”, and others which public health scientists have used for decades and continue to use.  What epidemiologists care about is the rate of person-to-person spread, one measure of which is R nought (R0), also known as the Reproduction Number, which can vary from town to town and from week to week but which tells us how quickly a disease is spreading.  When R0 is much higher than 1, the spread is geometric (predicted by an exponential equation).  When it is below 1 for an area, the outbreak is declining.

Early in the outbreak, pundits liked to talk about flattening the curve”, with accompanying pictures of a simple curve.  The valid point they wanted to make was the importance of slowing the spread of the disease as much as possible so health systems could catch up.  But it was misleading to the public to imply that there was a simple up-and-down curve to the whole epidemic.   In early 2020 we were unsure the extent to which the pattern of the Covid-19 pandemic would have seasonal ebbs or increases, orwhether it could be readily contained, or other patterns.  We misled at that time in pretending that it would be a simple curve.  We know now that the curve can be very complicated, with distinct waves and peaks.

The global health crisis underway can be a good teaching moment for us all to learn more about humanitarian crises and the science associated with them.  Journalists should up their game in learning to use more precise language.

 

      Steve Hansch is an editor and board member of WHES.

Peter Morris, Nutritionist and Long-term USAID Expert Leads WHES

The editorial staff of World Hunger Education Service recently sat down and interviewed Peter Morris for his insights about progress in international aid, hunger, nutrition and pandemics.  Mr. Morris has served in numerous crises around the world, leading USAID teams, including epidemic response to Ebola in Guinea.  A nutrition expert, he has been involved in critical funding decisions by the US Government for funding new approaches to treating malnutrition in the hardest hit countries.

Question:  We’re doing this interview in the middle of the Covid-19 epidemic; what do you think the public should know about how Covid-19 is increasing hunger and malnutrition?

Peter:  I think Covid-19 is increasing malnutrition beyond just when people get sick from the virus. It has disrupted the food systems so much, such as diminished transport of food to markets. People living with a narrow economic margin in countries have to change their strategies of how they use their money.  It’s almost like a famine because of the inability of people to access food.  The World Food Programme is now asking for around $5 billion more for all the places that need food assistance, necessary as COVID-19 is affecting every country.

Q:  While working for the United States Agency for International Development (USAID), you, like Ron Waldman, dealt with disease outbreaks, both those within conflict and displacements, but not epidemics that were themselves emergencies.  What did you learn about how aid agencies can better prepare for these emergencies and how they should respond?

Peter:  Responding to an outbreak as an emergency has never been in USAID’s wheelhouse.  The Centers for Disease Control and Prevention (CDC) would send teams out to countries and work with Ministries of Health to recommend epidemiologic approaches for what that country could do.  Examples of this are measles, diphtheria, encephalitis or cholera.  USAID has never responded to an outbreak per se until Ebola took place.  Having said that, the Office of U.S. Foreign Disaster Assistance (OFDA) and USAID’s Bureau for Global Health created a management operations center for the H1N1 crisis. However, that outbreak was not as virulent as people thought it might be.  From what we know the optimal way for USAID to deal with outbreaks of pandemic potential is through prediction and prevention.  USAID’s Emerging Infection group created the PREDICT project which is designed to identify outbreaks in advance and to prepare  trainings and provision of Personal Protective Equipment (PPE), etc.  They funded training in countries where people live in close proximity to zoonotic vectors, or where people eat wild-caught meat, or have many small holder poultry and water fowl farms.  USAID worked with local veterinary groups.  But with a country like China, a very large country, our contribution was a “drop in the bucket.”

As we in the Humanitarian Sector looking at it, there are two kinds of outbreaks.  There is the kind where a person has to have direct physical contact for transmission.  There is the other kind where it is airborne.  Covid-19 is a classic case of this second one, where it broke out of a localized area.  If you don’t contain it in the first ten days, it’s too late.  I’m surprised this Covid-19 outbreak occurred so soon.  It’s just fortunate that it wasn’t as virulent as it could have been.

In your experience, what are some of the most effective or pivotal anti-hunger programs you’ve seen?

In my opinion, School feeding has been really successful.  The United States Department of Agriculture (USDA) supports this.  Where they provide a meal that incentivizes vulnerable children to go to school as well as providing a nutritious meal.  The other programs were providing cash for families to buy food in the market which supports the family “pot” while supporting local food systems.

While working for USAID, what were pivotal issues you were involved in?

I was in charge of the technical assistance for OFDA, which included many sectors.  OFDA originally was focused on natural disasters and, later complex protracted emergencies.  After Ebola, we created a unit to deal with pandemic diseases because we realized we’d have to be in it in a response way.  As a result, OFDA has now set up an operations center team for COVID-19.

 How did you get interested originally in hunger and nutrition issues?

I’m originally from Detroit, where my initial work was in a hematology lab working on sickle cell deficiency diseases (SCD).  We saw a lot of patients with profiles that were similar to young people with severe zinc deficiencies. We wanted to see if zinc deficiency was a contributing factor to the severity of SCD, and if supplemental zinc would help.

I later went to grad school, starting out in biochemistry, which I found interesting.  I joined a lab group who were  looking into trans-fatty acids and as we found a correlation between diet and fat-related cancers.  I did my research on trans-fatty acids and cytochrome p-450, an enzyme system in the liver that hydroxylates compounds to get them out of the body.  As it happens, virtually all naturally occurring fats in food are cis fats and trans fats only occur when you process foods to allow them to be more solid at room temperature.  If you eat a lot of processed foods, then the idea was they become incorporated into your cell membranes and change the fluidity of the membrane and perhaps activity the cytochrome p-450.   Our idea was that if the cytochrome t450 protein is more or less active, and its purpose is to get rid of compounds that could be carcinogens.

Back in 1979 I decided to change my major from strict biochemistry to nutritional biochemistry.  I got a masters and went overseas.

Earlier, when I was in grad school, I was involved in a local church and set up a program to help resettle refugees in the United States.  In this program we sponsored refugees,  most of whom were from Cambodia, Laos, Eritrea and Afghanistan.

I had a cousin working for an NGO in India who said come on over to work when you get out of school.  When the Cambodian family heard I was going to India they gave me a fifty-dollar bill to give to their orphaned grandson on the Thai/Cambodian border.  I heard about the Khao- I- Dang refugee camp of Khmer fleeing from the war between the Khmer Rouge and Vietnamese into Thailand.

As it happened, I flew to Thailand, found the camp, and actually found the little boy who was living with another family.  When I was in Khao-I-Dang, I was offered a job by CARE International, an American NGO.

I started working for CARE’s supplementary feeding program, which was high-energy milk, and soup kitchens for moms.  In those early days, I relied on the famous UN nutrition guidelines for emergencies booklet by John Seaman and Claude de Ville de Goyet.  I liked everything about the work.  It fit into my world view and faith about helping people.

I met my now wife, Margie, there at a nutrition meeting.  We were married in 1984 and in 1985 we went to Agadez, Niger to work in Red Cross drought feeding centers with Tuareg people.

Later, in 1994 I worked in the Democratic Republic of Congo (DRC) – Congo (then Zaire), as their refugee nutrition coordinator for UN High Commissioner for Refugees (UNHCR), where we did sampling in all of the camps.  Then I moved to Washington DC and started working for USAID.

 Over the course of your career do you see progress made in reducing malnutrition and hunger?

I see progress in understanding malnutrition better, and in improving the methods to treat malnutrition.  For example: the transition from many years of our promoting the use of “high energy milk”, made in a big oil drum with dried milk, oil, sugar, water and vitamins, to the pre-packaged F-75 and F-100 milk formula was important, and then the transition to “Ready to Use Therapeutic Food” (RUTF) along with innovations such as The Community-Based Management of Acute Malnutrition (CMAM) was a great improvement over high energy milk and therapeutic feeding centers in emergencies.  I feel we are a bit like firefighters keeping a growing blaze at bay.  Yes, methods and practices have improved, but populations have increased, and disparities have increased, and resources and food security have been shrinking for much of the world’s populations.

In what ways have you witnessed the United States Government (USG) demonstrating distinctive leadership in addressing food shortages and hunger around the world?   

USAID, during Andrew Natsios time as its administrator, began looking at using cash as an alternative to in-kind food aid – I saw this personally in Afghanistan, when I was involved in assessing the food crisis.

I am very proud of the role the USG has played in providing leadership in both food security and nutrition.  USAID was leading the research funding for CMAM use and micro-nutrient fortification.  Now CMAM is Standard Operating Procedure for malnutrition since 2001.  CMAM is the marriage of RUTF (a.k.a. Plumpy’Nut) and a development model using positive deviance in a community call the hearth model.

How in your view can the CMAM-type treatment/recovery outreach scale up to reach the 95% of malnourished children who are currently not reached?

USAID funded most of the original research for this.  As the research began showing how well it worked, many of the leading NGOs such as Concern, Save the Children, and Action Contra la Faim began changing all their programs, and this lead the rest of the world to also adopt CMAM as the optimal approach to fighting severe malnutrition.  With CMAM you can have a much larger reach into a community.

Have you seen examples — worth noting/sharing — of Americans, civilians, or American voluntary organizations making important progress in any hunger zones?  (besides what we already discussed), i.e. from your work at OFDA?  

During the beginning of the Somali crisis (early 1990s), in one of the first daring innovations, the late Fred Cuny came up with a very clever system to get food aid into Somalia using private markets.   USAID’s Food for Peace (FFP) and the Africa Bureau have worked effectively with the Government of Ethiopia to create a system of food security safety net programs in Ethiopia which have made a big difference in their seasonal food crises.  In fact, USAID has created a Bureau for Food Security (BFS) –  now called the Resiliency and Food Security Bureau (RFS) – realizing that emergency funding is not the long-term answer – this has been an important step.  The International Rescue Committee (IRC) is working on a simplified protocol for CMAM combining Moderate and Acute Malnutrition protocols to increase the reach make the use of RUTF more sustainable (The jury is still out on this, but I hope that they continue to look at it).

What do you think the public should know about the best ways to combat hunger?  

I believe that if we look at the definition of food security:  a combination of “Access, Utilization, and Availability” – a common thread that facilitates these three aspects is Good Governance (both Public and Private sector).  Good Governance has to work hand in hand with technology (preventing post-harvest loss, better sustainable food production etc. equitable market systems, and intermediate financial institutions), use of good child feeding practices, education on both nutrition and agronomy, and adequate infrastructure (roads, transport) to open markets to people.  To me this means we need an integrated way of addressing hunger.  I am interested in the whole systems approaches that David Nabarro was promoting, who is currently the World Health Organization (WHO) Special Envoy for Covid-19, but previously was the Coordinator for Scaling Up Nutrition. David is now leading an organization called 4SD (Skills, Systems and Synergies for Sustainable Development) which looks at a whole systems approach to development.

Are there particular parts of the world today where hunger or disasters are being missed by the media, but which deserve more of our attention?

Syria, Bangladesh, and Yemen where you have really difficult problems but we’re seeing donor fatigue.  In northern Sahel, you have the whole political issues and vulnerability to droughts, 1975, 1985, and repeating, most recently in 2006.  Now the Sahel has increased conflict with  ISIS, it has effected the food systems.

We don’t know yet all of the effects of global warming.  Where it used to rain it now floods.  Where it used to flood, it now doesn’t rain at all.  Many of the poor in the world are subsistence farmers who live on the margins and can’t afford a crop failure.

What books about hunger or pandemics do you recommend to others?

I recommend people read Amartya Sen’s Poverty and Famines (1983).  More recently I’ve been reading Michael Osterholm’s “Deadliest Enemy: Our War Against Killer Germs”, with Mark Olshaker (2020).

 Now that you are, as of 2020, the new Chairman of the Board of World Hunger Education Service (WHES), what vision or directions do you have for this non-profit?

WHES has a great legacy but it’s not in the forefront of food issues as much as it used to be.  It’s a volunteer Board.  It would be good for us to do something no one has done before.   I think we really want to get a first-hand look at opinion leaders in the world on food security and nutrition and let more people know what they’re doing.

 

Note:   Peter Morris was recently elected Chairman of the Board of World Hunger Education Service, the publisher of this site.

Mr. Morris spent over 23 years with the USAID Office of US Foreign Disaster Assistance (OFDA), most of the time as technical lead as well as nutritionist and contingency planner.  He led the technical staff specializing in nutrition, health, water, agriculture, shelter, livestock and evaluation involved in roughly $2 billion/year of humanitarian assistance.  For several years, also, he was seconded by USAID as a director of health HNTS at the World Health Organization.  During the Rwanda crisis of 1994-95 he served as a health officer in Bukavu, DR Congo (then, Zaire) helping to manage refugees.   He earned an MS from the University of Maryland, College Park, and MPS in International Development from Cornell.  Peter and his wife Margie, who also served on the board of the World Hunger Education Service have two sons and a daughter.

* Reference made to two interviews conducted by Mr. Morris with Ron Waldman and David Nabarro:

An Interview with David Nabarro

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

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.