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:

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.  [ ] 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.



On Resilience: Hunger, Food and Disease Outbreaks

March 15, 2020

The current coronavirus (COVID-19) global outbreak – pandemic – may very well have implications for hunger and food security. This would be particularly so in poorer, developing countries where large urban populations may depend on fragile supply chains for food.

We know that shocks – including wars – can impair movement of basic life-sustaining foodstuffs, as in Yemen today. We also know that food is an intrinsic part of how we currently address some diseases. Many humanitarian agencies have published at length about the value of ensuring food and nutrition for African families affected by HIV/AIDS.

Food aid has been important for helping families or breadwinners to self-quarantine after being identified as having been in contact with a carrier of a disease in other instances. For example, in West Africa in 2014/2015, and in Central Africa today, nonprofits and the World Food Programme have been providing food or food-purchasing vouchers to families under watch for suspected new cases of Ebola.

Food aid also helps promote compliance for health care. Often food aid is helpful to ensure prenatal screenings in programs in refugee camps for pregnant and lactating women. As another example, in many countries today, low-income persons with Tuberculosis (TB) find it hard to take the complex regimen of drugs necessary each morning without food also provided, so aid agencies provide food assistance alongside the medical assistance to ensure compliance.

Hunger may also appear as a secondary crisis following the shocks of a larger pandemic. Often in pandemics, ports shut down, trade freezes up, and food does not transport as it had. Any time a city or region is quarantined, it automatically poses constraints to food trade.

Indeed, the food aspects of a pandemic could prove to be the most controversial, posing major policy dilemmas with highly variable outcomes. Many experts believe that the most variable or preventable forms of death due to a pandemic are not from the immediate medical impact, but from the food and social effects. A global public goods perspective of a pandemic suggests that whereas health programs are a win-win for everyone, other goods, such as food, energy, or oil, are competed over and may become scarce.

As of today, the World Health Organization has defined the current COVID-19 spread as a pandemic. From the past, we understand that many pandemics tend to flow as waves. The 1918 flu influenza killed 100 million people, by some estimates, and circled world several times over the span of a year. Health science was so imperfect in that time, and World War I was such a distraction, that the existence of a pandemic killing people from India to Africa to Illinois was not immediately understood. In today’s world, the extent of an outbreak is more immediately tracked and mapped, with the consequence that travel and markets freeze up.

To understand the counter-intuitive ways that markets may respond to fears, consider the large number of people who died in India due to famine during World War II. In 1941-42, a severe famine killed up to two million people in the Bengal region of India. In studying this famine, Nobel Prize winning economist Amartya Sen recognized that it occurred despite a better-than-average local food harvest. Food was sequestered and kept out of retail networks due to an overall atmosphere of uncertainty and anxiety about future events, i.e. an invasion by the Japanese army (which never occurred). This led to a lack of food availability in markets for most of the consumers. The lesson is that events in one domain (war, disease) can lead to market disruptions that can worsen poverty and hunger, and in some pockets of the world, starvation.

The diagram below depicts one scenario of how a disease may pass through a country during a pandemic, similar to the 1918 case. The inner full lines depict the period when it is spreading person-to-person in a particular country – a few months – during a year. The broken line above it depicts the shock wave that is longer as markets tighten and access to food becomes limited. This diagram comes from a USG-funded interagency working group of UN agencies and NGOs in the 2000s, looking at scenarios of how a pandemic might unfold:

Diagram courtesy of Steve Hansch


That same study found that:

“The increase in food prices for some countries – those that are not food self-sufficient but depend on grain imports – will be sharper and higher than that seen in 1974 or in 2008, when food price increases made international headlines as a pervasive crisis.  The tightness in food markets in 1974 and 2008 provide some lessons about the dynamics of global food markets, though a pandemic’s effects on food trade could be far more lethal.   Just as occurred in 2008, food trade will become restricted and food will be rationed and hoarded, with the result that food prices will increase for most locations where populations aggregate (cities, towns), though food prices will decrease in rural agricultural areas.  Even if the virus spreads from foci to foci, along lines of airplane travel, or migration, the wave of food panic may be more diffuse and global.”

The study also cautioned that in many locations, as commercial food pipelines break down, stores that sell food (particularly in urban areas) will likely be in a hurry to disburse fresh (perishable) foods to friends and family before the markets shut down to avoid ransacking. If the store owners trust rumors that food transport will be interrupted and their inventories not replenished, they may see an incentive to protect the store itself by closing it down, boarding it up and posting “no more food” signs, rather than face break-ins, threats, or government requisition.

For these and other reinforcing dynamic reasons, food prices may inflate in urban areas many times above normal levels over the first few weeks of a pandemic. For poor families who are already spending their limited income largely on food, increased prices leads to reduced consumption. Most famines in modern history have shown that increased food prices lead to increased hunger and malnutrition-related death.

Experts recommend that key national-level goals are to reduce national panic and distress migration (for instance away from urban areas to rural areas). Therefore, food programs can support leaders by helping them to maintain credibility when communicating to the public that people need not panic about food shortages; therefore, governments need to have some credible back-up reserves of food with which to promise to provide targeted food for the malnourished. Many governments already dabble in maintaining emergency reserves of food. So, when an outbreak—such as COVID-19—begins to spread on the health side, governments can and should begin to quietly store and then allocate food resources to work with civil society agencies, such as the Red Cross, to quickly pre-purchase and move food storage to decentralized locations, to reach the most vulnerable people.

About the Author: Steve Hansch is a WHES Board Member with long-standing association with Hunger Notes.