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.