As the world’s attention turns to the threat of the Coronavirus, we revisit our discussion on whether the world is prepared for the next global disease outbreak. The consensus seems to be we’re due a big epidemic — the kind that would fundamentally disrupt life as we know it. A pandemic could affect food supply, the global economy, energy, productivity, transportation, foreign relations, healthcare, and ultimately cause significant death on a global scale. Are we ready?
By Mike Coleman, Co-Director of Common Thread: Putting people at the centre of public health.
The Global Preparedness Monitoring Board published its annual report in September 2019 saying we’re not prepared for the global, catastrophic, biological risks that are upon us. They also said if a similar contagion to the Spanish Flu of 1918 occurred now it would be four times larger. That’s a terrifying prospect.
In December last year, we reached out to Dr Jonathan Quick, epidemiologist and author of The End of Epidemics for our year-end episode of The Stitch to ask him how we can minimize the risk of or even prevent the Next Big One?
He also discussed the role behavioural science, and those of us working in public health organisations like Common Thread can play.
Then, at the end of 2019, a cluster of cases of pneumonia with an unknown cause were reported from Wuhan City, Hubei Province, China.
We reached out to Jono last week to get his view on this new threat, and whether 2019-nCoV, as it’s been named, has the potential to become the Big One that he and other public health professionals have been predicting.
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MIKE: So Jono, tell me about your views and experience during times of major health crises?
JONO: I had seen how long it takes the world of global health to get stuff done.
“Looking back over the last century of epidemics it was so clear that we would panic — globally as health providers and as a global health community — and then we’d fall back into the trough of complacency. That’s what I was worried about would happen after Ebola.”
What you typically have is outsiders starting to come in, people who don’t understand messages. Guinea was a classic example — their whole first set of posters said ‘Ebola Kills!’ People are in the community and they are seeing people dying. And then they say, ‘there’s no treatment’ — but there is treatment.
Treatment will reduce the mortality from 60 or 70% that you get in poor environments to 10% that you get in high income environments. Yes there was no medicine, or vaccine back then. But basic care — antibiotics for infections, hydration all those things — they were life-saving treatment.
So they messed up the messaging because they didn’t have that skillset.
MIKE: Could the Coronavirus become a major health crisis? The latest information is showing that it’s accelerating really quickly?
JONO: It is very concerning that this new coronavirus has spread in just four weeks to more than 20 countries in Asia, Europe, and North America. The mortality rate for the Wuhan coronavirus is currently estimated at 2 to 3% — less than the 10% for SARS or 30+% for MERS. But in just four days between January 31 and February 4 the number of cases in China doubled to more than 20,000. This far exceeds the global total for SARS of 8,096 worldwide.
Time is a critical factor in outbreaks, and if the response to novel Coronavirus among lower level officials had been quicker — particularly if it had kicked in before the start of the (Lunar New Year) holiday season — that could have made a significant difference and reduced the spread both inside and outside of China.
However, the global outbreak control community is quickly mobilizing.
The 2003 SARS outbreak spread to at least 4 continents and 27 countries within a matter of weeks. Lacking neither a vaccine nor an effective medicine, once mobilized, national authorities used basic public health measures and were able to eliminate this first new pandemic human virus of the 21st century within six months.
Some elements of China’s official response have improved dramatically since then including a possible world first — China has shared the genetic code of the novel coronavirus which has allowed labs anywhere to start working on a vaccine without the need for a specimen of the virus. Reporting to WHO and public announcements have also improved, as well as the establishment of a centre for disease control led by renowned virologist and immunologist Dr George F Gao.
MIKE: In an information vacuum, epidemiologists and communications specialists absolutely have to work together to get the message across. So have we learned anything from the pattern of complacency and panic in a crisis between the West African Ebola outbreak and the current Ebola outbreak in North Kivu and Ituri provinces of the Democratic Republic of the Congo (DRC)?
JONO: The Ebola outbreak that we have now in the Eastern DRC is our first experience with conflict Ebola, really based on a long tough conflict, where trust is disrupted and everything else. I think many would agree we over-militarised in 2014 in West Africa — we panicked and finally sent the military and that wasn’t what turned it around. It was the community response.
In contrast, and some would disagree with this, but I think we are probably under-militarised the Eastern Congo right now.
It’s such a complex environment in the Eastern Congo right now as where the social fabric and trust is totally torn up by decades of civil war. That’s an area where I think the lessons and the tools and technologies that have come out of the West Africa experience are serving us well. But they can’t overcome the realities on the ground of disrupted, distrusting communities.
MIKE: What happens when there’s an erosion of trust with the state or anyone else perceived as delivering the health services and how can this affect the response on the ground?
JONO: The whole idea that as a country you can protect yourself by keeping to yourself is just an illusion.
“There are no walls you can build high enough…to keep out the flu virus or these other pathogens.”
MIKE: So how differently do we respond, or react in a crisis?
JONO: The brain works differently in times of panic. So the skills of delivering messages, the basic principles of communication in a pandemic — for government providers or anyone else — are to be first, be right, be caring.
There’s this panic and distrust that happens so that’s why being on the ground, in the community is a really important part. The other thing is the paradox of risk vs horror.
Ebola is a horrific disease — imagine blood coming out of the eyes and every orifice and that’s the reality, it’s horrific. But it’s never going to go global, yet it set Twitter records in August 2015 when the first two health workers were evacuated back to the hospital in Atlanta.
MIKE: We talk a lot about community trust, but how important is trust between countries?
JONO: One of the things that will worsen any outbreak is when there’s a delay in responding to the outbreak because there’s a delay in reporting it. Countries are really reluctant to report outbreaks if it affects their economy. That’s why the SARS virus got to more than two dozen countries in a matter of weeks in 2003 because China wouldn’t admit it. Fortunately we moved quickly on that.
If countries are not trusting that the information they share about diseases or other things will be used by professionals in an appropriate way to do appropriate responses then they are going to be less likely to share it.
MIKE: Now we know that Coronavirus can spread between humans — could China be doing more to lock it down?
JONO: China is actually responding quite aggressively, especially in comparison to the 2003 outbreak of the SARS coronavirus. By the end of January, 17 cities and 50 million people had been quarantined. Early on Chinese President Xi Jinping told party, government, and health leaders the outbreak “must be taken seriously” and that “all levels should put people’s lives and health first.”
Since SARS, The Chinese Center for Disease Control and Prevention has become a highly professional organization under the leadership of Dr. George Gao. WHO was alerted, the new virus isolated, and the genetic sequence was shared so tests could be developed.
Once a new virus is confirmed, it takes rapid epidemic detective work to map patient contacts to confirm the actual source. Epidemiologists move from “what we see” to “what we suspect” to “what we know.” The critical factor has been daily information-sharing on cases, which has enabled the Chinese CDC, WHO, and others to confirm human transmission.
MIKE: Is the global health world prepared for another SARS like respiratory virus?
JONO: As a result of SARS — and accelerated by 2014 West Africa Ebola outbreak — the worldwide infectious disease capabilities to prevent, detect, and respond to such outbreaks has been considerably strengthened.
Through the World Health Organization and partners, we now have a rigorous tool to assess national readiness. The Coalition for Epidemics Preparedness, CEPI, is a novel epidemic preparedness partnership based in London which is catalyzing development of vaccines for viruses with a high epidemic potential.
“Despite these and other advances, the world is still highly vulnerable to another pandemic respiratory virus — a more contagious and deadly SARS-like virus, a pandemic influenza virus as in 1918, or a Disease X virus that we’ve never seen before.”
Less than one-in-three countries worldwide — including several in Asia and many in Africa — are not fully prepared to prevent and respond to new outbreaks. Investment in vaccine development is still lagging. And international travel, global warming, and a web of other risk factors are only increasing the chances for another global pandemic.
MIKE: What’s the real threat of an as yet unknown disease, sometimes called a Disease X?
JONO: Disease X isn’t some science-fiction futuristic thing.
Ebola was the Disease X of the 1970s. Never seen before and scared the heck out of people.
AIDS was the Disease X of the 1980s where you had this virus that took a while to figure out and these strange deaths that brought panic.
And SARS was the disease X of the 21st Century. So Disease X is a real issue.
The Coronavirus is a known epidemic risk, and therefore not properly speaking a Disease X. However, a distinctly new, deadly, and highly contagious coronavirus jumping from animals to humans — for which we have no surveillance system, proven medical treatment, or vaccine prevention — would effectively be a Disease X.
Similarly, the Zika virus that arrived in Brazil and other Latin American countries in the mid-2010s, causing an explosion of birth defects, had existed quietly in eastern Africa for decades. But it was a Disease X for the mothers and families of Latin America.
MIKE: What are your views on the behavioural science side of things when it comes to dealing with outbreaks of disease?
JONO: When you see people reacting in a way that doesn’t make sense you really need to understand how they’re making those decisions.
We know for example the whole idea that health people communicate with facts and information. When someone is not accepting the flu or measles vaccine you want to give them more information.
But we now know from research in politics and now in public health that there’s something called the ‘Backfire Effect’.
People who have ego invested in a belief — whether it’s that vaccines cause autism or that a particular candidate has a particular view on something — when you really provide the best facts and evidence, they hold on to their belief even harder and don’t change their belief.
So we really need to understand what are the pathways that we have to get people on board. It’s often getting the right communicator, but it’s also understanding what they care about, what they value and what they’re willing to base their decisions on.
Dr Jonathan Quick — A Brief Introduction
Jono has worked in around 70 countries. He spent 10 years running the World Health Organisation’s essential medicines programme in Geneva, during the time when increased access to HIV/AIDS medications was developing.
In the middle of the West Africa Ebola outbreak (in 2014–2016) he was working with a non-profit and grew concerned that the world had not woken up to the threat of global epidemics, which is when he decided to write The End of Epidemics.