The End of Epidemics: how to stop viruses and save humanity now

By Jonathan D. Quick, Bronwyn Fryer and David Heymann

It’s the dystopian nightmare pandemic experts have warned about. But it’s happening right now.

COVID-19 has catapulted us into a science-fiction scenario — now our lived reality across the globe. Seemingly overnight, literally billions of people around the globe have had their lives upended by fear, uncertainty, bankruptcy, illness, or death.

At home, we ask: will the job I’ve been preparing for even exist when COVID-19 has passed? Will the business I built with sweat ever reopen? When can we safely travel abroad — or even to some parts of our own country? Will everyday life ever go back to normal? When will we have a vaccine?

Boiled up from the blood of a bat in rural China, the novel coronavirus has scourged every continent except Antarctica, and every major city — from Sydney to Stockholm, New York to Nairobi, Moscow to Miami, and Brasília to Bangkok. By the time the pandemic has passed, COVID-19 will have killed hundreds of thousands of people, sickened millions of people, upended the lives of tens of millions, and cost the global economy trillions of dollars.

An outbreak of a new, deadly, highly contagious virus was inevitable. But an explosive global pandemic was not inevitable. There is hope.

In The End of Epidemics, leading public health authority Dr Jonathan D. Quick tells the stories of the heroes, past and present, who have succeeded in their fights to stop the spread of illness and death. He explains the science and the politics of combatting epidemics. And he provides a detailed seven-part plan showing exactly how world leaders, health professionals, the business community, media, and ordinary citizens can work together to prevent epidemics, saving millions of lives.

• Language: English
• Publisher: Scribe Publications
• Release date: Mar 8, 2018
• ISBN: 9781925548327

Jonathan D. Quick

Jonathan D. Quick is a family physician, health-management specialist, managing director for pandemic response, preparedness, and prevention at The Rockefeller Foundation, and an adjunct professor of global health at the Duke Global Health Institute. He is also senior fellow emeritus at the global non-profit organisation Management Sciences for Health, where he served as president and chief executive officer for 2004 to 2017. Dr Quick has carried out assignments to improve the health and lives of people in over 70 countries in Africa, Asia, Latin America, and the Middle East.

Book preview

THE END OF EPIDEMICS

Dr Jonathan D. Quick is a family physician, health-management specialist, managing director for pandemic response, preparedness, and prevention at The Rockefeller Foundation, and an adjunct professor of global health at the Duke Global Health Institute. He is also senior fellow emeritus at the global non-profit organisation Management Sciences for Health, where he served as president and chief executive officer for 2004 to 2017. Dr Quick has carried out assignments to improve the health and lives of people in over 70 countries in Africa, Asia, Latin America, and the Middle East.

Bronwyn Fryer is a veteran writer, researcher, and editor, widely recognised for her collaborations with leading authors.

To the memories of

Dr D.A. Henderson, a tenacious and ultimately victorious

leader in the battle to end the scourge of smallpox.

and

Nurse Salome Karwah, an Ebola survivor who saved many lives

and later was left to die in childbirth, a victim of stigma.

Scribe Publications

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Published by Scribe 2018

This edition published 2020

Copyright © Jonathan D. Quick, MD, and Management Sciences for Health, Inc. 2018

Preface copyright © Jonathan D. Quick, MD, and Management Sciences for Health, Inc. 2020

All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the publishers of this book.

Book illustrations by Mia Roca Alcover

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9781911344377 (UK edition)

9781925548327 (ebook)

Catalogue records for this book are available from the National Library of Australia and the British Library.

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CONTENTS

Acronyms

Foreword by Dr. David L. Heymann

Preface

Prologue: A Fear I’d Never Felt Before

What can be done to stop the next killer virus from destroying millions of lives?

PART I. THE PANDEMIC THREAT

1. Stop Epidemics with The Power of Seven

We can end epidemics with seven sets of concrete actions proven over a century of epidemic response.

2. The Bush—Lessons from Ebola, AIDS, and Zika

How deforestation, climate change, and population movement are turning wildlife into pandemic incubators.

3. The Barn

Our global animal food industry and the renegade influenza viruses it spawns could one day annihilate the people it feeds.

4. The Triple Threat: Bioterror, Bio-Error, and Dr. Frankenstein

The threat of an epidemic unleashed by terrorists, lab errors, or irresponsible scientists has never been greater.

5. The Costs of Complacency

In addition to millions of deaths worldwide, we could face global recession and massive social upheaval.

PART II. STOPPING PANDEMICS BEFORE THEY START

6. Lead Like the House Is on Fire

When leaders work with urgency, decisiveness, and courage, they can defeat the deadliest viral enemies.

7. Resilient Systems, Global Security

Strong national public-health systems and robust international agencies can ensure health security for all.

8. Active Prevention, Constant Readiness

Vaccines, mosquito control, and other preventive measures will stop killer diseases before they spread. Constant readiness to respond will save lives.

9. Fatal Fictions, Timely Truths

Trustworthy communications, close listening, and local engagement are the best weapons for fighting disease and quelling rumors, blame, distrust, and panic.

10. Disruptive Innovation, Collaborative Transformation

Breakthrough innovations bring new tools for preventing, controlling, and eliminating infectious-disease threats.

11. Invest Wisely, Save Lives

The equivalent of just $1 per year for every person on the planet ($7.5 billion annually) will save lives and pay for itself in lower emergency costs and reduced economic disruption.

12. Ring the Alarm, Rouse the Leaders

Citizen activists and social movements must mobilize the public and hold leaders’ feet to the fire.

Epilogue: Headlines from the Future

The threat is imminent. The pathway is known. The time for action is now.

Acknowledgments

Notes

ACRONYMS

ACLU American Civil Liberties Union

ACT UP AIDS Coalition to Unleash Power

ADDO Accredited Drug Dispensing Outlet

AIDS Acquired Immune Deficiency Syndrome

BSE bovine spongiform encephalopathy

BSL Biosafety Level

CAFO Concentrated Animal Feeding Operations

CDC Centers for Disease Control and Prevention (U.S.)

DDT dichlorodiphenyltrichloroethane

DNA deoxyribonucleic acid

EIS Epidemic Intelligence Service

FAO Food and Agriculture Organization of the United Nations

G7 Group of 7

G20 Group of 20

GAO United States Government Accountability Office

GDP gross domestic product

GHSA Global Health Security Agenda

GPHIN Global Public Health Intelligence Network

GRID Gay Related Immune Deficiency

HIV human immunodeficiency virus

IHR International Health Regulation

ISIS Islamic State in Iraq and Syria

MERS Middle East Respiratory Syndrome

MBM meat and bone meal

MMR measles mumps rubella

MRSA Methicillin-resistant Staphylococcus aureus

MSF Médecins Sans Frontières (in English, Doctors Without Borders)

MSH Management Sciences for Health

NGO nongovernmental organization

NIH National Institutes of Health (U.S.)

PEF Pandemic Emergency Financing

PEPFAR President’s Emergency Plan for AIDS Relief (U.S.)

PHEIC Public Health Emergency of International Concern

R&D research and development

SARS severe acute respiratory syndrome

SMAC Social Mobilization Action Consortium

TAC Treatment Action Campaign

UNAIDS Joint United Nations Programme on HIV/AIDS

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

USDA U.S. Department of Agriculture

vCJD Creutzfeldt–Jakob (mad cow) disease

WHO World Health Organization

Unless otherwise specified, all dollar amounts are U.S. currency.

FOREWORD

For more than four decades, I have worked with others throughout the world to fight infectious diseases, beginning in India to eradicate smallpox; then moving to Africa to investigate the first Ebola outbreak, to respond to the many Ebola outbreaks that followed, and to investigate clusters of a then-unknown wasting disease we now know as HIV. Later in my career, I led the global program that responded to outbreaks of polio in countries in Asia, Africa, and the Middle East; and led the global response to the outbreak of SARS, an emerging infection that spread rapidly throughout the world.

For nearly ten years, I worked with Jonathan Quick when we were both at the headquarters of the World Health Organization. Jono led the program on essential drugs, while I led that on communicable diseases. In different ways, we each worked internationally and through national disease-control programs across the globe to strengthen national capacity to prevent and manage infectious-disease threats. Specifically, Jono’s team worked to increase access to safe and effective medicines; and as their leader, he never shied from difficult technical and political issues that at times challenged the status quo—while keeping the poorest of the poor at the forefront of his work.

In The End of Epidemics, Jono again keeps the poorest in focus, and likewise challenges the status quo. He calls on world leaders to quit their dithering, and to respond to the threat of epidemic as if it were a tough adversary that can be beaten, rather than an adversary that inevitably leads to massive sickness and death. Jono’s mission has now become one of prevention while infectious-disease outbreaks are small and remain local, to stop them from spreading and becoming major outbreaks, or more infrequently a pandemic.

Jono begins his book by clearly describing the factors that amplify the risk that outbreak-causing microbes will emerge in humans. He notes that deforestation and climate change cause unprecedented disturbances to the natural environment, resulting at times in the closer proximity of wildlife that carry organisms that cause infections, such as Ebola and SARS, in humans. At the same time, he suggests that the global animal food industry is failing to safeguard people from microbes such as the virus that causes influenza—microbes that are carried by animals on factory farms. In addition to these naturally occurring infections, Jono also discusses the threat of an epidemic caused by the deliberate release of a microbe to cause harm, the consequences of failed biosecurity in laboratories, and the carelessness of irresponsible scientists—suggesting that the danger they cause has never been greater.

Meticulously drawing on insights from infectious-disease outbreaks in the twentieth century, and the first two decades of the twenty-first, Jono proposes a set of actions that leaders and the public might take to prevent such outbreaks. He has arrived at these actions by drawing on some of the best minds in infectious disease, the most experienced professionals in epidemics preparedness, and the most successful citizen activists in global health. Reaching deep into the trenches of outbreak control, he has extracted evidence to help us understand why we continue to face the looming threat of infectious disease—and more importantly, what we can do about it. Through vivid accounts from the field—stories from scientists, journalists, and survivors of the fights against AIDS, SARS, Ebola, and other infections—he provides messages that will resonate with scholars and casual readers alike.

The aim of Jono’s book is ambitious—making the world safer from infectious-disease outbreaks—and it clearly demonstrates the insights he has gained from various work experiences: at the World Health Organization, the World Bank, and ministries of health; in the private sector and civil society; and with various international activist groups. His training in family and preventive medicine firmly underpins these experiences, leading to a broad public-health perspective for outbreak control. The years he has spent helping African, Asian, and Latin-American governments strengthen their health systems likewise provides a laser-sharp view of the realities of the sometimes-fragile public-health and patient-management capacities that are called upon for early response to infectious-disease outbreaks.

This book is not just written for professionals in global health and infectious diseases. It stands out among other books because it is written in a language easily understood by politicians, policymakers, and the general public—demonstrating evidence-based and feasible solutions to prevent deadly microbes from causing profound suffering and death. The proposed advocacy and accountability actions that Jono presents in this book have the potential to make a significant impact on a major global health threat. Similar efforts by other authors have led to progress against AIDS, malaria, and child health; Jono’s work could do the same for outbreak preparedness, prevention, and control.

Given the devastating emergence of Covid-19, the tragedy of the Ebola outbreaks in West Africa, and the rise of virulent influenza viruses and other dangerous microbes, The End of Epidemics is a welcome and timely book. In it, Jonathan Quick has given us a blueprint for the future.

Dr. David L. Heymann

Professor, Infectious Disease Epidemiology

London School of Hygiene and Tropical Medicine

Head and Senior Fellow, Centre on Global Health Security, Chatham House

PREFACE

It’s a dystopian nightmare, and it could happen tomorrow. An uncontrollable pandemic overwhelms public-health systems and wipes out millions of people in less than a year. Business and industry grind to a halt. Up to US $3 trillion, a tenth of the country’s global gross domestic product, evaporates as fear of infection stifles travel, tourism, trade, financial institutions, employment, and entire supply chains. Children stop attending school. Rumors abound; neighbors scapegoat neighbors. Millions of unemployed poor, always hit the hardest, resort to theft and violence in an effort to stay alive. People starve, even in the U.S. Those who do survive are left with their lives turned upside down.

When in 2018 I wrote the above words for the opening of chapter five, I never imagined that just two years later the world would be at once suffering the most devastating pandemic since the 1918 Spanish flu and the worst economic upheaval since the Great Depression. Seemingly overnight, a novel coronavirus (SARS-CoV-2) has dramatically changed our day-to-day lives. To slow the spread of this brand-new virus, to flatten the curve, we’ve had to avoid gatherings of over ten people and maintain a distance of six feet from others, often wearing face masks. This affected everything from grocery shopping to recreation to attending houses of worship. Grandparents have been unable to hug their grandchildren, and are uncertain when it might be safe to do so again. Old couples looking forward to time together instead found their partner in intensive care. Children have been unable to go to school, participate in sports, or see their classmates.

Workdays become a stream of videoconferences with a screen full of familiar and unfamiliar faces. Parents working from home struggle to divide their time between their job and their children’s remote education. Social lives take place on smartphones and computers for those with access. Entertainment may consist of curbside restaurant takeaways, Facebook concerts and art displays, puzzles, and board games.

Since this virus is new to the human species, we have no acquired immunity to it. Despite the record-setting 100+ vaccine candidates, it likely will be mid-2021 or later before we have a safe, effective, widely available vaccine. In the meantime, our only recourse is to reduce person-to-person transmission. Thus, populations in many countries have quarantined for two to three months, when families remained isolated in their apartments or houses. In hard-hit metropolitan areas, many people were not even able to go out for a walk. Meanwhile, advocacy groups for the un-housed hurried to find places where the homeless could safely shelter in place. Protests emerged to demand the release of prisoners and detainees from perilously confined spaces. Particularly at risk for deadly complications from the virus, elders in assisted living facilities have been cordoned off, forced to simply wave at loved ones through windows. At times, the news has been rife with frightening stories of hospitals overrun with Covid-19 patients, lacking enough beds and ventilators. Funeral homes and crematoriums have not been able to keep up. Due to contagion, families have not been able to even say goodbye to their loved ones.

The global economy has taken a mighty tumble. During lockdowns, economic activity screeched to a halt, as businesses in nearly every sector had to shutter their doors. Huge numbers of people have lost their jobs or been laid off. Those who are lucky enough to have savings or stock portfolios have watched those safety nets disappear. Millions are filing for unemployment, and people are standing in line at food pantries.

The tourist and service industries have been particularly hard hit. Airplanes were grounded as domestic and international travel carried the virus from country to country. Cruise ships were stranded offshore, with ports refusing to let sick passengers disembark. After decades of sweat and hard work, restaurant owners are wondering if they will ever reopen at full capacity or even survive. Even the summer Olympic Games that were to be held in Japan were called off. Sports buffs are so desperate that they have been watching animated games, series reruns, and even marble racing.

As the economy suffers—creating fear, uncertainty, threats of bankruptcy, and even starvation—pressure has mounted from leaders, industry executives, and citizens to reopen, even where opening is premature and risks more lives by possibly creating surges of community spread. Armed protests against lockdowns have erupted on the steps of government buildings. Yet essential workers on the front lines—grocery store clerks, supply-chain workers, doctors and nurses—carry on while exhausted and emotionally drained, often without nearly enough personal protective equipment such as masks, gloves, or even hand sanitizer. As a result, too many essential workers have died. To help, people at home dusted off sewing machines to make face masks out of old T-shirts. Liquor distilleries transitioned production to making hand sanitizer, helping them stay afloat since bars have remained closed for months.

All of this has thrown a pall over our lives. Our days are surreal, like we are living in a strange, apocalyptic novel. The impact of economic turmoil on people’s lives will last a decade. The memories will last for a lifetime as we are faced with basic questions we never imagined having to ask: Will life ever return to normal? What will the new normal be with coronavirus here to stay? How can I have the wedding I imagine? When will I be able to hug my granddaughter again? Get my hair cut? Listen to live music?

After weeks of lockdown during the first half of 2020, countries around the globe began wrestling with the best strategy to safely open and keep open their workplaces and communities, even as the global toll of cases and deaths continued to rise. While this novel coronavirus has now reached every populated corner of the world, epidemiologists are still learning the intricacies of how it behaves and the array of symptoms it can cause.

* * *

The novel SARS-CoV-2 coronavirus and the Covid-19 disease that emerged in late 2019 has been at once everything I had been expecting and fearing, yet full of one troubling surprise and after another.

SARS-CoV-2 is a classic pandemic pathogen: a respiratory virus that spreads easily from person to person, for which humans have no acquired immunity, and which is deadly enough to claim thousands or millions of lives—but not so deadly that it kills its human host before they can spread it to many others. Coronavirus has been high on the list of potential pandemic enemies, along with a pandemic strain of influenza like the 1918 flu.

As with three out of four new human pandemics, Covid-19 resulted from an animal to human spillover event. Bats are the most likely source, with transmission to humans via an intermediary wildlife host. Pangolins—armadillo-like mammals with covered sharp, leaf-like plates—are the likely, but not yet proven, intermediary hosts.

Initial reports identified the live animal Hunan Seafood Wholesale Market in Wuhan, China as the source of the outbreak. While 27 of the first 41 Covid-19 patients had direct exposure to the Wuhan market, the first case (patient zero) did not. Whatever the original source, Wuhan—described by some as the Chicago of China—proved to be a super-spreader location for the novel coronavirus. Central China’s political and commercial center as well as its most populous city, Wuhan has dozens of major highways and railways that link Wuhan to other major cities.

Wuhan health officials made the first public announcement of 27 patients with pneumonia of unknown cause on December 27, 2019. On January 7, 2020 Chinese authorities announced that a new type of coronavirus had been identified, and three days later posted its genetic sequence online. Over the following six months, the pandemic spread worldwide. Based on the daily number of coronavirus-related deaths, the pandemic peaked first in Asia, then shifted to Europe in early March, then to the U.S. in mid-April. By early June, with cooler weather in the Southern Hemisphere, new cases and deaths began rising Latin America, and the Caribbean, and India.

This virus has been full of treacherous, unexpected traits. Following SARS in 2003 and MERS in 2012, Covid-19 is the third deadly coronavirus to go global. Though not as deadly as SARS or MERS on a case-by-case basis, a distinguishing feature of Covid-19 is its ability to crash intensive-care units from Italy to New York City by the sheer volume of people with respiratory complications requiring prolonged hospital care. This virus has a long incubation period, up to 14 days, before symptoms emerge, in which time the carrier can unknowingly spread the virus. To complicate matters, up to half of those infected may spread the virus without ever having symptoms.

* * *

While the emergence of a new pandemic virus like Covid-19 was both predictable and inevitable, I believe a pandemic of this magnitude was preventable. It didn’t have to be this way. Two overarching lessons emerge from a careful analysis of the last the century of large-scale epidemics and pandemics.

First, there will always be outbreaks of new infectious diseases such as Covid-19 as well as periodic re-emergences of known diseases such as Ebola. Second, to a large extent the difference between a small-scale disease outbreak and devastating regional epidemics like Ebola and catastrophic pandemics like Covid is a human action—or more often, inaction. As I explain in the following pages, seven critical actions are needed to prevent local outbreaks from boiling over into ruinous pandemics. Here’s a brief overview of our global response to the novel coronavirus in these seven areas.

Lead Like the House Is on Fire

When leaders act with urgency, decisiveness, and courage, they can defeat the deadliest viral enemies. Concerned about reports of the new virus in China, the World Health Organization (WHO) announced on January 20, 2020 that it was forming an emergency panel of experts. Shortly after, on January 30, the WHO’s director-general declared a public health emergency of international concern.

On March 11, 2020, the director-general went a step further to classify Covid-19 as a global pandemic. Despite this clear signaling of the threat posed by Covid-19, leaders of a number of countries continued to drag their feet in responding, seemingly unprepared and caught by surprise. Governments failed to secure tests, personal protective equipment, ventilators, and hospital beds in time. Delays in implementing lockdowns or other social-distancing measures resulted in additional, needless loss of lives.

Indeed, a number of world leaders have had a dismissive attitude towards the pandemic. President Trump has vacillated between waving the virus off as insignificant and a hoax to declaring war on it. He has refused to wear a mask on camera, even though White House staff members have tested positive for the virus. Meanwhile Brazil’s Jair Bolsonaro insists that Covid-19 is nothing more than a little flu.

In contrast, days and weeks following the initial January 2020 WHO declaration, countries like Australia, Germany, New Zealand, Singapore, and South Korea took rapid action to mobilize strategies to fight the new invader. They not only flattened but decreased their epidemic curves through decisive leadership and rapid action, including lockdowns and large-scale testing.

As of June 2020, for example, Australia had just over 100 deaths—a rate-per-million-population that was a fraction of that of other high-income countries. Commentators attribute success in no small measure to the approach taken by Prime Minister Scott Morrison. His approach was to put health officials at the center of the response, create a bipartisan coronavirus cabinet, engage with trade unions, and increase unemployment payments.

Build Resilient National and Global Health Systems

Strong national public health systems and robust international agencies are vital to ensure health security for all. In 2005, infectious disease expert Michael Osterholm, in an article in Foreign Affairs, warned that, The arrival of a pandemic influenza would trigger a reaction that would change the world overnight. He ended his prediction, which has essentially come to pass in 2020, by saying that, This is a critical point in our history. Time is running out to prepare for the next pandemic. We must act now with decisiveness and purpose.

This was fifteen years ago, yet hospitals around the world were not prepared and still aren’t prepared for situations like the coronavirus pandemic. In a March 2020 CNN interview, Osterholm said that rather than being prepared, U.S. health systems are worse off. He noted that they are stretched thinner now than ever. There is no excess capacity. And public health funding has been cut under this administration.

This has had on-the-ground consequences. For example, the lack of availability of coronavirus tests, combined with backlogs at processing labs, had health officials flying blind when the virus first reached the United States. Initially, the supply of tests was used for essential personnel and the very sick. Many who displayed the symptoms Covid-19 were never tested. To avoid overrunning hospital resources, people were told to stay home and self-isolate for 14 days and to only come to the hospital if gravely ill. Thus, the official case count in the early weeks was far lower than the actual number of cases that were present which, combined with asymptomatic carriers, exacerbated community spread. Testing and contact tracing in the U.S. and elsewhere still have not reached the levels recommended to contain the virus.

Promote Active Prevention

Depending on the infectious disease involved, effective measures to prevent emergence and spread may include personal health-protection habits, vaccines, mosquito control, and other preventive measures.

The best long-term prevention for Covid-19 would be a safe, effective, low-cost, universally available vaccine. We prevent infectious disease outbreaks when a high-enough share of the population (the herd) has developed immunity, either from immunization or by recovering from Covid-19 with adequate antibodies. For Covid-19 the estimated herd immunity level is 60 to 70 percent. This would require a daunting 4.5 to 5.0 billion doses, assuming 5 to 10 percent of the population already has immunity from a previous Covid-19 infection.

Until we have a proven vaccine, our primary weapon against this coronavirus is herd behavior: six feet of personal space, facemasks in crowded settings, frequent hand-washing, limited periods in crowded places, and self-isolation when exposed. It is these herd behaviors—voluntary or mandated—that have enabled entire countries and several U.S. states to not only flatten (plateau) their curve, but in some cases to dramatically reduce new cases and deaths.

Humanity has had to undergo rapid and far-reaching social change to prevent the spread of the coronavirus. Yet, amazingly, in many places that have implemented intensive lockdowns, for the most part, we’ve been cooperative and compliant, wanting to do the right thing. We have remained in our dwellings. We’ve sung songs on balconies to connect to our neighbors. We have donned masks and lined up at grocery stores, waiting our turn to go inside so stores can keep to the recommended low capacity. We have cancelled travel plans and milestone gatherings such as birthday parties and weddings, all in the name of prevention.

Communicate Truthfully, Supportively, and Empathetically

The best tools for fighting disease are trustworthy communications, close listening, and local engagement. Consistent fact-based messaging is essential to succeed against a pandemic—especially in the context of the uncertainty, fear, and anxiety that pandemics often generate. Such messaging is also paramount to quell rumors, blame, distrust, and panic. The degree of success we’ve had in enlisting communication to fight this pandemic has depended upon culture, politics, and leadership styles. Clear, compassionate, decisive communication gains public trust and buy-in to prevention protocols.

Germany’s Covid-19 mortality rate remains markedly below the rates of France, Italy, Spain, and the United Kingdom. Germany’s chancellor, Angela Merkel, with a doctorate in quantum chemistry, navigates leadership and difficult situations with the exacting approach of a scientist. She has shared information about the coronavirus based on data, and has been transparent about what she and her circle of experts know and don’t know. Her grounded communications helped to gain trust and compliance for measures needed slow the virus and reduce mortality.

Contrast this approach to pandemic communications with President Bolsenaro’s pronouncement that the virus is just a little flu, or one of President Trump’s more audacious statements, repeated in public at least 15 times, that, One day, it’s like a miracle, it will disappear.

In a Center for Strategic and International Studies interview, John Barry, pandemic historian and author, said the main thing he learned while researching the iconic 1918 influenza pandemic was the importance of truth: People in authority need to tell the truth.

Effective communication can be especially challenging when new information leads to changes in public health recommendations or when guidelines differ among countries or jurisdictions. One example is the murky topic of wearing face masks. Having dealt with the outbreak of SARS in 2002–2003, many Asian countries already had a culture of mask wearing. In Japan, Singapore, Taiwan, and South Korea, wearing masks is expected. Hence, governments were able to implement the strategy with little resistance. This was the story in India as well. As the virus crept around the globe, an American woman traveling in India caught one of the last flights out before the lockdown was implemented. The first thing she texted to a friend when she landed on U.S. soil was, Where are the masks? Why are people not wearing masks?

In the United States, in part due to concerns about scarcity of personal protective equipment, early on people were told not to wear masks. US Surgeon General Jerome Adams at one point tweeted, STOP BUYING MASKS! Over time, CDC changed its tune. Governors and U.S. businesses and other Western countries began recommending or requiring people to wear masks to protect others from the virus—especially asymptomatic carriers unaware they are spreading it. In the U.S. the aftermath of the mixed messages has been a bitter divide between those who wear masks and those who don’t. The result is angry exchanges between wearers and non-wearers, mask shaming, and hassling of essential workers trying to enforce store rules.

Pursue Game-Changing Innovations

Breakthrough innovations are needed to bring new tools for the prevention, control, and elimination of epidemic threats. During this pandemic, we’ve made game-changing innovations in a very short time. Early on in the outbreak, Chinese scientists were able to quickly sequence the genomes of the virus and share the sequence with the world. Viral evolution expert Andrew Rambaut from the University of Edinburgh commented that the feat was, unprecedented and completely unbelievable. He had worked on genome sequencing for the 2014 Ebola outbreak, which took much longer.

Within months after isolating the virus, scores of coronavirus candidate vaccines had been identified. As of mid-2020, at least half a dozen of them are entering into human trials. A roadmap was developed to fast-track the process for vaccine development, production, and distribution. The approach would reduce this timeline from the five years it took to develop an Ebola vaccine (already a historically fast process) to 18 months.

Rapid, accurate diagnostics are another game-changing innovation. There will be recurrences, even with social distancing, face masks, handwashing and other personal protective habits. With a rapidly spreading virus like Covid-19, early detection means fewer new cases, fewer deaths, and less economic disruption. This requires testing for the Covid-19 virus with specific protocols for public health surveillance, clinical care, and healthcare personnel. Testing in congregate settings (for example, in, nursing homes and prisons), schools, densely crowded urban areas, and other settings will depend on disease prevalence and local circumstances.

Compact, accurate, affordable point-of-service viral tests with rapid 10- to 30-minute turnaround times will greatly facilitate such testing. Contacts exposed to someone with Covid-19 would be saved the inconvenience and cost of self-isolating while awaiting results. Frontline workers and other people in occupations at high-risk for exposure could better protect their families and workmates.

Invest Wisely to Save Lives

Just $7.5 billion to $15 billion per year ($1 to $2 for every person on the planet) of additional investment in prevention and preparedness would save millions of lives and pay for itself many times over, lowering emergency costs and economic disruption. Penny-pinching has often been admired when it comes to financial wellness, but it is not an effective strategy when it comes to fighting pathogens and pandemics. Tight hospital budgets and dissolved health-preparedness initiatives have resulted in lack of coherent planning and mitigation, as well as shortages of supplies, staff, and beds. Instead, we need increased investments in specific areas such as a universal flu vaccine and development of effective potential medications. We need to replenish medical-supply stockpiles. We need to set aside space in hospitals just in case.

Investments through the Global Health Security Agenda have improved epidemic responses in a number of countries, including Uganda and Ethiopia. In The Neglected Dimension of Global Security: a framework to counter infectious disease crises, from the secretariat of the National Academy of Medicine’s Global Health Risk Framework for the Future, the case for investment is clear:

The global community has massively underestimated the risks that pandemics present to human life and livelihoods, at least in terms of policy outcomes. The resources devoted to preventing and responding to such threats seem wholly inadequate to the scale of the risk. While it is impossible to produce precise estimates for the probability and potential impact of pandemics, it is not difficult to demonstrate a compelling case for greater investment. There are very few risks facing humankind that threaten loss of life on the scale of pandemics.

Ring the Alarm, Rouse the Leaders

Citizen activists and social movements are vital to mobilize the public and to hold local, national, and global leaders accountable for safeguarding our lives, communities, and economies. Since the 2014 Ebola crisis, numerous new national and international organizations involved in epidemic and pandemic advocacy have emerged. One such organization is the Global Preparedness Monitoring Board (GPMB), co-convened by the World Health Organization and the World Bank. "Composed of political leaders, agency principals and world-class experts, the