The Rotarian Conversation:
When it comes to addressing epidemics, the public health expert says we have the solutions. We simply have to embrace them
Jonathan Quick thinks on a grand scale. His book The End of Epidemics: The Looming Threat to Humanity and How to Stop It argues that we can end not just one particular epidemic, but all epidemics. He lays out a seven-point call to action (e.g., “Invest wisely, save lives”; “Active prevention, constant readiness”) to prevent the inevitable outbreaks of diseases from growing into epidemics that kill thousands or even millions. The scale of his ambition is matched only by the scale of the problem and the price tag on his proposed solution: Quick calls for an investment of $7.5 billion annually for the next 20 years in prevention, but he points out that a severe pandemic — when an epidemic goes global, something made more likely by our interconnected world — could cost the global economy up to $2.5 trillion.
When it comes to public health and disease prevention, Quick knows what he’s talking about. He earned his M.D. at Duke University and spent 10 years at the World Health Organization, working with local governments on access to medicine, particularly AIDS medications, in Pakistan and Kenya. During his time in Kenya, he was a member of the Rotary Club of Nairobi-South and was involved in the club’s polio vaccination efforts. When he returned to the United States in 2004, he led Management Sciences for Health, a nonprofit focused on helping governments develop effective health systems management.
Quick decided to write The End of Epidemics in 2014 during an Ebola outbreak in West Africa. He viewed with alarm the failure of governments, nongovernmental organizations, and affected populations to learn the lessons of recent epidemic outbreaks. “Based on what I’d seen with AIDS, with SARS [severe acute respiratory syndrome] in 2003, with Ebola, I asked myself where we would be in three years,” he recalls. “And my sense was we’d be just as vulnerable because we tend to go through a cycle of panic and neglect. I fear we’re going to leave my daughters’ generation a world that’s in more danger of pandemics if we don’t really get a good, solid, persistent response.” Senior editor Hank Sartin spoke with Quick about the factors that make for robust public health infrastructure, how engaged individuals have made a difference, what we should be focused on now, and the recent measles outbreak.
THE ROTARIAN: Since your book came out, we’ve faced a serious measles outbreak. What happened? And does this temper your optimism about the end of epidemics?
QUICK: The recent measles outbreaks in the United States and around the world are no surprise to those of us who have been tracking the rise of the vaccine resistance movement and the resulting global decline in measles immunization in many countries. This is a surmountable setback, but it must be confronted with utmost urgency.
The decade of the 2010s has seen an alarming decline in measles immunization. Between 2010 and 2017, more than 20 million children worldwide missed their first measles vaccination.
The global rise in vaccine rejection has been driven largely by a discredited and retracted 1998 article in a prestigious medical journal. The purported link between measles vaccine and childhood autism has been repeatedly disproven in rigorous scientific studies. As important, we now know much more about the real causes of autism, which include a combination of genetic and environmental factors, both prenatal and postnatal.
Our greatest challenge is not the microbes. Our greatest challenge today is combating the disinformation and underlying distrust of science that lead to vaccine rejection. The first step is to strengthen epidemic literacy, including vaccine literacy, from primary to graduate school and in continued public education. The second step is to acknowledge and respond to sincere concerns about past vaccine safety issues and to ensure the safety of new vaccines. The third, and most daunting, step is to develop local, national, and international vaccine acceptance efforts capable of turning around a well-organized global anti-vaccine community that has a simple, emotive message — “measles vaccine causes autism” — is highly effective on social media, and has enlisted stars and political leaders.
TR: You argue in the book that we need to move into prevention mode when it comes to epidemic diseases. But every time we’ve faced a previous epidemic, we have gone through a cycle of funding during the crisis and then defunding after. Is there any reason to think we will support a prevention strategy now?
QUICK: We had the combination of Ebola in 2014 and then the Zika virus in 2015. Coming so soon after Ebola, the Zika outbreak focused public attention on epidemics. And then in 2018, we had 80,000 flu deaths in the U.S. That accelerated the research on the flu vaccine. We have something new, the Coalition for Epidemic Preparedness Innovations, dedicated to developing new vaccines. We have more funding put in the right places, and we also have much greater attention to building good public health systems. The global public health community put the SARS virus back in the box in 2003. We did that without a vaccine because of good public health: Go find the cases, isolate them, get their contacts, and stop it that way. The innovation, the funding, and the work on systems — those are the reasons I think it is possible.
TR: You write a lot about the 2014 Ebola outbreak in West Africa. Why was that out-break so serious?
QUICK: Just about everything that could go wrong did go wrong. Before the West Africa outbreak, which infected over 28,000 people and killed more than 11,000, Africa had experienced 22 outbreaks since Ebola was first discovered there in 1976. Each of those previous outbreaks involved fewer than 1,000 cases and even fewer deaths. Most of the time these outbreaks were 50 or 100 cases. In this outbreak, the region wasn’t prepared. The conventional wisdom was that Ebola wasn’t in West Africa. In fact, there was evidence that it was there going back several decades, but that evidence was sitting in Europe, not with the people in Africa. Experts also said that Ebola was a “dead-end event” because it would burn out too quickly to spread. These three countries [Guinea, Liberia, and Sierra Leone] had all experienced horrific civil wars and resulting poverty, so people didn’t trust the governments. And they didn’t have the basic health systems to be able to identify Ebola and quickly respond.
And the leader of the World Health Organization in 2014 [Margaret Chan] had not prioritized the emergency response and was more of a consultative decision-maker. It took the director-general of WHO four months before a global emergency was called; back in 2003, when the SARS outbreak occurred, the director-general at that time [Gro Harlem Brundtland] made a decision in four hours, and SARS was stopped within six months. In West Africa in 2014, we didn’t have decisive leadership and we didn’t have the early communication around safe burial and prevention. People panicked after SARS and made a lot of promises, but by 2008 the message had been forgotten, and when the financial crash started pinching the budgets, both the World Health Organization and to some extent the U.S. Centers for Disease Control and Prevention started defunding and de-staffing some of the emergency response capabilities. So it really was a perfect storm of all the things that could go wrong.
TR: What lessons can we draw from that outbreak about things that work?
QUICK: The story that took hold in the West about the Ebola outbreak in West Africa is that it was a disaster. That’s true about the start, but the success story that doesn’t get told is how quickly the epidemic came to an end once all the communities were mobilized. Mohammad Jalloh is a Sierra Leonean social scientist who runs a nonprofit that did a lot of work on immunization and was able to use communication and social engagement to get immunization rates up. When outsiders came in and tried to bring the messages, it was a disaster. Eight health workers and journalists drove into a town in Guinea and were killed by the population and thrown in the school cistern because the locals believed these outsiders were spreading the disease.
Jalloh was part of a team that went out and surveyed to find out what people believed. Then they mobilized the 4,000 market women — the small-business owners in the marketplaces where a lot of people gather. And they also involved the thousands of traditional healers, the religious community, and the popular press. With a consistent message, they were able to capitalize on the trust these community leaders had built. In times of real fear, it’s not facts that are going to convince people; it’s having the message from people they trust. And those trusted people were all carrying the same message.
TR: Rotary has helped put systems in place for polio vaccination and surveillance. Do those systems help in approaching other epidemics?
QUICK: Yes, absolutely. In Nigeria in July 2014, just when Ebola was coming up, a Liberian American lawyer was on his way to a conference. He collapsed in the airport in Lagos, Nigeria, and was hospitalized and found to have Ebola. Immediately the government mobilized the emergency command center that had been set up to detect polio. They got a rapid response team of 100 Nigerian doctors and identified 900 possible contacts this lawyer had made. They made 18,000 face-to-face visits to check on the temperatures of these people. They were able to get 100 percent follow-up of potential contacts. Building on the system that had been set up for polio, they were able to prevent an outbreak in Nigeria.
TR: In the book, you seem more concerned with influenza than Ebola or Zika. Why?
QUICK: Influenza is harder to stop. First, it is transmitted through the air. And typically, there is not one flu in one season; the different flu strains travel in packs, so that complicates it. The vaccine development process involves making a scientifically informed best guess of what strains of flu will be prevalent in the coming year. Then you make the vaccine with those strains. There are typically three or four different strains of flu viruses that go into the vaccine because in any one year, two or three or four different strains of flu are circulating. And they will evolve during the epidemic, and that’s why the epidemic can sometimes in one season look different in the United Kingdom, say, than it does in the United States.
And the genes of influenza mutate very fast. If the virus changes suddenly, you get people who don’t have any immunity. We always have some partial immunity to the flu, but when you have significant mutations, you get a pandemic. Influenza is constantly exchanging genes among humans, pigs, wild birds, poultry.
We have been really slow to recognize how inadequate the flu vaccine is and to properly invest in developing a flu vaccine that can outsmart the virus or at least keep ahead of it. We are used to one-and-done or two-and-done vaccines like what we have for measles, but we have not invested in doing the same thing for influenza. One of the major achievements in the past few years has been an explosion of work on a universal flu vaccine. In early 2018, the National Institutes of Health released its Strategic Plan for Influenza vaccine and the Bill & Melinda Gates Foundation announced its Universal Influenza Vaccine Development Grand Challenge. While a universal flu vaccine is at least five to 10 years from routine use, several promising universal flu vaccines are already in clinical trials.
TR: You argue that epidemics should be a concern not just for governments, but for businesses too. What should business leaders be doing to prepare for possible epidemics?
QUICK: Look at what companies do in terms of business preparedness planning. They think about what happens if there is a tsunami in Indonesia, what happens if there is an active shooter in a corporate facility. They prepare for a problem with global IT systems and cybercrime. What they don’t think about is what happens when we have an epidemic disease event that will affect suppliers, employees, and customers over perhaps a two-year period. Every business needs a pandemic preparedness plan. Businesspeople need to ask themselves, “What is our plan for a pandemic or for regional outbreaks?”
TR: You seem generally hopeful about our ability to stop small outbreaks from becoming epidemics. Is that partly because of technological advances that have made us better able to deal with viruses?
QUICK: The scientists and public health people know what to do. It’s really clear. It wasn’t anywhere near as clear five or 10 years ago, so that’s what gives me hope. Since the book came out, I’ve spent a year doing lectures about this topic. I know there are many committed people. We’re not moving quickly enough yet, because there are not enough people in enough positions of authority among political leaders and business leaders that are going to keep the policies going. Only one out of three countries worldwide have the systems in place to prevent, detect, and respond to epidemic outbreaks. The United States had provided incredibly good leadership in initiating a global effort to build epidemic preparedness worldwide, but we’ve stepped back. The support to do the things that need to be done is still subject to both political pressures and complacency.
Fighting disease is one of Rotary’s areas of focus. Learn how you can be part of the solution at rotary.org/our-causes.
• Illustration by Viktor Miller Gausa
• This story originally appeared in the August 2019 issue of The Rotarian magazine.