COVID-19 March 13, 2020

The COVID-19 Epidemic and Pandemic Preparedness in the United States

Eric Gaillard/Reuters
from Member Conference Calls

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Public Health Threats and Pandemics

Larry Brilliant, Tara O’Toole, and Mark Smolinski discuss the COVID-19 epidemic and pandemic preparedness in the United States and worldwide, as well as the importance of health to our economic and national security.


Larry Brilliant

Chair, Ending Pandemics; CEO, Pandefense; Former Chair, National Biosurveillance Advisory Subcommittee, Centers for Disease Control and Prevention

Tara O’Toole

Executive Vice President, In-Q-Tel; Former Undersecretary of Science and Technology, U.S. Department of Homeland Security

Mark Smolinski

President, Ending Pandemics; Former Director, Predict and Prevent Initiative,


Irina A. Faskianos

Vice President, National Program and Outreach, Council on Foreign Relations

FASKIANOS: Good afternoon and welcome to this Council on Foreign Relations conference call. I’m Irina Faskianos, vice president of the National Program and Outreach at CFR. As a reminder, today’s discussion is on the record, and the audio and transcript will be posted on Joining today’s call are CFR members, corporate members, and members of the press.

Today we have with us Larry Brilliant, Tara O’Toole, and Mark Smolinski. Larry Brilliant is the chair of Ending Pandemics and the chief executive officer of PanDefense. He formerly served as chair of the National Biosurveillance Advisory Subcommittee at the Centers for Disease Control and Prevention and was on the UN team that led the World Health Organization’s successful smallpox eradication program. He is founding president of the Skoll Global Threats Fund, where he also served as chairman.

Tara O’Toole is the executive vice president and senior fellow at In-Q-Tel, where she leads the B.Next team, which is devoted to understanding the national security implications of advancements in life sciences and biotechnology. She served as the undersecretary of science and technology at the Department of Homeland Security from 2009 to 2013.

And Mark Smolinski is the president of Ending Pandemics, where he leads a team that co-creates tools for early detection, advanced warning, and prevention of pandemic threats. He formerly served as the chief medical officer and director of global health at Skoll Global Threats Fund.

I have done brief introductions of them so that we can get to the meat of this conversation on the COVID-19 epidemic and pandemic preparedness. Larry, Tara, and Mark, thanks very much for being with us. Let’s start with you, Larry, about COVID-19 and how this compares to other pandemics. Give us the context of what we’re looking at.

BRILLIANT: Good morning, everyone. I know this is a fraught and tense time. And by now, many of us have friends and relatives who have been put in isolation or come in contact with the disease. And all of us have people who are quite worried about this disease, as they see it on television twenty-four by seven. And this is the nature of the knock-on effects of a pandemic. This disease has been pandemic for a number of weeks, WHO only this week has declared it a formal pandemic. But whether formal or informal, a pandemic is a disease which spreads on its own from person to person on multiple continents at the same time. And while the name of the pandemic is COVID, it is a coronavirus and a class of viruses. Many of us use the terms coronavirus, COVID-19 interchangeably. We may do that on this call as well.

We’ve seen other pandemics in the last two hundred years. In 1918, the great influenza killed between fifty and one hundred million people at a time when the population of the world was between two and two and a half billion. Influenza in 1957–58, which was a H2N2 virus, killed over a million. Asian flu killed over one million people in 1968. And that was worth noting, because in that instance, as in the case of COVID, most of those deaths and most of those severe reactions were elderly people. H1N1, the swine flu in 2008–2009, mostly killed and injured people who were young—something that’s very unusual but is specific for swine flu. HIV/AIDS, which has infected over seventy-five million and killed more than thirty million is certainly a pandemic, though because it moves very slowly it often is not afforded that title.

We’ve had other global epidemics. SARS in 2002 and 2003, another coronavirus, had about 7,500 cases, nearly a thousand deaths. A death rate of 11 percent, which is important to note. MERS, which had about 2,500 cases, another coronavirus, with nearly nine hundred deaths, which is a death rate of almost one-third. I cannot help but mention smallpox—(laughs)—which between 1900 and 1980, in the twentieth century, which wasn’t so long ago, killed over five hundred million people, half a billion.

It too probably, like all these others, began thousands of years ago as an animal virus. I’m not even talking about Ebola, Zika, dengue, chikungunya, West Nile, or a myriad of other diseases, although they’re important to understand that we are in the age of pandemics. And a pattern has emerged, where fifty or more viruses of animals have jumped species from animals to humans. And when they first make contact with a human being, they are called a novel virus, as is COVID-19. Today’s not the day to go through and delve on the one health idea of animals, humans, and the environment. I know Mark will talk a little bit about that. But we can’t ignore it, because this is the context in which we are dealing with this pandemic.

So when we say that something is a novel virus, it means that today of our nearly eight billion population, none of us—except for the hundred thousand or so who have recently got the disease—are immune to it. There is no vaccine, nor will there be for twelve to eighteen months, although new technology may shorten that time. There is no antiviral, although hundreds of people are working feverishly to find one. Quarantine, isolation, closure of large events and small, prohibitions on travel—as critical as they are and as vital that we do them, they are part of reducing the number of susceptible people. But that social distancing is only a speed bump on the path of this virus, until we have a vaccine.

The COVID pandemic is the most dangerous of my lifetime. Not as deadly as Ebola, not as deadly as smallpox, not as transmissible as even measles or some influenzas. It may not kill as many people as the great influenza—please, God—and certainly not as smallpox did. But it will—for all of us on this phone and all the rest of us—cause global disruption on a scale we have not seen in more than a hundred years. It is an unusual combination of infectivity and transmissibility, and the speed at which it is moving that cause disruption in every company, every nonprofit, every part of government, every facet of our life, every American will someday in some way be affected by it.

In 1910—I’m sorry—in 2010, right after the swine flu outbreak, a group of us, including all three of us, as epidemiologists were concerned that people seeing the swine flu pandemic did not think that it was a very serious pandemic, serious outbreak. And we decided to work to help create a movie called Contagion. That movie, which was a very different virus with a much higher death rate, but in some ways it was very prescient because it also, like COVID-19, showed a disease originating in bats, going to an intermediate animal, and then to humans.

I am sure that COVID-19 will not be anywhere close to as bad as the virus in Contagion, but it’s up to each one of us to make sure that the social disruption that we showed in that movie remains fiction, remains Hollywood. And it is in our power to stop it from happening in reality. Thank you.

I’ll now turn it over to Tara.

O’TOOLE: Thank you, Larry.

So here we are. And certainly we need to deal with the COVID-19 pandemic before us. As of yesterday, there were about 118,000 confirmed cases of COVID-19 around the world and about 4,200 deaths globally. Ten thousand of those cases were in Italy alone. And, as we know, their health-care system is struggling to cope with the onslaught of seriously ill people who need hospital care and intensive care in northern Italy, which, by the way, has quite a sophisticated health-care and hospital system. And the U.S., as of yesterday, we had somewhere between 900 and 1,300 cases. At least 900 were confirmed by CDC, with twenty-nine deaths across thirty-eight states and in the District of Columbia. And we’re seeing closures of everything from the March Madness basketball games to the Metropolitan Museum of Art in New York.

I think the media has done actually an excellent job covering the clinical features of (COVID)-19 and explaining that the task before us right now is to slow down transmission of disease. All of these interventions and closures are not intended to stop the transmission. What we’re trying to do is slow down the spread of the disease so everybody doesn’t get sick at once, creating a tsunami of seriously ill people slamming into our health-care system, which simply does not have the surge capacity or the resilience to deal with even a small fraction of the U.S. population suddenly getting sick at once. We have a very limited number of ICU beds in this country, maybe sixty-five (thousand) to one hundred thousand all counted. The available beds, beds with people who aren’t in them, are in the hundreds or maybe low thousands. So it doesn’t take a large number of people getting sick all at once to stretch or even overwhelm our capacity to take care of the seriously ill. And, again, we’re trying to slow down the spread in order to give the health-care system a chance to take care of people over time.

I’m sure we’ll have more questions on that, but I want to turn to thinking about epidemics and epidemic response more strategically. As Larry said, we are in an age of epidemics. This is a consequence of humans intruding into new ecosystems and coming into contact with new animal diseases, as well as trade and travel patterns. And that is not going to change. They are going to keep coming. We need to think about epidemics in four big pieces—or, rather, epidemic response. In order to handle an epidemic, we need to do four things. We need to be able to detect and diagnose and characterize the pathogen. We have not done a great job with diagnosing COVID-19 or having the materials that we need to do these diagnoses on a mass scale.

The irony of that is that we’re in a renaissance era of diagnostic technologies thanks to rapid advances in science, such as CRISPR. And we need to rethink our technological approach to epidemic response, starting with being able to rapidly—as in, a week—design, manufacture, and, at scale, distribute diagnostics. The second thing we need to be able to do in an epidemic is protect the well, ideally with vaccines. If you don’t have a vaccine, you’re back to the kind of prohibition of mass gatherings and individual isolation that we’re doing now.

Again, the science in our side. As Larry said, there’s many companies trying to invent vaccine. We need a national, if not an international, push to move the science forward so that we can design, manufacture, and distribute vaccines in real time so they have a meaningful impact on an epidemic. That has never happened before. We are entering an era when that is possible, but it’s going to require government backing. Thirdly, you have to take care of the sick. We are moving out very quickly to try and understand what remedies and what treatments might work. That whole effort to rapidly screen existing antiviral medicines and new ones should be better organized than it is now and encouraged.

And finally, in all epidemics data and communication is absolutely key. We have to get much more adept using tools that are used by the commercial sector all the time, every day, routinely. We must get much more adept at collecting, analyzing, and disseminating information about what’s going on, what’s working, what isn’t, and including communicating with the public so that as we go through these epidemics we learn, week by week, what’s working and what isn’t—what’s getting better, what isn’t, where to put our resources, and so forth. And also, that we learn one epidemic after another. All three of us have watched the last twenty years of epidemics go by. We’ve gotten a little better, but not nearly the improvement that we need to see.

BRILLIANT: Tara, thank you very much.


SMOLINSKI: Thank you. Hello, everyone.

This novel coronavirus, SARS-CoV-2 is joining the rapidly growing list of microbes that jump from animal to human, known as zoonoses. Emerging from the complex interactions among humans and animals in the ever-changing ecosystem, zoonoses demand our serious and sustained focus to find and respond to outbreaks faster and more effectively. Beyond the many worries, challenges, and great toll in human suffering, death, and financial loss entailed in this pandemic, the complacency that seems to cyclically return after the world’s response to public health emergencies—as witnessed with SARS, H1N1, MERS, Zika, and Ebola—will eventually be another challenge.

The longer we keep repeating this pattern, the more we’ll have to put up with preventable outbreaks, and the more people will get sick and die as a result. This outbreak is hopefully breaking the cycle of alarming complacency as this pandemic moves into everyone’s space. We need to make certain the snooze button is never hit again after this wake-up call as nature will inevitably deal us with a very bad hand, a pathogen that possesses a catastrophic combination of lethality and transmissibility. We’re seeing the emergence of two to five new zoonotic disease each year, any of which can become the next pandemic.

COVID-19 is reminding us of our vulnerability to emerging and unexpected infectious disease threats. In a modern world, a microbe can travel very fast, very far, and widely disperse, as evident in COVID-19 outbreak in China that has become a pandemic in a couple of months. Under conditions of uncertainty and fear, policies and procedures are not all we face, and the best possible science. Yet, these present opportunities to better understand risk and explore innovations if we take the time to be thoughtful and systematic. As we talk about travel bans, social distancing, and the cancellation of mass gathering and large events, can we do it in a systematic way to optimize the potential impact but also to collect the data necessary to apply proven methods to the next outbreak?

We must do this now. While we’re still wide awake it’s a good time reconsider how we think about our response to disease outbreak. If we reframe the issue, not as an isolated emergency response but as an ongoing effort to prevent outbreaks from happening in the first place by being prepared, it will serve us all well. When it comes to any outbreaks, speed is of the essence. Speed of detection, speed of reporting, speed of response are all crucial so that the global community can be as prepared as possible to address the threat and limit or prevent spread. Any delay in detecting a novel threat translates into greater spread, illness, social and work disruption, and additional lives lost.

Much of what needs to be done involves applying age-old fundamentals of public health. And we must recommit to ensuring a strong public health infrastructure around the globe, with robust and sustained funding. We also have an opportunity, as Tara was just talking about, to apply more sophisticated approaches to the fundamental needs of disease detection and surveillance. In some countries, farmers and workers in live animal markets have the highest contact with potential new pathogens, and are now being connected to innovative, community-led surveillance systems to report symptoms of illness, and sick or dead animals in a very timely manner.

In Cambodia, for example, a simple hotline that’s free to everyone through a collaboration of all the telecom companies, built by a local tech company, is receiving one thousand calls a day for COVID-19. And 90 percent of all the surveillance in that country are identified through this hotline. This hotline was built during a non-epidemic period. It is what we need to do in all countries. In the U.S. we have a system called Flu Near You, where people report symptoms of flu every Monday, to give us a better idea of how much illness is circulating in community, as well as how many people are well. Flu near you is currently being adapted to add questions about coronavirus to alert the population and get them to report anything they see in collaboration with the U.S. Center for Disease Control.

Other innovations in self-reporting, social media, machine learning, and artificial intelligence are providing opportunities to find outbreaks faster, so that we can stop a threat anywhere from becoming a threat everywhere. Thank you very much, and I look forward to your questions.

BRILLIANT: Thank you, Mark.

FASKIANOS: Larry, Tara, and Mark, thank you very much. Really appreciate your opening remarks. We are going to open now for questions from the audience. Just to set the ground rules here, we have over 700 confirmed for the call. So there are going to be a lot of people who want to ask questions. So I ask you all to say who you are, and your affiliation, and please keep your questions to a question and limit it to one so that we can really get to as many questions as possible in the next forty minutes.

So, Chelsea, let’s open it up to the group.

OPERATOR: Thank you, ma’am. At this time we’ll open the floor for questions.

(Gives queuing instructions.)

All right. Our first question will come from Andy Revkin with Columbia University.

REVKIN: Andy Revkin, Columbia University, Initiative on Communication and Sustainability.

It’s great that you’re doing this. A couple points. Larry mentioned the use of the film, which was influential. Mark mentioned communication, including the Cambodia example. What I’d like to know, or facilitate, is having some kind of a real—is there a Manhattan Project here, whether you’d call it a Manhattan Project or not—is there a thing—who’s not in the room? Like, from Madison Avenue, from other circles, who can get together promptly and do what Mark said, to make this a non-emergency normal capacity that can be ramped up as things come around?

BRILLIANT: Andy, it’s Larry. Let me try to respond to that. There are a large number of private sector philanthropic and NGO centers of people who are really concerned about and work on pandemics from day to day. And maybe you could interact with Mark at Ending Pandemics and shoot him mail afterwards. There’s a group of foundations that are called the Pandemic Collective, about a dozen foundations and a few companies, that have now been together since the Ebola outbreak in West Africa seven years ago, that have been working together to work on vaccines, antivirals, communication strategies. Rockefeller even had a Bellagio conference on the topic that you’re talking about.

But if you—I think that this—your question would be best handled offline, except to say there are a large number of groups that have been working, dedicating themselves, at universities and the nonprofit sector. And of course, within government. I mean, I think all of us are a little bit alarmed that the usual focus inside of government, the Pandemic Preparedness Group, has not been as fast and robust as we would like. But it’s nice to see—it’s wonderful to see the philanthropic community play some of that role.

Next question, please.

OPERATOR: Thank you. Our next question will come from Mary Boies with Boies Schiller Flexner.

BOIES: Why is the United States so far behind in testing? And how soon will we have adequate testing?

BRILLIANT: That’s a wonderful question for Tara.

O’TOOLE: Well, I don’t know when we’ll have adequate testing. There’s a lot of effort going on now to try to get the private sector laboratory entities online. They have, in theory, enormous capacity. I think you’ve all read about the technical explanations of why we didn’t have testing ready. I think the more strategic answer is that our public health system, as it now stands, was not built for speed. We have three thousand state and local health departments, public health departments, all of whom are chronically starved for resources. And they are not glued together organizationally very efficiently. And CDC also has less resources than would be ideal.

I think also the public health laboratory network that was set up after the anthrax attacks has increased the capacity of state health labs to do this kind of testing, if they are given the proper equipment. I think we need to rethink the way we do diagnostics in emergencies in this country in order to take advantage of available technologies. I would have answered the last question by saying that the big entity that isn’t in the room that would advantage the United States in helping to quench pandemics is technology. For reasons that are partly attributable to lack of public resources, but are somewhat mysterious, public health has not absorbed technologies at the rate of the commercial sector. And we need to change that. Public health needs to be able to move at least at the speed of business in an emergency. And that is not now the case.

FASKIANOS: Next question.

OPERATOR: Our next question comes from Rick Lifton with Rockefeller University.

LIFTON: Thank you very much. And thank you for the excellent presentation. One of the major issues confronting New York City right now is the question of whether we are beyond the point at which containment strategies of any sort are worthwhile, and simply resort to mitigation, which has commented as a goal to slowdown transmission but not limit the ultimate number of cases. It seems, and I completely agree with the comments made on this call, that use of technology changes the opportunities to consider the use of containment strategies. And the only question at this point if whether we’re past the point where containment strategies will be useful. We know from yesterday’s—

BRILLIANT: Rick, this is a really—Rick, just let me interrupt. I’m sorry. This is a really important question. And Mark Smolinski is passionate on this subject. And let’s give him a chance to answer that, if we could.

LIFTON: Thank you.

SMOLINSKI: So, yeah, thank you for the question. This is an example of, you know, going blind through an outbreak, because we don’t really have the data to understand what, I worry, has just become an acceptance that this is widely spread. And it changes the whole dynamic. Because my opinion is we are still in active containment mode. Now, it gets a little confusing because certainly mitigation measures can be part of a containment mode. But it ends up being, are we thinking about this as individuals—and this comes into a lot of the questions we get about travel—you think of that different if you’re answering that about someone in their individual risk.

During a pandemic, we’re all in this together. So everything that is happening in New York to help containment, even though it may seem and it could be much wider-blown than we know because we don’t have the data about surveillance and the community as a whole—what you’re doing there is helping the country and may even be helping the globe, because we need to contain every spark that’s happening from becoming the fires we see in South Korea, and we see in Italy, and we know we will have one or more in the U.S. So every community needs to take this absolutely seriously, and hopefully we can have some data to actually show which measures work and which would not, so we wouldn’t be answering these questions because of the uncertainty of having hard data. Over.

BRILLIANT: And I’d just mention that Tedros, the director-general of WHO, at every one of his morning briefings says: It’s both/and not either/or containment and mitigation.

Can we have the next question, please?

OPERATOR: Thank you. Our next question comes from Megan Carroll with United Nations.

CARROLL: Hi. Thank you. I’m curious, if someone is exposed and/or contracts COVID-19, do they gain some immunity? For example, if someone has contracted the virus and survived, does the virus appear in their bloodstream, IgG like HSV and EBV, and provide future immunity?

BRILLIANT: I’ll answer that. You know, as far as we know—of course, we don’t know the answer. That’s the right answer. But as far as we can tell, this virus will not behave differently, out of the box, of what we expect of viruses in its class. So one infection should confer immunity. We don’t know if that’s lifetime immunity or not. There will, of course, always be exceptions. There will be people whose immune status—if they have no IgM, for example, they will not ever be able to be immune. But these are not of epidemiological importance. They’re very important clinically, but they’re not important in the big picture of the public health issue.

FASKIANOS: Thank you. Next question.

OPERATOR: Our next question comes from Jonathan Berman with Invest Africa.

BERMAN: Thanks for your expertise. Even once LabCorp and Quest come onboard, it will still—samples still need to go to their labs and come back. Tara, is there an opportunity here to have rapid diagnostic test cartridges in the field at clinic sites, for this and future pandemics? And if not, why not?

BRILLIANT: And, Tara, that question is for you.

O’TOOLE: Yes. And we ought to be working on that now. Diagnostics are more complicated than they appear. We want to be sure that diagnostics are accurate, and we need to know how specific and sensitive they are to make good clinical decisions. So FDA review, I think, is certainly necessary. As I said, the science is there now to create very rapid readout, points of care diagnostics. And if we do the right things, in a year or two we ought to have in hand diagnostics that can be mailed to everybody and perform like pregnancy tests. In other words, you could do them at home and figure out if you’re infected with virus X or not. That ought to be a major goal of the U.S. government and the CDC.

But it involves more than just getting one diagnostic. It involves putting together a much more systematic approach to diagnostics so that, for example, companies or universities who want to develop a new diagnostic tool have access to samples of the virus, of the pathogen that they are seeking to identify. That’s not possible right now without a lot of work and some delay. But if we had government-validated banks of pathogens that companies and universities could use, that would be a big help. And there’s a number of other steps that we should go through to build essentially a machine to produce rapid diagnostic technologies when we need it, and as we need it.

There’s also market forces at work that discourage entrepreneurs from developing diagnostics. And we have to fix some of those, many of which are riven into the way that Medicare and insurance companies value diagnostics. It takes about as much investment to get one through the regulatory hurdles as it does to get a therapeutic through, but the return on investment is much lower. And we ought to look at that and see what we could do to incentivize diagnostic production.

BRILLIANT: I just want to make a comment. I think that we’re not thinking big enough when it comes to diagnostics. You know, it’s pretty apparent to everybody that in the area of vaccination we have a market failure. We have a public good that can’t be produced by the private sector in the way that we need to have it, so we’ve created IAVI. And Seth Berkley at IAVI has done a really good job of putting together a large amount of capital. He acts like a monopsony, buys up a lot of vaccines. I think that we need an IAVI-type structure that will kickstart a global effort in the area of point-of-care diagnostics. The goal is exactly as Tara talks about. We need home pregnancy test kind of test for pathogens. We need to be able to get them everywhere, all at once. And perhaps this failure of the U.S. government in helping us to get diagnostics for COVID-19 in anywhere close to the quantity, the speed, and the accuracy that we need, maybe that’ll kickstart a global national conversation like that.

Next question, please.

OPERATOR: Thank you. Our next question comes from Nick Turse with the Intercept.

TURSE: Nick Turse from the Intercept. Thank you so much.

I realize that forecasting is fraught, but given the situations we’re seeing in Italy, Iran, and elsewhere, I hoped you could weigh in on what the worst-case scenarios we could be facing would be in terms of morbidity, mortality, and duration.

BRILLIANT: I’ll let Mark and Tara speak if they want to talk about this, but I will just point you to today’s New York Times, which has article called, “What’s the Worst Case.” And it assembles the work of half a dozen modelers working with CDC and other agencies and leaks to the press of some of these conversations. Certainly the numbers that they’re talking about, worst case in the United States—and please, God, prevent it from coming—they’re talking about well in excess of a third of the U.S. population being sickened, and death rates in the 1 percent range, maybe more.

I think one of the reasons they do that is they’re looking at the most recent pandemic that has characteristics that are similar, with was swine flu in 2008, which did in fact infect about one third of Americans and one third of the world. So that’s not preposterous. And a death toll of a million or more is not a high death toll globally, because we had it in ’57, we had in it ’58, and we had it in the swine flu in 2008. Maybe that was six hundred fifty thousand. But if you read that article, which I commend to you—and I think Nick Kristof has a model that’s going to be presented. If you look at it, I think that you’ll see what some of the worst cases are.

It is, however, up to us that we get the best case. And with that, let me see on this important question if Mark or Tara want to say something.



BRILLIANT: Oh, OK, go ahead, Mark.

SMOLINSKI: No, no, I was going to let Tara go first, but I would be happy to jump in.

Yeah, this is one of the reasons we created Flu Near You back in 2012 was because we don’t really even understand with a seasonal respiratory disease, and 80 percent of people probably never seeking health care during the flu season, with the exception of maybe, you know, H1N1 or one of the pandemic strains, that information is so critical so that modelers and forecasting can base things on, you know, real data. And, you know, when Larry and I were at Google and working with the engineers in creating Google Flu Trend, really revolutionized the idea that there’s signals hidden in so much data that can help us find things faster. But the reason we created Flu Near You was to have that two-way communication and to have that community.

So while we’re having the forecasting and many efforts going on right now, let’s not forget, you know, the egg on everybody’s face when the publication of the Ebola in 2014 said, you know, we would have a million deaths. And it was all based on modeling and forecasting, but didn’t take into account that we’re not going to sit around and do nothing. So worst-case scenarios are kind of strange to me, because I don’t want them to become self-fulfilling prophecies or add to complacency because people think: It’s too big. I can’t do anything, or whatever messaging that might send. When with today’s technology—and I agree completely with what Tara was saying—we’re not applying technology we’re using in every other sector to public health. That is our mission at Ending Pandemics. We apply technology to find and report outbreaks faster that is technologies that already exist.

So right now we could have the community help us. And it doesn’t have to necessary be modeling and forecasting. I mean, if we are recording people’s symptoms, you know, whether they’re getting tested for flu and/or coronavirus, the idea to directly engage the population to be part of the solution, and the population that’s begging to do something, this is our chance to really, you know, change the way we do public health. Put the public into public health surveillance. Over.

BRILLIANT: Tara do you—on the record, we are on the record. Do you want to give your forecast for the worst case?

O’TOOLE: No. I think the modelers are working very hard. They do need data to create adequate models. I’ve never been in a drill or exercise around pandemics when the question wasn’t asked: How bad could this get? The question now is really not how bad could it get, but how can we slow transmission, because the ultimate outcome at least in terms of deaths is going to depend on whether we can sustain the function of the health-care system, particularly intensive care units, by slowing transmission. And that’s up to each of us as individuals in our workplace and in our community. So if you’re within three feet of someone and you’re exhaling respiratory droplets that contain COVID, you are contributing to transmission and contributing possibly to an increase in deaths at the end.

BRILLIANT: Well said. Next question, please.

OPERATOR: Thank you. Our next question will come from Nirmal Ghosh with the Straits Times.

GHOSH: Hi, there. Thanks for doing this. I just wanted to ask, President Trump is expected that he might—well, he’s expected to declare a state of emergency this afternoon. What difference would that nominally make? I mean, we have states—individual states which have declared states of emergency. But at the federal level, what kind of resources does that bring to the table, and what do you expect from that?

BRILLIANT: Tara, could you take that?

O’TOOLE: Declaring a state of emergency allows federal agencies to do things that they couldn’t do, at least not as swiftly or easily without that declaration. And it opens up avenues for FEMA to act, for example, to move stuff, and people, and money around. So it is essentially a governmental device that unleashes different capacities in government. Exactly how it will play out, I’m not sure. But it basically says go now, go faster.

BRILLIANT: Yep. Next question, please.

OPERATOR: Thank you. Our next question comes from Joel Gehrke with the Washington Examiner.

GEHRKE: Hi. Thank you for doing this. I wanted to ask a question about the World Health Organization. This may be a little bit more on the political side. I was talking to a doctor at an international organization, an NGO, about Syria. And he said, it’s hard to know what’s going on in Syria, for instance, although the chances are that there’s a serious crisis there. And the WHO in Syria will—it often hesitates to criticize the government there in Damascus. I wonder, have you observed that kind of trend more broadly? And what do you think as we—as we saw weeks of compliments for the—for how the Chinese authorities were handling this, compliments there. But is there some hesitance to criticize some of those governments?

BRILLIANT: Yeah, I’m happy to answer that question.

So I worked for WHO for ten years. At that time, we all had a love/hate relationship with WHO, and I suspect that that’s probably still the case in many quarters. I was privileged to work on the smallpox eradication program, polio eradication program, blindness, many successful programs at WHO. But I’m well aware that many have not been successful. I think Tedros is an excellent DG, and we’re lucky to have him. But every government—forget about WHO—in every—in every public health emergency initially is concerned about not over exaggerating, I would say, an outbreak.

I think when Mark said that the early estimates of Ebola—which is a bloodborne disease and can never really be something you think about as transmissibility on the level of COVID or influenza—when the model suggested there’d be a million cases and so many deaths, governments tend to hold down that number, especially early on, to not create panic. But many governments, especially repressive regimes, hide everything about an epidemic. They hide its source. They hide the number. Certainly China in the SARS epidemic in 2002–2003, China’s inaction was responsible for helping that virus become global. I can’t imagine—I can’t remember—even smallpox, as well as the Indian government ultimately worked, the first year the Indian government desperately tried to suppress the number of cases.

So it’s not just China with COVID. It’s not just the U.S. It seems to be more, I would say—it’s more common than we think. It’s more the rule than it is the exception. And as far as WHO, if anybody doesn’t, I encourage you all to listen to Tedros’s morning briefs and think about any time in the past when WHO had attempted to be as transparent as it is now. We owe them a great deal of gratitude.

Next question, please.

OPERATOR: Thank you. Our next question did not record their information, so please make sure that you announce your name and affiliation. Your line is live and open.

All right, we’ll go to the next question. Jon Murray with Denver Post.

MURRAY: Hi. My question—you know, we’ve seen rising counts in confirmed cases. Yesterday the mayor of Seattle said it’s possible her city really has a thousand or more cases right now. What is the best available evidence today about how much higher actual case counts—what they are versus what has been confirmed through testing?

BRILLIANT: Tara, would you like to take that?

O’TOOLE: So this is always a problem at the beginning of an epidemic. It is very difficult to extrapolate early on from the number of cases you’re seeing to the total number of cases. The problem is that the people who come to notice first are usually the sickest, at least in the absence of widespread diagnostics, which we don’t have. And you don’t know how many people are walking around with milder cases and not seeking medical attention. This is particularly problematic in COVID-19, because we know that the majority of people seem to have mild symptoms, and some have no symptoms at all. So we assume that the number—the total number of people is much greater than the number of people that we are counting, either because they’ve been tested, or they’ve come to the attention of health-care professionals.

What that number is I won’t even guess at, but I think what we will probably see in the next few days, given the number of cases that we know about, and given that we know that the total number is many times that count, I think what we will see as we start to do more and more testing around the country is a very rapid increase in the total number of cases. That doesn’t mean we’ll get that same kind of increase in the total number of deaths. That will depend on how well the health-care system can cope with that 20 percent of infected people who get really, really sick. But I think we’re going to see a rapid increase in the number of cases, both as a consequence of more testing and because we’ll get a better grip on the modeling as the testing increases and gives us more data.

BRILLIANT: Thank you.

Next question, please.

OPERATOR: Our next question will come from William Tovell with JPMorgan.

TOVELL: Hi. Thanks for taking the questions. Yeah, you mentioned earlier in the comment, I think, Tara, it was you, about being three feet away from people. You saw a lot of people wearing masks, and we’re told by the government that that was not helpful at all. Is that basically they want to limit the number of people getting masks individually, that they’d rather have that at hospitals? Or is there any benefit? Or what can individuals be doing here?

BRILLIANT: Is it a question you want to direct to Tara, or would you like me to handle that? Because let me start it and then Tara can jump in.

So there’s masks and there’s masks, as you well know. The difference between surgical masks, the kind of masks that are used more prevalently in Asia but increasingly in parts of the United States. When somebody is sick, the mask is used as a courtesy to public health to protect the sick person from spreading the disease. The physical barrier is so important. These masks, the surgical masks, are not of much help in protecting an individual from a virus, which is one micron wide. The N95 masks are effective in both directions. You may have heard they’re not effective. Well, they are. You also may hear that the virus of COVID-19 is one micron wide. And the holes in the mask are three microns. And you can almost imagine three football players in high school trying to get through a door that’s the width of one of them. It’s—you get a physical barrier when you use this N95 mask, even though the holes may not—may be larger than you’d like for a one-micron virus.

There’s also something about a mask that protects you from touching your face as often and serves as a warning for people around you to give you a little bit more space. There’s so many reasons why masks of either kind are helpful. Nonetheless, we have such an undersupply, especially of N95 masks, which were predominantly manufactured in China. So since the outbreak was there, China’s internal domestic use consumed most of the production—almost all of the production—of N95. So it was logical for public authorities in the U.S. to say to people: Don’t hoard masks for your individual home use when they’re so scarce we don’t have enough for health care personnel. I think that’s probably the narrative that you heard so much.

But China is now in a position they’re starting to export N95 masks. Other countries are producing them. We’ve seen 3M in Minnesota opening up big production lines for N95. I hope we have sufficient masks that we can use them for what they’re for. The studies that I’ve read show that wearing an N95 mask affords you a five times greater protection against the COVID-19 virus. But whatever the actual number really is, let’s hope there’s sufficient quantities that we can use them based on science, not on scarcity.

Next question, please.

OPERATOR: Thank you. Our next question will come from Joan Kaufman with the Schwarzman Scholars Program.

KAUFMAN: Thank you very much for a very informative talk. I wanted to ask you the question about seasonality and also just to push a little on the underlying immunity after illness of infection, and what would happen—you know, what happens when the coronavirus becomes endemic, you know, from a public health perspective next year, in terms of the severity of the epidemic? And just to say, I’m a proud former employee of IAVI. So I support everything you said about IAVI. (Laughs.)

BRILLIANT: (Laughs.) Good. Thank you. Mark has been thinking a lot about this issue.


SMOLINSKI: So our goal, thank you for your question, is to not let this become an endemic disease. I mean, if we look at our lessons, you know, from West Nile—and this is, you know, the value of thinking about what Larry called the one health approach, you know, the human and animal connection. You know, when that disease first appeared in the United States in 1999, it only took three years before that became an endemic disease throughout the entire United States that we now deal with as our list of diseases. SARS did not become that in 2003. This is a coronavirus. This is why containment is so critical, because the idea is if we don’t contain this then we may allow this to take a foothold and become an endemic disease. We certainly hope not. So that’s why it’s really important to not be complacent, do everything we can, because that’s the situation we have one chance to avoid. And so we’re doing everything we can to do that.

The seasonality question, most people don’t realize that while we have a seasonality of flu, we have very little science to understand why we have seasonality. There’s lots of theories. Because we spend more time indoors in the winter, we’re closer together, the windows are closed, they—you know, we’re breathing that air. I mean, that’s logical. It makes sense. But we also know that flu is around the world in different climates and, you know, at the most recent international influenza meeting, called Options X, it was shared that 75 percent of the globe have no flu surveillance whatsoever.

So the seasonality, even understanding something as simple as flu, is not really well understood. And I’m not sure why this became such a—you know, a meme or, you know, an understanding and hopeful, you know, nature of this one just going away with the warm weather. I have nothing to support that in science to think that we should be thinking that will just happen. If this is some feature of the virus that we’re going to discover, that would be amazing, and we would welcome it. Over.

FASKIANOS: Next question.

OPERATOR: Thank you. Our next question comes from James Winship with Diplomatic Connections magazine.

WINSHIP: Yes. Thank you for this session. I want to go back to the political for a moment. My question is really sparked by something Mark said early on about the need for speed. And that need for speed is constantly countered, as we’ve heard, by the reluctance of political structures to acknowledge the nature of the problem. And that seems to be a recurring problem, and a problem from which we never learn. Do you have any insights about how we might encourage better government learning for the next time around?

BRILLIANT: Mark, you’ve been namechecked.

SMOLINSKI: Yeah, that’s OK. I’ll be happy to take this one. I was sharing with Larry the other day, I mean, I’ve been involved in many epidemics. You know, even as a resident I was on the team that investigated the hantavirus when that was discovered in the United States in 1993. And that has a 75 percent mortality among twenty- to thirty-year-olds, so you can imagine the chaos that that was causing during those days. And we saw some politics even enter in outbreaks back then. We’ve certainly seen that happen in other ones.

This one, to me, is the first time I feel that politics are out-trumping the public health. And I don’t mean that in the namesake, but, you know, in some ways I think the hardest moment for me—and there’s been many, including, you know, the first lawsuit to prevent a federal building being used by a quarantine. That is not exactly the kind of cooperation we need across the globe. But honestly, when the president did not want a cruise ship to come into port because our numbers would double, that to me was the defining moment of politics outplaying public health in a way that as a public health professional I never thought we would see. Over.

O’TOOLE: May I offer another answer?

BRILLIANT: Please, please.

O’TOOLE: We will always have politics. But if I had a magic wand and a wish, I would create interoperable electronic health records across the country, so that we could see what is happening—or, CDC, at least, could see what is happening at any given time. Our health-care system is at least as much of a barrier to coherent public health surveillance as politics is right now. And it continues to be a problem as we try to tote up daily what’s going on all across these three thousand public health systems and five thousand hospitals. We need to use modern technology to get us the information we need to manage large-scale disasters, including epidemics. We haven’t done that yet.

SMOLINSKI: And I would just add to that, that is the reason we need more community-based tools that supersede the individual mosaic health-care system and even public health system we have, and let the public volunteer and help us get that information, because it’s possible and we know from our history, with the several tools we’ve done around the world, including the ones with Flu Near You, the public is not only reliable, they’re consistent, and the signals match our systematic government systems and others. So this is one way we could be doing it now, you know, and not have to think about systems that are not even built to do what exactly, Tara, I agree, needs to happen long term. Over.

BRILLIANT: Next question.

OPERATOR: Thank you. Our next question comes from Valentina Barbacci with BioSure.

BARBACCI: Yes. Thank you. I wanted to ask about the digital nature here is that, you know, certain countries are already weaponizing the situation for their advantage. And wanted to talk about the technology that you just mentioned to leverage the data and information, but also how we can leverage that to counteract the disinformation that’s happening, and how countries are weaponizing that against us.

BRILLIANT: Excuse me. Are you asking about weaponizing the information of the prevalence of the disease, or weaponizing the actual virus?

BARBACCI: Weaponizing the information about how it’s contracted, how it’s spread, the prevalence about it and prevalence of it, and therefore spreading disinformation that could hurt our economy and other industries.

BRILLIANT: You mean, like China saying it came in the U.S., and the U.S. calling it the Chinese virus?

BARBACCI: Yes. I’ll say China and Russia weaponizing it. I can’t exactly say how I know this, but I know this for a fact from people working in the administration, so—

BRILLIANT: Tara, do you want to take that?

O’TOOLE: I’m not sure I understand the question.

BARBACCI: Sure. Let me try and clarify. So Russia and China are known to be weaponizing this—the spread of the virus and hurting foreign economies, so that they have an advantage. Obviously, this having started in China, they’re two months ahead of us. And they’ve learned some things that they have managed to contain the virus as a result. So I’m wondering if any of these people that you’re working with are, A, aware of this and, B, how they might be leveraging the information and knowledge we’ve gained in the U.S. to counteract the disinformation that’s coming from Russia and China, and hurting our economy therefore.

O’TOOLE: Well, I’m still not sure I understand your question precisely, but I would say that if you want to fight an epidemic—

BRILLIANT: You could—

O’TOOLE: —if you want to fight an epidemic, one of the key aspects of the battle is to be very open and transparent about all data, and to try and quench and avoid supporting, you know, so-called fake news, misinformation, and, you know, panic-inducing narratives and stories. But I don’t have any information about what I think you’re talking about, that—

BRILLIANT: Let me just comment and move it on to probably the last question. If you take a look at what South Korea’s doing, I think it comes as close to radical transparency as we’ve seen before, where the South Korean government is sending out text messages to every individual in the country saying: There is a corona case near you. Here’s what you can do. Please tell us how you’re doing. Publishing the daily counts, publishing the mistakes that are being made, that’s the best way to deal with a pandemic—radical transparency, the opposite of weaponizing information.

I think we probably have time for only one more question, is that right?

FASKIANOS: One more we’ll take, thank you.

OPERATOR: All right. Our last question will come from Rachel Gerrol with Nexus Global Summit.

GERROL: Can you hear me? OK.

FASKIANOS: Yes, go ahead.

GERROL: Sorry. Sorry. I can’t tell if I can be heard.

The question is that without adequate testing, therapeutics, and vaccines, what would you advise the U.S. government to do at the federal, state, and local level? And is the government legally capable of containing the spread? Can we should—can we or should we do what China has done? What would you advise?

BRILLIANT: I think I’ll leave the last answer then up to Tara. This is in her ballpark.

O’TOOLE: We should not do what China has done. This is the United States of America, and we do not pen people into cities and forbid them to travel. And it usually won’t work. History has shown that that kind of attempt at cordon sanitaire motivates people to try and do otherwise. And I don’t think the cost is worth the benefits. There’s a lot that’s going on right now in the absence of proven antivirals or vaccines that’s going to be helpful both in preventing the spread and also in treating the sick.

In terms of treating the sick, we have got to give the health-care system in America, which does not have much surge capacity, time to take care of the stream of people who are going to be coming at it. That is dependent on all of us doing what we can individually and in communities to stop transmission.

FASKIANOS: Thank you. I’m sorry to say that we must end there. Larry Brilliant, Tara O’Toole, and Mark Smolinski, thank you very much for today’s call. I am sorry to all of you. We had many, many questions in queue. Could not get to you all. But they have offered that they can answer questions if you want to send questions to [email protected]. We will try to collect answers and share them back out with you.

As you probably saw from our notes from CFR President Richard Haass, we have suspended in-person programming at the Council at least through April 3. We will be reevaluating. But Richard Haass is committed to offer more briefings such as this via conference call. To that end, we have two more confirmed: Thursday March 19 at 11:00 a.m. with Tom Frieden and others, and [Monday] March 23 at 1:00 p.m. with Tom Bollyky and Yanzhong Huang. You will see those invitations coming across your emails. We will be adding more calls to the schedule.

And I will also direct you to We have a number of resources there on COVID-19, as well as on other things, as well as a new online magazine called, which is offering a lot of resources in this area. So please go there for information. The audio and transcript of this call will be posted on as well, if you would like to listen to it again, read it, or share it with your colleagues.

So, again, Larry Brilliant, Tara O’Toole, and Mark Smolinski, thank you very much. And we hope that everybody stays safe.


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