Learning From Past Pandemics

Thursday, June 11, 2020
China Daily CDIC

President, Anthropos Initiative

Executive Vice President and Chief Patient Officer, Merck & Co., Inc.

William H. Welch Professor and Chair, Department of the History of Medicine and Director, Center for Medical Humanities and Social Medicine, Johns Hopkins University School of Medicine


Correspondent, New York Times

FINK: Welcome to today’s Council on Foreign Relations conference—virtual meeting with Laurie Garrett, Julie Gerberding, and Jeremy Greene on “Learning From Past Pandemics.” I’m Sheri Fink. I’m a correspondent for the New York Times, and I’ll be presiding over today’s discussion.

So we have Laurie Garrett, who’s president of the Anthropos Initiative and, of course, has written books and has focused on the topic at hand for many, many years. Julie Gerberding, who’s the executive vice president and chief patient officer of Merck & Co., Inc., who, as many know, was—is a former director of the Centers for Disease Control and Prevention, and we have Jeremy Greene, who’s a professor and chair of the Department of History of Medicine and the director for the Center for Medical Humanities and Social Medicine at Johns Hopkins University School of Medicine, and who was working a virtual COVID clinic with community patients who are at home today. So everybody has really relevant expertise and I’m sure we’re going to have a great discussion.

So our subject matter today is learning from history and, certainly, there’s so much that we will be learning from this pandemic. But let’s sort of cast our minds back, and let’s start with Laurie Garrett.

Laurie, I think you have a very deep knowledge of the history of pandemics, and can you tell us a little bit about the fourteenth century?

GARRETT: Today’s news guided me to the fourteenth century because the Dow has plummeted 7 percent in the last few hours and last I looked was still falling, and it’s because we’ve just sort of—are beginning to become aware, and Wall Street world, that this epidemic is not ending, that any myth that it’s just around the corner has thoroughly collapsed. And a new poll from Washington Post shows that six out of ten Americans say that they are experiencing, quote, “severe economic impact from the COVID crisis.”

The U.S. budget deficit now tops $400 billion, which is double our 2019 deficit, and the Fed chair, Jerome Powell, yesterday warned, this is going to be a long haul, people, and that we will, certainly exceed, the hundred and ten thousand deaths we’ve so far felt, with most modelers looking at sometime in August or September hitting a death toll of two hundred thousand in the United States.

And we just saw yesterday in a single twenty-four-hour period Texas had a jump of 28 percent in their case reports, which, certainly, also affected the mood on Wall Street, given that Texas was thought to be safely reopening and it, clearly, is not.

Globally, every one of the BRICS countries is now experiencing full-blown epidemics, India, Brazil, Russia, South Africa, Mexico, and Indonesia all in real trouble with no end point in sight, no really apparent downturn of any kind.

The OECD has put out a report saying that all G-7 countries plus the EU are going to experience severe GDP downturns in the 2020 period with U.K., France, and Italy leading at a negative-14 percent GDP, the EU at 11.5 percent negative, Canada negative-9 (percent) and the United States the “best” at 8.5 percent negative GDP.

The U.N. issued a joint cross-agency report this week saying we’re looking at an unparalleled economic shock, and the World Bank is saying we’re going to have a net global shock of negative-5.2 GDP, which will lead to the deepest recession we’ve experienced as a planet since World War II, though actually some of the key World Bank advisors are pointing back further in history to come up with a parallel to how deep this economic turmoil will be. They’re pointing to 1873 which, of course, was one of the first real global economic shocks. Started in Europe with the over investment in railroads. As the banks called in the loans, a decline in exports from the United States, and that led to a total collapse of an inflated, artificially valuated—have we heard of that, by the way, people? Artificially valuated stocks situation. The biggest loan company, the Jay Cooke & Company, declared bankruptcy and instantly eighteen thousand businesses went under and unemployment hit 14 percent and stayed there for almost ten years.

So looking at all of that I asked myself, where is this all heading? I mean, the IMF is now saying that they need an additional borrowing power of $2.5 trillion to prevent extreme poverty from overtaking the developing world—in other words, complete reversal of all the investments made in development, in foreign assistance, over the last thirty, forty years; the entire Bretton Woods investment.

So I felt that when you look at the economic ramifications, the total societal upheaval, nothing—1929 doesn’t do it. The 1918 flu doesn’t do it. You have to go back to 1347 to 1351 and the Middle Ages when a third of Europe perished in, basically, three and a half years, and probably the same estimate would apply to North Africa and the Middle East. It was followed by an astonishing level of mortality across from Mongolia, beginning in 1331, and then throughout Asia with what was referred to as the Great Horror hitting India in 1346.

As the plague swept across it was preceded by the Great Famine, and the Great Famine was caused by the first great climate change event noted in Europe, which caused the Little Ice Age. Temperatures plummeted. Crops were wiped out all over Europe from southernmost level all the way up to Norway. And the Great Famine had already led to some human die off even before the plague occurred.

On top of that, there had been a great financial crisis, if that sounds familiar to people, akin to, roughly, the 2008 financial crisis in the United States, that was a direct result of overextended banks making bad loans to a whole host of feudal lords and their respective enterprises, and that had just collapsed not long before the plague began.

And then you also had a deeply divided church, which divided the entire power structure of Europe with one pope declaring himself to be so in Avignon, France, and another declaring himself to be so at the Holy See in Rome.

And so all of this was in bad shape, sorry, vulnerable state of the world before plague arrived. So once it arrives, it’s utterly devastating. No one understands what it is and, by the way, nobody called it the plague. That came centuries later. It was called the Great Mortality, and the Great Mortality obliterated 50 percent of the agrarian workforce of the European continent and, as a result, it caused a tremendous rebalancing of the entire economy, the structure of labor, and feudalism across all of Europe because suddenly you didn’t have the right as an overlord to declare that your slave serf harvest your crops for nothing, that your artisans build grand furniture for your palace for next to nothing.

All of a sudden, the skilled labor force had, largely, died out and this led to the rise of guilds, of negotiating power, of agrarian capitalism and the ability of labor forces to say, we refuse to harvest your crops unless you pay us the right amount of money. And if it hadn’t been for constant warfare across the continent and people being pressed into service to one overlord or another, there might have been a recovery fairly quickly that saw a complete upheaval of the global economy or at least the Western European economy.

But the plague lingered, and it went on and on for another two hundred and fifty, three hundred years in sporadic outbreaks, the worst of which was 1665 in London, which was the one referred to as the Black Death, and we now know that was all because of the Silk Road trade routes and the wool trade. So it was people dealing in furs and wool, which, of course, carried fleas which, of course, carried the bacterium that causes plague, Yersinia pestis.

What we can see if we want to compare it to where we are now is such a dramatic potential upheaval in everything about the global economy that I, honestly, think anybody who’s making a forecast today of what COVID’s going to look like and what our societies are going to look like when we get to the other end of this, whenever that may be, certainly, not in six months, not in twelve months. I have constantly been arguing we’ll be lucky if it’s thirty-six months.

And when we get to the other end of this, we have many of the earmarks of the fourteenth century already plaguing us—sorry to use that verb—including giant wealth gap, hugely disproportionate balance of wealth, a tremendous sense of religious tension and division, a sense of a large undervalued labor force, and no clear answers, no clear understanding, striving for innovation and some way of explaining what is happening to us with almost daily pronouncements reversed almost, you know, the next day from one “source” or another.

So with that, I’ll hand off to whoever is next.

FINK: That’s an amazing summation—thank you for that—and so well-studied, and I think it’s a good jumping-off point. I also will add I agree with you completely. Whenever anybody asks me what’s tomorrow going to be like, I say no prognosticating. I agree with you on that. I think that’s a very dangerous thing to try to do in the midst of this. But some really interesting parallels with history and very cautionary ones.

However, you mentioned innovation, and I want to switch to Julie Gerberding now. One of the things that we learned in medical school was how tied the history of medical innovation has been to extreme situations. Usually we think about wars, for example, as being these catalysts for great innovation. But are there any examples from these historical pandemics, Julie, that have led to, you know, any types of innovations? What does that kind of history tell us?

GERBERDING: Well, you know—thank you, and thank you for moderating this and for creating such an amazing assembly of wise historians, if you will. And I had to really think hard what could I, as an infectious disease doctor, really contribute to this historical conversation. But I have long been interested in the history of bioemergencies on a global basis.

Some of them are not technically pandemics but I think they fit into this conversation, and I usually think about the big five. So, for me, prior to coronavirus, for me the big five were, obviously, smallpox, plague, polio, influenza, and then AIDS. And so I’ll speak from the standpoint of those five but many of the observations could apply to some of the other important global bioemergencies as well.

And in all of these cases the characteristics were high burden, significant morbidity and mortality, rapid spread, disruption to society, and often fear and incredible stigmatization of the people who were affected. Except for AIDS, these are also old diseases that have long histories, and yet when you dig into how people coped and what happened as a consequence of them in either the area of detection or containment or treatment and, ultimately, prevention, you found not only effective innovation but some of those innovations that occurred a long time ago are still relevant and have continuously been improved and adapted for the problems that we’re facing today.

So I just thought I would illustrate a couple of these points to sort of get people started in thinking about—while necessity may be the mother of invention we wish we didn’t have so much necessity, of course—if you think about smallpox, you know, of course, everyone is familiar with the story of variolation, which goes back probably in ancient history, the inoculation of the virus into skin to try to create immunologic protection, and that was, of course, an innovation that was adopted in various cultures.

But it wasn’t really until the 1700s that it got studied, and probably the first vaccine study occurred with variolation. It was not a controlled study in its first iteration, but by the time smallpox arrived in the United States in the time of the Revolutionary War, the first comparative study of vaccination was conducted and really proved that variolation was effective and is part of the reason why our troops got inoculated to protect themselves while they were fighting the British.

You can also think about smallpox as the motivation for an incredible intervention, ring vaccination, which had the amazing success story in helping us to eradicate this infectious disease but, obviously, laid the groundwork for the strategies that were used in West Africa during Ebola. The ring vaccination clinical trial of Merck’s Ervebo vaccine was studied is one example of that, but also in Nigeria the containment of Ebola there really was successful in part because they used kind of a ring quarantine strategy for curtailing the transmission from the inoculation—the infected people who were identified there.

So we can take a look at plague as another example where incredible innovations occurred. Here, probably the biggest historical impact was on the use of serum therapy and, you know, that’s something that started back in the plague days but is still one of the things we’re looking at as we speak for COVID, taking immune serum from people who have been infected and recovered and using it to try to protect those who are recently exposed or beginning to get sick.

And the first randomized trial of serum therapy was conducted at the end of the 1800s or early 1900s in India. That really created the framework for randomized clinical trials that set the stage and the gold standard for the way we study interventions today. Fortunately, in that case, the passive immune therapy did prove to be successful and so it (sped ?) forward. And that serum therapy has, obviously, been used for many emerging infectious diseases since that point in time.

Now let me talk about the third bioemergency, polio. I’m not going to talk about the vaccine development there, which, obviously, is, again, a story people are familiar with. But the iron lung was, certainly, a dramatic innovation that was scaled and improved in the context of the tragic outbreaks of polio that occurred.

But I think what a lot of people don’t remember is that it was polio that actually led to the relevance of environmental assessment in understanding disease epidemiology. It became clear that polio was a water-borne illness, and the Yale Poliomyelitis Unit started a six-year study sampling sewage in the effluent of the East River of New York City to try to determine when the polio virus was being transmitted. This led to some understandings about fecal-oral transmission about also seasonality, et cetera, et cetera.

Influenza isn’t on our minds now because of all the analogies that have been created with coronavirus, and I would just say about influenza, again, the mother of a great deal of innovation, but probably the most relevant today were the innovations that occurred around social distancing and how we are really learning from that 1918 pandemic, and making earlier decisions about closing schools and shutting down crowds and managing outbreak hotspots really based on things that people implemented in 1918 with very little data. But, fortunately, a few communities were able to manage that data, examine those data, and preserve them in a format where we can continue to learn from them to this very day.

And I’ll just end with a mention of HIV/AIDS because the story of antiviral treatment for HIV/AIDS is a little bit of a predictor of where I think we are with coronavirus. It took us a lot longer to get the drug cabinet full of medicines for HIV that we have today. But, clearly, that terrible global pandemic motivated an enormous amount of innovation.

For me, personally, I think the pre-exposure prophylaxis and the post-exposure prophylaxis are something that really became a dominant component of our intervention studies. My early career was based on post-exposure prophylaxis for HIV among occupationally-exposed health workers, and I think that innovation led to innovations in post-exposure prophylaxis for people with broken condoms or morning-after exposures sexually, and that then led to some of the early data and the scientific justification for PrEP, which is becoming one of the most important interventions that we have for HIV prevention.

So I could go on, but I just—you know, I think when we think about all the tragedy and the calamity and the sadness and grief that we experience in the context of an outbreak or a global threat of pandemic’s scope, we often forget that humans are incredibly innovative, and while we may not catch up with Mother Nature, we can still find ways to learn and experiment and innovate, even under these very, very trying times.

FINK: Thank you for that, and I’ve seen that over and over, too, reporting on various disasters, and it’s something that really strikes me and I feel like it’s also a part of the American character. I remember—I mean, we’re seeing it right now and we’re seeing it—I saw it in the hospitals that were getting, you know, so overwhelmed here in New York City with patients and just some of those scenarios where we were afraid that there would be, you know, these very, very stark choices made, and that sort of spirit of innovation kicked in and that was incredible to see. Certainly, many, many issues, many problems, many tragedies. But that is the positive side and maybe something positive that can come out.

And just before we go to Jeremy, there’s one pandemic that you didn’t mention, and I’m curious because I think you were the head of the CDC during the 2009 H1N1 pandemic. Is that right? Were you still—

GERBERDING: Actually, I had just left the CDC when that pandemic started. But I did spend at least three or four years of my tenure preparing for that pandemic. We were very deeply involved in full-scale functional exercising, building up vaccine capacity, et cetera, anticipating, partly motivated by the avian influenza that was popping up now and then with a 50 percent mortality rate.

So we were feeling the urgency of moving forward in terms of influenza pandemic preparedness. It was my relief that when we finally did see the emergence of the H1N1 in 2009 that it was regular flu and not avian influenza because, you know, obviously, we had a hard enough time managing a relatively mild pandemic of H1N1.

I can’t even imagine what the situation would be if we were—had to deal with an avian influenza with that kind of mortality rate. And I would just say the same thing about where we are with coronavirus today. This is devastating, and I’m sure we’ll say more about it during this segment.

But I lived through SARS and a 10 percent mortality rate from that coronavirus. When I saw this virus emerge in China I was frightened about what this would really mean. And while it’s nothing to be grateful for, I do think we’re fortunate that the mortality rate is not as bad as it could be with the other emerged coronaviruses that we’ve seen in the last decade.

FINK: Are you seeing any big differences between how the CDC functioned during those times, the previous times that you just mentioned, and currently, and what are you willing to say about that? I’m—

GERBERDING: You know, it’s a really interesting thing. Of course, I think about it a lot. I’m very worried about how the CDC is being perceived. I’m in close enough contact with people at the state and local level to know that there is an incredible amount of good work going on, and I know that the people who are leading this effort are the same scientists that I worked with very successfully during SARS and a number of other outbreaks that occurred during my tenure.

So I don’t think there’s an issue of the scientific competency or capability of the agency, and I also know that things look very different from the outside than they do when you’re in the inside. So it’s a little bit hard for me to draw any conclusions and I maintain my enormous respect for the agency, and I’m worried about the perception and I hope that we can work together to bring forward the best of the CDC that we’re all used to seeing.

FINK: Thanks for that, and let’s go to Jeremy Greene.

Jeremy, you’re a historian of science and medicine, and I’m just curious, are there any dangers with, you know, looking at the last war and applying those lessons to the current one? You know, are there some pitfalls in looking at these lessons from history? What can they tell us and what are maybe the limitations of that?

GREENE: Yeah. Thanks for that question, Sheri, and if I rolled my eyes for a second while Dr. Gerberding was calling it wasn’t at anything she was saying. It was that my neighbor chose this moment here in leafy green Baltimore behind me to turn on I think is a chainsaw and start hacking away at something. So if that happens at any moment, you know, hopefully my—(inaudible)—will come through.

FINK: Nothing to do with the politics, CDC, nothing—(laughter).

GREENE: So I think that your question is a very important one, right. What are the limitations of history for the present? Certainly, as the director of a department of history of medicine I’m going to be a booster for the field, and this is a moment in which to the relevant historians in medicine it’s just so blindingly obvious that everyone wants to know what did we learn from 1918 and 1919 and what did we learn from H1N1, what did we learn from Ebola, what did we learn from the Black Death. And I think the truth is that all of these examples are—offer incredibly important insights into the present.

But historians need to be careful, right, in working with both continuity and change. So none of these—each one of these moments is a mirror or a lens into the present day but none of them is a perfect window into our current situation.

So, you know, the saying that often gets invoked, that, you know, those who fail to learn history are condemned to repeat it, is not entirely true, right. We never really repeat history. The phrase that I prefer is one which is erroneously attributed to Mark Twain, which is that history doesn’t repeat itself but it often rhymes.

And so in the comments that we’ve had already, and I was—I’m so thankful to Laurie Garrett for bringing in 1347, but, you know, we’ve also had 1918 and 1919. We’ve had 1929 evoked, 1968, and each of these years is a useful frame for reflecting on this present unprecedented moment that we’re in. But none of them captures the complete picture.

I’d like to talk about—if there’s time, I’ll touch really lightly about five different ways to think about how the history of prior epidemics can help us think about the ending of this one, because it’s much easier to look at the history of beginnings of epidemics than to look at the history of endings, and this is a project that I’ve been working on with a historian, a colleague at the University of Exeter in the U.K., Dora Varga.

And, you know, I just want to touch lightly on the problems of a biological and social ending, right, of the way we use military metaphors and the problems of thinking about a single ending, about the national and international frames for understanding how epidemics end, about the way that we focus on interventions, and I think Dr. Gerberding’s analysis very appropriately looks at how do we understand the interventions we develop in prior epidemics. And, yet, interventions are only one part of understanding the endings of epidemics.

And then, finally, to look at the relationship between epidemics and endemics, and how this actually plays out in a way that’s very important for how we think about coronavirus.

So I’ll be very quick. I don’t want to take too much time and I want to get to the questions. But, first, you know, I think that we’ve all gotten to know these curves very well in the past few months and, of course, these are the curves that are based on SIR, you know, susceptible infected resistant, you know, models of infectious disease modeling, right, used to be things that only people who studied epidemiology knew. And now all of us—like, everybody, the curves, they’re just memes of 2020.

And yet, the curves—the deterministic curves of epidemic courses only tell us so much. I mean, those of us who have been refreshing the—you know, the COVID web pages, you know, every morning see that the line actually looks much more jagged, right, and I think part of the problem here is that many of the predictions for how and when this epidemic would end, and we’ve already been through several different models that have been promised to Americans that, of course, haven’t panned out, which is really where Laurie Garrett is beginning by invoking Jerome Powell’s speech today, this resetting of the benchmark—that these oftentimes make an error thinking of the epidemic as a purely biological phenomenon.

I think all of the panelists here today would acknowledge that epidemics are not purely biological phenomena. They are a complex interaction of biological and social forces. But there’s a problem here in that the way that we think of the timing of epidemic, both when it begins and when it ends, that the biological basis of the—you know, of the coronavirus epidemic as it played out in North America, clearly, was happening well before any of us recognized that it was happening.

So the social responses to the epidemic or whether it’s just fear individually based or in the media or whether it is actually these increasingly disruptive, you know, instruments that have taken apart our social life, brought us out of contact with each other, shuttered our businesses and our schools, that these social responses all happened on a time course that was actually slower than when the biological-based epidemic was taking place.

And I think, you know, if we look at Texas today we see the dangers on the other end, that that dyssynchrony between relaxing the social responses to the epidemic before the biological basis of the epidemic has actually really been mitigated also holds dangers.

So I don’t mean to suggest that these are two fully separable things, right. As a historian of medicine and a physician, I see disease as always irreducibly biological and social. And yet, somehow in our treatment of them, if we allow these two—if we think of one piece and not the other and if we allow them to get out of step, we can actually find ourselves in really, you know, substantial problems.

Secondly, to talk a bit about military metaphors, I was thinking about this today for the Council of Foreign Relations, that so much of the way that we’ve evoked a response to coronavirus has to do with a defense, with containment, with the war on coronavirus, a war on disease. And this is not unusual. I think historians find this in pretty much every major epidemic or pandemic that you can look back on.

But one of the problems I want to bring up about this analogy is that we tend to then use this to suggest, well, we know that wars end on a certain day and we can have a timing of a war. The war is a discrete moment, and an epidemic is a discrete moment as well. And I think in some cases, like, if you look at the 1918-1919 influenza pandemic, it can seem pretty clear that this is something that happened over a relatively short period of time and had a massive mortality and occurred nearly synchronistically with World War I, and so the analogy between epidemic and war kind of seems to hold up.

But I think if you examine this a little more closely, even the timings of the ends of wars, it’s rarely just a single day, like the Battle of Waterloo or the armistice that ends World War I, right. So if we take World War II, we know that three months separate V-E Day and V-J Day, right, so when does World War II actually end.

But if you want to get down to when the last combatant in World War II lays arms, right, that takes us to Teruo Nakamura in 1974, who was the last Japanese combatant to lay down arms after he came out of thirty years in hiding in a remote island in Indonesia.

And I don’t want to push this point too far, right, but, you know, similarly, the end of World War II, you know, we have sixty million people displaced in Europe alone. The last displaced persons camp doesn’t close until 1959. The food rationing in the United Kingdom after World War II doesn’t really stop until 1954.

So the moment in which a war ends and normal life resumes is not a clean line, and I want to hold this as a historian firmly in our minds when we think about how we think about the ending of coronavirus because any evocation of a single ending and a quick moment in which we resume normality is really not an adequate place to start with. And I think this resonates with Laurie Garrett’s comment about how we are then systematically underrating the degree to which our current situation is disruptive on a level that we haven’t fully accounted for.

My dog now wants to come in on the screen and work with me. I might let him in in a second. But I’ll say two more things. One is this challenge of national and international division. So when is a pandemic over? Well, technically, a pandemic is over when the World Health Organization declares that the PHEIC has ended, and the PHEIC, right—the Public Health Event of International Concern—is something that was invented after SARS in 2002, 2003. And, yet, if we look at even recent PHEICs like the recent Ebola epidemic, just suggesting that the scale of an epidemic is such that individual countries should be able to handle it within their own national systems doesn’t mean that the epidemic is over.

And so there’s a very complicated tug between the international basis of a pandemic and then devolving to a moment where perhaps the world says a pandemic isn’t occurring anymore and, yet, this disease is still ravaging people in different places.

And I point this out because if we think about how heterogeneous different countries experience the pandemic and responses to lockdown have been to date, what does that portend for the moments when we try to open back up and reestablish the degree of internationalism that has been lost?

And I think that the pathway towards reestablishing international travel is going to be deeply heterogeneous, and the current crisis that the WHO has been set into in part through the U.S.’s withdrawal is only going to make that part more challenging.

Now, the last thing I wanted to say, very briefly, is about one of the multiple endings for epidemics is that the epidemic doesn’t go away, and so I really appreciate Julie Gerberding bringing up HIV/AIDS because it’s so important for us to go back to that moment in the early 1980s when AIDS wasn’t even HIV yet and then the HIV, you know, virus was discovered and established as this new emerging disease, a new causative agent. And it was clearly understood in epidemic terms, and it is hard to understand how much of the world continues to see HIV/AIDS as an epidemic at this point rather than as an endemic, right.

So we know—in a way, as HIV and AIDS has become manageable through an intervention through antiretroviral treatment, is has become rendered more like a chronic disease. You know, the analogy is often made with diabetes. Diabetes—before insulin, type 1 diabetes was an invariably fatal disease, and insulin didn’t cure diabetes but it rendered it into a chronic condition that could be manageable if you had access to appropriate medical care and pharmaceutical supplies.

And so part of the challenge here is that, you know, AIDS—you know, AIDS still infects 1.7 million people a year and claimed seven hundred and seventy thousand lives in the year 2018 alone. So but we don’t think about this in the same terms. We have no vaccine for AIDS, and one possible future for coronavirus is to look a lot like HIV/AIDS, in which case the question is not do we come to accept it, is it just part of the new normal, but is there a way in which epidemicity fades into endemicity.

And the last thing I’ll say here is, well, what does that really mean. Because a similar thing would have happened, for example, to a disease like tuberculosis. Tuberculosis was once a problem of Europe and North America and it became perceived, increasingly, as a problem that was in the past in such places but in the present in countries in the Global South.

Even though if you look at the city of New York City and there’s some excellent historical analyses showing that TB rates in New York City changed dramatically in certain parts of New York but not in other parts of New York over the latter half of the twentieth century. And what this really has to do with is understanding class, race, ethnicity, and immigration, and who was visible as a public health target. Right now, coronaviruses seem to affect us all. In ten to fifteen to twenty years will it still be felt the same way, even if it still persists?

FINK: Very relevant question. All of you are so erudite that I’m sure that our members are really appreciating all of these remarks and how much you prepared to speak about this history and the links. And because all of you are so erudite, we’re already—time to go to our questions.

So at this time, I would like to invite members to join our conversation with their questions. The operator will remind you how to join the question queue.

Go ahead, operator.

OPERATOR: (Gives queuing instructions.)

We will take the first question from Valentina Barbacci.

Q: Yes. Good evening. Sorry. I said good evening because I’m in London at the moment. Thank you all so much for your points. It’s really fascinating and really helpful. I’m currently working on COVID testing and this is really helpful.

My question is not intentionally provocative but one of genuine concern, and it’s what lessons can we learn from the impact on prior pandemics that corruption in politics have in terms of getting in the way of the most effective forms of testing and treatments getting to market and actually, therefore, impeding our ability to handle these pandemics quickly and effectively.

I ask this because I have, unfortunately, seen in both working first with HIV testing and now more recently COVID testing what seems like a greater desire sometimes to find the quickest fix than the best one. With HIV, for example, we saw this with self-testing, which was first downplayed and even rejected for a long time, and for some valid reasons, obviously, but in the last five to ten years has proven to be incredibly effective and even crucial in some areas in getting to people, especially those who are heavily discriminated against and/or cannot get professional testing in a professional facility.

With COVID, we’ve seen it more recently in light of both the U.K. and some European countries disregarding the effectiveness of—or potential effectiveness of self-testing, particularly when it’s upwards of 98 percent accurate in some cases, whereas other professional tests have been somewhere between 75 (percent) and 85 percent accurate with their results. Obviously, it depends from test to test.

So I’d just be really grateful for your thoughts on this matter because, obviously, we all want to resolve this as quickly as possible. Thank you.

GREENE: (Inaudible)—a very quick response, which is just to say that, you know, John Barry, who is one of the foremost chroniclers of the 1918-1919 influenza epidemic, you know, has consistently been writing op-eds in the present epidemic saying the single most important lesson to draw from that pandemic was to tell the truth, and that it was—when there was good governance and when there was open transparency about the nature of the disease, the threats, what was known and what was unknown and what could be done one saw the best results, and in situations in which local or state or national governments including, you know, Woodrow Wilson’s presidency, sought to obscure, obfuscate, or prevent the transmission of knowledge that they thought might be damaging that is when actually the worst tragedies of the epidemic, at least on the American soil, took place.

OPERATOR: Excellent. Our next question will come from Patricia Rosenfield.

Q: Thank you very much. I am delighted by this wonderful panel. I work at the Rockefeller Archive Center, where we maintain the records of the history of American philanthropy, for the most part, which includes a large measure of public health, and it’s important to draw those lessons, too.

But I would love to hear your perspectives on the historical lessons and including how to draw the lessons from COVID to talk about preventing or protecting for the next epidemic and the next pandemic.

I just think it’s important to pull—to start to pull together, even at this early stage, the perspective on COVID and what lessons can be learned, particularly the interdisciplinary, the intersection of social and behavioral and the political lessons, including the development of early warning systems, epidemiological surveillance around the world, all—how would you begin to frame that? And how would you ensure that historians play a role on those—the developing of not only those lessons but the policies, moving forward?

GERBERDING: So I can say something, just wearing my hat as the co-chair of the CSIS Commission on Global Health Security, because in November, before COVID emerged, we had made some very specific recommendations about furthering global health security.

One of our top recommendations is the same recommendation that came from the Blue Ribbon Panel, which is that we need consistent long-term leadership of the effort. We can’t go from crisis to complacency. Funding needs to follow that. We can’t go from reactive boluses of emergency supplementals and then crash down to some kind of base case level of support for ongoing improvements in preparedness.

So I’m pleased to tell you that not just the CSIS Commission but several other reputable entities and think tanks, so to speak, are already heavily engaged in trying to answer your question, not just looking at the COVID situation but COVID in the context of the broader biologic emergencies and global engagement.

I don’t think we’re going to have all the answers, but we have a real moment of opportunity here. People are listening and they’re leaning into the fall, worrying about the congruence of influenza and perhaps recrudescence of COVID.

But, more importantly, I think the lesson in this teachable moment has finally sunk in that we are not prepared for the kind of biothreats that are likely to continue to emerge in the world order that we are experiencing now. So more to come on that. But I can at least say that thank you for the question because I think it’s absolutely critical that we do it better this time than we’ve done all the other times. (Laughter.) And probably Laurie’s done the same thing. We’ve read so many after action reviews of all past outbreaks and emerging threats that it’s hard not to be cynical about the impact.

But I think this time the energy is there and, hopefully, with a surround sound of influential people insisting on it we may be able to move the ball down the field, so to speak.

FINK: Julie, can I just jump in and ask you to expand on that, or the others, perhaps? But is it that we didn’t know? Are there things that we’re finding we weren’t prepared because we—something’s taken us completely by surprise? Or is it more that sort of knowledge to implementation gap or knowledge of what needs to be done versus political will or economic realities getting in the way? Do you understand the question? Like—

GERBERDING: I mean, I understand your question. I’m interested in Laurie’s point of view on this. But I will say that the title of our first report was Crisis to Complacency. I mean, it’s, basically, we fight the last war. So something happens and we’re all learning from it and we come up with the answers to how we could avoid that one again, manage it better the next time.

But we’re not really in the mindset that health security is national security is global security and that we have to have a very different doctrine and a very different level of investment and I think a tolerance for not making sure that our investments in this space are efficient, meaning that we use them and we should never have anything go to waste but, rather, our investments are sufficient to assure that when the next thing happens we have a margin of error or, you know, a defense system that we can call on to help protect us.

So I think there’s a philosophic reorientation that’s necessary. There’s a leadership reorientation. At least in the United States I think there’s a structural reorientation. Our structure is discombobulated. I think we’ve seen plenty of evidence of that in what we’re dealing with right now, and there’s a financial budgetary, you know, improvement that’s necessary.

Part of that also is that we fund biopreparedness on the annual budget basis, and things that we invest in today don’t score well in the CBO process and so, therefore, it’s very difficult. We need to get that budget out of the discretionary funding and away from the budget cap so that we can do it right. And, hopefully, these trillions of dollars that we’ve spent to improve our survivability for COVID-19 will result in different thinking about how we invest.

FINK: What about—Jeremy or Laurie, do either of you have a thought on that? Was it a failure of imagination or was it a failure of implementation of what we knew?

GARRETT: Well, I have very strong views on this. I think I disagree with Julie a little bit. I agree with her completely about this awful cycle thing we get into where there’s suddenly concern, investment, policy discussion, a flurry of think-tank reports and academic studies right after an epidemic, and then it all just dies out and the funding goes away and the sense of urgency goes away, and then we’re not ready, and when something arrives we’re surprised yet again.

But in this particular case, I really think we had some unprecedented obstacles that continue to unfold. I have never been in an epidemic before—and I’ve been in, like, more than thirty of them—I’ve never been in an epidemic before where the history is being rewritten in real time by very powerful political forces and where the dominant political force at one moment, China, had clear obfuscation, clear lying, clear cover up, but, fortunately, for a far shorter time period than it did in 2003 with SARS. And now we have a United States response that seeks to blame China in order to offset its own failures in its response.

We’re in a situation I haven’t really encountered before where writing the true history, understanding how did this arise, what were the key contributors—your question, were we blindsided or should we have seen it coming, all this sort of thing—is now completely connected to a political fight between the two superpowers, threatening almost a Cold War like struggle.

And with now the United States saying they’re pulling out of WHO and Brazil saying, yeah, we’re going out as well, and China, meanwhile, saying—just released their white paper this week rewriting the entire history so that it says Xi Jinping saved the world. Literally says Xi Jinping saved the world.

In the midst of all that, it’s very hard to do good science. It’s very hard to do good public health. It’s very hard to come out of that kind of tension and say uh, you know, it’s pangolins, and there’s an underground pangolin trade of wildlife, and some pangolin dealer went here, and then da-da. We don’t know. And so what we’re left with is, on the scientific side, a lot of conversation derived, basically, from examining genomic sequences of viruses and trying to trace back history and rewrite the history that way.

But that’s woefully inadequate, and I’m afraid that we actually could get the politics of this so ugly and so deeply mired in larger fights between superpowers that we never will be able to actually get to the bottom of where this all came from.

FINK: Well, Jeremy, isn’t the history of epidemics full of political upheaval and obfuscation? I mean, is this, you know, an unknown phenomenon, or do we see this in the past?

GREENE: Well, I don’t know. I think—I mean, I think that we’ve, certainly, seen forms of obfuscation in the past and that was part of what I was alluding to before in terms of, you know, what happened with the actions both locally in, say, Philadelphia or on the national scale in terms of Wilson’s cabinet, of moments in which the 1918-19 epidemic could have taken a very different turn in North America had there been more transparency and less obfuscation at that point.

Although I approach this question, and I want to thank Patricia again—particularly, again, for representing the Rockefeller Archive Center, which is a wonderful institution in the world and I’ve benefitted directly from being able to do research there. And, of course, Rockefeller had such a profound—the Rockefeller Foundation—such a profound impact on the basis of American investments in international health over the course of the twentieth century.

But this question of what will it be like next time, you know, I answer this a bit more from a clinical perspective. So sitting in my clinic, you know, week by week, watching February go and then March go by, and realizing that the guidance that we had for managing who should get these tests was based so clearly on knowledge that was already two weeks old, right, and also with the knowledge—and we all know, you know, the coronavirus, you know, is an element of the presentation of the common cold, right. Like, the common cold is many different things. It can be coronavirus.

We know that from the example of polio that you can have an epidemic disease which is really devastating in a small portion of the population but leaves a large percentage of people only minimally affected, right.

So we were blindsided, in a way, by the idea that the fever scan itself or having traveled just to China was not enough to actually stop this. But on some level, that is a form of, you know, looking back, why did we think that was the case? So I think, looking forward, I would hope that further pandemic responses won’t make the assumption that an epidemic needs to have this bright signal around it in which every case is clearly that epidemic case. Although, looking backward, I think there were already historical antecedents to suggest that.

And so I think that—I think that, you know, Dr. Gerberding is right when she says that, you know, we always fight the last war. I think the challenge as a historian is that our epidemic memory tends to only go back to, say, the early twenty-first century. It’s hard for us to get back even into the middle of the twentieth century. Had we done so, we may have actually faced coronavirus differently from the get-go.

FINK: Thank you. And speaking of memory, I meant to say that whoever thanked me for picking these wonderful panelists should be thanking the meetings department at CFR because I’m just lucky to be here moderating.

So with that, let’s go, operator, to our next member question.

OPERATOR: Our next question will be from Hillary Carter.


Ms. Carter, if you can unmute your mic now.


I believe we’re having some technical difficulties. We’re going to go to the next person, which is Kilaparti Ramakrishna.

Q: Thank you very much. This is such a wonderful panel. We could listen to it for hours at end.

I have one question. Looking at the history and, more particularly, at COVID, and this is something that each of the panelists had alluded to, what is your sense that people in the United States—I’m talking mostly about people in the government—and, more broadly, in the world have more respect and reliance on science and facts, moving forward? Thank you.

GARRETT: Well, now there’s a loaded question for you but I love it. (Laughter.) We are in an anti-facts counter-facts world. A new survey shows 27 percent of polled Americans would refuse to take a vaccine for COVID and another 23 percent in that poll said—this is a Pew poll—said, mmm, I’d wait to see what happened to other people before I would agree to take a vaccine.

We have a counter-factual world and it is a counter-factual world fueled by the internet and by active forces actively trying to put out disinformation, undermining the credibility of science for various reasons and with various targets in mind.

I think the scientific community has been slow to appreciate how deep and dark it is and figure out ways to counter it. Similarly, the public health community you have a sense that WHO, with its limited resources and, certainly, our CDC, which is all but silent, are way behind the curve.

The counter forces, the disinformation efforts, are out in front. Just today, or last night, I guess, the European Commission for the EU put out a direct and formal intergovernmental attack against China, saying China is flooding Europe with disinformation about COVID and is, clearly, bent on disrupting the cycle of credibility, scientific and public health leadership, across the European continent.

So I think we’re in a unique world right now on this, and for everybody involved in science and health communication it’s just—my colleague from Science magazine, Jon Cohen, likens this to getting up every morning and sticking a fire hose at full volume down your throat and the water just pours over you all day long. There is—I’m sure Sheri sees this, too—there is this sense that you’re just overwhelmed with information about COVID and a good percentage of it some days, seemingly, the majority of it is incorrect. It’s just wrong.

FINK: We have one final question so let’s hear that, really quickly, and then if any of the other two panelists want to address both of those we can end that way.


OPERATOR: Our final question just lowered his hand, so actually, we are all set.

FINK: OK. Does Jeremy or Julie want to address the last one before we end or does anybody have any parting remarks just to sum things up?

GREENE: Sure, and I think this question of how we relate science and media and broad trust is a crucial one, moving forward. I wouldn’t claim to know the way that it’s going to go. But I do think that one of the things we see, though, is a broad faith among many that this epidemic will end when we have the vaccine for it, and then when that possibility is, perhaps, questioned or with an asterisk leads to dramatic loss of trust and faith.

And so it’s this balancing problem, which I think Julie referred to earlier on, in which there needs to be some form of hope; there is some way of needing to project a future in which we can get through this. And many people want to invest science as that form of hope, specifically, twenty-first century science. As a historian, though, I want to balance that against the real problem of even the twentieth-century science that we don’t have access to.

So we learned at critical points of the pandemic during the surge in New York that actually 50 percent of people who even made it to ICU beds couldn’t be maintained on basic mid- twentieth-century medications, right, like Albuterol, like sedatives, analgesics, because they had gone into situations of shortage.

So I think part of the problem with science is trying to think of science as not just the image of the innovation of the future but also the maintaining of what we’ve actually developed over the twentieth century, that in the future of twenty-first-century cures that twentieth-century cures need to be maintained as well, and I think coronavirus taught us that in a very powerful way.

FINK: Julie, would you like the last word?

GERBERDING: Well, I’d love to say something to round out this view on science but I’m as worried about it as anyone, and I’m specifically worried about over promising on science. Now, right now we have five hundred products in evolution for this pandemic and I hope and pray that some of them cross the finish line fast and I hope they’re effective and I, certainly, hope they’re safe. And I’m an optimist that we will have products cross the finish line but I’m worried about the over promising on when and how good and how realistic we’re bringing the reality to the people who have to make decisions about using them first.

So it’s one thing to have a product. It’s another thing to have trust in that product, and that is really where we all need to come together as scientists, as pharmaceutical companies, as the people who are making the policy decisions. We have to lay all the cards on the table, and that’s going to be a really tough order for some of us.

So I look forward to maybe having a conversation like this again on that topic because I think that’s really what’s going to end the pandemic is trust in the advice, whether it’s vaccine treatment, immunotherapy, or social distancing. If we don’t have trust in the advice that people are delivering then we will really be in for a very long ride.

FINK: Thank you for that, a powerful statement from somebody who works for—one of the leaders of a company that’s trying to produce some of those much hoped for solutions.

Thank you so much to everybody who joined today’s virtual meeting and especially, of course, to our extraordinary panelists. Please note that the audio and video of today’s meeting will be posted on the CFR website. 

Thank you, everybody.

GERBERDING: Thank you.

GREENE: Thank you so much

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