How to Prevent the Next Pandemic (2022) is a blueprint for the international pandemic prevention plan the world sorely needs. Learning from the mistakes of the Covid 19 pandemic, Gates lays down a series of steps governments need to take if we’re to protect ourselves and ensure another global health catastrophe of this scale never happens again.
Science, Politics, Medicine, Virology, Forensic Medicine, Viral Diseases,
Introduction: Learn what it takes to prepare for a crisis.
If there was one person who wasn’t surprised by the pandemic that engulfed the world in the early months of 2020, it was Bill Gates. In fact, he’s been trying to warn governments to take action against a coming pandemic for years.
Back in 2015, Gates gave a now-famous TED talk where he warned the world of how woefully unprepared we were to deal with a deadly new virus. He pushed for a solution and explained exactly what we could be doing to prepare.
Unfortunately, hardly anyone took any notice. None of his suggestions were implemented. Gates was shocked by how little people seemed to care about this issue.
These days, of course, things have changed – Gates’s TED talk has now been viewed over 43 million times. But with 95 percent of those views coming after the Covid pandemic began, it was too little, too late.
Now that we have the benefit of hindsight, we’re all painfully aware of just how real the threat of a global pandemic actually is. But especially now, we shouldn’t become complacent. Already, the sense of urgency we felt during the height of the pandemic is starting to fade as the world turns its attention to other problems. It’s vital that we take action now and put a plan in place to deal with future pandemics before the last one becomes old news.
This summary to Bill Gates’s How to Prevent the Next Pandemic outlines exactly such a plan. Drawing on the knowledge of the world’s foremost experts in the field of epidemiology, as well as on Gates’s own experience in disease prevention through his work at the Gates Foundation, it highlights exactly where the gaps in our system are – and how we can address them to ensure another Covid-like catastrophe never happens again.
The countries that handled the Covid pandemic best were the ones that had plans for testing and tracing already in place.
Now that we’re (hopefully) at the tail end of the Covid pandemic, we have one very good reason to be optimistic that we’ll handle things better next time: experience.
Countries who had recently dealt with other outbreaks tended to perform better during this pandemic. In 2003, countries like China, Taiwan, Singapore, and Vietnam were hit hard by the SARS outbreak. When Covid struck, they all responded quickly and effectively – and were able to successfully limit new cases for over a year. Clearly, these countries did something right.
So, if we want to protect ourselves from future pandemics, a good bet is to look at – and copy – what these countries have learned through experience.
As it turns out, there are three things all these countries excelled at right from the get-go. First, they were all able to quickly ramp up testing for a large proportion of their population. Second, they all had systems in place to trace people who had potentially come into contact with the disease. And third, they isolated everyone who tested positive or had been exposed to the virus.
By contrast, the US floundered in all three of these respects simply because of its inability to fully utilize testing. Early on, this was because tests were in short supply and the country struggled to acquire the kits it needed. But even by the time the Omicron variant appeared, many people were still unable to get tested because the testing centers were so flooded.
What’s more, the US never created a centralized way to prioritize testing and share the results. This was a missed opportunity. Any software company worth its salt could have whipped up a solution in a heartbeat if it had been asked. Instead, states and cities were left to their own devices, which led to a chaotic, inconsistent rollout of testing across the country.
The bottom line is that testing is something we’ll need to prepare for in advance next time. In the early days of an outbreak, if we can test a large segment of the population, isolate those who may be infected, and trace anyone coming from abroad, we’ll be well-positioned to keep cases at a manageable level. If we don’t prepare, we might have to again resort to unpopular measures like lockdowns to prevent huge casualties.
The world has not yet properly invested in the systems and tools we need to undertake large-scale testing. It’s about time we did.
The world needs an international pandemic prevention team.
If you think about it, it’s kind of odd that we don’t have a branch of emergency services dedicated to preventing pandemics.
To put it into perspective, the US employs about 311,000 full-time firefighters across 30,000 departments throughout the country. In all, local governments spend over $50 billion a year just to have firefighting crews on call in the event of a fire. That might seem like a lot of money to prepare for an event that’s relatively rare, but it’s worth it. It’d be far more costly, in terms of both money and lives, to be unprepared if a fire did break out.
Given how much effort and money governments put into preparing for fires, it’s striking how little they put into preparing for pandemics – especially because the latest pandemic was far deadlier and more damaging to economies than any fire has ever been.
If we take fires seriously, we should be even more serious about pandemics. What we need is something equivalent to a fire department, but with the mission of stamping out diseases wherever they emerge. It would have to be a global institution because, unlike fires, pandemics are capable of spreading across any ocean and terrain to every corner of the Earth within weeks.
The only institution that currently comes close to fulfilling this role is the World Health Organization, or WHO. Unfortunately, as it stands, the WHO is chronically underfunded and has almost no full-time personnel responsible for managing pandemics. That means there’s currently no institution with the size, funding, or authority necessary to serve as an international pandemic response team.
For the sake of argument, let’s imagine what this squad of virus-fighting superheroes might look like. Let’s call them GERM, or Global Epidemic Response and Mobilization. GERM would be made up of a team of specialists whose task it is to wake up every morning worrying about one thing: Are we prepared for the next deadly outbreak?
Ideally, the GERM team would have the authorization to work with governments and the World Bank to coordinate every aspect of a pandemic response. They would be responsible for identifying potential outbreaks and raising the alarm. They would serve as a hub for global health data and use it to run computer models. And they would draw on this data to advise governments on measures to take, such as closing borders or mandating mask use.
One thing the GERM team wouldn’t be responsible for is actually treating people. GERM wouldn’t replace hospitals and national health agencies, which do important work at a national level. Their job would simply be to coordinate the patchwork of national health organizations into a single, integrated global health system. Such a system would significantly improve the world’s ability to share data and coordinate activities, which would help to avoid the chaotic “every-state-for-itself” approach we saw during COVID-19.
The GERM team would play an essential role in all aspects of pandemic prevention, which we’ll explore more in the following chapters. Let’s start with the most important one: disease surveillance.
A global disease surveillance system would be our first line of defense against an outbreak.
Disease surveillance was an obscure field for most of its existence. That changed when COVID-19 thrust it into the limelight. Of course, it would have helped to have paid more attention before we were hit by a pandemic – but better late than never.
Put simply, disease surveillance is about keeping track of diseases – detecting outbreaks and monitoring how they spread through a population. The information this provides helps with everything from shaping public policy to selecting which strain of flu to vaccinate people against each year.
It’s not as easy as it may sound. The trouble is, people are always getting sick. But not every instance of a sickness leads to an outbreak. So disease surveillants have to comb through all the cases and decide which ones seem the most likely to cause problems. It’s not like looking for a needle in a haystack – it’s like looking for a really sharp needle in a pile of blunter ones.
The trick is to keep an eye out for suspicious clusters of an illness. Clusters should immediately raise a red flag because they indicate that a pathogen is contagious and has already begun to spread. To be able to spot a cluster early, though, you need good data. Things like who got sick, what their symptoms were, and where they likely picked up the pathogen are all valuable information.
Some of that data will come from clinics and hospitals as people check themselves in. But as we know from Covid, not everyone who gets sick feels bad enough to bother getting help. That’s why it’s important in the early stages of an outbreak to be proactive with testing; that way, you can get an idea of how many mild and asymptomatic cases are out there.
Aside from testing, countries are increasingly turning to more innovative methods of gathering health data, such as scanning social media for reports of illness. For example, in Vietnam, pharmacists are instructed to file a report if sales of fever and cough medication start to increase.
Another promising new approach involves searching for pathogens directly in the environment. Many pathogens can be found in human feces, for instance, which means you can check for them in the wastewater of sewage systems. Studies show that this could be an effective way of detecting diseases even before patients start showing up at the clinic.
Collecting data is only one half of the problem. To effectively carry out disease surveillance, you need to have a system for sharing and accessing that data over large regions. In Africa, a system like this already exists. It’s called the Disease Surveillance and Response System, and it enables countries across the continent to aggregate their data on certain diseases such as malaria and AIDS. This is invaluable for people who do disease surveillance because it means they can compare regions and track the spread of diseases.
We need this kind of system – but for the whole planet. This is where our fictional GERM team comes in. They would be the hub for global health data. And they’d share access to that data with everyone. It would mean an outbreak could be detected on one continent and immediately set off the alarm on all the others.
With this kind of infrastructure in place, we’d be much more likely to detect a new disease before it spread too far. In turn, we’d have a much higher chance of containing the outbreak – and more time to prepare before it got out of control.
We need to create a system that funds better tools, treatments, and vaccines.
Disease surveillance is the first defense in any pandemic prevention plan. If we have any hope of stopping a disease, we obviously first need to know that it exists. The next step would be to roll out treatments and vaccines to combat the disease as quickly as possible.
Now, if there’s one thing we got right during Covid – which surprised even the experts – it was this aspect. The fact that scientists were able to design multiple vaccines in the space of a year was unprecedented in the history of medicine. But what was even more miraculous was the sheer speed and scope with which we managed to get them into people’s arms all over the world. Vaccines really were the great success story of the whole Covid pandemic.
Even so, we can do better – and we’ll need to if we want to avoid large-scale lockdowns again. Ideally, vaccines would go from the lab to the public within six months of identifying a dangerous pathogen. This is achievable if we can find innovative ways to speed up the development, manufacturing, and delivery of vaccines without skimping on safety.
But we can’t expect innovation to just happen by itself. Innovation usually takes years of painstaking research, and that requires funding. The Covid vaccines, for example, were the result of decades of research into mRNA technology and other cutting-edge science.
What we need is a system for nurturing innovation in health care. Again, our friends at GERM could be the answer. The GERM team could oversee and coordinate research all over the world. They could also help funnel government funding into the most promising new ideas.
Just to give you a sense of the range of exciting new technologies already in the pipeline, let’s look at some of the things researchers are currently working on.
One area that’s rife with new ideas is vaccine delivery. Researchers are looking into the possibility of creating vaccines that don’t require needles. Instead, they might be administered using nasal sprays or even by placing a micro-needle patch on your arm – sort of like a nicotine patch. Just imagine: in the future, you could be buying vaccines over the counter and applying them yourself!
Other promising areas of research include vaccines that don’t need to be kept cold, ones that only require a single dose, and others that would protect not just against one strain of a virus, but against entire virus families. If we can get these innovations off the ground, it would revolutionize our capacity to vaccinate people, especially in poorer countries.
In the end, this chapter boils down to two main points. First, the world is lucky that we were able to produce vaccines against Covid so quickly – and that’s definitely something to celebrate. But second, we’ve only scratched the surface of what we can achieve with vaccines. Since we can’t assume we’ll be so lucky next time, we should pursue an ambitious research agenda right now to improve vaccine technology as quickly as possible.
GERM would help organise international pandemic simulations to prepare for an outbreak.
Part of the reason we were caught so off guard by Covid was that we’d grown complacent. We hadn’t experienced a truly devastating pandemic, at least not in the West, since the 1918 influenza – and that was a hundred years ago. We can’t allow time to make us so complacent again.
Fortunately, there’s an easy way to solve this problem. We can run periodic practice exercises to test our global response systems and keep them alert.
Exercises like this are already commonplace for other kinds of crises. Militaries, for example, run war games to prepare for a possible invasion. Airports run drills in the event of a plane crash or a terrorist attack. And local governments run city and state-wide exercises to prepare for natural disasters such as earthquakes and tsunamis.
One of the most famous of these is called Cascadia Rising. This is a periodic full-scale drill designed to test the readiness of the Pacific Northwest for the next mega-earthquake, which is due anytime now. When the last drill took place back in 2016, thousands of people were involved – including dozens of government agencies, private businesses, and the military.
But when it comes to pandemics, real-world practice exercises like these just don’t seem to happen. It’s true, there are a few countries that are ahead of the curve. Indonesia deserves credit for running what was probably the world’s first full-scale outbreak exercise back in 2008. Still, events like this are absent in most regions of the world.
This is another area in which our GERM team could help out. GERM could coordinate with governments, national health institutions, and military leaders to help them undertake these exercises. They could give advice, review their performance, and even provide resources for countries that need them.
Here’s what a full-scale outbreak exercise might look like. First, you’d choose the city or region to test. Then you’d sprinkle in a few fake reports of a serious illness by, say, asking volunteers to report symptoms at their nearest clinic. Once the alarm’s been raised, you would then monitor the region’s progress as it sets up systems for testing new cases, analyzing the pathogen, and reporting this data.
After the exercise is complete, GERM would review the findings, identify weak points in the system, and distill these into a list of recommendations. These might include things like how to strengthen supply chains and distribute medicines, or offering more efficient methods to conduct testing and data collection. If necessary, GERM could also put political pressure on leaders to translate these recommendations into action.
Hopefully we’ve learned from our experience with Covid, and will start treating pandemics with the same gravity we treat earthquakes and other disasters. We can’t control when a disaster will strike. But we can practice how we’ll respond to one when it happens.
Tackling global health inequality is essential for protecting everyone against pandemics.
There’s a big elephant in the room that needs to be addressed before we wrap up – and that elephant is inequality. Another lesson many of us learned the hard way during Covid is that the pandemic didn’t affect everybody equally.
Within the US, Black, Latino, and Native American people were twice as likely to die during the pandemic than white people. On an international level, the situation was just as dire. In 2020, nearly 100 million people around the world were forced into extreme poverty – the first time global poverty has gone up in decades.
And those who were most affected by the pandemic were also those who received the least help. People in low-income countries were far less likely to be tested or treated for Covid. When it comes to vaccines, the disparity is even more dramatic. Of the 10 billion vaccine doses that have so far been administered, only 1 percent of those have gone to people in low-income countries.
Many people in the West were rightfully shocked and outraged by this disparity. How is it that the world can produce enough doses to vaccinate everybody – and yet not distribute them equally? But the truth is, this inequality is nothing new. The Covid pandemic was simply the latest event to highlight a deep-seated health disparity between the developed and developing worlds.
Consider that many people in Sub-Saharan Africa die from diseases that rarely kill people in North America. Over the past decade alone, 4 million children in Sub-Saharan Africa have died from malaria, while in the US only 100 people died from the disease in the same period. And millions more in Africa die every year from other preventable diseases or during childbirth.
A child born in Nigeria is 28 times less likely to see her fifth birthday than a child born in the US. Where you’re born in the world determines to a great extent your chances of growing up to adulthood. This will still be true once the Covid pandemic is over and done with.
We’re not trying to depress you – but this is a problem that deserves more attention! Part of the difficulty is that basic health-care infrastructure in many low-income countries is often very limited. That means that vital medical resources, such as drugs, vaccines, and treatments, simply can’t reach the people who need them.
The governments of wealthier countries can help to solve this problem by investing more in the health infrastructure of poorer countries. Rich countries should do this not only because it’s the morally right thing to do, but because it’s in their interest for foreign countries to have a robust health-care system.
As Covid made clear, pathogens don’t care about human borders. What happens in one region of the world can have consequences for every other. If a pathogen in one country can’t be controlled due to a lack of tools to detect or contain it, it will likely spread to other countries too.
Conversely, when we strengthen local health systems, we increase our chances of catching new pathogens early – before they turn into pandemics. It also helps us vaccinate people more efficiently when the time comes.
Ultimately, closing the global health gap is a long-term project. We’re not going to solve inequality overnight. But that’s exactly why it’s essential to start now. The earlier we try to tackle this problem, the better prepared we’ll be the next time everything goes awry.
This summary has very much focused on the big picture – and that’s because there’s a huge role that big institutions, like governments and our fictional GERM team, will need to play in order to control the spread of disease on a global scale. On the individual level, it may seem like there’s not much you can do to influence the course of a pandemic.
But that’s not true. Pandemics are caused by the cumulative actions of many individuals, so there are plenty of ways you can help keep your community safer.
For one, you can do your part in following any health and safety guidelines that may be put into place during an emergency – like wearing a mask, social distancing, and getting vaccinated as soon as you’re able to. You can also help by electing leaders who value science and will take advice from experts when the time comes.
But, most of all, you can help to keep health and disease prevention on the agenda by not letting the world forget just how devastating Covid was. Sure, we all can’t wait to put Covid behind us, but there’s one thing we simply can’t afford to do: return to being complacent about pandemics.
That doesn’t mean we have to live in perpetual fear of another deadly outbreak. It just means we have to understand that another pandemic is possible – and be willing to do what we know it takes to prevent it.
About the author
BILL GATES is a technologist, business leader, and philanthropist. In 1975, he cofounded Microsoft with his childhood friend Paul Allen. Today, he is cochair of the Bill & Melinda Gates Foundation, where he has spent more than twenty years working on global health and development issues, including pandemic prevention, disease eradication, and problems concerning water, sanitation, and hygiene. He has three children.
Table of Contents
1 Learn from COVID
2 Create a pandemic prevention team
3 Get better at detecting outbreaks early
4 Help people protect themselves right away
5 Find new treatments fast
6 Get ready to make vaccines
7 Practice, practice, practice
8 Close the health gap between rich and poor countries
9 Make—and fund—a plan for preventing pandemics
Afterword: How COVID changed the course of our digital future
From the author of the #1 New York Times best seller How to Avoid a Climate Disaster: The COVID-19 pandemic isn’t over, but even as governments around the world strive to put it behind us, they’re also starting to talk about what happens next. How can we prevent a new pandemic from killing millions of people and devastating the global economy? Can we even hope to accomplish this?
Bill Gates believes the answer is yes, and in this book he lays out clearly and convincingly what the world should have learned from COVID-19 and what all of us can do to ward off another disaster like it. Relying on the shared knowledge of the world’s foremost experts and on his own experience of combating fatal diseases through the Gates Foundation, he first helps us understand the science of infectious diseases. Then he shows us how the nations of the world, working in conjunction with one another and with the private sector, can not only ward off another COVID-like catastrophe but also eliminate all respiratory diseases, including the flu.
Here is a clarion call—strong, comprehensive, and of the gravest importance—from one of our greatest and most effective thinkers and activists.
Video and Podcast
“In this concise and lucid book, global health activist Gates reflects on the current COVID-19 pandemic, considers future ones, and renders several sensible recommendations for prevention . . . Passionate but never preachy, Gates delivers an expert, well-reasoned, and robust appeal for the world to unite in averting upcoming pandemics.” – Booklist (starred review)
“Gates delivers a thoughtful exploration of how lessons learned from Covid-19 can inform future global public health policies. In accessible prose, he spells out steps for preventing future pandemics, among them creating a global task force dedicated to doing so . . . Gates is realistic about what he’s up against . . . but he does a good job of making [the task force’s] $1 billion price tag seem reasonable.” – Publishers Weekly
Read an Excerpt/PDF Preview
I was having dinner on on a Friday night in mid-February 2020 when I realized that COVID-19 would become a global disaster.
For several weeks, I had been talking with experts at the Gates Foundation about a new respiratory disease that was circulating in China and had just begun to spread elsewhere. We’re lucky to have a team of world-class people with decades of experience in tracking, treating, and preventing infectious diseases, and they were following COVID-19 closely. The virus had begun to emerge in Africa, and based on the foundation’s early assessment and requests from African governments, we had made some grants to help keep it from spreading further and to help other countries prepare in case it took off. Our thinking was as follows: We hope this virus won’t go global, but we have to assume it will until we know otherwise.
At that point, there was still reason to believe that the virus could be contained and wouldn’t become a pandemic. The Chinese government had taken unprecedented safety measures to lock down Wuhan, the city where the virus emerged—schools and public places were closed, and citizens were issued permission cards that allowed them to leave their homes every other day for thirty minutes at a time. And the virus was still limited enough that countries were letting people travel freely. I had flown to South Africa earlier in February for a charity tennis match.
When I got back from South Africa, I wanted to have an in-depth conversation about COVID-19 at the foundation. There was one central question I could not stop thinking about and wanted to explore at length: Could it? be contained, or would it go global?
I turned to a favorite tactic that I’ve been relying on for years: the working dinner. You don’t bother with an agenda; you simply invite a dozen or so smart people, provide the food and drinks, tee up a few questions, and let them start thinking out loud. I’ve had some of the best conversations of my working life with a fork in my hand and a napkin in my lap.
So a couple of days after returning from South Africa, I sent an email about scheduling something for the coming Friday night: “We could try and do a dinner with the people involved with coronavirus work to touch base.” Almost everyone was nice enough to say yes—despite the timing and their busy schedules—and that Friday, a dozen experts from the foundation and other organizations came to my office outside Seattle for dinner. Over short ribs and salads, we turned to that key question: Would COVID-19 turn into a pandemic?
As I learned that night, the numbers were not in humanity’s favor. Especially because COVID-19 spread through the air—making it more transmissible than, say, a virus that is spread through contact, like HIV or Ebola—there was little chance of containing it to a few countries. Within months, millions of people all over the world were going to contract this disease, and millions would die from it.
I was struck that governments weren’t more concerned about this looming disaster. I asked, “Why aren’t governments acting more urgently?”
One scientist on the team, a South African researcher named Keith Klugman, who came to our foundation from Emory University, simply said: “They should be.”
Infectious diseases—both the kind that turn into pandemics and the kind that don’t—are something of an obsession for me. Unlike the subjects of my previous books, software and climate change, deadly infectious diseases are not generally something that people want to think about. (COVID-19 is the exception that proves the rule.) I’ve had to learn to temper my enthusiasm for talking about AIDS treatments and a malaria vaccine at parties.
My passion for the subject goes back twenty-five years, to January 1997, when Melinda and I read an article in The New York Times by Nicholas Kristof. Nick reported that diarrhea was killing 3.1 million people every year, almost all of them children. We were shocked. Three million kids a year! How could that many children be dying from something that was, as far as we knew, little more than an uncomfortable inconvenience?
We learned that the simple lifesaving treatment for diarrhea—an inexpensive liquid that replaces the nutrients lost during an episode—wasn’t reaching millions of children. That seemed like a problem we could help with, and we started making grants to get the treatment out more broadly and to support work on a vaccine that would prevent diarrheal diseases in the first place.
I wanted to know more. I reached out to Dr. Bill Foege, one of the epidemiologists responsible for the eradication of smallpox and a former head of the Centers for Disease Control and Prevention. Bill gave me a stack of eighty-one textbooks and journal articles on smallpox, malaria, and public health in poor countries; I read them as fast as I could and asked for more. One of the most influential for me had a mundane title: World Development Report 1993: Investing in Health, Volume 1. My obsession with infectious diseases—and particularly with infectious diseases in low- and middle-income countries—had begun.
When you start reading up on infectious diseases, it isn’t long before you come to the subject of outbreaks, epidemics, and pandemics. There aren’t strict definitions for these terms. A good rule of thumb is that an outbreak is when a disease spreads locally, through a community or small region; an epidemic is when an outbreak goes national; and a pandemic is when an epidemic goes global, affecting more than one continent. And some diseases don’t come and go, but stay consistently in a specific location—those are known as endemic diseases. Malaria, for instance, is endemic to many equatorial regions. If COVID-19 never goes away completely, it’ll be classified as an endemic disease.
It’s not at all unusual to discover a new pathogen. In the past fifty years, according to the World Health Organization (WHO), scientists have identified more than 1,500 of them; most began in animals and then spread to humans.
Some never caused much harm; others, such as HIV, have been catastrophes. HIV/AIDS has killed more than 36 million people, and more than 37 million people are living with HIV today. There were 1.5 million new cases in 2020, though there are fewer new cases each year because people who are being properly treated with antiviral drugs don’t spread the disease.
And with the exception of smallpox—the only human disease ever eradicated—old infectious diseases are still hanging around. Even plague, a disease most of us associate with ancient times, is still with us. It struck Madagascar in 2017, infecting more than 2,400 people and killing more than 200. The WHO receives reports of at least 40 cholera outbreaks every year. Between 1976 and 2018, there were 24 localized outbreaks and one epidemic of Ebola. If you include small ones, there are probably more than 200 outbreaks of infectious diseases every year.
AIDS and other “silent epidemics,” as they came to be known—tuberculosis, malaria, and others—are the focus of the foundation’s global health work, along with diarrheal diseases and maternal mortality. In 2000, these diseases killed more than 15 million people in all, many of them children, and yet shockingly little money was being spent on them. Melinda and I saw this as the area in which our resources and our knowledge of how to build teams to create new innovations could make the biggest difference.
This is the subject of a common misconception about our foundation’s health work. It’s not concentrated on protecting people in rich countries from diseases. It’s concentrated on the gap in health between high-income countries and low-income ones. Now, in the course of that work, we learn a lot about diseases that can affect the rich world, and some of our funding will help with these diseases, but they are not a focus of our grantmaking. The private sector, rich-country governments, and other philanthropists put a lot of resources into that work.
Pandemics, of course, affect all countries, and I have worried a lot about them since I began studying infectious diseases. Respiratory viruses, including the influenza family and the coronavirus family, are particularly dangerous because they can spread so quickly.
And the odds that a pandemic will strike are only going up. That’s partly because, with urbanization, humans are invading natural habitats at a growing rate, interacting with animals more often, and creating more opportunities for a disease to jump from them to us. It’s also because international travel is skyrocketing (or at least it was before COVID slowed its growth): In 2019, before COVID, tourists around the world made 1.4 billion international arrivals every year—up from just 25 million since 1950. The fact that the world had gone a century since a catastrophic pandemic—the most recent one, the flu of 1918, killed something like 50 million people—is largely a matter of luck.
Before COVID, the possibility of a flu pandemic was, relatively speaking, well known; many people had at least heard of the 1918 flu, and they might have remembered the swine flu pandemic of 2009–10. But a century is a long time, so almost no one alive had lived through the flu pandemic, and the swine flu pandemic didn’t turn out to be a huge problem because it wasn’t much more fatal than the normal flu. At the time I was learning all this, in the early 2000s, coronaviruses—which are one of three virus types that cause most common colds—weren’t discussed nearly as often as the flu.
The more I learned, the more I realized just how unprepared the world was for a serious respiratory virus epidemic. I read a report on the WHO’s response to the 2009 swine flu epidemic that concluded, prophetically: “The world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency.” The report laid out a step-by-step plan for getting prepared. Few of the steps were taken.
The next year, my friend Nathan Myhrvold started telling me about some research he was doing into the greatest threats faced by humanity. Although his biggest worry was an engineered bioweapon—a disease made in a lab—naturally occurring viruses were high on the list.
I’ve known Nathan for decades: He created Microsoft’s cutting-edge research division and is a polymath who has done research on cooking (!), dinosaurs, and astrophysics, among other things. He’s not prone to exaggerating risks. So when he argued that governments around the world were doing essentially nothing to prepare for pandemics of any kind, either natural or intentionally created, we talked about how to change that.
Nathan uses an analogy that I like. Right now, the building you are sitting in (assuming you’re not reading this book at the beach) is probably fitted with smoke detectors. Now, the odds that the building you’re in will burn down today are very low—in fact, it might go 100 years without burning down. But that building isn’t the only one around, of course, and somewhere in the world, at this very moment, a building is burning down. That constant reminder is why people install smoke detectors: to protect against something that’s rare but potentially very destructive.
When it comes to pandemics, the world is one big building fitted with smoke detectors that aren’t especially sensitive and have trouble communicating with one another. If there’s a fire in the kitchen, it might spread to the dining room before enough people hear about it to go put it out. Plus, the alarm only goes off about every 100 years, so it is easy to forget that the risk is there.
It’s hard to get your head around just how quickly a disease can spread, because exponential growth isn’t something that most of us encounter in our day-to-day lives. But consider the math. If 100 people have an infectious disease on Day 1, and if the number of cases doubles every day, the entire population of the earth will be infected by Day 27.
In the spring of 2014, I started getting emails from the health team at the foundation about an outbreak that sounded ominous: A few cases of Ebola virus had been identified in southeastern Guinea. By that July, there had been Ebola cases in Conakry, the capital of Guinea, and in the capital cities of Guinea’s neighbors, Liberia and Sierra Leone. Eventually the virus would spread to seven other countries, including the United States, and more than 11,000 people would die.
Ebola is a scary disease—it frequently causes patients to bleed from their orifices—but its rapid onset and immobilizing symptoms mean that it can’t infect tens of millions of people. Ebola spreads only through physical contact with the bodily fluids of an infected person, and by the time you’re really infectious, you’re too sick to move around. The biggest risks were to people who were taking care of Ebola patients, either at home or in the hospital, and during funeral rites, when someone would wash the body of a person who had died of the disease.
Even though Ebola wasn’t going to kill many Americans, it did remind them that an infectious disease can travel long distances. In the Ebola outbreak, a frightening disease had come to the United States as well as the United Kingdom and Italy—places that American tourists liked to visit. The fact that there had been a total of six cases and one death in those three countries, versus more than 11,000 in West Africa, didn’t matter. Americans were paying attention to epidemics, at least for the moment.
I thought it might be an opportunity to highlight the fact that the world wasn’t ready to handle an infectious disease that really could cause a pandemic. If you think Ebola is bad, let me tell you what the flu could do. Over the Christmas holidays of 2014, I started writing a memo about the gaps in the world’s readiness that had been highlighted by Ebola.
The gaps were enormous. There was no systematic way to monitor the progress of disease through communities. Diagnostic tests, when they were available, took days to return results—an eternity when you need to isolate people if they’re infected. There was a volunteer network of brave infectious-disease experts who went to help authorities in the affected countries, but there wasn’t a large full-time team of paid experts. And even if there had been such a team, there was no plan in place to move them to where they needed to be.
In other words, the problem was not that there was some system in place that didn’t work well enough. The problem was that there was hardly any system at all.
I still didn’t think it made sense for the Gates Foundation to make this one of its top priorities. After all, we focus on areas where the markets fail to solve big problems, and I thought that the governments of rich countries would get in gear after the Ebola scare, if they understood what was at stake. In 2015, I published a paper in The New England Journal of Medicine, pointing out how unprepared the world was and laying out what it would take to get ready. I adapted the warning for a TED talk called “The Next Epidemic? We’re Not Ready,” complete with an animation showing 30 million people dying from a flu as infectious as the 1918 one. I wanted to be alarming to make sure the world got ready—I pointed out that there would be trillions of dollars of economic losses and massive disruption. This TED talk has been viewed 43 million times, but 95 percent of those views have come since the COVID pandemic started.
The Gates Foundation, in partnership with the governments of Germany, Japan, and Norway, and the Wellcome Trust, created an organization called CEPI—the Coalition for Epidemic Preparedness Innovations—to accelerate work on vaccines against new infectious diseases and help those vaccines reach people in the poorest countries. I also funded a local study in Seattle to learn more about how the flu and other respiratory diseases move through a community.
Although CEPI and the Seattle Flu Study were good investments that helped when COVID came, not much else was accomplished. More than 110 countries analyzed their preparedness and the WHO outlined steps to close the gaps, but nobody acted on these assessments and plans. Improvements were called for but never made.
Six years after I gave my TED talk and published that NEJM paper, as COVID-19 was spreading around the world, reporters and friends would ask me if I wished I had done more back in 2015. I don’t know how I could have gotten more attention on the need for better tools and practice scaling them up rapidly. Maybe I should have written this book in 2015, but I doubt many people would have read it.
* * *
In early January 2020, the Gates Foundation team we had set up to monitor outbreaks after the Ebola scare was tracking the spread of SARS-CoV-2, the virus we now know as the one that causes COVID-19.[*3]
On January 23, Trevor Mundel, who leads our global health work, sent Melinda and me an email outlining his team’s thinking and requesting the first round of funding for COVID work. “Unfortunately,” he wrote, “the coronavirus outbreak continues to spread with the potential to become a serious pandemic (too early to be sure but essential to act now).”[*4]
Melinda and I have long had a system for making decisions about urgent requests that can’t wait for our annual strategy reviews. Whoever sees it first sends it to the other and says, basically, “This looks good, do you want to go ahead and approve it?” Then the other one sends an email approving the spending. As co-chairs, we still use this system for making big decisions related to the foundation, even though we’re no longer married and are now working with a board of trustees.
Ten minutes after Trevor’s mail came through, I suggested to Melinda that we approve it; she agreed and replied to Trevor: “We are approving $5M [i.e., $5 million] today and realize there may be an additional amount needed in the future. Glad the team has jumped on top of this so quickly. It is very concerning.”
As both of us suspected, there were definitely additional amounts needed, as became clear at the mid-February dinner and many other meetings. The foundation has committed more than $2 billion to various aspects of fighting COVID, including slowing its spread, developing vaccines and treatments, and helping make sure that these lifesaving tools reach people in poor countries.
Since the pandemic began, I’ve had the chance to work with and learn from countless health experts at the foundation and outside it. One deserves special mention.
In March 2020, I had my first call with Anthony Fauci, the head of the infectious diseases institute of the National Institutes of Health. I’m lucky to have known Tony for years (long before he was on the cover of pop-culture magazines), and I wanted to hear what he was thinking about all this—especially the potential for various vaccines and treatments that were being developed. Our foundation was backing many of them, and I wanted to make sure our agenda for developing and deploying innovations was aligned with his. Also, I wanted to understand what he was saying publicly about things like social distancing and wearing masks so I could help by echoing the same points when I did interviews.
We had a productive first call, and Tony and I would check in monthly for the rest of the year, discussing the progress on different treatments and vaccines and strategizing about how work done in the United States could benefit the rest of the world. We even did a few interviews together. It was an honor to sit next to him (virtually, of course).
One side effect of speaking out, though, is that it has provoked more of the criticisms of the Gates Foundation’s work that I’ve been hearing for years. The most thoughtful version goes like this: Bill Gates is an unelected billionaire—who is he to set the agenda on health or anything else? Three corollaries of this criticism are that the Gates Foundation has too much influence, that I have too much faith in the private sector as an engine of change, and that I’m a technophile who thinks new inventions will solve all our problems.
It’s certainly true that I’ve never been elected to any public position, and I don’t plan to seek one. And I agree that it’s not good for society when rich people have undue influence.
But the Gates Foundation does not use its resources or its influence in secret. We’re open about what we fund and what the results have been—the failures as well as the successes. And we know that some of our critics don’t speak up because they don’t want to risk losing grants from us, which is one of the reasons we make extra efforts to consult outside experts and seek out different viewpoints. (We expanded our board of trustees in 2022 for similar reasons.) We aim to improve the quality of the ideas that go into public policies and to steer funding toward those ideas that are likely to have the greatest impact.
Critics are also correct that the foundation has become a very large funder of some big initiatives and institutions that are predominantly the preserve of governments, such as the fight against polio and support for organizations like the WHO. But this is largely because these are areas of great need that do not get nearly enough funding and support from governments even though, as this pandemic has shown, they clearly benefit society as a whole. Nobody would be happier than I would if the Gates Foundation’s funding became a much smaller proportion of global spending in the coming years—because, as this book will argue, these are investments in a healthier, more productive world.
On a related point, critics argue that it’s not fair that a few people like me got wealthier during the pandemic, while so many other people suffered. They’re absolutely right. My wealth has largely insulated me from the impact of COVID—I do not know what it is like to have your life devastated by this pandemic. The best I can do is to uphold the pledge I made years ago to return the vast majority of my resources to society in ways that make the world a fairer place.
And yes, I am a technophile. Innovation is my hammer, and I try to use it on every nail I see. As a founder of a successful technology company, I am a great believer in the power of the private sector to drive innovation. But innovation doesn’t have to be just a new machine or a vaccine, as important as those are. It can be a different way of doing things, a new policy, or a clever scheme for financing a public good. In this book you’ll read about some of these innovations, because great new products only do the most good if they reach the people who need them most—and in health, that often requires working with governments, which even in the poorest countries are nearly always the entities that provide public services. That’s why I’ll make the case for strengthening public health systems, which—when functioning well—can serve as the first line of defense against emerging diseases.
Unfortunately, not every criticism of me is as thoughtful. Throughout COVID, I’ve marveled at how I became the target of wild conspiracy theories. It’s not an entirely new sensation—nutty ideas about Microsoft have been around for decades—but the attacks are more intense now. I have never known whether to engage with them or not. If I ignore them, they keep spreading. But does it actually persuade anyone who buys into these ideas if I go out and say, “I am not interested in tracking your movements, I honestly don’t care where you’re going, and there is no movement tracker in any vaccine”? I’ve decided that the best way forward is to just keep doing the work and believe that the truth will outlive the lies.
* * *
Years ago, the eminent epidemiologist Dr. Larry Brilliant coined a memorable phrase: “Outbreaks are inevitable, but pandemics are optional.” Diseases have always spread among humans, but they don’t have to become global disasters. This book is about how governments, scientists, companies, and individuals can build a system that will contain the inevitable outbreaks so they don’t become pandemics.
There is, for obvious reasons, more momentum than ever to do this now. Nobody who has been through COVID will ever forget it. Just as World War II changed the way my parents’ generation looked at the world, COVID has changed the way we see the world.
But we do not have to live in fear of another pandemic. The world can provide basic care to everyone, and be ready to respond to and contain any emerging diseases.
What would it look like in practice? Imagine:
Research allows us to understand all respiratory pathogens and prepares us to create tools like diagnostics, antiviral drugs, and vaccines at higher volumes and far faster than is possible today.
Universal vaccines protect everyone from every strain of the respiratory pathogens most likely to cause a pandemic—coronaviruses and influenza.
A potentially threatening disease is rapidly detected by local public health agencies, which function effectively in even the world’s poorest countries.
Anything out of the ordinary is shared with capable labs for study, and the information is uploaded to a global database monitored by a dedicated team.
When a threat is detected, governments sound the alarm and initiate public recommendations for travel, social distancing, and emergency planning.
Governments start using the blunt tools that are already on hand, such as mandatory quarantines, antivirals that protect against almost any strain, and tests that can be performed in any health clinic, workplace, or home.
If that isn’t sufficient, then the world’s innovators immediately get to work developing tests, treatments, and vaccines for the pathogen. Diagnostics in particular ramp up extremely fast so that large numbers of people can be tested in a short time.
New drugs and vaccines are approved quickly, because we’ve agreed ahead of time on how to run trials quickly and share the results. Once they’re ready to go into production, manufacturing gears up right away because factories are already in place and approved.
No one gets left behind, because we’ve already worked out how to rapidly make enough vaccines for everyone.
Everything gets where it’s supposed to, when it’s supposed to, because we’ve set up systems to get products delivered all the way to the patient. Communications about the situation are clear and avoid panic.
And this all happens quickly. It takes just six months to go from raising the first red flag to making enough safe, effective[*5] vaccines to protect the population of the earth.
To some people reading this book, the scenario I’ve just described will sound overly ambitious. It’s certainly a big goal, but we’re already headed in that direction. In 2021, the White House announced a plan for developing a vaccine in the next epidemic within 100 days, if resources are allocated. And lead times are already shrinking: It took just twelve months from the time the COVID virus was analyzed genetically until the moment the first vaccines were tested and ready for use, a process that usually takes at least half a decade. And technological advances made during this pandemic will speed things up even more in the future. If we—governments, funders, private industry—make the right choices and investments, we can do this. In fact, I see an opportunity not just to prevent bad things from happening, but to accomplish something extraordinary: eradicating entire families of respiratory viruses. That would mean the end of coronaviruses like COVID—and even the end of the flu. Every year, influenza alone causes around one billion illnesses, including 3 million to 5 million severe cases where someone ends up in the hospital. And it kills at least 300,000 people. Add in the impact of coronaviruses, some of which cause the common cold, and the benefits of eradication would be staggering.
Each chapter in this book explains one of the steps we need to take to get ready. Together, they add up to a plan for eliminating the pandemic as a threat to humanity and reducing the chance that anyone ever has to live through another COVID.
One final thought before we dive in: COVID is a fast-moving disease. In the time since I started writing this book, several variants of the virus have appeared, most recently Omicron, and others have vanished. Some treatments that appeared very promising in early studies turned out to be less effective than some people (including me) had hoped. There are questions about vaccines, including how long they provide protection, that can only be answered over time.
In this book I have done my best to write what is true at the time of publication, with the understanding that the state of play will inevitably change in the coming months and years. In any case, the key points of the pandemic prevention plan that I propose will be relevant just the same. Regardless of what COVID does, the world still has a lot of work to do before it can hope to keep outbreaks from turning into global disasters.
*1 I’ll tell you how it turned out in Chapter 3.
*2 Nathan eventually wrote a paper about these ideas called “Strategic Terrorism: A Call to Action” for the journal Lawfare. You can find it at https://papers.ssrn.com. I wouldn’t advise reading it before bed—it is sobering.
*3 A word about terminology. SARS-CoV-2 is the name of the virus that causes the disease COVID-19. Technically, COVID refers to all diseases caused by coronaviruses, of which COVID-19 is one. (The 19 comes from the fact that it was discovered in 2019.) But to keep things readable, from here on out, I’m going to use COVID to refer to both the disease COVID-19 and the virus that causes it.
*4 I’ve already mentioned the Gates Foundation several times in this Introduction, and I’ll be mentioning it more throughout this book. This is not because I want to brag, but because the foundation’s teams played an important part in much of the effort to develop vaccines, treatments, and diagnostics for COVID-19. It would be hard to tell that story without mentioning their work.
*5 In the medical field, effectiveness and efficacy mean different things. Efficacy is a measure of how well a vaccine works in a clinical trial. Effectiveness is a measure of how well it works in the real world. For the sake of simplicity, and because efficacious is an eyesore of a word, I’ll use effectiveness to mean both.
CHAPTER 1 LEARN FROM COVID
It’s easy to say that people never learn from the past. But sometimes we do. Why hasn’t there been a World War III yet? Partly because, in 1945, world leaders looked at history and decided there were better ways to settle their differences.
That’s the spirit in which I look at the lessons from COVID. We can learn from it and decide to do a better job of protecting ourselves from deadly diseases—in fact, it’s imperative to put a plan in place and fund it now, before COVID becomes yesterday’s news, the sense of urgency fades, and the world’s attention moves on to something else.[*1]
Many reports have documented the good and the bad of the world’s response to COVID, and I’ve learned a lot from them. I have also pulled together a number of key lessons from my work in global health, including projects such as polio eradication, and from following the pandemic day to day with experts at the foundation and in governments, academia, and the private sector. A key element is to look at the countries that did better than others.
Doing the right things early pays huge dividends later.
I know this sounds odd, but my favorite website is a treasure trove of data that tracks diseases and health problems all over the world. It’s called the Global Burden of Disease,[*2] and the level of detail it contains is astonishing. (The 2019 version tracked 286 causes of death and 369 types of diseases and injuries in 204 countries and territories.) If you’re interested in how long people live, what makes them sick, and how these things change over time, this site is the best source. I can spend hours at a time looking at the data.
The site is published by the Institute for Health Metrics and Evaluation (IHME), which is located at the University of Washington in my hometown of Seattle. As you can probably guess from its name, IHME specializes in measuring health around the world. It also does computer modeling that attempts to establish cause-and-effect relationships: Which factors might explain why cases are going up or down in some country, and what does the forecast look like?
Since early 2020, I’ve been peppering the team at IHME with questions about COVID. What I’ve hoped to find out is what the countries that are dealing most successfully with COVID have in common. What did they all do right? Once we answer that question with some certainty, we’ll understand the best practices and be able to encourage other countries to adopt them.
The first thing you have to do is define success, but that’s not as easy as you might think. You can’t just look at how often people with COVID in a given country went on to die from it. That statistic will be skewed by the fact that older people are more likely to die from COVID than younger people, so countries with especially old populations will almost inevitably look worse. (One country that did particularly well—even though it has the world’s oldest population—is Japan. It had the best compliance with mask mandates of any country, which helps explain some of its success, but other factors were probably also at play.)
What you really look for in a measure of success is a number that captures the overall impact of the disease. People who die of heart attacks because the hospital is too overwhelmed by COVID patients to treat them ought to be counted just as much as people who die of the disease itself.
There’s a measure that does exactly that: It’s called excess mortality, and it includes people who die because of the disease’s ripple effect as well as those who die directly from COVID. (It’s the number of excess deaths per capita, in order to account for the size of a country’s population.) The lower your excess mortality, the better you’re doing. In fact, some countries’ excess mortality is actually negative. That’s because they had relatively few deaths from COVID, and there were also fewer traffic accidents and other fatal incidents because people were staying home so much more.
The true toll of COVID. “Excess deaths” measures the impact of COVID by including people whose deaths were indirectly caused by the pandemic. The top bar shows the number of COVID deaths through December 2021. The bottom bar shows the estimated number of excess deaths, with a range between 16.5 million and 18 million. (IHME)
Toward the end of 2021, America’s excess mortality was more than 3,200 per million people, roughly on par with Brazil’s and Iran’s. Canada’s, by contrast, was around 650, while Russia’s was well over 7,000.
Many of the countries with the lowest excess mortality (near zero or negative)—Australia, Vietnam, New Zealand, South Korea—did three things well early in the pandemic. They tested a large share of the population quickly, isolated people who tested positive or had been exposed, and carried out a plan for detecting, tracing, and managing cases that may have come across their borders.
Containing COVID in Vietnam. Government officials implemented measures for controlling the virus during 2020. Having just thirty-five deaths over an entire year in a country of 97 million people is a major accomplishment. (Exemplars in Global Health program)
Unfortunately, early success can be hard to maintain. Relatively few people in Vietnam were vaccinated for COVID—partly because of the limited supply of vaccines, and partly because vaccines didn’t seem as urgent when the country had done such a good job controlling the virus. So when the much more transmissible Delta variant came along, there were relatively few people in Vietnam who had any immunity, and the country was hit hard. Its rate of excess deaths went from just over 500 per million people in July 2021 to nearly 1,500 per million people in December—though even at the higher rate, Vietnam was still doing better than the United States. Overall, it was better off having taken those early measures.
IHME’s data also suggests that a country’s success against COVID correlates roughly with how much people there trust the government. This makes intuitive sense, since if you have confidence in your government, you’re more likely to follow its guidelines for preventing COVID. On the other hand, trust in government is measured by polls, and if you live under an especially repressive regime, you’re probably not going to tell a random pollster what you really think about the government. And in any case, this finding doesn’t easily translate into practical advice that can be implemented quickly. Building trust between people and their government takes years of painstaking, purposeful work.
Another approach to identifying what works is to look at the problem from the other end: Find exemplars that did individual things especially well and study how they did them so that others can do the same. A group called, appropriately enough, Exemplars in Global Health is doing just that, and they have made some fascinating connections.
For example, all other things being equal, countries whose health systems function well in general were more likely to respond well to COVID. If you have a strong network of health clinics that are well staffed with trained personnel, are trusted by people in their community, have supplies when they’re needed, and so on, you are in a better position to fight off a new disease. This suggests that any pandemic prevention plan needs to include, among other things, helping low- and middle-income countries improve their health systems. We’ll return to this subject in Chapters 8 and 9.
Another example: The data suggests that cross-border trucking was responsible for a fair amount of spread from one country to another. So which places managed it well? Early in the pandemic, Uganda required COVID tests for all truckers coming into the country, and the region of East Africa followed suit soon after. But because the testing process was slow and kits were in short supply, the policy caused major backups at the border—of up to four days—and transmission went up while truckers waited around in cramped quarters.
Uganda and its neighbors did several things to fix the logjam, including dispatching mobile testing labs to border crossings, creating an electronic system to track and share results, and requiring truckers to get tested in the country where they started their route, rather than at the border. Soon, traffic was flowing again, and cases were kept under control.
Truck driver Naliku Musa waits for the results of his COVID test at the border between Uganda and South Sudan.
Bottom line: In the early days, if you’re able to test a large share of your population, isolate the positive cases and their contacts, and handle possible cases coming from abroad, you’ll be well positioned to keep the caseload manageable. If you don’t do those things quickly, then only extreme measures can prevent a large number of infections and deaths.
Some countries show us what not to do.
I don’t like to dwell on failures, but some are too egregious to ignore. Although there are positive exemplars, most countries handled at least some aspects of their COVID response poorly. I’m calling out the United States here because I know its situation well, and because it should have done so much better than it did, but by no means is it the only country that made a lot of mistakes.
The White House’s response in 2020 was disastrous. The president and his senior aides downplayed the pandemic and gave the public terrible advice. Incredibly, federal agencies refused to share data with one another.
It certainly didn’t help that the director of the Centers for Disease Control and Prevention is a political appointee subject to political pressure, and some of the CDC’s public guidance was clearly influenced by politics. Even worse, the person running the CDC in 2020 wasn’t trained as an epidemiologist. The former CDC directors who are still remembered today for their amazing work—people like Bill Foege and Tom Frieden—were experts who had spent much or all of their careers in the organization. Imagine a general who has never even been through a battle simulation suddenly having to run a war.
One of the worst failures, though, is that the United States never got testing right: Not nearly enough people were tested, and results took far too long to come back. If you’re carrying the virus but don’t know it for another seven days, you’ve just spent a week potentially infecting other people. To me, the most mind-boggling problem—because it would have been so easy to avoid—is that the U.S. government never fully maximized the capacity for testing people, nor did it create a centralized way to both identify those who should be first in line to get quick results and record the outcomes of all tests. Even two years into the pandemic, as Omicron spread rapidly, many people weren’t able to get tested, even when they had symptoms.
In the early months of 2020, any people in America who were worried about having COVID should have been able to go to a government website, answer a few questions about symptoms and risk factors (such as age and location), and find out where they could get tested. Or, if test supplies were limited, the site might determine that their case wasn’t a high enough priority and notify them when they could be tested.
Not only would the site have made sure that testing kits were used most efficiently—for the people most likely to actually test positive—it also would have given the government additional information about parts of the country where too few people were showing an interest in getting tested. With this data, the government could have directed more resources toward getting the word out and expanding testing in those areas. The site would also have provided people with instant eligibility to participate in a clinical trial if they tested positive or were at high risk, and it could later have been used to help make sure that vaccines went to the people at the highest risk of getting severely sick or dying. And the site would also be useful in nonpandemic times for fighting other infectious diseases.
Any software company worth its salt could have built this site in no time,[*3] but instead states and cities were left to their own devices, and the whole process was chaotic. It was like the Wild West. I remember one especially heated call with people from the White House and CDC in which I was quite rude about their refusal to take this basic step. To this day I don’t understand why they wouldn’t let the most innovative country in the world use modern communications technology to fight a deadly disease.
In the face of something the world should have been better prepared for, people did heroic work.
Whenever there’s a disaster, the children’s TV host Fred Rogers used to say, “Look for the helpers. You will always find people who are helping.‰? During COVID, it takes very little looking to find the helpers. They are everywhere, and I’ve had the pleasure of meeting some of them and learning about many more.
Every day for five months of 2020, as a COVID tester in Bengaluru, India, Shilpashree A.S. would put on a protective gown, goggles, latex gloves, and a mask. (Like many people in India, she uses initials referring to her hometown and her father’s name as her last name.) Then she’d step into a tiny booth with two holes for her arms and spend hours performing nasal swab tests on long lines of patients. To protect her family, she had no physical contact with them—for five months they saw one another only on video calls.
Shilpashree A.S. takes samples in Bengaluru, India, while stationed in a booth and wearing protective gear.
Thabang Seleke was one of 2,000 volunteers in Soweto, South Africa, to participate in a study on the effectiveness of the COVID vaccine developed at Oxford University. The stakes for his country were high: By September 2020, more than 600,000 people had been diagnosed with COVID and more than 13,000 people had died from it. Thabang heard about the trial from a friend and stepped forward to help bring an end to the coronavirus in Africa and beyond.
Sikander Bizenjo went from Karachi to his home province of Balochistan, a dry, mountainous region in southwestern Pakistan where 70 percent of the population lives in poverty. He founded a group called Balochistan Youth Against Corona, which has trained more than 150 young boys and girls to help people across the province. They’re hosting COVID awareness sessions in local languages while also building reading rooms and donating hundreds of thousands of books. They’ve provided medical equipment to 7,000 families and food to 18,000 families.
Ethel Branch, a member of the Navajo Nation and its former attorney general, left her law firm to help form the Navajo & Hopi Families COVID-19 Relief Fund, an organization that delivers water, food, and other necessities to people in need throughout the Navajo and Hopi nations. She and her colleagues have raised millions of dollars (some of it through one of the top five GoFundMe campaigns of 2020) and organized hundreds of young volunteers who have helped tens of thousands of families from both nations.
The stories of people who are making sacrifices to help others during this crisis could fill an entire book. Around the world, health care workers put themselves at risk to treat sick people—according to the WHO, more than 115,000 had lost their lives taking care of COVID patients by May 2021. First responders and frontline workers kept showing up and doing their jobs. People checked in on neighbors and bought groceries for them when they couldn’t leave home. Countless people followed the mask mandates and stayed home as much as possible. Scientists worked around the clock, using all their brainpower to stop the virus and save lives. Politicians made decisions based on data and evidence, even though these decisions weren’t always the popular choice.
Not everyone did the right thing, of course. Some people have refused to wear masks or get vaccinated. Some politicians have denied the severity of the disease, shut down attempts to limit its spread, and even implied that there’s something sinister in the vaccines. It’s impossible to ignore the impact their choices are having on millions of people, and there’s no better proof of those old political clichés: Elections have consequences, and leadership matters.
Expect variants, surges, and breakthrough cases.
Unless you work on infectious diseases, you had probably never heard of variants until COVID. The idea may have seemed new and scary, but there’s nothing particularly unusual about variants. Influenza viruses, for instance, can quickly mutate into new variants—which is why flu vaccines are reviewed each year and frequently updated. Variants of concern are the ones that are more transmissible than others, or better at evading the human immune system.
Early in the pandemic, there was a broad belief in the scientific community that, although there would be some mutations of COVID, they wouldn’t cause a big problem. By early 2021, scientists knew that variants were emerging, but they appeared to be evolving in similar ways, leading some scientists to hope that the world had already seen the worst mutations that the virus was capable of. But the Delta variant proved otherwise—its genome had evolved to make it far more transmissible. The arrival of Delta was a bad surprise, but it convinced everyone that even more variants could show up. As I finish this book, the world is facing a sweeping wave of Omicron, the fastest-spreading variant to date—and in fact the fastest-spreading virus we’ve ever seen.
Viral variants are always a possibility. In future outbreaks, scientists will monitor variants closely to make sure that whatever new tools come out will still work on them. But, because every time a virus jumps from one person to another is an opportunity for it to mutate, the most important thing will be to keep doing the things that definitely reduce transmission: Follow the experts’ recommendations on masks, social distancing, and vaccines, and make sure low-income countries get vaccines and the other tools they need to fight the pathogen.
Just as the rise of variants wasn’t a surprise, neither were so-called breakthrough cases, in which people who have been vaccinated end up getting infected anyway. Until vaccines or drugs can block infections perfectly, some vaccinated people will still become infected. As more people get vaccinated in a given population, the total number of cases will go down, and a growing percentage of the cases that do occur will be breakthroughs.
Here’s one way to think about it. Imagine that COVID starts spreading through a town with a fairly low vaccination rate. A thousand people get so sick that they end up in the hospital. Out of those 1,000 severe cases, 10 are breakthroughs.
Then the virus spreads to the next town over, which has a high vaccination rate. That town sees only 100 severe cases, of which 8 are breakthroughs.
In the first town, breakthroughs represented 10 out of 1,000 severe cases, or one percent. In the second, they made up 8 out of 100, or 8 percent of the total. Eight percent sounds like bad news for town #2, right?
But remember, the important number is not the breakthrough rate. It’s the total number of severe cases, and that number went from 1,000 in the first town to just 100 in the next. That is progress by any definition. You’re safer by far in town #2, where lots of people are vaccinated, and if you’re one of them.
Along with variants and breakthrough cases, waves—big spikes in the number of cases—were not a surprise in and of themselves. We know from the history of previous pandemics that waves occur, yet countries in every region of the world were caught off guard by them. I admit to having been surprised, as many people were, by the size of the Delta wave in India in mid-2021. It was partly the result of wishful thinking—the mistaken idea that the country could relax because it had contained the virus in the early days of 2020. Another explanation is sadly ironic: Countries that do the best job of suppressing the virus early on will often be susceptible to later surges, because their suppression measures kept people from getting sick and developing natural immunity. The aim is to use suppression to delay widespread infection, prevent hospitals from getting overloaded, and buy time for vaccines to protect people. But if an especially transmissible variant shows up before vaccines are widely distributed, and if suppression measures are ended, then a big wave is almost inevitable. India did learn these lessons quite rapidly and ran a successful COVID vaccination campaign later in 2021.
Good science is messy, uncertain, and prone to change.
Here’s a partial list of the U.S. government’s various positions on wearing masks during COVID:
Feb. 29, 2020: The surgeon general tweets that people should “STOP BUYING MASKS” because they are “not preventing” COVID (which turned out not to be true) and buying them will make it harder for health workers to access them (which was true at the time, although it was fairly easy to make more masks).
March 20, 2020: The CDC reiterates that healthy people who do not work in health care or are not taking care of a sick person do not need masks.
April 3, 2020: Two weeks later, the CDC recommends masks for all people over age two who were in a public setting, traveling, or around others in the same household who might be infected.
Sept. 15, 2020: The CDC recommends that all teachers and students who attend school in person wear masks whenever feasible.
Jan. 20, 2021: President Biden signs an executive order requiring masking and physical distancing in federal buildings, on federal lands, and by government contractors. The next day he signs an order requiring masks when traveling, and nine days later the CDC issues an order that makes refusing to wear a mask in federally mandated spaces a violation of federal law.
March 8, 2021: The CDC releases new guidance that fully vaccinated people do not need to wear a mask when visiting other vaccinated people inside.
April 27, 2021: The CDC announces that people do not need to wear masks outdoors when they walk, bike, or run alone or with members of their household regardless of vaccination status. Fully vaccinated people do not need to wear masks outdoors at all unless they’re at a large gathering like a concert.
May 13, 2021: The CDC announces that fully vaccinated people no longer need to wear a mask or physically distance inside. Some states, like Washington and California, continue mask mandates through some or all of June.
July 27, 2021: The CDC recommends that fully vaccinated people resume wearing masks indoors in parts of the country where case counts are surging. It also recommends that masks be worn indoors by all teachers, staff, students, and visitors to schools regardless of their vaccination status.
You could get whiplash from trying to follow along.
Does this mean the staff of the CDC were incompetent? No. I won’t defend every decision the CDC made—as many experts argued at the time, the CDC was wrong in May 2021 when it said that vaccinated people didn’t need to wear masks—but during a public health emergency, decisions are made by imperfect people using imperfect data in an environment that’s constantly changing. We should have studied respiratory virus transmission a lot more beforehand, instead of having to learn during the pandemic. And expecting perfection during an outbreak actually sets up a perverse dynamic, as the story of David Sencer illustrates.[*4]
Born in Michigan in 1924, Sencer joined the U.S. Navy after graduating from college. After a yearlong bout with tuberculosis, he ended up joining the U.S. Public Health Service, intent on saving people from diseases like the one that had sidelined him for so long.
Sencer made his mark early on with vaccines. After moving to the Centers for Disease Control, he helped draft legislation that created the first broad vaccination program in the U.S. and dramatically expanded the number of children who received the polio vaccine. He became director of the CDC in 1966 and led its expansion into work on malaria, family planning, smoking prevention, and even the quarantine of astronauts after returning from space. Sencer was a master of logistics, a skill that made him indispensable in the successful effort to eradicate smallpox.
In January 1976, a soldier serving at Fort Dix in New Jersey died from swine flu after doing a five-mile march while sick. Thirteen others were hospitalized with the disease. Doctors discovered that the men all had a strain of influenza similar to the one that had caused the 1918 pandemic.
The outbreak never expanded beyond Fort Dix. But in February 1976, worried that there could be a replay of the 1918 disaster when flu season came around that fall—which would mean tens of millions of deaths around the world—Sencer called for mass immunization against this particular strain of swine flu, using an existing vaccine. A presidential panel that included the legendary researchers Jonas Salk and Albert Sabin, both of whom had developed groundbreaking polio vaccines, backed the idea. President Gerald Ford went on television to announce his support for a mass immunization drive, and the campaign quickly kicked into gear.
By mid-December, signs of trouble were emerging. Ten states reported cases of vaccinated people contracting Guillain-Barré syndrome, or GBS, an autoimmune disease that causes nerve damage and muscle weakness. The vaccination program was suspended later that month and never reinstated. Shortly thereafter, Sencer was informed that he would be replaced as head of the CDC.
In total, GBS cases occurred in 362 patients out of the 45 million people vaccinated—a rate around four times higher than you would expect with the general population. One study concluded that even if the vaccine did cause GBS in rare cases, its benefits vastly outweighed the risk. But someone needed to take the blame, and Sencer was the fall guy.
Sencer, who died in 2011, remains highly regarded in the world of public health. The consensus is that pushing for mass immunizations was worth the risk: If he had been right about a pandemic, the cost of inaction would have been enormous. But critics focused more on the risk of a rare autoimmune disease—which was real—than on the possibility that tens of millions could die.
In public health, you have to be careful about sending a message that says, “Act early, but you’ll be fired if you get it wrong.” Of course, if someone makes a truly wretched decision, firing may be in order. But officials need the leeway to make tough calls, because there will always be false alarms, and distinguishing them from the real thing is not an easy task.
What if Sencer had done nothing and his fears had turned out to be valid? Tens of millions of people would have died of a virus that had started in the United States, which had a chance to stop it but chose not to. When people like Sencer act in good faith and with the best data they have available to them, they should not be attacked for possibly having made the wrong call purely because we have the benefit of hindsight. It creates a perverse incentive to be overly cautious—to protect their careers by holding back. And when it comes to public health, holding back can lead to disaster.
It pays to invest in innovation.
It’s tempting to assume that invention occurs practically overnight. If in January you wouldn’t know what messenger RNA was if it walked up to you on the street, and by July you’ve read all about it and are getting a vaccine that uses it, you might think it went from idea to reality in just six months. But innovation does not happen in an instant. It takes years of patient, persistent effort by scientists—who will fail more often than they succeed—as well as funding, smart policies, and an entrepreneur’s mindset to get an idea out of the lab and into the market.
It’s frightening to imagine how much worse COVID would’ve been if the U.S. government and others hadn’t invested years ago in research on vaccines that use messenger RNA (mRNA, which I’ll explain in Chapter 6) or another approach called a viral vector. In 2021 alone, they accounted for roughly 6 billion doses delivered worldwide. Without them, we would’ve been far worse off.
The pandemic has offered up dozens of other concrete examples of innovative ideas, scientific insights, new diagnostic tools, treatments, policies, and even ways to fund the delivery of all these things around the world. Researchers have learned a lot about how viruses move from person to person. And since transmission of the flu virus essentially came to a halt during the first year of COVID, researchers now know that it’s possible to stop influenza, which bodes well for future outbreaks of flu and other diseases.
COVID also highlights an inescapable fact about innovation: Most of the world’s greatest talent for translating research into commercial products is in the private sector. Not everyone likes that arrangement, but the profit motive is often the most powerful force in the world for getting new products created quickly. It’s the government’s role to invest in the basic research that leads to major innovations, adopt policies that let new ideas flourish, and create markets and incentives (the way the United States accelerated vaccine work with Operation Warp Speed). And when there are market failures—when the people who most need lifesaving tools can’t afford them—then governments, nonprofits, and foundations should step in to fill the gap, often by finding the right way to work with the private sector.
We can do better next time—if we start taking pandemic preparation seriously.
The world responded to COVID faster and more effectively than to any other disease in history. But as the late educator and physician Hans Rosling put it, “Things can be better and bad.” In the Better column, for example, I’d put the fact that the world developed safe, effective vaccines in record time. In the Bad column, I’d put the fact that too few people in poor countries are getting them. I’ll return to this problem in Chapter 8.
Another entry in the Bad column so far: the world’s failure to get serious about preparing for and trying to prevent pandemics.
Governments are responsible for the safety of their people. For common events that cause damage and deaths—fires, natural disasters, wars—governments have a structure for their response: They have experts who understand the risks, get the resources and tools they need, and practice how they’ll respond in an emergency. Militaries run large-scale drills to make sure they’re prepared for action. Airports run exercises to see if they’re ready for an emergency. City, state, and federal governments practice responding to natural disasters. Even schoolchildren go through fire drills and, if they live in the United States, active-shooter drills.
When it comes to pandemics, though, virtually none of this happens. Although people had been raising the alarm for decades about novel diseases that could kill millions of people—a long succession of warnings came before and after mine in 2015—the world didn’t respond. For all the effort that humans put into preparing for attacks from fires, storms, and other humans, we had not prepared seriously for an attack by the smallest possible enemy.
In Chapter 2, I’ll argue that what we need is a global corps of people whose job is to wake up every day thinking about diseases that could kill huge numbers of people—how to spot them early, how to respond, and how to measure whether we’re ready to respond.
To sum up: The world has never invested in the tools it needs or properly prepared for a pandemic. It’s time we did. The rest of this book will describe how we can do it.
*1 About the word we: I use it in various ways in this book. Sometimes I’m referring to work I am personally involved in (or the Gates Foundation is). But for the sake of simplicity, I also use we to refer to the global health sector more broadly, or to the world at large. I will try to make my meaning clear in context.
*3 Microsoft would’ve done it for free, and I’m sure many other companies would have too.
*4 Michael Lewis tells Sencer’s story well in his book The Premonition.
CHAPTER 2 CREATE A PANDEMIC PREVENTION TEAM
In the year 6 CE, a fire devastated the city of Rome. In its aftermath, the emperor, Augustus, did something that had never been done in the history of the empire: He created a permanent team of firefighters.
The fire brigade, which would grow to include nearly 4,000 men, was equipped with buckets, brooms, and axes and divided into seven groups that stood watch at barracks placed strategically throughout the city. (One of these barracks was discovered in the mid-nineteenth century and is sometimes open to visitors.) Officially, the squad was known as the Cohortes Vigilum—which can be loosely translated as “Brothers of the Watch”—but locals came to use the term of endearment Sparteoli, or “Little Bucket Fellows.”
Elsewhere around the world, China’s first professional fire brigade was established in the eleventh century by Emperor Renzong of the Song Dynasty. Europe followed roughly 200 years later. In America, there were volunteer groups before the American Revolution, formed at the urging of a young Benjamin Franklin (who else?), as well as private ones that were paid by insurance companies to save burning buildings. But the United States didn’t have a single government-run, full-time firefighting corps until 1853, when one was established by the city of Cincinnati, Ohio.
There are now about 311,000 full-time firefighters in the United States, stationed at nearly 30,000 departments.[*1] Local governments in the U.S. spend more than $50 billion a year staying ready to deal with fires. (I was surprised by how large these numbers are when I looked them up!)
And that’s not to mention all the steps we take to prevent fires from starting in the first place. For nearly 800 years, governments have passed laws to reduce the risk of conflagration, including banning thatched roofs (London in the thirteenth century) and requiring the safe storage of fuels for bread ovens (Manchester, England, in the sixteenth). Today, one large fire-prevention nonprofit publishes a list of more than 300 building codes and standards designed to minimize the risk and extent of fires.
In other words, for some 2,000 years, humans have recognized that individual families and businesses aren’t solely responsible for protecting themselves—they need help from the community. If your neighbor’s house is on fire, your home is at risk, and firefighters will take steps to prevent the flames from spreading. And when they’re not actively battling a blaze, the fire department will run drills to keep their skills sharp and help out with other activities related to public safety and service.
Fires don’t spread across the entire world, of course, but diseases do. A pandemic is the equivalent of a fire that starts in one building and within weeks is burning in every country in the world. So to prevent pandemics, we need the equivalent of a global fire department.
At the global level, we need a group of experts whose full-time job is to help the world prevent pandemics. It should be responsible for watching out for potential outbreaks, raising the alarm when they emerge, helping to contain them, creating data systems to share case numbers and other information, standardizing policy recommendations and training, assessing the world’s ability to roll out new tools quickly, and organizing drills to look for weak spots in the system. It should also coordinate the many professionals and systems around the globe who do this work at the national level.
Creating this organization requires a serious commitment from rich-country governments, including making sure it is staffed properly. It will be hard to get the right consensus at the global level, as well as the right level of funding—but even knowing the obstacles, I feel it is a critical priority for the world to put this team in place. In this chapter I want to make clear how it should work.
* * *
You might think a group like the one I’m proposing already exists. How many movies and TV shows have you seen where there’s an outbreak of a scary disease and the world seems perfectly prepared? Someone starts showing symptoms. The president of the United States gets briefed on the situation with a dramatic animated computer model that shows the disease spreading worldwide. A team of experts get the phone call they’ve been waiting for (always during breakfast with their families, for some reason) and spring into action. Wearing hazmat suits and carrying expensive equipment, they are flown in on helicopters to assess the situation. They take a few samples, speed off to the lab to make the antidote, and go on to save humanity.
Reality is a lot more complicated than that. For one thing, the Hollywood version underplays one of the most important (but admittedly undramatic) tasks in pandemic prevention: making sure that countries have strong health systems. In a well-run system, clinics are fully staffed and equipped, pregnant women get pre- and postnatal care, and children get their routine vaccines; health care workers are well trained in public health and pandemic prevention; and reporting systems make it easy to identify suspicious clusters of cases and raise the red flag. When that kind of infrastructure is in place—as it is in most wealthy nations and some low- and middle-income ones—you’re much more likely to notice the early stage of a new disease emerging. Without that infrastructure, you don’t notice the new disease until it has spread to tens of thousands of people and probably reached into many countries.
But what’s most unrealistic about what you see in the movies is that it suggests there’s some agency that pulls together all these different capabilities, acting swiftly and decisively to prevent a pandemic. My favorite example is season 3 of the TV show 24—a show I really liked—where a terrorist intentionally releases a pathogen in Los Angeles. Word gets to practically every government entity in no time. The hotel where the release took place is immediately sealed off. A computer modeling genius figures out not only how the disease will spread, but how quickly news of the disease will get around, and (the best part) how bad traffic will get as people flee the city. I remember watching those episodes and thinking, “Wow, that government sure knew how to prepare.”
It made for great TV, and of course we could all sleep better at night if things really worked that way. But they don’t. Although there are many organizations that work hard to respond to a major outbreak, their efforts largely depend on volunteers. (The best known is the Global Outbreak Alert and Response Network, or GOARN.) Regional and national response teams are understaffed and underfunded, and none of them has a mandate from the international community to work globally. The only organization that sort of has that mandate, the WHO, has very little funding and almost no personnel dedicated to pandemics, relying instead on the mostly volunteer GOARN. There is no organization with the size, scope, resources, and responsibility that are essential for detecting and responding to outbreaks and preventing them from becoming pandemics.
Let’s consider the sequence of events that are involved in an effective response to an outbreak. Sick people have to go to a clinic, and the health workers there have to diagnose them properly. Those cases must get reported up the chain, and an analyst has to notice an unusual cluster of cases with similar suspicious symptoms or test results. A microbiologist must get samples of the pathogen and determine whether it’s something we’ve seen before. A geneticist may need to map its genome. Epidemiologists have to understand how transmissible and severe the disease is.
Community leaders need to get, and share, accurate information. Quarantines might need to be put in place and enforced. Scientists need to get cracking on diagnostic tests, treatments, and vaccines. And, just as firefighters run drills when they’re not putting out a blaze, all of these groups need to have practiced, testing the system to find the weak spots and fix them.
Bits and pieces of what you’d want in a monitor-and-respond system exist. I’ve met people who have dedicated their lives to this work, and many put their lives on the line for it. But COVID did not happen because there were too few smart, compassionate people trying to prevent it. COVID happened because the world hasn’t created an environment in which smart, compassionate people can make the most of their skills as part of a strong, well-prepared system.
What we need is a well-funded global organization with enough full-time experts in all the necessary areas, the credibility and authority that come with being a public institution, and a clear remit to focus on preventing pandemics.
I call it the GERM—Global Epidemic Response and Mobilization—team, and the job of its people should be to wake up every day asking themselves the same questions: “Is the world ready for the next outbreak? What can we do to be better prepared?” They should be fully paid, regularly drilled, and prepared to mount a coordinated response to the next threat of a pandemic. The GERM team should have the ability to declare a pandemic and work with national governments and the World Bank to raise money for the response very quickly.
My back-of-the-napkin estimate is that GERM would need about 3,000 full-time employees. Their skills should run the gamut: epidemiology, genetics, drug and vaccine development, data systems, diplomacy, rapid response, logistics, computer modeling, and communications. GERM should be managed by the World Health Organization, the only group that can give it global credibility, and it should have a diverse workforce, with a decentralized staff working in many places around the world. To get the best staff possible, GERM should have a special personnel system different from what most U.N. agencies have. Most of the team would be based at individual countries’ national public health institutes, though some would sit in the WHO’s regional offices and at its headquarters in Geneva.
When there’s a potential pandemic looming, the world needs expert analysis of early data points that can confirm the threat. GERM’s data scientists would build a system for monitoring reports of clusters of suspicious cases. Its epidemiologists would monitor reports from national governments and work with WHO colleagues to identify anything that looks like an outbreak. Its product-development experts would advise governments and companies on the highest-priority drugs and vaccines. GERMers who understand computer modeling would coordinate the work of modelers around the world. And the team would take the lead on creating and coordinating common responses, such as how and when to implement border closures and recommend mask use.
Diplomacy will inevitably be part of the job. After all, national and local leaders are the ones who understand the unique conditions in their country, who speak every local language, who know the key players, and to whom the public looks for leadership. People from GERM would have to work closely with them, making it clear that their job is to support, not supplant, local expertise. If GERM becomes—or even appears to be—something imposed from the outside, some countries will reject its recommendations.
For countries that need additional support, GERM should fund or loan public health experts who would participate in this global pandemic-prevention network. They would train and drill together to keep their skills sharp, and they would stay ready to respond locally or globally when they’re needed. Countries with greater need and a high risk of outbreaks would bring in more GERM team members from the network and host them to build local expertise in infectious diseases. Regardless of where they’re assigned, these GERMers would have a dual identity: They’d be part of the national detection-and-response system, and also part of GERM’s rapid response.
Finally, the GERM team should be responsible for testing the world’s monitor-and-respond system to find the weak spots. They would develop a checklist for pandemic preparedness, similar to the ones that airplane pilots follow before every takeoff and many surgeons now go through during an operation. And just as militaries do complex exercises where they simulate different conditions and see how well they respond, the GERM team would organize outbreak response exercises. Not war games, but germ games. This will be the team’s most important role, and we’ll return to it in much more detail in Chapter 7.
* * *
The group I’m describing would be new, but not exactly unprecedented. It’s based on a model I’ve seen work extremely well against another disease, one that we are achingly close to eradicating.
Polio—a paralyzing disease that usually affects the legs but can, in rare cases, affect the diaphragm and make it impossible to breathe—has probably been around for thousands of years. (An Egyptian tablet from the sixteenth century BCE portrays a priest with what appears to be a leg withered by polio.) Even though polio vaccines were invented in the mid-1950s and early 1960s, for decades they didn’t reach everyone who needed them. As recently as the late 1980s, there were still 350,000 cases of wild polio every year, in 125 countries.[*2]
But in 1988, the WHO and its partners—led by the volunteer group Rotary International—set out to eradicate polio. By adding a vaccine for it to the list of routine childhood immunizations, and by undertaking massive vaccination campaigns, the world cut cases of wild poliovirus from 350,000 a year to fewer than a dozen in 2021. That’s a drop of more than 99.9 percent! And instead of existing in 125 countries, wild polio exists in only two: Afghanistan and Pakistan.
Ending polio. A worldwide effort has caused wild polio cases to plummet, from 350,000 in 1988 to just 5 in 2021. (WHO)
A main ingredient in the secret sauce is what are known as emergency operations centers, or EOCs. These have been around for the past decade, starting in Nigeria and becoming the mainstay of the polio program in more than a dozen countries where polio has been hardest to eliminate.
Picture the office of a political campaign in the last days before the election, and you’ll get an idea of what an EOC looks like. Maps and charts are pasted up on the walls, but instead of tracking poll numbers, they’re revealing the latest polio data. It’s the nerve center where public health workers from the government and international partners (such as the WHO, UNICEF, CDC, and Rotary International) drive the response to any reports of polio—in a paralyzed child, or if the virus is found in a sewage sample. (I’ll explain more about sewage sampling in the next chapter.)
Nigeria’s national emergency operations center, in Abuja, is a hub for dealing with public health threats, including Ebola, measles, and Lassa fever—and in 2020, it quickly pivoted to COVID.
EOCs typically oversee the distribution of millions of doses of oral polio vaccine every year, managing tens of thousands of vaccinators who go house to house to vaccinate children multiple times, maintaining relationships with local leaders to stamp out misperceptions and misinformation about vaccines, and using digital tools to find out whether vaccinators are able to reach all of the places they’re scheduled to go.
Thanks to this system, the staff at an EOC even know how many households refuse to have their children vaccinated. The measurement is incredibly precise: The coordinator of Pakistan’s national EOC reported that they had reduced the refusal rate from 1.7 percent in 2020 to 0.8 percent the next year, and that in one campaign, just 0.3 percent of households had refused the vaccine. And in March 2020, the government used its polio EOC as the model for one focused on COVID.
The GERM team should be a worldwide EOC on steroids. Just as emergency operations centers fight endemic diseases like polio while staying ready to pivot when something new emerges, the GERM team would do double duty as well—only with the focus reversed. Emerging diseases should be their top priority, but when there isn’t an active pandemic threat, they would keep their skills sharp by helping out with polio, malaria, and other infectious diseases.
You might have noticed one obvious activity that’s missing from GERM’s job description: treating patients. That’s by design. GERM wouldn’t need to replace the rapid response clinical experts like those at Médecins Sans Frontières. Its job would be to coordinate their efforts and complement their work by doing disease surveillance, computer modeling, and other functions. No one from GERM would be responsible for caring for patients.
I put the cost of running the GERM team in the neighborhood of $1 billion a year to cover salaries for 3,000 people plus equipment, travel, and other expenses. To put that number in perspective: $1 billion a year is less than one one-thousandth of the world’s annual spending on defense. Given that it would be an insurance policy against a tragedy that costs the world trillions of dollars—as COVID has—and also help drive down the human and financial burden caused by other diseases, a billion dollars a year would be a bargain.[*3] Don’t think of this spending as charity or even traditional development assistance. Just like defense spending, it would be part of every nation’s responsibility to ensure the safety and security of its citizens.
The GERM team is essential to running a proper monitor-and-respond system, and I will return to it repeatedly in the coming chapters. You’ll see the crucial role it will play in every aspect of pandemic prevention: disease surveillance, coordinating the immediate response, advising on the research agenda, and running tests of systems to find their weak spots. Let’s turn first to the problem of how you detect an outbreak to begin with.
*1 There are also about 740,000 volunteer firefighters in the United States.
*2 I’m specifying “wild” poliovirus here to distinguish it from vaccine-derived cases, which are quite rare.
*3 This organization should not be paid for by private citizens. It needs to be accountable to the public and have authority from the WHO.
CHAPTER 3 GET BETTER AT DETECTING OUTBREAKS EARLY
How many times have you been sick in your life? Most people have probably suffered through a number of colds and stomach bugs, and if you’re unlucky, you may have caught something worse like the flu, measles, or COVID. Depending on where you live in the world, you may have dealt with malaria or cholera.
People get sick all the time, but not every illness leads to an outbreak.
The task of watching for the cases that are merely troublesome, the ones that could be catastrophic, and everything in between—and ringing the alarm bell when necessary—is known as epidemic disease surveillance. The people who do disease surveillance aren’t looking for a needle in a haystack; they’re looking for the sharpest, deadliest needles in a mountain of somewhat duller ones.
The term surveillance has an unfortunate Orwellian connotation, but in this sense it just refers to the networks of people around the world who keep track of what’s happening with health day to day. The information they provide does everything from shaping public policy to informing the decision about which strain of flu you’ll be vaccinated against each year. And as COVID has made clear, the world woefully underinvests in disease surveillance. Without a stronger system, we won’t detect potential pandemics soon enough to prevent them.
Fortunately, this is a solvable problem, and in the rest of this chapter I’ll explain how we can solve it. I’ll start with the local health care workers, epidemiologists, and public health officials who are the first people to see evidence of a pandemic in the making. Next, I’ll explain some of the obstacles that make disease surveillance difficult for everyone—the fact that many births and deaths are never officially recorded, for example—and tell you about how some countries are overcoming these hurdles.
Finally, I’ll explore the cutting edge of disease surveillance: the new tests that will radically change the way doctors detect diseases in their patients, and a novel citywide approach to studying the flu that was pioneered in my hometown of Seattle. (The twists and turns and ethical dilemmas in that story are intense.) By the end of this chapter, I hope to persuade you that, with the right investments in people and technology, the world can get ready to see the next pandemic coming before it’s too late.
* * *
January 30, 2020, marked a major milestone in the COVID pandemic: The director-general of the WHO declared the disease a “Public Health Emergency of International Concern.” That’s an official designation under international law, and when the WHO invokes it, every country in the world is supposed to respond by taking various steps.[*1]
Although a few diseases, such as smallpox and new types of flu, are so alarming that they’re supposed to be reported as soon as they’re detected, most of the time the system operates as it did with COVID. The WHO—trying to protect the public without causing panic—waits until it has enough data before setting a major international response into motion.
One source of information, as you might expect, is the everyday operations of a health care system: doctors and nurses interacting with their patients. With a few exceptions such as the ones I mentioned earlier, a single case of some disease isn’t going to set off alarm bells; most staffers at a clinic won’t be unnerved by one individual who shows up with a cough and a fever. Generally, it’s the suspicious-looking clusters of cases that will draw attention.
This approach is called passive disease surveillance, and here’s how it works. The staff at a clinic pass information about the cases of reportable diseases they’re seeing up the chain to their public health agency. They won’t share details about each case, but they will give the aggregate numbers of reportable illnesses. From there, ideally, the data will be fed into a regional or global database, which makes it easier for analysts to see patterns and respond accordingly. Countries in Africa, for example, enter aggregated data on certain diseases into something called the Integrated Disease Surveillance and Response system.
Suppose their aggregate data shows an unusual number of pneumonia cases in health care workers. That’s a red flag, and hopefully an analyst for a state or national health agency who’s monitoring the database will note the spike in cases and mark it for further investigation. In the world’s most advanced health systems, the spike might be flagged by a computer system, which then notifies people at the health agency that they need to take a closer look.
Once you suspect there is an outbreak, you need to find out far more than the number of cases. You first need to confirm that the numbers are higher than expected, which requires knowing the size of the population you’re dealing with, based on tracking the numbers of births and deaths—a subject I’ll return to later in this chapter. If you determine that the disease might spread quickly, you need information such as exactly who was infected, the locations where the infected people might have picked up the pathogen, and the people to whom they may have passed it. Gathering this information can be a time-consuming task, but it’s an essential step in disease surveillance, and one of the many reasons that health systems need to be well funded and staffed.
Clinics and hospitals are primary sources of information about the diseases that are passing through a community, but they aren’t the only ones. After all, they see only a small fraction of what’s going on. Some people who are infected don’t feel sick enough to bother going to the doctor, particularly if getting to the clinic is expensive or especially onerous. Others don’t have any reason to see a doctor, because they don’t feel the least bit sick. And some diseases spread so quickly that it’s a bad bet to wait for infected people to show up at the clinic. By the time you notice a jump in cases, it may be too late to stop a big outbreak.
That’s why, in addition to monitoring the people who come to clinics and hospitals, it’s important to go looking for known diseases by meeting potential patients where they are. That’s called active disease surveillance, and a great example is the outreach done by workers in polio campaigns. They go on rounds in the community not only to vaccinate children but also to be alert for kids with polio symptoms, such as unusually weak leg muscles or leg paralysis that can’t otherwise be explained. And polio surveillance teams can often do double duty, as they did during the Ebola epidemic in West Africa in 2014–15, when they were trained to watch for telltale signs of Ebola as well as polio.
Some countries are developing smart ways to get even more eyes watching for signs of danger, whether they’re coming from a known disease or a new one. Most of the major outbreaks in recent years also showed up in blog posts and social media. This data can be subjective, and there’s a lot of noise surrounding the signal, particularly online, but it’s often a useful supplement to the insights that health officials get from more traditional indicators.
In Japan, postal workers perform some health services and disease surveillance. In Vietnam, teachers are trained to file a report with local health authorities if they ever notice that several children are absent from school with similar symptoms in the same week, and pharmacists are instructed to raise the alarm when they see a spike in sales of medicines for fever, cough, or diarrhea.
Another relatively new approach is to go looking for signals in the environment. Many pathogens, including poliovirus and coronaviruses, show up in human feces, so you can detect them in the sewage system. Workers take samples of wastewater from treatment plants or open sewers and bring them to a lab, where they’re checked for these viruses.
If the sewage samples come back positive, someone will visit the community they came from to identify people who might be infected, step up vaccination efforts, and educate everyone on what to watch for. The idea of checking wastewater was first developed for polio surveillance, but in some countries the technique is also employed to study the use of illicit drugs and the spread of COVID. Studies have shown it can even be part of an early warning system, letting officials prepare for a surge in cases before they show up in clinical test results.
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In most rich countries, it is hard to be born or die without the government recording it—the odds are high that the event will be entered into a birth or death registry. But in many low- and middle-income countries, that’s not the case.
Many of them estimate the number of births and deaths using household surveys that are held several years apart, which means they don’t have precise data—just a wide range of possible numbers. And it may take years for someone’s birth or death to be counted in the government’s records, if it ever gets counted at all. According to the WHO, only 44 percent of children born in Africa show up in their government’s registry. (In Europe and America, more than 90 percent do.) In low-income countries, just one out of every ten deaths is recorded by the government, and only a tiny fraction of those records includes a cause of death. Many communities where births and deaths aren’t recorded are essentially invisible to their country’s health system.
Given the challenge of recording major life events, it is hardly surprising that many cases of illness in these communities go undetected too. At the end of October 2021, estimates showed that about 15 percent of COVID infections worldwide were being detected. In Europe the rate was 37 percent, but in Africa it was only one percent. With so little precision, and with samples taken only every few years, the death statistics won’t help us detect or control an epidemic.
When I first got involved in global health, around 10 million children under the age of five were dying every year, the vast majority of them in low- and middle-income countries. That number was shocking on its own, but even worse, the world knew little about why these children died. Official reports would show a huge percentage of deaths that were simply labeled “diarrhea,” but lots of pathogens and conditions can cause diarrhea, and since nobody knew for certain which ones were the main causes of child mortality, we didn’t know how to prevent those deaths. Over time, the Gates Foundation and other organizations funded studies that pointed to rotavirus as a major cause, and researchers were able to develop an affordable rotavirus vaccine that prevented more than 200,000 deaths in the past decade and will prevent more than half a million by 2030.
Yet identifying rotavirus as a chief culprit solved only one of the mysteries of child mortality. The places that experience the highest rates of child mortality are also, not coincidentally, the ones that are least well equipped with diagnostics and other tools that might help them understand what happened. A large share of the deaths happen at home, not in a hospital, where the staff could have recorded the child’s symptoms. It has taken dozens of studies to gain an understanding of questions like why children die in their first thirty days of life and which respiratory diseases cause the most child mortality.
Mozambique is a good example of how the system can work better. Until fairly recently, the government there counted deaths by surveying small samples of the country every few years and then using the data to estimate nationwide mortality. In 2018, though, Mozambique began building what’s known as a “sample registration system,” which involves continuous surveillance in areas that are representative of the country as a whole. Data from these samples is fed into statistical models that make high-quality estimates about what’s going on throughout the nation. For the first time, Mozambique’s leaders can see accurate monthly reports on how many people died, how and where they died, and how old they were.
Mozambique is also one of several countries that are deepening their understanding of child mortality by participating in a program called Child Health and Mortality Prevention Surveillance, or CHAMPS, a global network of public health agencies and other organizations. The genesis of CHAMPS dates back nearly two decades to some of my earliest meetings on global health, when I was hearing from experts about the gaps in the field’s understanding of why children die. I remember asking, “What do the autopsies reveal?” and being educated on how impractical they are in developing countries. A full autopsy is an expensive, time-consuming task, and the child’s family often won’t consent to such an invasive procedure.
In 2013, we funded researchers at the Barcelona Institute for Global Health to refine a procedure called minimally invasive autopsy, or tissue sampling, which involves getting small samples from the child’s body for testing. Sometimes, of course, the family members find it too painful to allow a stranger to study their baby in this way. But many agree to the request.
As the name implies, the process is far less invasive than a full autopsy, yet studies have shown that it produces comparable results. Although it is used in only a small number of cases and wasn’t created with pandemic prevention in mind—the purpose was to give broader insights into child mortality—the information gleaned from minimally invasive autopsies can give researchers early evidence of an outbreak that is killing children.
I witnessed one of these autopsies during a trip to South Africa in 2016. I had read about how the procedure worked, but I knew that watching one in person would help me understand it in a way that no memo or briefing document ever could. It’s an experience that I will never forget.
On July 12, 2016, a baby boy had been born to a family in Soweto, outside Johannesburg. Three days later, he died. His heartbroken parents, hoping to spare other families the same grief, decided to allow doctors to perform the minimally invasive tissue sampling. They also graciously agreed to let me be present when it was done. (I was not there when the request was made.)
At a mortuary in Soweto, I watched as a doctor carefully used a long, narrow needle to remove small samples of tissue from the baby’s liver and lungs. He also drew a small amount of the child’s blood. The samples were stored safely and would later be tested for viruses, bacteria, parasites, and fungal pathogens, including HIV, TB, and malaria. It was over in just a few minutes. Throughout the entire procedure, the medical team treated the boy’s body with great respect and care.
Observing a minimally invasive autopsy in Soweto is a moving experience that I will never forget.
The parents were informed confidentially of the results. I never met them, but I hope they got some answers about what happened to their son, as well as a small measure of solace from the fact that their decision to participate in CHAMPS contributed meaningfully to the world’s efforts to save children like him.
Today, data on more than 8,900 cases from the CHAMPS network is giving researchers valuable insights into child mortality. The minimally invasive autopsy, and the systemic improvements that Mozambique and other countries are making, are deepening our understanding of why people die. We need to expand these innovative approaches to understand even better how we can intervene to save lives.
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Most people will never take a monthly household survey about births and deaths or have anything to do with a CHAMPS-type network. But during COVID, and during major outbreaks in the future, we want to sample the community to find out how many asymptomatic or unreported cases of sickness are out there. The field of diagnostics is rife with innovation to make the process cheaper and simple
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