The Viral Storm

by Nathan Wolfe

  The good news is that the years of harping on about pandemic prevention have begun to pay off. Under the leadership of the forward-thinking government official Dennis Carroll, who directs the Avian Influenza and Other Emerging Threats Unit at the US Agency for International Development (USAID), a large program to understand and develop global capacities to counter Emerging Pandemic Threats (EPT) has flourished, a program that I am proud to be a part of. Other organizations like Google.org and the Skoll Global Threats Fund have identified prediction and prevention of pandemics as a central goal and brought fascinating technological and entrepreneurial perspectives to the problem.

  The US Department of Defense (DoD) has also played a pivotal role. While the press continues to focus almost exclusively on their involvement in wars, the truth is that their international disease tracking and control systems are among some of the strongest in the world. In the name of protecting global troops and combating biological threats, organizations within the DoD like the Defense Threat Reduction Agency (DTRA) and the Armed Forces Health Surveillance Center (AFHSC) have devoted serious technical expertise and resources to understanding the nature of threats, finding diagnostics and treatments, and developing local capacity around the world to help engage microbiologists to fight natural pandemics.

  I’m lucky to be able to work with all of these groups. Together with a number of other organizations, we’re beginning to craft the strategies needed to seed a full paradigm shift from response to prevention in the area of global pandemics. The hope is that it will not take as long as it took public health officials to embrace prevention of diseases like heart disease and cancer, but however long it takes it is imperative we move in this direction.

  * * *

  Another huge problem that interferes with our ability to stop future pandemics is the inaccurate assessment of risk by the public. This is something that I heard referred to as “risk literacy” at the 2010 Skoll World Forum by one of the early founders and constant supporters of the field of pandemic prevention, Larry Brilliant. Larry, who won a prestigious TED prize for his wish to “help stop the next pandemic” has been a central leader in getting this movement off the ground through leadership at Google.org and now the Skoll Global Threats Fund. Larry was a key team member on the smallpox eradication program, so he couldn’t be better suited for the task.

  The term risk literacy is an important one. The idea is that part of the solution is having an informed public that can understand and appropriately interpret information on pandemics.

  Risk literacy, the ability to distinguish between different levels of risk severity, is not only for policy makers. Effective response to natural disasters depends on individual people and how well they stay calm and follow instructions. The constant barrage of threats articulated by the media has led to chronic risk habituation. The only way to break that logjam is for everyone to understand risk, to be able to assess the differences between different kinds of disasters, and to respond appropriately to them.

  Widespread risk literacy will help the public support the massive government expenditures that will be needed to appropriately predict and prevent pandemics. It will give us a sense of how best to expend funds. From April 2001 to August 2002, a period which includes the 9/11 attacks, it’s estimated that around eight thousand people in the world died from terrorism. From April 2009 to August 2010, the same period of time but eight years later, over eighteen thousand people were confirmed dead from the H1N1 pandemic alone—a pandemic dismissed by the public as insignificant. And that number is certainly an underestimate. I’m not claiming that proportionality in deaths is the only factor we should take into account when preparing for threats. But the trillions of dollars spent to prevent terrorism seem wildly disproportionate to actual risks when we put the threats in their proper context.

  * * *

  Perhaps my favorite question to answer is “What are you doing about all of this?” During the past two years, I’ve had the honor of leading an incredible group of scientists and logisticians who work around the clock and around the world to develop and deploy systems with a single objective—to catch pandemics before they spread and stop them.

  This work has come out of the past fifteen years of research I’ve done, much of it described in these pages. In 2008 I made a decision, seen by most of my colleagues as lunatic at the time, to quit my job at UCLA as one of the increasingly rare lifelong tenured professors. I left to start Global Viral Forecasting (GVF), an independent organization devoted to monitoring global medical intelligence and using it to catch pandemics early.

  Based in San Francisco, where I continue to teach at Stanford, GVF uses every possible tool at its disposal to identify and defuse epidemics. In government or academia, there’s always a sense that you should stick to a particular approach to solving a problem. Microbiologists use microbiology and epidemiologists use epidemiology. At GVF the tool is unimportant—we care only about the goal of early actionable intelligence on the trends and movements of infectious diseases in human and animal populations.

  We combine on-the-ground epidemiological tools for early detection of outbreaks and documenting the microbes in human and animal communities with cutting-edge information and communication technologies to monitor “digital signals” of the next plagues. The goal of the organization (to chart infectious diseases and to reach a point when we can predict and even prevent pandemics) is ambitious, but our laserlike focus on a single objective also provides a certain freedom—if it’s not on task, we shouldn’t be doing it.

  Global Viral Forecasting’s sites around the world. (Dusty Deyo)

  No matter what novel technologies and tools we use, there is nothing like on-the-ground information. So the backbone of our work is ongoing field efforts in countries around the world. The objective is to understand the microbes present in animals that might jump into humans. We also chart and follow the microbes that are already in humans that might cause diseases in ways we haven’t identified yet. And finally, we try to catch new outbreaks and epidemics early, before they hit the radar of traditional health and media organizations.

  To do this we conduct regular surveillance in hospital and clinical settings. We also focus energy on particular groups of people we believe to be sentinels—populations that because of their locations or behaviors will, like the canaries in the coal mine, become infected first before a microbe enters wide circulation. Through ongoing monitoring of hunters, we’ve found a range of new microbes that had not previously been seen. Using this kind of painstakingly collected surveillance data, we’ve also documented evidence that known viruses, like human parvovirus 4, have spread much more substantially than was previously considered possible.

  Our model for studying sentinel populations that represent portals of entry for new animal microbes on their route to pandemics has proved very successful. Along with our partners in the USAID-EPT Program, the DoD, and a number of other partners, we are pushing that model out to over twenty countries around the world. Yet more is needed. In each of those countries, we need to monitor more people who are at risk of acquiring new and potentially transmissible agents from the animals they have contact with. We need to be active in more regions of each country in which we work, and we need to expand the effort to many more countries. In many ways, the work of surveillance for potential pandemics has only just begun.

  In addition to studying the points at which agents enter the human population from animals, we also work extensively to monitor critical populations that are central in the networks wherein microbes spread. For example, we carefully follow groups of individuals who receive regular blood transfusions. Since some of these individuals will receive many hundreds of transfusions from numerous people, they will be infected early and can help indicate when something new is on the move. There are many groups of people who are at the center of hubs and will likely be among the first to get a new agent that’s spreading—health care workers and airline flight attendants, to name just two. C
ritical to our work is to continue bringing more of these populations into our monitoring system.

  Animals are vital too. In chapter 9, I outlined the way that the head of GVF’s Ecology Team, Mat LeBreton, and I developed an approach to using simple pieces of standard laboratory filter paper to quickly amass large numbers of blood specimens from animals in the places where we work. To that we have now added monitoring of so-called animal die-offs. Each day, somewhere on the planet, a group of wild animals dies just as the apes in Cameroon who succumbed to anthrax did. Small animal outbreaks provide unique opportunities to understand what microbes are out there.

  Animal die-offs can also presage a human outbreak, as occurs in the case of yellow fever, for example, in South America. Often after the deaths of forest monkeys, human settlements will become infected with the deadly virus. Yet currently very few animal die-offs are identified. Now with help from some of the hunters we work with in biodiverse forests throughout the world, we are beginning to set up a system to investigate more of them. Ideally, we should know whenever a group of animals dies anywhere in the world, but in our current reality we have almost none of this critical information.

  While the majority of our fieldwork at GVF is catching any one of a vast range of new agents, in some of our sites we focus largely on a single known agent. In Sierra Leone, Joseph Fair, the virologist and field epidemiologist who leads GVF’s field and laboratory efforts, has conducted challenging, cutting-edge research to understand and control a deadly virus called Lassa fever. Lassa is a fascinating and dangerous virus that passes from rodents to humans when it comes into homes and contaminates food.

  Lassa causes the same sort of devastating symptoms as Ebola and Marburg. The Lassa site that Joseph has developed in west Africa provides a model that allows us to understand these agents and how best to anticipate and respond to them. Other than Lassa fever, all of the hemorrhagic fever viruses—the deadly class that includes Ebola and Marburg—occur sporadically. Lassa on the other hand, is a regular part of life in these regions. Because it is nearly impossible to really monitor viruses that occur only occasionally, Joseph and his colleagues have used the important sites in Sierra Leone to study and learn the best ways to catch and control these kinds of viruses before they spread. For the fans of outbreak movies, it is a sexy site with a high level of biological containment and workers scrambling to save lives while risking their own. Yet its importance goes far beyond that. If we learn to anticipate and respond well to Lassa, it will help us to make sure that viruses like Ebola and Marburg never get out of control.

  * * *

  Perhaps one of the most exciting things we do at GVF has nothing to do with cutting-edge science. It’s prevention.

  Among the most substantive risks for the emergence of novel pandemics is the close contact between humans and animals, particularly wild mammals. Changing human behavior to decrease this sort of contact can begin long before we have the ideal prediction systems in place.

  Karen Saylors, a devoted medical anthropologist who has been on our team for years, living in field sites in central Africa and now in our headquarters in San Francisco, spends long hours working with GVF teams and other colleagues in field sites around the world to prevent new pandemics. We have conducted this work for years but are now pushing to expand quickly. For nearly a decade Mat LeBreton and his colleague Joseph LeDoux Diffo and others have developed a program we consider central to our work—the Healthy Hunter Program. In this program we try to find ways to decrease the risks of acquiring new viruses in the wild-game hunters we work with in central Africa. Since this is the place and manner in which HIV emerged, we consider the work vital. But it’s not easy.

  I can remember in the early days of my work in central Africa the response I got from hunters when I described my sense of the risks associated with their hunting and butchering wild mammals: “We have done this for years and our parents and grandparents did this for years. Surely it cannot be as much of a risk to us as the many other things that kill us here.” It was a response I was to get in all the places we worked. And there is truth to it. In an environment where malaria, unsafe water, and poor nutrition kill on a daily basis, the risk of acquiring a novel agent from an animal seems minimal. And in some ways it is.

  The problem is a perfect example of a tragedy of the commons. For the vast majority of individual subsistence hunters, the risk of acquiring a novel deadly disease will be less than the nutritional and other costs of not hunting. Yet when many thousands of people in regions with high diversity of microbes hunt wild animals, we enter into a situation that can result in the emergence of some new agents—agents that could devastate the entire planet. The problem is not the hunters’ alone. It belongs to all of us.

  While we work diligently to help inform these people of the risks associated with hunting, we also recognize that the real enemy is rural poverty. To solve this universal problem, we need to do more than explain risks. We need to devote ourselves to helping to find viable solutions to the nutritional needs of rural populations. We need to help them find alternatives to unsafe hunting, and we cannot blame them for trying to feed their families. As we expand our Healthy Hunters Program to more sites, we simultaneously work with development and food organizations to provide real solutions.

  If we could snap our fingers and eliminate the hunting of wild game for subsistence in viral hot spots like central Africa, southeast Asia, and the Amazon Basin, we certainly would do just that. In addition to the risks of pandemics, these practices have well-known negative implications for the biological heritage of our planet and for the food security of vulnerable populations living off non-renewable animal protein sources. Yet the solution will require real energy and resources on a global scale. It will be energy well spent. In addition to the self-serving goals of wealthy populations around the world to stop plagues and preserve biodiversity, it would also help some of the poorest populations in the world to live a reasonable life. The problem of bushmeat is not a boutique issue for those wanting to save some charismatic endangered species. It affects global health, and we cannot afford to ignore it.

  As GVF looks for more partners and more resources to help extend our first efforts at changing the behaviors that allow new agents to enter into our species, we recognize there is more we can do now to prevent the activities that lead to pandemics. And some of the things we can do align perfectly with other public health initiatives. As we discussed in chapter 8, immunosuppression that occurs with AIDS facilitates the entry of new microbes into human populations. We must work to guarantee efforts to extend the antiretroviral drugs that control AIDS to even the most rural populations that have contact with wild animals through hunting. We have worked with some of the pioneers in this field—scientists like Debbi Birx, who left a successful career overseeing a productive research group at WRAIR (Walter Reed Army Institute of Research) to lead the CDC’s Global AIDS Program, which focuses on the nuts and bolts of getting antiretroviral therapy to some of the neediest parts of the world. This will help us all.

  There are ways that each of us can help this process. It is vital that we all put pressure on policy makers and politicians to support long-term approaches to pandemic prevention. An informed public must push governments to provide more funding aimed at generic approaches to controlling future pandemics rather than simply focusing on a single threat.

  In an ideal world we might embrace changes suggested by some in the wake of recent pandemics. At the 2009 TED conference in Long Beach, Fred Goldring, an influential entertainment lawyer, suggested that we should advocate a “safe shake,” where we shake by touching elbows rather than hands. Certainly this would help to decrease the spread of some infectious agents in the same way that sneezing into an elbow rather than a hand does. To my knowledge no one has conducted detailed studies of the health impact of bowing (rather than shaking hands) in countries like Japan, but it would be expected that it should decrease the transmission of some infections. Similarly the p
ractice of wearing surgical masks in public when ill, seen in Japan, could well dampen some bugs from spreading. Changing habits like these is incredibly difficult, but the models show that useful possibilities exist.

  * * *

  You may ask yourself when we will see the ideal control room that began this chapter. Though that scenario was fiction, there is no reason that we need to wait centuries or even decades for it to occur. In fact, one of our goals at GVF is to make this a reality. Our data team, headed up by Lucky Gunasekara, consists of a completely new breed of digitally minded young scientists who meld the work we do in the field with the entirely new set of data we discussed in chapter 10. Detailed data from the field and lab will soon combine with data from cell phones, social media, and other sources to create the ultimate outbreak data mash-up.

  A decade ago the main structures that organized the world’s information were governmental, like the Library of Congress. Yet this was not the final answer. Today, organizations like Google have used innovative methods and incentives to build tools for accessing information that we could barely have dreamt of a few decades ago. We must be open to innovation of this sort in the area of global health. It is often said that organizations like Google have helped create a global nervous system. If we are ever to have the equivalent of a global immune system, we will need to develop new approaches that combine governmental and nongovernmental systems and use the latest approaches and technology.

  In fact, this has already begun. In the coming years, whether you are a head of state wary of political and economic costs of a disease catastrophe, a CEO concerned by supply-chain and staff disruption associated with the next pandemic, or a citizen worried about your family, you will have access to better, more accurate, and rapidly available data on actual outbreaks. And not just from governments but from organizations like my own, which will combine lab results in far-flung viral listening posts with international news feeds, text messages, social networks, and search patterns to create a new form of epidemic intelligence.