In 2015 Bill Gates gave a TED Talk on the importance of preparedness for a global pandemic caused by “a highly infectious virus”.

An Ebola epidemic that began in December 2013, and continued until 2016, had by that time killed around 10,000 people in West Africa. Gates cites three reasons as to why there weren’t more deaths. 1.) The selfless work by front line health workers including locating infected persons and preventing further spread (see Contact Tracing below). 2.) Ebola is not an airborne virus and by the time those who are infected become contagious, most are so ill as to be bedridden. 3.) The virus did not reach many urban areas and this directly kept the number of cases lower than had Ebola spread throughout urban communities.

Yet he also refers to what he calls “a global failure”. Noting the slowness of response. The failure to study treatment approaches, diagnostics and the application of epidemiological and medical tools.

In what has been shown to be an uncomfortably prescient statement Gates notes;

So next time, we might not be so lucky. You can have a virus where people feel well enough while they’re infectious that they get on a plane or they go to a market.

Gates uses the Spanish Flu of 1918 to demonstrate how quickly an airborne virus can spread. He observes that the World Bank have estimated that a global flu epidemic will cause a drop in global wealth of “over three trillion dollars” and there would be “millions and millions of deaths”.

It’s important to note that the present reality with COVID-19 is not absolutely reflected in Gates’ TED Talk. Trends of global financial impact have not yet played out. Total fatalities will be disturbing and many may lose friends and loved ones, yet the prediction of “millions and millions” of deaths is not a current reality.

Nonetheless the reason that the capacity to reduce morbidity and mortality – to flatten the curve – is in our hands is indeed touched on by Gates. Just after the five minute mark he speaks of our ability to use certain tools to create an effective response system. Science and technology. The use of cell phones to inform the public. Satellite maps to inform on the movement of people. Advances in biology and research that will support rapid turnaround of drugs and vaccines to fit the pathogen responsible for the pandemic.

As I touched on above another factor discussed but not labelled as such by Gates, that is presently more robustly employed to reduce the spread of COVID-19 is Contact Tracing. Gates talks about locating infected persons and preventing further spread. In May 2017 African Health Sciences published a review of contact tracing in containing the 2014 Ebola outbreak. However with an airborne coronavirus this has proven, as expected, to be enormously more complicated.

At the time of writing there exists a spectrum of tactics in various countries, with some considered invasive to privacy. Israel has passed emergency laws to allow its security agency, Shin Bet to tap peoples phones without a warrant.

According to the Computational Privacy Group in the case of Singapore (using TraceTogether), Taiwan and South Korea this involves using cell phones and dedicated software in the;

…recording [of] close proximity between people using Bluetooth, WiFi, or GPS data, [which] could help efficiently notify people that they have earlier been in contact with someone now diagnosed with coronavirus and should self-isolate

The CPG have published Can we fight COVID-19 without resorting to mass surveillance? which looks at both location data and contact tracing in different regions, and the technology used.

Reports in Australia have suggested that tracking the public through their phones has been considered and that the federal government is “looking to Singapore” and the TraceTogether app. Victoria’s Department of Health and Human Services has expanded contact tracing to include use of the messaging platform Whispir.

IT News reports;

The department will begin using the cloud-based platform from Thursday to regularly interact with those that have come into close contact with someone who has contracted COVID-19.

The platform, which will automate interactions between the department and select individuals, will also be used to enforce self-isolation for Victorians who have confirmed cases of the virus.

Gates was more than reasonably accurate in predicting our response. Presented without exact figures from the epidemiology and pathology of the infectious agent Gates’ description of how we could and would respond deserves high marks.

Presently we are witnessing the application of the tools at our disposal to flatten the curve of morbidity and mortality. We know that only an effective vaccine can break the back of the pandemic as it now exists. Drugs that target specific symptoms and slow or prevent the impact on COVID-19 comorbidity are greatly needed. The use of cell phone apps to both inform and trace the public is well underway.

Most importantly we have accepted that staying at home, social distancing and increasingly reducing the number of people together in public, together with effective hand washing and smothering of coughs or sneezes are vitally effective measures. Some of these measures should be employed every flu season and it’s hoped we will continue to do just that.

One imagines we will be better prepared in future for the emergence of another pandemic. Gates was right in that we needed to prepare. We see that clearly now in the need for hospital beds, ventilators and other medical equipment. He also noted the necessity of strong health systems in poor countries and presently the need for increased funding in developing nations is a reality. [AlJazeera news video]

To finish off perhaps we should focus on what Gates observed at the end of his talk;

So I think this should absolutely be a priority. There’s no need to panic. We don’t have to hoard cans of spaghetti or go down into the basement. But we need to get going, because time is not on our side.

In fact, if there’s one positive thing that can come out of the Ebola epidemic, it’s that it can serve as an early warning, a wake-up call, to get ready. If we start now, we can be ready for the next epidemic.

Of course we were not utterly unprepared for a pandemic. Far from it. There are global and national agencies throughout the world that focus on both the risk of a viral pandemic and how we can best prepare. Developing nations are closely monitored by organisations such as the WHO and the UN. Still the lack of any treatment or vaccine to prevent COVID-19 has proven to be an enormous hurdle.

Developed nations are in a better position to fund and respond to recommendations. Australia has a Health Management Plan for Pandemic Influenza, last updated in August 2019. The UK has its Pandemic Contingency/Major Infectious Diseases Outbreak Plan. Similar plans exist around the world.

An interesting dynamic in the USA at present is whilst President Trump has criticised the CDC for its response to coronavirus, he had from 2018 cut their budget for global disease management and closed government units dedicated to preventing pandemics.

Trump’s administration has also cut similar funding for the National Security Council (NSC), Department of Homeland Security (DHS), and Health and Human Services (HHS). Other cuts to CDC funding used to manage chronic disease are scheduled for 2021 and as yet have not been approved by Congress. Perhaps justifiably Trump has come under scorn for his approach to the coronavirus outbreak.

Funding for the prevention of pandemics is an essential part of a solid public health budget. Without a doubt these budgets should be designed with input from scientists. By shirking reason and evidence in their pursuit of “alternative facts” and a post truth world, the Trump administration had maneuvered itself into an increasingly perilous position.

One hopes that as we move toward the future and find ourselves past the COVID-19 pandemic that we aim to listen to the evidence, learn from the past and prepare for pandemics we cannot yet predict.

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TRANSCRIPT

00:17
When I was a kid, the disaster we worried about most was a nuclear war. That’s why we had a barrel like this down in our basement, filled with cans of food and water. When the nuclear attack came, we were supposed to go downstairs, hunker down, and eat out of that barrel.

00:37
Today the greatest risk of global catastrophe doesn’t look like this. Instead, it looks like this. If anything kills over 10 million people in the next few decades, it’s most likely to be a highly infectious virus rather than a war. Not missiles, but microbes. Now, part of the reason for this is that we’ve invested a huge amount in nuclear deterrents. But we’ve actually invested very little in a system to stop an epidemic. We’re not ready for the next epidemic.

01:20
Let’s look at Ebola. I’m sure all of you read about it in the newspaper, lots of tough challenges. I followed it carefully through the case analysis tools we use to track polio eradication. And as you look at what went on, the problem wasn’t that there was a system that didn’t work well enough, the problem was that we didn’t have a system at all. In fact, there’s some pretty obvious key missing pieces.

01:51
We didn’t have a group of epidemiologists ready to go, who would have gone, seen what the disease was, seen how far it had spread. The case reports came in on paper. It was very delayed before they were put online and they were extremely inaccurate. We didn’t have a medical team ready to go. We didn’t have a way of preparing people. Now, Médecins Sans Frontières did a great job orchestrating volunteers. But even so, we were far slower than we should have been getting the thousands of workers into these countries. And a large epidemic would require us to have hundreds of thousands of workers. There was no one there to look at treatment approaches. No one to look at the diagnostics. No one to figure out what tools should be used. As an example, we could have taken the blood of survivors, processed it, and put that plasma back in people to protect them. But that was never tried.

02:53
So there was a lot that was missing. And these things are really a global failure. The WHO is funded to monitor epidemics, but not to do these things I talked about. Now, in the movies it’s quite different. There’s a group of handsome epidemiologists ready to go, they move in, they save the day, but that’s just pure Hollywood.

03:22
The failure to prepare could allow the next epidemic to be dramatically more devastating than Ebola. Let’s look at the progression of Ebola over this year. About 10,000 people died, and nearly all were in the three West African countries. There’s three reasons why it didn’t spread more. The first is that there was a lot of heroic work by the health workers. They found the people and they prevented more infections. The second is the nature of the virus. Ebola does not spread through the air. And by the time you’re contagious, most people are so sick that they’re bedridden. Third, it didn’t get into many urban areas. And that was just luck. If it had gotten into a lot more urban areas, the case numbers would have been much larger.

04:17
So next time, we might not be so lucky. You can have a virus where people feel well enough while they’re infectious that they get on a plane or they go to a market. The source of the virus could be a natural epidemic like Ebola, or it could be bioterrorism. So there are things that would literally make things a thousand times worse.

04:39
In fact, let’s look at a model of a virus spread through the air, like the Spanish Flu back in 1918. So here’s what would happen: It would spread throughout the world very, very quickly. And you can see over 30 million people died from that epidemic. So this is a serious problem. We should be concerned.

05:04
But in fact, we can build a really good response system. We have the benefits of all the science and technology that we talk about here. We’ve got cell phones to get information from the public and get information out to them. We have satellite maps where we can see where people are and where they’re moving. We have advances in biology that should dramatically change the turnaround time to look at a pathogen and be able to make drugs and vaccines that fit for that pathogen. So we can have tools, but those tools need to be put into an overall global health system. And we need preparedness.

05:41

The best lessons, I think, on how to get prepared are again, what we do for war. For soldiers, we have full-time, waiting to go. We have reserves that can scale us up to large numbers. NATO has a mobile unit that can deploy very rapidly. NATO does a lot of war games to check, are people well trained? Do they understand about fuel and logistics and the same radio frequencies? So they are absolutely ready to go. So those are the kinds of things we need to deal with an epidemic.

06:13
What are the key pieces? First, we need strong health systems in poor countries. That’s where mothers can give birth safely, kids can get all their vaccines. But, also where we’ll see the outbreak very early on. We need a medical reserve corps: lots of people who’ve got the training and background who are ready to go, with the expertise. And then we need to pair those medical people with the military. Taking advantage of the military’s ability to move fast, do logistics and secure areas. We need to do simulations, germ games, not war games, so that we see where the holes are. The last time a germ game was done in the United States was back in 2001, and it didn’t go so well. So far the score is germs: 1, people: 0. Finally, we need lots of advanced R&D in areas of vaccines and diagnostics. There are some big breakthroughs, like the Adeno-associated virus, that could work very, very quickly.

07:21
Now I don’t have an exact budget for what this would cost, but I’m quite sure it’s very modest compared to the potential harm. The World Bank estimates that if we have a worldwide flu epidemic, global wealth will go down by over three trillion dollars and we’d have millions and millions of deaths. These investments offer significant benefits beyond just being ready for the epidemic. The primary healthcare, the R&D, those things would reduce global health equity and make the world more just as well as more safe.

07:55
So I think this should absolutely be a priority. There’s no need to panic. We don’t have to hoard cans of spaghetti or go down into the basement. But we need to get going, because time is not on our side.

08:09
In fact, if there’s one positive thing that can come out of the Ebola epidemic, it’s that it can serve as an early warning, a wake-up call, to get ready. If we start now, we can be ready for the next epidemic.

08:26
Thank you.