Preparing for emerging epidemics

A conversation with William Powderly, MD, the director of the Institute for Public Health

Q: How should we as a society approach emerging infectious diseases?

William Powderly, MD, is the director for the Institute for Public Health, the William Campbell Professor of Medicine and co-director of the Division of Infectious Diseases. (Photo: James Byard)
William Powderly, MD, is the director of the Institute for Public Health, the William Campbell Professor of Medicine and co-director of the Division of Infectious Diseases at Washington University. (Photo: James Byard)

WP: What has tended to happen over the past 30 to 40 years is that a crisis happens; money is invested into it; things settle down; funding is reduced. When the next crisis happens, we are not as prepared as we should be, and we have to start the process over again.

The fundamental lesson is that we need to have sustained investment in a public health infrastructure, not only in the United States, but across the world, to be able to get an early indication of a disease when it is emerging and ideally start to plan to control it before it becomes an epidemic.

It’s a combination of preparing our local and state health departments, strengthening our Centers for Disease Control and Prevention (CDC), and building out from there globally — working with relevant ministries of health through the World Health ­Organization and strengthening WHO, because the Ebola crisis showed it has some issues as well.

I think the Europeans have a very similar view. They’ve gone from each country having its own to having a European CDC equivalent based in Sweden. I think they, too, would see the value of partnering to strengthen preparedness on a worldwide level.

It’s a lot like insurance: If you take the view not to have homeowner’s insurance and to just pay every time a tornado hits and hope that it doesn’t, that’s one approach. And that’s what we’ve been doing with public health regarding preparedness for epidemics.

Many of us think there is a better approach, which is actually to build a baseline insurance system to give infectious disease experts an early warning, so that we are able to see what’s coming and be more prepared.

This is not fanciful; an epidemic is going to happen. We’ve already had examples: Ebola was one. In many ways, we were fortunate with Ebola, even though people were understandably scared, because quarantine works.

If you were to ask most infectious disease specialists “What virus worries you most?” they would say a virulent influenza. People dismissed the pandemic we had in 2009 — the H1N1 strain — yet many people died, particularly younger people and pregnant women. And it spread all over the world very rapidly.

Q: Why do you think the response to influenza is so laissez-faire?

WP: We in the medical field in 2009 saw young people and pregnant women die, but for most people in the community, it was still a flu. They’ve recovered.

We get complacent. The whole measles vaccination situation is an example of people becoming complacent about an illness that they think has gone away — one that doesn’t affect them on a day-to-day basis. If you go back a couple of generations, people remember enough about polio. But that memory will recede, and maybe a generation from now, people will ask, “Who needs a polio vaccine?” Then you’ll see kids with polio. Unfortunately, that’s human nature — not to worry about something because it’s not part of your folk memory.

Q: Could you speak about the need to improve predictive models?

WP: It is certainly an area that needs to be developed. If you were to create an infrastructure to identify disease patterns earlier, then you would need to develop models that actually work. Just as weather predictions have become so much better than, say, 20 years ago, we need similar predictive model — one that could identify whether a small outbreak of a viral infection in country X or country Y could become a worldwide epidemic.

In other words, we would have both the satellite images and warning signals — ways of tracking and saying that this is behaving in a way that is worrying. For example, if tracking found three cases in country X last week and 10 cases this week, we’d be able to infer, if there are 20 cases next week, we need to do something.

Q: Who would be responsible for looking at patterns?

WP: It’s a combination of infectious disease ­epidemiologists, statisticians and data analysts — people who are able to examine the data, pick out the needle in the haystack and see different patterns. It’s people who know how to use data, and they often don’t come from medical backgrounds. The people with the necessary skills might come out of Google, but it would need to be in combination with an infectious disease epidemiologist who understands the dynamics of infection.