THE PROBLEM WITH PANDEMIC PLANNING - Nature
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THE PROBLEM WITH
Feature
PANDEMIC PLANNING
Two decades of war-game scenarios foresaw leaky travel
bans, a scramble for vaccines and disputes between state
and federal leaders. But none predicted Donald Trump.
By Amy Maxmen and Jeff Tollefson
ILLUSTRATION BY ANA KOVA
L
ike all pandemics, it started out small. Morhard was not the only one sounding 150,000 deaths, the country has proved itself
A novel coronavirus emerged in Brazil, the alarm. Event 201 was one of dozens of to be one of the most dysfunctional. Morhard
jumping from bats to pigs to farmers simulations and evaluations over the past and other biosecurity specialists are asking
before making its way to a big city two decades that have highlighted the risks what went wrong — why did dozens of simu-
with an international airport. From of a pandemic and identified gaps in the lations, evaluations and white papers fail to
there, infected travellers carried it to ability of governments and organizations predict or defend against the colossal mis-
the United States, Portugal and China. around the world to respond. steps taken in the world’s wealthiest nation?
Within 18 months, the coronavirus had The exercises anticipated several failures By contrast, some countries that hadn’t ranked
spread around the world, 65 million people were that have played out in the management nearly so high in evaluations, such as Vietnam,
dead and the global economy was in free fall. of COVID-19, including leaky travel bans, executed swift, cohesive responses.
This fictitious scenario, dubbed Event 201, medical-equipment shortages, massive dis- The scenarios still hold lessons for how to
played out in a New York City conference cen- organization, misinformation and a scramble curb this pandemic, and for how to respond
tre before a panel of academics, government for vaccines. But the scenarios didn’t antici- better next time. Deadly pandemics are inev-
officials and business leaders last October. pate some of the problems that have plagued itable, says Tom Frieden, a former director of
Those in attendance were shaken — which is the pandemic response, such as a shortfall of the US Centers for Disease Control and Preven-
what Ryan Morhard wanted. A biosecurity diagnostic tests, and world leaders who reject tion (CDC). “What’s not inevitable is that we
specialist at the World Economic Forum in the advice of public-health specialists. will continue to be so underprepared.”
Geneva, Switzerland, Morhard worried that Most strikingly, biosecurity researchers
world leaders weren’t taking the threat of didn’t predict that the United States would be More than a game
a pandemic seriously enough. He wanted among the hardest-hit countries. On the con- Pandemic simulations first started gaining
to force them to confront the potentially trary, last year, leaders in the field ranked the popularity in the 2000s. Biosecurity and
immense human and economic toll of a global United States top in the Global Health Security public-health specialists took their cue from
outbreak. “We called it Event 201 because we’re Index, which graded 195 countries in terms war-game exercises used by the military, in an
seeing up to 200 epidemic events per year, and of how well prepared they were to fight out- effort to stress-test health systems, see what
we knew that, eventually, one would cause a breaks, on the basis of more than 100 factors. could go wrong and scare policymakers into
pandemic,” Morhard says. President Donald Trump even held up a copy fixing the problems. In these round-table
The timing, and the choice of a coronavirus, of the report during a White House briefing on events, academics, business leaders and
proved prescient. Just two months later, China 27 February, declaring: “We’re rated number government officials made real-time decisions
reported a mysterious pneumonia outbreak in one.” As he spoke, SARS-CoV-2 was already to deal with an expanding crisis, laid out in
the city of Wuhan — the start of the COVID-19 spreading undetected across the country. television-news-style reports.
pandemic that has so far killed around Now, as COVID-19 cases in the United Two early simulations involved biological
650,000 people. States surpass 4 million, with more than attacks, in which other countries unleashed
26 | Nature | Vol 584 | 6 August 2020
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smallpox in the United States. Operation 11,000 people — roughly half of those infected.
Dark Winter, in 2001, and Atlantic Storm, in In response to the drumbeat of epidemics,
2005, were orchestrated by biosecurity think the United Nations commissioned a panel to
IT’S BECOME CLEAR
tanks in the United States and attended by explore how the world could better prepare
influential leaders, such as the former head for future threats. The resulting 2016 report
THAT ALL THE THINGS
of the World Health Organization (WHO), Gro made several recommendations, including
Harlem Brundtland, and Madeleine Albright, investment in vaccines, therapeutics and
WE WORKED ON WERE
the secretary of state under former president diagnostics for emerging infectious diseases
Bill Clinton (see ‘Games without frontiers’). — and a need for “all relevant responders” to
During the course of Dark Winter and
Atlantic Storm, participants found that power NOT COMMENSURATE TO take part in infectious-disease simulations (see
go.nature.com/2pc4bst).
struggles between federal and state leaders
bogged down a health response as the epi-
demic doubled and quadrupled. Hospitals
WHAT WE NEED.” In January 2017, the World Bank and the Bill
& Melinda Gates Foundation in Seattle, Wash-
ington, backed a pandemic simulation at the
were unable to handle the influx of people internationally. Not long after the 2003 out- World Economic Forum in Davos, Switzerland
requiring care, and national vaccine stockpiles break of severe acute respiratory syndrome — a gathering of global leaders in business, pol-
ran dry. Tom Inglesby, director of the Center (SARS) spread to more than two dozen coun- itics and academia. The exercise highlighted
for Health Security at Johns Hopkins Univer- tries, and killed 721 people in mainland China, a need for better coordination between com-
sity in Baltimore, Maryland, which helped Hong Kong and Taiwan, the 194 member states panies, governments and non-profit organiza-
to lead both of the exercises, says that along of the WHO agreed to bolster the world’s tions when it came to managing global supply
with the fresh memory of terrorist and anthrax defences against health threats through a set chains for medical equipment, diagnostic
attacks in 2001, these events encouraged the of rules called the International Health Regula- tests, treatments and vaccines. The scenario
US Congress to act. Not long after the Dark tions. These included commitments by coun- coincided with the launch of an Oslo-based
Winter exercise, the US government commit- tries to invest in pandemic preparedness, and foundation to develop and distribute vaccines
ted to developing a national supply of small- to report outbreaks to the WHO so that other for emerging infections, called the Coalition
pox vaccines. And in 2006, Congress passed nations could be alert. The regulations were put for Epidemic Preparedness Innovations (CEPI).
the Pandemic and All Hazards Preparedness to the test in 2009, when an H1N1 influenza virus It has received funding from the Gates Foun-
Act, to improve the nation’s public-health and is estimated to have killed more than 100,000 dation, the UK biomedical charity Wellcome
medical response capabilities in the event people, and again in 2013, with the spread of and countries including Japan and Germany.
of an emergency. This included funding for Middle East respiratory syndrome (MERS). At the same time, Morhard and his colleagues
research on emerging infections. Then came the world’s largest outbreak of the set about building a network that would coor-
Anxiety about pandemics was also rising Ebola virus, in 2014–16, which killed around dinate logistics and regulations globally, such
Nature | Vol 584 | 6 August 2020 | 27
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.Feature
GAMES
as those associated with the use of potential Health Security Index, and in a complementary
new treatments, if an epidemic caught hold. effort overseen by the WHO, called the Joint
WITHOUT
“We were working on that when this pandemic External Evaluation. When it came to detect-
hit,” Morhard says. “But it’s become clear that ing new pathogens, this ranking commended
FRONTIERS
all the things we worked on were not commen- the United States for its laboratory networks
surate to what we need.” and “an extensive commercial market” for
diagnostic tests.
False security As the coronavirus pandemic gained speed
As these global efforts were under way, Simulations and real-world events have this year, it became clear that the United States
Inglesby felt that his own country wasn’t helped to influence pandemic-preparedness needed more than exceptional lab capacity
devoting enough attention to preparing for policy over the years. and legions of epidemiologists to contain the
a pandemic. The fact that the United States spread of the virus.
saw relatively few deaths from MERS and Ebola 2001: A simulation of a smallpox bioterror
might have given policymakers a false sense of attack, called Dark Winter, precedes a series The reckoning
security, he says. of US anthrax attacks by several months. By late January, Inglesby was anxious. The
In May 2018, with leaders in the White coronavirus outbreak was escalating at a
House and Congress who had never dealt 2003: Severe acute respiratory syndrome frightening pace in China and spreading to
with a major epidemic, Inglesby and his col- (SARS) is reported in Asia. Caused by a other countries, including the United States.
leagues at Johns Hopkins University hosted coronavirus, it spreads to more than two These were the kinds of foreboding signs
an exercise in Washington DC called Clade X. dozen countries. that he had plugged into his simulations.
It featured a respiratory virus that was engi- But the Trump administration seemed to
neered in a laboratory. One early lesson of this 2005: The World Health Organization revises view the outbreak as China’s problem, says
simulation was that travel bans didn’t stop the its International Health Regulations, including Inglesby. During the third week of January,
virus from gaining ground. Infections spread an agreement by countries to improve disease Trump posted one reassuring tweet about
rapidly below the radar because half of the surveillance and reporting. the coronavirus and around 40 regarding his
people infected showed few or no symptoms. impeachment hearings, his rallies and defeat-
Medical supplies ran short, and hospitals were 2009: H1N1 influenza (‘swine flu’) emerges in ing the Democrats. The only public action that
overwhelmed. Federal and state leaders issued the United States. the government took was to screen travellers
conflicting messages. More than 20 months coming from China for symptoms at a handful
passed before a vaccine was available. 2014: An outbreak of the Ebola virus is of international airports.
Six top-line recommendations emerged reported in West Africa. Inglesby knew that travel bans and check-
from the exercise. These included reduc- points don’t sufficiently prevent the spread
ing vaccine production time, and creating a 2015: A Zika virus outbreak is confirmed in of contagious pathogens. So, on 26 January,
“robust, highly capable national public health Brazil. he listed a series of actions needed to prepare
system that can manage the challenges of the United States for the coronavirus — dubbed
pandemic response”. Some argue, however, 2017: A pandemic simulation takes place at nCoV — in a 25-part Twitter thread. “Global and
that this emphasis was misplaced in subse- the World Economic Forum meeting in Davos, national leaders should be looking ahead to
quent discussions. Jeremy Konyndyk, a senior Switzerland. what must be done to prepare for the possibil-
fellow at the Center for Global Development ity nCoV can’t be contained,” he wrote. The list
in Washington DC, says that members of the 2018: Two separate Ebola outbreaks begin in included vaccine development, expansion of
biosecurity community have often focused the Democratic Republic of the Congo. personal protective equipment for health-care
on vaccines, rather than on the complex, workers, and “very high numbers of reliable
systemic deficiencies in the public-health 2019: Event 201, a simulation of a novel diagnostic tests”.
system. They often overlooked the “middle coronavirus pandemic, is held in New York City. These actions are key to curbing most infec-
game” in outbreak responses. tious diseases, but, in an outbreak, they must
“We have a strong end game once there 2020: The SARS-CoV-2 pandemic kills more occur at hyperspeed. Biosecurity experts
is a vaccine, and we have a strong opening than 670,000 people in the first half of the year. had woven this lesson into every simulation,
game if countries contain an outbreak when because muddling the response in the early
case numbers are low,” he says. But insuffi- deepened at local, state and federal levels, as months of an epidemic has catastrophic reper-
cient attention is devoted to harnessing and leaders scrambled to implement policies and cussions. J. Stephen Morrison, director of
coordinating enough health workers and bio- procure equipment. global health policy at the Center for Strategic
medical resources to efficiently test people, A report that followed the simulation noted and International Studies in Washington DC,
treat them, find their contacts and quarantine that the HHS — the agency that oversees the says: “You can’t fart around for weeks on end
them. This is precisely the conundrum that the CDC and the Food and Drug Administration and then give a confused, half-baked, not very
United States finds itself in right now. (FDA) — doesn’t have clear authority to lead a serious response.”
Clade X and other simulations did capture federal response to a pandemic, or access to Infectious-disease researchers were also
the challenge of the missing middle game. For the funds to roll out such a response. But as worried. Fearing undetected transmission in
example, in an exercise conducted by the US with Clade X, the discussion after the simu- the United States, scientists in the states of
Department of Health and Human Services lation focused on straightforward end-game Washington, New York and California started
(HHS) last year, dubbed Crimson Contagion, strategies such as vaccine development, rather vetting tests that detect the genetic sequence
tourists returned from China with a new flu than the more complicated strengthening of of the virus in late January — including a pro-
virus that took hold in Chicago, Illinois, and the national public-health system. tocol developed by German researchers and
infected 110 million Americans (the exercise Still, at least Clade X and Crimson Contagion disseminated by the WHO. But their efforts
assumed the pathogen was more conta- highlighted governmental weaknesses. These to roll tests out for public use hit a wall at the
gious than SARS-CoV-2 is). Disorganization shortcomings were less apparent in the Global FDA, which wasn’t ready to authorize them.
28 | Nature | Vol 584 | 6 August 2020
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.drive policymakers to prioritize and fund
improvements to the public-health system.
Morrison now questions whether it’s even pos-
sible to do that through simulations alone, or
whether people must experience an epidemic
at first hand.
After more than 70 people in Taiwan died
as a result of SARS in 2003, the government
mapped out its emergency-response network.
JOHNS HOPKINS CENTER FOR HEALTH SECURITY
“Every year since then, for the past 17 years,
they’ve held annual outbreak exercises and
practised, practised, practised,” Morrison
says. When the first coronavirus cases were
reported in mainland China, Taiwan’s well-
oiled systems quickly kicked into gear. Despite
its proximity to the outbreak, Taiwan has had
only seven deaths from COVID-19 so far.
Now, the United States has experienced
a tragedy, too. The daily number of new
Public-health specialist Margaret Hamburg at the Clade X pandemic simulation in 2018. COVID-19 cases broke records throughout
much of July, after many states attempted
Meanwhile, officials at the CDC insisted that to reopen their economies. Frieden says
labs exclusively use tests that it had developed. that one of the most crucial actions now is
The CDC started shipping test kits to for health departments to strengthen their
YOU CAN’T FART AROUND
public-health departments on 6 February. response systems by analysing data in real
On a Sunday morning, three days later, Kelly time, so that they can tailor interventions as
FOR WEEKS ON END AND
Wroblewski, the infectious-disease director needed. “The best public-health programme
at the Association of Public Health Labora- is a programme that uses real-time data to
tories in Silver Spring, Maryland, woke up to
a flood of e-mails saying that the tests didn’t THEN GIVE A CONFUSED, make real-time decisions,” he says. “Real life
is our exercise.”
work. “We always knew laboratory testing
was complicated, but it’s something that was HALF-BAKED, NOT VERY But the end game that received the most
attention in the aftermath of many simula-
often overlooked in these simulations,” says
Wroblewski; she had participated in Crimson
Contagion just months earlier.
SERIOUS RESPONSE.” tions — drugs and vaccines — might indeed
be the only way out for countries, such as the
United States and Brazil, that have failed to
While the CDC scrambled to fix the faulty National Institute of Allergy and Infectious contain the virus. Here, too, the simulations
tests, labs lobbied for FDA authorization to Diseases and a leading scientist on the White have warned about the disjointed efforts of
use tests that they had been developing. Some House Coronavirus Task Force. governments and businesses. Biosecurity
finally obtained the green light on 29 February, Confusion emerged in most pandemic experts hope that CEPI and other initiatives
but without coordination at the federal level, simulations, but none explored the conse- to coordinate research and assistance will
testing remained disorganized and limited. quences of a White House sidelining its own finally pay off.
And despite calls from the WHO to implement public-health agency. Perhaps they should Looking forward, many hope that the mis-
contact tracing, many city health departments have, suggests a scientist who has worked in takes in handling the coronavirus will spur a
ditched the effort, and the US government did the US public-health system for decades and fundamental reset in how US policymakers
not offer a national plan. Beth Cameron, a asked to remain anonymous because they did think about pandemic preparedness. This
biosecurity expert at the Nuclear Threat Ini- not have permission to speak to the press. means restructuring health systems, empow-
tiative in Washington DC, which focuses on “You need gas in the engine and the brakes to ering public-health leaders and ensuring that
national-security issues, says that coordina- work, but if the driver doesn’t want to use the all components function in unison in the
tion could have been aided by a White House car, you’re not going anywhere,” the scientist event of a crisis.
office responsible for pandemic preparedness. says. Towards the end of the Event 201 exercise in
Cameron had led such a group during Barack By contrast, New Zealand, Taiwan and New York City last year, participants watched
Obama’s presidency, but Trump dismantled South Korea showed that it was possible to a mock news report forecasting that financial
it in 2018. contain the virus, says Scott Dowell, an infec- turmoil would last for years, or even a decade.
In March, the CDC stopped giving press tious-disease specialist at the Gates Founda- But societal impacts — including loss of faith in
briefings and saw its role diminished as tion who spent 21 years at the CDC and has government and the media — could last even
the Trump administration reassured the participated in several simulations. The places longer. The TV reporter signed off with a ques-
public that the coronavirus wasn’t as bad as that have done well with COVID-19 had “early, tion: “Are we as a global community now finally
public-health experts were saying. An editorial decisive action by their government leaders” ready to do the hard work needed to prepare
in The Washington Post in July by four former he says. Cameron agrees: “It’s not that the US for the next pandemic?”
CDC directors, including Frieden, described doesn’t have the right tools — it’s that we aren’t The pandemic in that simulation failed to
how the Trump administration had silenced choosing to use them.” convince policymakers to act. It remains to
the agency, revised its guidelines and under- be seen whether this one will.
mined its authority in trying to handle the The end game approaches
pandemic. Trump has also questioned the Perhaps the biggest limitation of simulation Amy Maxmen and Jeff Tollefson are senior
judgement of Anthony Fauci, director of the exercises was that they didn’t actually reporters for Nature.
Nature | Vol 584 | 6 August 2020 | 29
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