SARS: The Pandemic that Never Was: Part 3

0:02 Narrator: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. This episode is part of a series of special editions of our podcast, focusing on the ongoing Coronavirus pandemic.

This week we're doing something a little different. A group of undergraduate students at the University of Michigan School of Public Health recently created a three-part podcast series looking back at the 2003 SARS epidemic and how it relates to the coronavirus pandemic. SARS and COVID-19 are both caused by coronaviruses and share a lot of similarities, but they have had very different effects on the world. In this episode, the students are looking to the future. What can we learn from past epidemics like the 2003 SARS outbreak and from the current COVID-19 pandemic? How can we use this knowledge to be better prepared for the next pandemic?

1:08 Anjali Vaishnav: Alright. Hello and welcome back to SARS: The Pandemic that Never Was. My name is Anjali Vaishnav and today I'm joined by Jon Zelner an assistant professor of Epidemiology at the University of Michigan School of Public Health. Hi Jon, how are you doing today?

1:21 Zelner: Pretty good. Yeah.

1:23 Vaishnav: Awesome. So today I just wanted to dive more deeply into what the future of post SARS COV 1 looked like. We’ve spent some time talking about the history, the social context of this pathogen, and I really wanted to focus on is, if in your eyes, there are really key lessons that were taken away from this time period...if the way that we thought about pandemics and the global impact of disease outbreaks was changed following that SARS epidemic?

1:55 Zelner: Yeah, it's a really good question. I would say yes and no. So on the Yes side, the 2003 outbreak was really kind of a sort of watershed moment in the way, at least in the way that epidemiologists thought about infectious disease transmission at a global level, and it was certainly the beginning of a period of time where people started building mathematical models and thinking more concretely about the ways that spread can happen on a global level.

I think though, what all of the models from the time tended to focus in on was this idea that you could block a pathogen from moving from place to place by constraining international air travel, but not necessarily thinking about what happened as much within the countries once it got there as being this heterogeneous thing, right? So if we think about the pandemic as it's unfolded in the US, we didn't necessarily anticipate that we would have this kind of geographic heterogeneity incompliance with all of these protocols, right? We really always thought of these pandemic preparedness measures as being mostly about keeping the bug out, keeping it from getting in, and I think what we didn't really think about in the US at least, was what happens once it gets here.

So I would say that is kind of how it changed the way we think about this scientifically in the United States, but how it also, we didn't anticipate all of the kind of social and political complexities of the pandemic. I would say if you look at places that were actually hit quite hard, like China, like Taiwan, Hong Kong, you see that there was a level of preparedness that we didn't see here, because people really saw what could happen. And so I think that sparked a different approach that led places like China to clamp down early and hard and to really appreciate the potential for these things to easily get out of control if you're not really on top of the details of testing and transmission and so forth. 

4:29 Vaishnav: Definitely, and that's something we've been coming back to in each episode is what if the US had been hit just as hard as these other countries were during the SARS epidemic. Would the response that we're seeing now look differently? And I guess it's not really a question we'll ever get the answer to, but it's nice to hear that that insight is shared.

4:50 Zelner: Yeah, I wonder. And I don't know that I have the greatest confidence that it would have turned out all that differently here, I think...I guess a question, and you're saying these are impossible to answer, but I think also very important to at least think about, is do we have the political capacity to learn the lessons that we need to learn in a country where public health routinely becomes a political issue and where we're very geographically and economically fragmented, and we don't have a unified approach to public health, and public health is under-funded? So do we have the ability to consume that information or maybe this is the beginning of developing some of that? I'd like to think so, but only time will tell.

5:46 Vaishnav: Definitely. On the topic of communication and political complexity surrounding these pandemics, something that we dove into in our last episode was the role that both the government and the media played in driving disease burden during the SARS epidemic and COVID-19. I was wondering if you had any insight on how we can better ensure more transparent and more accurate information being translated to the public that mitigates misinformation and then increases trust in health, as you said.

6:19 Zelner: So I think it's tricky. I wish I could just say that if we put more data out there and we just kind of gave people more information, then things would be better. But I think there's two challenges associated with that. One is that the way people consume this information always has been and always will be political in nature. And if we think back to things like tuberculosis in the United States in the 1920s and 30s, the messaging around that was very politicized. There was a lot of that around World War I, with sexually transmitted infections and the pandemic flu that arose in as well. So, good information isn't really the only answer.

The other side of that, I think, is that the data, one thing I think we've really seen with this pandemic is that the data are not...you can't just put today's data out there and expect that it will never change or that it's necessarily informative about what's gonna happen next. So it takes a long time for some of the reporting to come in, also when we're thinking about mortality, it can take a long time from infection to death for people, and so it's hard to give a day-to-day snapshot. And it also gives it, I think we saw this very early on, it gives a very unrealistic sense of kind of being up to the minute. Like we're getting the latest data, we see what's happening, our models are predicting what happens next, and that's clearly, the models are valuable, but they're not arbiters of truth. They’re really things that let us think a little bit ahead.

8:06 Vaishnav: Definitely, and I feel like what we've seen now is with all of these increases in the data that's out there for the public to consume, not only is the information overwhelming, but then it also is so much more likely to get misinterpreted by perhaps those that don't look at these models on a daily basis. It isn't necessarily their field of line of work, but yet we're consuming so much of that information.

8:34 Zelner: No, definitely. And I think the other thing is, I think you're right, that people are picking up this data and interpreting it in all of their various ways but you can also turn that around. And I think one of the challenges that we've seen here too is kind of over-confident of experts, of people who should, we're all led to believe, should know something more. And of course, to some extent they do, but that doesn't mean that because you understand what's happened in the past pretty well, that you're gonna be much better at predicting what comes next. And I think the people who made the best predictions about the future weren’t people who, at least with respect to the SARS 2 outbreak, and are people who consume the lessons of the SARS 1 outbreak properly. Which was that this thing was kind of stochastic and tricky and hard to understand and that you should exercise kind of maximal caution, collect as much information as you can, move as quickly as you can, and didn't take the lesson like that, what we need is a model is gonna predict tomorrow, and will tell us what to do and will be agile and respond to it.

So I think if we think about the lessons learned from the first SARS pandemic, I think the people who I think took the best lessons are people like Marc Lipsitch at Harvard who came out early and said, “Look, this thing could infect 60% of the population. We should expect that it will spread. We should behave like it’s going to and do everything we can to prevent that from happening”. Which is kind of like, prepared for the worst case and hope for the best. So to me, that's a really important lesson of this last pandemic. You shouldn't look at the last one that didn't spread globally in the way that this one has and say, “Well, nothing to worry about”. That's like the exact wrong lesson.

10:32 Vaishnav: Yeah, that definitely makes sense. I also wanted to kind of go back to...I was going to pose a question about global collaboration, how we can leverage that more when dealing with these global public health threats but when you mentioned the amount of heterogeneity that's within or even national response, I guess, how do we encourage collaboration on that level in addition to making sure that we're collaborating with other nations and ensuring that these pathogens don't cause the burden that they are today?

11:04 Zalner: Yeah, and that's a great question. I would say a lot of the collaboration on a scientific level does exist. If you think about scientists at the CDC, they're often in close contact with their counterparts in other countries, including the China CDC, public health authorities throughout Asia. So it's not as though that collaboration doesn't exist to a certain extent, but it clearly has not percolated into the policy response this time around and that is primarily a function of I think of two things. One is obviously the political environment. The Trump administration is just a deeply nationalistic and was just intent on pinning the blame for the pandemic on China on whoever else, but not us, and so that really closed the door to really formal high level collaboration. And now there's this thread, this idea of vaccine nationalism, where different countries have their vaccines and there's kind of a competition for who can vaccinate their citizens first and so forth. And again, if we think about the SARS 1, one of the successes of that was the highly international nature of the response, which came in the wake of 9-11 and the beginning of the Afghan war, and so certainly we wouldn't wanna log that as a great era of international collaboration and open-mindedness because it wasn't, but I think there is the US had kind of pivoted towards these kind of global, if you wanna call them alliances. There was just more of an international sort of connectivity at that moment that did facilitate this response from a national security perspective. I don't think that's the way we should approach public health, but it did seem to help in that moment.

13:10 Vaishnav: Definitely. On the topic of vaccine nationalism, this episode is really meant to focus on what are the lessons that we can take away and what does the future of these pandemics look like, and with the most upcoming news with the vaccine development, I was wondering, in your opinion, how do you feel like we can ensure that global health equity and equity with our own country is secured with the development of these new vaccines?

13:37 Zelner: Yeah, no, I think this is the hardest question of the moment. We have limited numbers of doses that are coming out of the pipeline, and so part of it is eventually we'll have enough doses to cover everybody in the United States, and I think we will successfully distribute vaccine to everybody regardless of race, SCS, even nationality. I really think we're going to get a very, very high level of coverage as long as people are willing to take the vaccine. We do have the infrastructure to do that quite well. But when we think about how it's gonna take a while and so you have to get those first doses to the people who are most vulnerable, and thinking about who is most vulnerable is a tricky thing, or how to protect people that are most vulnerable is the tricky thing when you only have so many doses. So it's like if we could just run around and vaccine everybody right now, we had as many doses as we needed and we could just kind of get out there, we would go find elderly people, we’d find people in long-term care facilities, we’d find people in the hospitals and we would just do that.

But since we're kind of all standing in this imaginary queue waiting our turn to get vaccinated, I do think think that the ACAP recommendations that came out to say, “Okay, let's vaccinate people in nursing homes and also workers in those facilities” is exactly the right kind of thing we should be doing. And I think as we go along, we wanna think about how do we maximize the direct protection of vaccination on the people who are most vulnerable, so by vaccinating them, but also how do we ensure that we also get an equitable kind of indirect protection where individuals who are at risk are exposed as minimally as possible? So that means vaccinating healthcare workers, vaccinating teachers, right? So I think there's multiple dimensions to the equity here too. It's not only can we prevent people from getting infected? Can we also open up people's lives in a way that is beneficial and do that again in an equitable way?

So from a selfish perspective, I have two little kids, one of them is back at pre-school, one of them is having school from home, and obviously for me, it would be really good if my almost seven-year-old son could go back to school in person. But at the end of the day, it's like I can wait it out, my wife and I will not lose our jobs, you won't lose our home, but for people who are more on the margins, it becomes just so much more important to have that sort of child care for so many reasons. Child care, education, nutrition, and so on and so forth. So if we think about how this has developed, just as a case in point, a lot of children in private schools are able to go back, but those in public schools, generally speaking, are not by and large. I worry that when we get to vaccinating teachers, so that we can get the kids back in schools, the order of operations may not necessarily be that everybody gets it in proportion to their need. It may be the folks with the connections, with the power, with the ability to get their school districts vaccinated at first will do so. And then those better off kids are gonna be just that much more better off. So I think when we think about what our approach needs to be, we need to think about all the dimensions that come along with vaccinating people. Yeah. Does that answer the question?

17:33 Vaishnav: No, definitely it does.

17:35 Zelner: Mean, we talked about, and this is the domestic part, I don't know if you wanna talk about the international part as well? 

17:41 Vaishnav: Sure, yeah, no, definitely.

17:44 Zelner: I think...So those are the kind of issues or some of the issues in the US, I think globally, it just is just even more thorny because you have some countries that are developing their own vaccines, like the United States, like the UK, like China, Russia has this vaccine that nobody's quite sure about, but they have something maybe, but then there are other countries that countries in Sub-Saharan Africa that are gonna be likely relying on the Chinese vaccine pipeline, and it opens up questions of political power and the relative standing of those countries in the global economy. And one thing that has been kind of swept under the rug a little bit is the risk in countries like South Africa, which have actually done a good job of controlling their pandemic or controlling the epidemics in their country, but I don't know what's going on in terms of inequality in these different contexts, but it's hard to believe that when vaccines become available, we won't see the same kinds of patterns playing out like we would expect in the US. And I just don't know what to expect from that. But I think it's just an enormously tricky problem. 

And when you think about these MRNA vaccines that need to be part of a cold chain, getting those out to people in places that are more remote becomes really problematic and I wonder if there's gonna be differences in efficacy associated with the type of vaccine product. I don't know if that's true or not, but there are some, the MRNA ones seem to have very high efficacy, very high levels of protection, whereas the ones that are delivered by a virus vector, we haven't really seen the efficacy numbers on those yet. They may be really, really good, but they might also be just a little bit lower down, so it's like If wealthier countries, wealthier people are getting the more efficacious vaccine, that also I think is obviously really problematic.

20:02 Vaishnav: Definitely. I think there's multiple layers to all of these levels of achieving equity, and at each there's another hurdle and another hurdle.

20:09 Zelner: Yeah, oh yeah.

20:11 Vaishnav: Definitely. Well, thank you so much for your time, we really appreciate it.

20:16 Zelner: Oh yeah, it's my pleasure. I love that you guys are doing this, and I think if there was ever a time to look back in recent history and say “what have we learned?”, this is that moment. And I think this is the exact right comparison. And often in public health, we don't get credit for success because things that just that don't happen are very hard to kind of explain to people that we were lucky that they didn't happen and they might not have happened because of something that we did. And I think we're doomed to kind of repeat the cycle over and over again, but I think that by doing a bit of an autopsy on the last almost pandemic and talking about trying to get to the root, like you're doing, of why did this not turn out to be the catastrophe that it could have. I think what more important question is there right now when we're kind of living through this just unfolding and seemingly unending (although I hope that we’ll soon turn the corner on it) situation?

21:25 Vaishnav: Definitely, and as do I. And hopefully with this information, we can better inform ourselves and whoever else has listened today. So thank you again, really appreciate it. And thank you for all this information on managing not only the current outbreak but what the future looks like ahead.

21:40: Zelner: Yeah. Thanks a lot. Have a good one.

21:51 Narrator: This was the final episode in a three-part series produced by students at the University of Michigan School of Public Health. If you haven’t listened to the other two episodes in the series yet, be sure to check them out on our website at publichealth.umich.edu/podcast or wherever you listen to podcasts.

This has been a special edition of Population Healthy, a podcast from the University of Michigan School of Public Health. During the ongoing coronavirus pandemic, we’ll work to bring you analysis from our community of experts to help you understand what this public health crisis means for you. To stay up-to-date in between special edition episodes, be sure to check out our website publichealth.umich.edu, subscribe to our Population Healthy newsletter at publichealth.umich.edu/news/newsletter and follow us on Twitter, Instagram, and Facebook @umichsph.