The Four Pillars of Outbreak Preparedness (and How to Rebuild Them)

[MUSIC PLAYING] ADAM LEVINE: I like to say that our global public health system for detecting outbreaks is only as good as the remote nurse working in a rural village in Africa or Indonesia or anywhere else in the world. If that remote nurse is not well trained and able to identify the first case of that epidemic, then our whole system is at risk.

SARAH BALDWIN: From the Watson Institute at Brown University, this is Trending Globally. I'm Sarah Baldwin. According to Johns Hopkins University, the number of COVID-19 cases worldwide is approaching 1 million from Greenland to Guam, from Madagascar to Mongolia.

Here to talk with us this morning and give us a global perspective is Dr. Adam Levine. Adam's director of the Center for Human Rights and Humanitarian Studies at Watson and Director of the Division of Global Emergency Medicine at Brown University's Alpert Medical School.

Adam is no stranger to the front lines of disease outbreak and response. He's an expert in the field of epidemic management. But let's be clear. He's also an emergency medicine doctor. He's in the field providing care under really challenging conditions.

Adam, I've known you for a long time now. And between all you do, the research, the teaching, not to mention being in the emergency room and then rushing off to provide disaster relief in places like Haiti and Rwanda and Libya, I have to admit that for a long time now I've suspected you have a clone. You don't have to tell me if I'm right or not. I just want to say how very glad I am to have you on the show. Thanks for talking with us this morning.

ADAM LEVINE: Thank you, Sarah. It's wonderful to join you.

SARAH BALDWIN: From your personal experience, at what point did you think that these cases of the disease and watching the numbers, when did you think, oh, this is going to be a pandemic?

ADAM LEVINE: Well, I think as a scientist and as a humanitarian, I think in terms of risk. And so there was no point where I said I know for sure this is going to be a pandemic. But I think certainly by late January as we saw the numbers increase rapidly in China, which is quite a developed health care system, and as we saw cases popping up elsewhere around the world, it became clear that there certainly was the risk for this to become a global pandemic.

At the end of the day, that is what is really important-- having a global system that can respond not to definitive cases of a pandemic because by the time there is a pandemic definitively, it's almost too late, but respond to the possibilities of a pandemic quickly in order to try and reduce its impact or maybe even stop it in some cases.

SARAH BALDWIN: How would you rate the global response this time?

ADAM LEVINE: Well, I think in some ways, it has learned the lessons of the past. So in particular, the World Health Organization has improved its capability of responding to pandemics and its ability to identify them much quicker than it had in the past.

So in the aftermath of the Ebola epidemic in West Africa, the World Health Organization reorganized its systems to create a specific health emergencies program that was really set up specifically to identify and respond to large-scale epidemics and pandemics around the world.

They also learned the lesson from the Ebola epidemic by not waiting too long to declare it a public health emergency of international concern, which is really a specific legal definition under the International Health Regulations that almost all countries on the planet are party to and allow basically, in fact, require data sharing between the countries that are affected by the epidemic and the World Health Organization.

And also, even though there's no sort of enforcement capability, they do also require countries around the world to provide support to those countries that are experiencing the epidemic and need help. So the triggering of that early on in the face of this epidemic was certainly the right step.

The reality is, though, that the World Health Organization is still small compared to the budgets of all of the wealthy countries around the world. And their capabilities are limited. Mostly, they are a technical advisory organization. They're a group that can develop best practices and guidelines, has very smart scientists.

But they don't have the resources to actually physically respond and prevent the spread of an epidemic in individual countries. For that, we really have to rely on the countries themselves first and foremost and then really other countries and organizations to support those that can't do it themselves.

SARAH BALDWIN: Well, speaking of global response and helping different countries with different capabilities respond better, your center recently announced that it was partnering with the Global Humanitarian Relief Organization Project HOPE. And the plan is as I've understood it for the two entities to develop a COVID-19 training program for health care workers around the world, especially in high risk countries.

So can you tell us about the goal of such a training program and sort of what's specific about your approach? It's so interesting to me to think of how you're going to train people all over the world when we're all supposed to be sheltering in place and we're thousands of miles apart.

ADAM LEVINE: Yeah, it's incredibly difficult but not impossible. So this grew out of actually a long collaboration that our Center for Human Rights and Humanitarian Studies has had, not just with Project HOPE but with more than a dozen different United Nations agencies such as the World Health Organization and the United Nations Office for the Coordination of Humanitarian Affairs and a number of humanitarian organizations and human rights organizations, including Project HOPE, but also Americares, Human Rights Watch, International Crisis Group, and a number of others.

And so having these sort of longstanding relationships in place mean that when there is an acute emergency such as this COVID-19 pandemic, we can move quickly to apply for funding to work together on projects in order to respond to that acute emergency.

So that's what happened in this case. Project HOPE reached out to us and said that it had received funding and was looking to partner with Brown to develop a training program for COVID-19 that could be specifically implemented in low and middle-income countries around the world that Project HOPE already had partnerships with where they already had country staff in place.

They'd already been working with ministries of health and local health systems in these countries for years to improve the health care delivery in those settings and wanted to be able to do something in these settings to help those systems prepare for COVID-19.

In most cases, these are countries that are not making the headlines because they don't have huge numbers of cases like we've seen in China and South Korea and Europe and the United States, but they will. And they will be part of the next wave of this epidemic that will happen after it's crested perhaps in the northern developed economies after perhaps we've started to forget about it.

And then the developing world and the global south will experience their individual epidemics that will, in fact, probably be much more severe because of their less-developed health systems and will cause more deaths in the end than we've seen in the developed world.

SARAH BALDWIN: So what is the strategy? What does the training program entail?

ADAM LEVINE: So originally when we first began developing it, the idea had been that it could be delivered as an in-person training in these different settings. And that quickly became clear as international borders were closed and airlines stopped flying that it wasn't going to be an in-person training. So instead, we adapted this to a remote training using all the sort of remote tools that we have at our disposal. In general, we are running the training now over a Zoom platform.

We've adapted the training into eight separate modules covering different aspects of COVID-19 preparedness and response, including the public health aspects such as infection prevention and control, surveillance or contact tracing to identify cases and to prevent exposure to those cases, how to screen, how to triage, how to actually care for patients with different levels of severity of illness, and then finally, around risk communication, how we talk to the public about this disease and how we educate the population.

So these different modules are developed by our faculty here at Brown University. And then those trainings are delivered-- those modules are delivered by those faculty over the Zoom platform. And then we have a training of the trainers' manual which is intended for use by these trainers that we're training for them to then be able to take our training and deliver it to others within their health system. And that includes question banks and tests and all sorts of instructions about how to deliver this training themselves.

So right now, we are training about 50 health care leaders in North Macedonia. In a few hours, we're going to start our training of 60 health leaders in Puerto Rico. Later this week, we'll be training leaders in Kosovo and next week in Indonesia. And the idea is that those 50 or 60 participants in our training will each go on to train 50, 100, 500 people, health care workers and public health professionals, in their local setting.

SARAH BALDWIN: I'm wondering-- there is no way to measure the effectiveness of this because all we'll have is how well each country responds, right? Wouldn't it be great to be able to say, if we hadn't done this, this many more people would have gotten sick and died? Do you now what I mean?

ADAM LEVINE: I understand. So I wouldn't say there's no way to measure the effectiveness of this training. But I would say that this is not going to be a randomized controlled trial where we can definitively say this training helped saved x number of lives. What we can say very clearly is how many people we've trained.

We can also talk about how their knowledge has improved. We're using pre and post-tests to determine whether trainer's knowledge has improved. And then they will use those pre and post-tests to determine whether the knowledge of people that they're training has improved.

And then we'll have feedback as well about how the training is being implemented in these various countries partly because of the fact that Project HOPE has teams on the ground in each of these countries already. They have country offices that are already set up.

So they'll be in a place to actually measure kind of the impact of these trainings in specific hospitals and health systems on the ground and report back. So we will have some measure. It may not be a perfect measure of the effectiveness.

SARAH BALDWIN: And speaking of reporting back, will people in these different countries be able to report back and say, hey, we figured this out. This might be useful.

ADAM LEVINE: Yeah, absolutely. We're taking feedback from all of the participants in our trainings who themselves are health leaders in their countries. These are hospital directors and folks in the Ministry of Health. And in addition, it's really important to recognize that there's no one-size-fits-all approach. So the level of resources that different places have is going to be widely different.

The health care staffing is going to be wildly different. Their protocols at the government level for social distancing, for testing, for managing this-- we see that it actually differs even in the United States from one state to another. So it certainly is going to be very different in Indonesia than it's going to be in Kosovo.

SARAH BALDWIN: That's so interesting. I've heard you say, Adam, that pandemics are going to occur more frequently. Can you say a little bit more about why?

ADAM LEVINE: Well, to put it simply, we are a more interconnected world. And we're interconnected in a lot of different ways. So for instance, if you look at Ebola, we've had more than two dozen Ebola epidemics in the last 40 years in sub-Saharan Africa.

The vast majority of those, in fact, pretty much all of them up until the last two, were contained to small areas, either one village or maybe a cluster of villages in a remote area of central or southern or western or eastern Africa.

And what happened in West Africa was for the first time, the disease was able to spread to major cities so in this case, the capitals of Liberia, Sierra Leone, and Guinea and, in fact, orders of magnitude more patients and caused orders of magnitude more deaths as a result of that. And the reason is simply that we've laid down more tarmac roads throughout Africa. And so it's made it easier for people to get from remote villages to big cities.

And then if you take that to another level, as we've seen with the COVID-19 epidemic, you have an epidemic in a province in China. And that province, not just China itself, but that one province is interconnected through airline travel to hundreds of locations around the world. And so you can have a disease that starts in one place spread quickly to all different parts of the world.

And that is the reality of our globalized world. And so it's one that we have to adapt to and get ready for. And we need to think about responding to epidemics not simply at a local level but on a global level.

SARAH BALDWIN: Well, you say response. But what about prevention?

ADAM LEVINE: Prevention is even more important than response. And also, that needs to be done on a global level. I teach a course on human security and humanitarian response at Brown. And I have a whole class in that course on epidemics and pandemics, which I'm going to be teaching remotely this Thursday as it turns out.

And in that class, I talk about sort of the different aspects of outbreak preparedness and response. And there are essentially four different pieces to it. If you don't have all four of those pieces working together, then it doesn't work at all. I think about it like four legs of a chair. If even one of the legs is broken or missing, the whole chair doesn't work. And there's no point in arguing kind of which piece of that we should focus on the most.

And those four aspects are community education and awareness, number two, surveillance and contact tracing, number three, laboratory testing, and number four, clinical management. And all four of those really have to be in place to prevent the spread of an outbreak and to respond to and manage it.

SARAH BALDWIN: Just to underscore the interconnectedness point you were making, those four legs have to be in place pretty much everywhere because it serves--

ADAM LEVINE: Exactly.

SARAH BALDWIN: --no purpose for one country to be really good at it, right?

ADAM LEVINE: I like to say that our global public health system for detecting outbreaks is only as good as the remote nurse working in a rural village in Africa or Indonesia or anywhere else in the world. If that remote nurse is not well trained and able to identify the first case of that epidemic, then our whole system is at risk.

And so health worker training, health worker support, health system preparedness in every country on the planet is key in order to prevent these outbreaks from turning into pandemics again in the future.

Because we will have outbreaks. There are innumerable numbers of diseases out there. Many of them live in animal hosts. And we don't know about them and don't detect them until the random event where they happen to transfer over into a human host. Or one of the many infectious diseases that humans are infected with and never take notice of because it only causes mild symptoms one day mutates and then causes more severe symptoms.

And until that moment happens, there's no way for us to know what that disease is going to be. There's no way for us to stop that moment of transfer into humans or that moment of transfer into a more severe disease. But it's after the first few humans are infected that we have the opportunity to detect it and to respond to it.

And so in that sense, response is prevention. The way to prevent this is going to have a system in place to respond to those first cases anywhere that they happen in the world and then to have multiple systems on top of that, if it's missed at the local level, to have that response at the regional level, if it's missed there, to have the response at the national level, if it's misses there, to have the response at the continental or international level. And all of those different levels have to be in place.

SARAH BALDWIN: Adam, one of the goals of your center or the goal of your center is to bridge the academic-humanitarian divide. I wonder what can academics learn from people on the ground and what can people in the field learn from academics who are basically working on computers.

ADAM LEVINE: Yeah, so one thing I learned early on is that academics and practitioners, specifically in the humanitarian setting academics and humanitarian practitioners, have very different cultures and speak very different languages. And I don't mean their actual languages. I mean the way that they communicate with each other and communicate ideas. And that is a barrier.

Because at the end of the day, they really need each other. And the only way we're going to make humanitarian response better is number one by studying it and learning what works and what doesn't work and then number two by educating the next generation of humanitarian responders, training them into using best practices and using what we know works when they respond.

For decades, humanitarian response has been similar to what medicine was in the middle of the 20th century-- based not on evidence but on a anecdotal see one, do one, teach one model. You do what you were taught to do during your first emergency without knowing if it actually works or helps, and then you teach someone else to do that. And they keep doing it without knowing if it works or helps.

And so what we need actually is a system where every aspect of humanitarian response or as many aspects as we can are actually being studied. We're identifying using evidence the best practices and then teaching and disseminating those best practices to humanitarian responders.

And that's not something the humanitarian community can do on its own. It's also not something the academic community can do on its own because it doesn't have the actual on-the-ground logistics to be able to carry out a research study or to be able to train humanitarian responders in the field. Only through partnerships between academics and humanitarian responders can we have that effect.

SARAH BALDWIN: That's a nice segue back to your partnership with Project HOPE. Is there any way our listeners can support this new effort?

ADAM LEVINE: It's a little bit tricky, but certainly we are hoping to expand the initial pilot training that we've done with Project HOPE to many more countries and many more settings. So certainly, there is a great need for additional support. Our Center for Human Rights and Humanitarian Studies through Brown University can accept donations if people are interested in supporting this work as can Project HOPE, of course, directly.

SARAH BALDWIN: And Project HOPE is projecthope.org. And I also want to say your website, the center's website, is an incredibly comprehensive resource for all things coronavirus related.

ADAM LEVINE: We have a coronavirus resource hub and then more information about our partnership with Project HOPE and other work that we're doing.

SARAH BALDWIN: And that's at watson.brown.edu/chrhs. Well, Adam, I just want to say huge thanks not only for talking with us today, but also for everything you do here and around the world taking big risks to improve and save people's lives. Thank you. And I think I should let you get back to that important work now.

ADAM LEVINE: Thank you, Sarah.

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SARAH BALDWIN: This episode of Trending Globally was produced by Dan Richards and Jackson Cantrell. Our theme music is by Henry Bloomfield. I'm Sarah Baldwin. You can subscribe to us on iTunes, Stitcher, or your favorite podcast app. If you like what you hear, leave us a rating and review on iTunes. It really helps others find the show. For more information about this and other shows, go to watson.brown.edu.

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