The Discussion.

I'm sure you have all noticed the high prevalence of upper respiratory tract infections in the Brisbane community at present.  We don't usually see this till August - September so it is a bit early this year.  Most are relatively mild though inevitably some people end up in ICU and some people sadly die. It reminds us of Covid times though without all the attendant anxiety and public health measures (btw there is still plenty of Covid about and you are justified in wearing an N-95 mask in crowded public spaces right now. I also hope you have had your flu shot!).  

Covid was a virus which was relatively mild but enormously prevalent.  What would it be like if bird flu (H5N1) mutated and had both high contagion and high mortality?  What would we do? Would we close schools?  Would we close the borders again?

Charles Gilks is an International Public Health specialist and Clinical Academic. He is Dean of the School of Public Health at the University of Queensland (UQ).  He was Professor of Tropical Medicine at the Liverpool School of Tropical Medicine then moved to the World Health Organisation. He was in WHO from 2001-2010, as Director of HIV Prevention, Care and Treatment scale-up. He led ART scale-up (including “3by5”); he pioneered the Public Health approach to HIV, and edited all the Prevention and Treatment guidelines that set the global norms and standards for HIV programming. He has published over 240 peer-reviewed papers and his Google H-index is 66.

Professor Charles Gilks is a Public Health Specialist and Clinical Academic with a distinguished career internationally collaborating with organisations such as WHO and UNAID and is currently Dean of the School of Public Health at the University of Queensland.  His presentation led to an interested and at times worried discussion on the global approach to a pandemic.  Brisbane Dialogues would like to thank Professor Gilks for his valuable perspective on what needs to be addressed in future pandemics.

Overview

Professor Gilks addressed in general four key issues.  Firstly, it is important to realise that we are talking about epidemics and pandemics that are infectious in nature.  We are not talking, for example, about a disease like diabetes which is currently in epidemic proportions.  Secondly, what have we learned from the Covid 19 pandemic?  Thirdly, we need to support global control measures. Finally, what do we need to do now?

Key points made by Professor Gilks

• All of the pandemics/epidemics in the last century came from animals.  It is important to distinguish between epidemic which refers to a rapidly spreading disease and endemic which refers to a disease which has stopped spreading rapidly and has stabilised in the community (cf enzootic and epizootic in non-human animals).

• What are the core actions that characterise how hospitals respond to a pandemic?

(i) The system has to recognise unusual disease activity, ie observation and description of the disease. 

(ii) The focus then has to be in finding out what is happening through epidemiological surveillance, and

(iii) what is causing it ie need to identify an agent. 

(iv) There needs then to be intense R&D to identify appropriate diagnostics, followed by industry and academia R&D into vaccines and interventions. (v)Finally appropriate measures need to be implemented to decrease the disease transmission. 

• What have we learned from the Covid 19 pandemic? 

(i)There should be active disease surveillance (China had the surveillance but had a lack of transparency and honesty). 

(ii)There should be rapid and appropriate R&D to identify the causative agent.  (This was discovered and publicised within about 8 weeks of the disease first being acknowledged.)

(iii)There needs to be point of care diagnostics ie diagnostic tools for the agent rather than the disease. 

(iii)There needs to be interventions which treat and stop the spread of the disease.  Note here it was discovered that steroids were more important than anti-virals.

(iv) Finally there needs to be political leadership that has legitimacy at the global level ie UN agencies, WHO, and at governmental level.  

• Political leadership was sometimes good and sometimes bad. China did not have the legitimacy to impose the draconian measures it forced on its population.  Our own Federal government failed in not ordering vaccines quickly enough, it failed when it led a global campaign against China which should have been left to WHO and which needed to be detoxified by the current government. Victoria had a greater amount of infections than other states and responded well.  The UK government led an efficient campaign to get people to lockdown but was criticised heavily for its own non-compliance with the rules, and for its allegedly corrupt behaviour in awarding contracts for eg. PPE equipment.  WHO showed significant leadership in trying to untangle the evasiveness of the Chinese government around the origin of the disease and in trying to identify the animal host and how it had crossed the species barrier.

• Global control measures need to be supported.  WHO has the legitimacy founded in its 1948 charter to impose quarantine on cities (as it has done in Canada) where there is a PHEOC. 

• It is important to maintain some residual level of focus on Covid. It is now endemic and still causing significant issues with significant mortality.  Noted that the life expectancy in Australia has now gone down by one year. 

• What do we need to do now. 

(i) Heightened surveillance is important.  Reference was made to Rumsfeld’s quote of “known knowns, known unknowns, unknown unknowns”.  We do not know where the next challenge will come from.  HIV was circulating for 50-60 years in the Congo before it reached North America and was noticed because of its impact.  Mad Cow Disease came out of nowhere with a totally new infectious agent, the prion, which was just a protein, no nucleic acid, and so challenged the germ based theory of disease.  Its mode of transmission was unknown, possibly through surgery on patients.

(ii) Universities and industry need R&D for diagnostics and vaccines.  From covid has come a whole new revolutionary technology, the mRNA vaccines.  Diagnostic nasal swabs with results available in two hours have been developed. 

(iii) We need to fund international agencies, eg WHO (which has had a funding problem for many years and we need to have good political leadership and transparent exchange of information. 

• Two conclusions:

(i) Invest in basic science

(ii) clinical scientists and investigators need to think outside the box.

Questions/Comments from the table

Q: Was WHO slow off the mark?

A: Yes, it was impacted by its overreaction to avian flu which caused countries to spend millions of dollars unnecessarily.  It was also not sure how to deal with China.

Q: Where did the virus arise?

A: It is unknown.  The labs in Wuhan collected specimens from fruit bats so it could have originated from the lab or from the wild animal markets. There is no definitive answer as to why it crossed the species barrier.  We do not know whether the Chinese government knows.  The information will probably never come out.  At the start of the pandemic scientists were talking to scientists and in fact had published the genome of the virus by the middle of January 2020 but then the Chinese government became involved. 

Q: How early do people realise there is a problem in a pandemic?

A: When healthcare workers die.  Ebola was first recognised as a real problem when Belgian nuns who were looking after patients who were bleeding to death started bleeding to death.

Q: Why do we never hear about the victories? 

A: Covid 19 was a success story as the way we responded was effective.  We have not had a cholera epidemic for a long time.  Small pox has been all but elixatedA.  Zika virus burned itself out. 

Q: What have the politicians/public/experts learned?

A: Would like to be optimistic but some politicians get it and some don’t.  They need to treat individuals as if they are intelligent, to be open and transparent.  Communication is key. 

There was much discussion and questions about legitimacy, transparency, trust and communication.  How do you know who is telling the truth? How do you communicate that you need to go out of business for the public good, to lockdown for the public good.  The suggestion was made that we currently have a lot of transparency but a low level of trust and the comment was made that this could be due to information overload and the difficulty in determining what are credible sources.  

There was discussion about how to have a strong pandemic communication that people can identify with, e.g. in the UK “protect the NHS” and whether our “flatten the curve” was equally successful. A suggestion was made that a pandemic could be framed as an external enemy, we are all in this together.  Reference was then made to the parties in Downing Street and Cummings’ behaviour during lockdown, indicating that we are not all in this together.  

There were questions about the Swedish approach of not locking down, was this better?  Difficult to say as cannot do a trial on lockdown.  Were masks and distancing effective and what was the scientific basis for the type of mask and the level of distancing. 

The comment was made that scientists/academics are not incentivised to think out of the box making it more difficult to deal with unknown unknowns.