The Epidemiologist Who Helped Defeat Smallpox Explains What's Coming

Steven Levy: I was in the room in 2006 when you gave that TED talk. Your wish was “Help Me Stop Pandemics.” You didn't get your wish, did you?

Epidemiologist Larry Brilliant: No, I didn't get that wish at all, although the systems that I asked for have certainly been created and are being used. It's very funny because we did a movie, Contagion—

We're all watching that movie now.

People say Contagion is prescient. We just saw the science. The whole epidemiological community has been warning everybody for the past 10 or 15 years that it wasn't a question of whether we were going to have a pandemic like this. It was simply when. It's really hard to get people to listen. 

I mean, Trump pushed out the admiral on the National Security Council, who was the only person at that level who's responsible for pandemic defense. With him went his entire down line of employees and staff and relationships. And then Trump removed the [early warning] funding for countries around the world.

I've heard you talk about the significance that this is a “novel” virus.

It doesn't mean a fictitious virus. It’s not like a novel or a novella.

Too bad.

It means it's new. That there is no human being in the world that has immunity as a result of having had it before. That means it’s capable of infecting 7.8 billion of our brothers and sisters.

Since it's novel, we’re still learning about it. Do you believe that if someone gets it and recovers, that person thereafter has immunity?

So, I don't see anything in this virus, even though it's novel, [that contradicts that]. There are cases where people think that they've gotten it again, [but] that's more likely to be a test failure than it is an actual reinfection. But there's going to be tens of millions of us or hundreds of millions of us or more who will get this virus before it's all over, and with large numbers like that, almost anything where you ask “Does this happen?” can happen. That doesn't mean that it is of public health or epidemiological importance.

Is this the worst outbreak you’ve ever seen?

It's the most dangerous pandemic in our lifetime.

We are being asked to do things, certainly, that never happened in my lifetime—stay in the house, stay 6 feet away from other people, don’t go to group gatherings. Are we getting the right advice?

Well, as you reach me, I'm pretending that I'm in a meditation retreat, but I'm actually being semi-quarantined in Marin County. Yes, this is very good advice. 

But did we get good advice from the president of the United States for the first 12 weeks? No. All we got were lies. Saying it’s fake, by saying this is a Democratic hoax. There are still people today who believe that, to their detriment. Speaking as a public health person, this is the most irresponsible act of an elected official that I've ever witnessed in my lifetime. 

But what you're hearing now [to self-isolate, close schools, cancel events] is right. Is it going to protect us completely? Is it going to make the world safe forever? No. It's a great thing because we want to spread out the disease over time.

Flatten the curve.

By slowing it down or flattening it, we're not going to decrease the total number of cases, we're going to postpone many cases, until we get a vaccine—which we will, because there's nothing in the virology that makes me frightened that we won’t get a vaccine in 12 to 18 months. Eventually, we will get to the epidemiologist gold ring.

What’s that?

That means, A, a large enough quantity of us have caught the disease and become immune. And B, we have a vaccine. The combination of A plus B is enough to create herd immunity, which is around 70 or 80 percent.

I hold out hope that we get an antiviral for Covid-19 that is curative, but in addition is prophylactic. It's certainly unproven and it's certainly controversial, and certainly a lot of people are not going to agree with me. But I offer as evidence two papers in 2005, one in Nature and one in Science. They both did mathematical modeling with influenza, to see whether saturation with just Tamiflu of an area around a case of influenza could stop the outbreak. And in both cases, it worked. 

I also offer as evidence the fact that at one point we thought HIV/AIDS was incurable and a death sentence. Then, some wonderful scientists discovered antiviral drugs, and we've learned that some of those drugs can be given prior to exposure and prevent the disease. Because of the intense interest in getting [Covid-19] conquered, we will put the scientific clout and money and resources behind finding antivirals that have prophylactic or preventive characteristics that can be used in addition to [vaccines].

When will we be able to leave the house and go back to work?

I have a very good retrospect-oscope, but what's needed right now is a prospecto-scope. If this were a tennis match, I would say advantage virus right now. But there's really good news from South Korea—they had less than 100 cases today. China had more cases imported than it had from continuous transmission from Wuhan today. The Chinese model will be very hard for us to follow. We're not going to be locking people up in their apartments, boarding them up. But the South Korea model is one that we could follow. Unfortunately, it requires doing the proportionate number of tests that they did—they did well over a quarter of a million tests. In fact, by the time South Korea had done 200,000 tests, we had probably done less than 1,000.

Now that we've missed the opportunity for early testing, is it too late for testing to make a difference?

Absolutely not. Tests would make a measurable difference. We should be doing a stochastic process random probability sample of the country to find out where the hell the virus really is. Because we don't know. Maybe Mississippi is reporting no cases because it's not looking. How would they know? Zimbabwe reports zero cases because they don't have testing capability, not because they don't have the virus. We need something that looks like a home pregnancy test, that you can do at home.

If you were the president for one day, what would you say in the daily briefing?

I would begin the press conference by saying "Ladies and gentlemen, let me introduce you to Ron Klain—he was the Ebola czar [under President Barack Obama], and now I’ve called him back and made him Covid czar. Everything will be centralized under one person who has the respect of both the public health community and the political community." We're a divided country right now. Right now, Tony Fauci [head of the National Institute of Allergy and Infectious Diseases] is the closest that we come to that.

Are you scared?

I'm in the age group that has a one in seven mortality rates if I get it. If you're not worried, you're not paying attention. But I'm not scared. I firmly believe that the steps that we're taking will extend the time that it takes for the virus to make the rounds. I think that, in turn, will increase the likelihood that we will have a vaccine or we will have a prophylactic antiviral in time to cut off, reduce, or truncate the spread. Everybody needs to remember: This is not a zombie apocalypse. It's not a mass extinction event.

Should we be wearing masks?

The N95 mask itself is extremely wonderful. The pores in the mask are three microns wide. The virus is one micron wide. So, you get people who say, well, it's not going to work. But you try having three big, huge football players who are rushing for lunch through a door at lunchtime—they're not going to get through. In the latest data I saw, the mask provided 5x protection. That's really good. But we have to keep the hospitals going and we have to keep the health professionals able to come to work and be safe. So, masks should go where they’re needed the most: in taking care of patients.

How will we know when we’re through this?

The world is not going to begin to look normal until three things have happened. One, we figure out whether the distribution of this virus looks like an iceberg, which is one-seventh above the water, or a pyramid, where we see everything. If we're only seeing right now one-seventh of the actual disease because we're not testing enough, and we're just blind to it, then we're in a world of hurt.

Two, we have a treatment that works, a vaccine or antiviral.

And three, maybe most important, we begin to see large numbers of people—in particular nurses, home health care providers, doctors, policemen, firemen, and teachers who have had the disease—are immune, and we have tested them to know that they are not infectious any longer. And we have a system that identifies them, either a concert wristband or a card with their photograph and some kind of a stamp on it. Then we can be comfortable sending our children back to school, because we know the teacher is not infectious.

And instead of saying "No, you can't visit anybody in nursing home," we have a group of people who are certified that they work with elderly and vulnerable people, and nurses who can go back into the hospitals and dentists who can open your mouth and look in your mouth and not be giving you the virus. When those three things happen, that's when normalcy will return.

Is there in any way a brighter side to this?

Well, I'm a scientist, but I'm also a person of faith. And I can't ever look at something without asking the question of isn't there a higher power that in some way will help us to be the best version of ourselves that we could be? I thought we would see the equivalent of empty streets in the civic arena, but the amount of civic engagement is greater than I've ever seen. But I'm seeing young kids, millennials, who are volunteering to go take groceries to people who are homebound, elderly. I'm seeing an incredible influx of nurses, heroic nurses, who are coming and working many more hours than they worked before, doctors who fearlessly go into the hospital to work. I've never seen the kind of volunteerism I'm seeing.

I don't want to pretend that this is an exercise worth going through in order to get to that state. This is a really unprecedented and difficult time that will test us. When we do get through it, maybe like the Second World War, it will cause us to reexamine what has caused the fractional division we have in this country. The virus is an equal opportunity infector. And it’s probably the way we would be better if we saw ourselves that way, which is much more alike than different.   

This interview is from Wired.

Larry Brilliant, MD MPH: Chair, Ending Pandemics; CEO, Pandefense; former Chair, National Bio-Surveillance Advisory Subcommittee; former Prof Epidemiology, UMich, Head of Google.org, CEO Skoll Global Threats, smallpox eradication program WHO, CDC, board member Skoll Foundation, Salesforce.org founder, Seva Foundation, co-founder The Well and author of Sometimes Brilliant and The Management of Smallpox Eradication. TIME100 and Ted Prize; multiple honorary doctorates, CNN on-air analyst @larrybrilliant. info@larrybrilliant.com