Civil Society’s Role in a Public Health Crisis

By Jay Walker

When the next major pandemic strikes, it will be accompanied by something never before seen in human history: an explosion of billions of texts, tweets, e-mails, blogs, photos, and videos rocketing across the planet’s computers and mobile devices.

Some of these billions of words and pictures will have useful information, but many will be filled with rumors, innuendo, misinformation, and hyper-sensational claims. Repeated tidal waves of messages and images will quickly overwhelm traditional information sources, including national governments, global news media outlets, and even on-the-ground first responders. As a result, hundreds of millions of people will receive unvetted and incorrect assertions, uncensored images, and unqualified guidance, all of which, if acted on, could endanger their own health, seriously damage their economies, and undermine the stability of their societies.

The impact of technology on pandemics is as old as mankind. When new technologies such as jet travel and global mass transit appear as they did in the 1950s, we update our thinking and containment strategies.

In terms of pandemics, the consumer information revolution today is just as significant a development as the commercial jet was in the 1950s. Within just the past few years, an entirely new worldwide information architecture has emerged. Modern communications enable uncensored, user-generated words, voices, photos, and videos to be broadcast globally by anyone, anywhere, 24/7,at no real cost and often anonymously.

Relatively new technologies, such as texting, chat, blogging, posting, and voice-over-Internet, as well as media platforms, such as Twitter, Facebook, Skype, and YouTube all began as secondary “backchannels” in a much larger information universe. That is no longer true. In the next major pandemic, when fatalities in a developed country start mounting past a few dozen, these backchannels will outrun and overwhelm the front channels of traditional media and official sources in terms of speed, volume, relevance, and credibility. Twenty billion personalized web and mobile messages a day could easily become the norm.

In addition, in a world of low-cost, ubiquitous mobile web and media, groups with destructive agendas could “infect” the information channel with the kind of intentional lies or highly disruptive bio-terror propaganda that will be specifically designed to be quickly forwarded by millions of people in minutes.

Are we prepared?

As a result of a backchannel explosion of unfiltered communications, entire segments of modern societies could easily slide into a kind of anaphylactic shock. Without some kind of effective counterforce, panic, chaos, and disorder are almost certain to break out during the next major pandemic.

There is a fundamentally unmeasurable, but nevertheless high probability that a kind of destructive feedback loop could emerge. If unchecked, it could quickly amplify a pandemic’s biological effects and create a secondary set of consequences that may be equally deadly, if not worse.

Here are a few examples of how runaway backchannel messages can create immediate and substantial damage:

• An unfounded rumor sends tens of thousands of citizens to local pharmacies in dozens of major cities, overwhelming them and triggering riots or looting as panicked people demand a drug the stores don’t carry or that is irrelevant to the pandemic disease.
• In cities that serve as major airport hubs, a handful of cases of a disease are filmed and sensationalized, generating enough fear to cause tens of thousands of people to flee those cities and effectively cripple them. Business, industry, and air travel would quickly become disrupted.
• An unfounded rumor persuades enough health workers not to show up to the leading hospitals in a handful of major cities, effectively shutting them down. A chain reaction ensues whereby hundreds of other hospitals are quickly inundated and then overwhelmed.
• A terrified population clears out store shelves across an entire state or region in hours. Truck drivers, retailers, and even medical personnel refuse to enter a perceived danger zone to restock supplies. In three or four days, a region’s hungry residents are forced to evacuate.
• Critical government agencies such as the US Centers for Disease Control and Prevention (CDC) are hacked and discredited in 36 hours. False videos are spread by a terrorist group or other organization that intentionally targets trusted health information sources. A crisis of confidence quickly escalates and undermines government and police authority.

Advances in communications are not the only developments that have the potential to magnify health emergencies. A variety of “superforces” are increasing the world’s vulnerability to pandemics. Ironically, many of the same factors that make our modern civilization successful and powerful can also be exploited by deadly pathogens, or by bad actors, leaving the entire world more vulnerable to a fast-moving catastrophe than ever before.

Technology is often a double-edged sword: it can be used to help or harm. In our time, we can identify a number of superforces that have already begun to transform science and technology, and will soon transform civilization itself.

These superforces have the capacity to improve our lives immeasurably by strengthening our health, our knowledge and access to data, our economies, our connectedness, our communications, our mechanical and scientific capabilities, and much more.

Yet these same superforces could—either inadvertently or deliberately—help spread the next global pandemic, causing casualties in the millions, tens of millions, or conceivably in the billions. These superforces include:

Urbanization, which concentrates populations, enabling greater cooperation while making it easier for pathogens to spread far more quickly and to infect far larger populations. Air travel and mass transit systems support and connect these urban environments at the speed and scale needed to keep populations fed and keep cities functioning.

Synthetic biology can design and create useful new biological agents, agricultural products, and even entirely new forms of living things. Synbio can also be used to design and create a pathogen that spreads more easily than a naturally emerging pathogen, kills faster, is more drug-resistant, and is harder to detect. So-called “chimeras” can artificially combine the most dangerous features of known killers.

Connectivity makes it easier for doctors, hospitals, and medical experts to track and support individuals on a 24/7 basis. Yet connectivity also makes it easier to order many existing pathogens from online sources or download digitized genomic blueprints, along with procedures to reassemble, modify, or weaponize them.

3D printing: Current bioreactors are inexpensive, but 3D printing will soon make it possible to replicate a powerful new customized drug or bio-agent quickly and cheaply, anywhere in the world. This capacity applies equally to life-saving medicines and to deadly pathogens.

Advanced robotics, such as self-flying programmable drones, offer a practical and inexpensive platform for many tasks, ranging from commercial package delivery to real-time traffic studies. Yet drones can also be used to deliver a pathogen to thousands, tens of thousands, or even millions of people at a time, in ways that bypass many traditional defenses.

As deadly as nuclear war

When an outbreak of a communicable disease rapidly exceeds the expected numbers of patients (for example, a normal seasonal flu or other malady) within a single city, region, or country, scientists call it an epidemic. When cases of that disease then pop up in a second region of the world, it is classified as a pandemic by the World Health Organization (WHO). Pandemics are not classified by their scale in numbers of human victims, but by their geographic breadth. They can start small and grow quickly. WHO has developed scenarios in which a modern global pandemic could rapidly escalate to the point where it might kill 7.4 million people. The organization refuses to speculate on maximum potential fatalities if a completely unanticipated disease appears.

A global corps of qualified volunteer reservists could play a critical supporting role to national health ministries and local governments during a pandemic.

From 1945 through today, the prevention of nuclear war has been the world’s top security priority. At the same time, emerging new technologies have now elevated the threat of pandemics—whether unleashed malevolently, triggered accidentally, or occurring naturally—to levels comparable with nuclear destruction.

In just the past 100 years, pandemics have killed from 1 million (1968 Hong Kong flu) to 40+ million people (WHO estimate, 1918 Spanish flu). The potential of bio-agents to spread widely and rapidly is why governments take them so seriously. The US went to war against Iraq in 2003 based partly on its belief that Iraq possessed chemical and biological weapons, and would use them against the West as it had previously done against its regional enemy, Iran. Just the threat of bio-terror can alter the course of history.

Pandemics have always been a threat. However, as global trade and international travel continues to escalate, as habitats for wild species shrink, and as the world’s population grows and tens of billions of animals are raised for food, the vectors and channels for pandemics have increased dramatically. What’s more, recent technological advances in areas such as synthetic biology have created a disturbing new reality: an attempt to create a bio-weapon that can trigger a man-made pandemic no longer requires large teams of world-class scientists or expensive labs full of advanced equipment. Instead, such attempts can be made using commercially available, affordable equipment—such as is found in a growing number of university and high school labs as well as easily ordered online—and requiring no more expertise than that of a high school biology teacher.

This level of technology and skills has already spread to tens of thousands of individuals worldwide and will soon be within reach of hundreds of thousands. Consequently, bio-weapons are an increasingly attractive option for non-state actors, making prevention of man-made pandemics even more difficult. If perpetrators have no official geographic base, then a target nation cannot deter this kind of attack by simply threatening a counterstrike. This is just one way that bio-weapons bypass many of our highly evolved defenses (such as secure borders and governmental control of the skies) that makes us feel safe and invulnerable to “far away” problems.

Bio-weapons, along with the world’s greatly increased vulnerability to naturally-occurring pandemics, are a genie that cannot be put back in the bottle. It requires imaginative new thinking to conceive of countermeasures that could contain and possibly deter the worst possible outcomes with fatality rates of potentially tens of millions of people along with possible economic collapse.

Using the latest tools of genetic engineering, a unique pathogen can now be designed in a lab that largely or totally bypasses our body’s highly-evolved natural defenses, including lethal variations of diseases that we have already been immunized against and thus feel “safe” about. Worst case, it could make the human species as extinct as the dodo bird or the Dutch Elm tree. Our mass numbers are no real defense. In 1860 there were billions of passenger pigeons. Just 50 years later there were none.

Containment and mitigation

How well any civil society addresses pandemics—potential and actual—depends, in part, on that society’s resiliency. Building resiliency means increasing our multi-layered capacity to do two things: containment to help slow or halt the spread of deadly pathogens before outbreaks grow to uncontrollable levels, and mitigation to prevent or reduce non-medical effects of pandemics (such as fear and panic that can paralyze economies and depopulate cities) and to recover as quickly as possible from whatever damage is sustained. Both containment and mitigation can reduce the risk that an epidemic will escalate into a major pandemic and can reduce the total number of fatalities substantially.

Containing pandemics begins with medical actions: identifying the source of a pandemic; tracing exposed individuals and tracking the spread of cases; declaring and imposing quarantines when needed; vaccinating threatened populations; decontaminating people, places, and things; instituting hygienic policies to reduce the spread of the pathogen; and, perhaps, searching for cures, antidotes, and therapies.

These medical efforts to contain actual and potential pandemics are largely the responsibility of government agencies at all levels. Understandably, this focus occupies most of government’s attention during a health crisis. Specifically, in the event of a pandemic, the government of any country will often have its hands full directing the actions of that country’s first responders, medical professionals, and healthcare organizations; tracking exposure; controlling the release of stockpiles of drugs, vaccines, food, water, and other emergency supplies; and quickly rebuilding or restoring everything from inadequate medical facilities to crisis-shattered public confidence.

Equally critical to saving lives is the second response strategy: mitigating the broader social and economic “ripple effects” of a pandemic. Even if initial mass casualties from a pandemic seem to be avoided, the cascading consequences of a potential high-impact pandemic—such as widespread fear and panic as well as economic disruption—can easily undo the positive effects of any medical defenses that authorities put in place and trigger a skyrocketing death toll. For example, if infected people—motivated by fear—travel or flee the contaminated area despite medical advice; if infected people ignore recommended hygienic precautions for dealing with food, water, clothing, burials, animals, and other people; if potentially infected people continue to have their normal interactions with non-infected persons, then such actions promote a wider spread of the disease, which threatens far higher causalities and disruptions.

When a potential pandemic emerges, public health professionals typically want entire populations to change many things about their regular day-to-day behaviors—and to do so quickly. For example, the science may indicate that to prevent the spread of disease, people should adopt a series of tactics, both novel and familiar—potentially with different behaviors for different populations in different areas, and often with different specific behavior regimens for work, home, school, retail environments, and so on. Behaviors that work to contain the most virulent and deadly influenza may not work for novel pathogens, whether naturally occurring or man-made. And, behaviors that work for airborne pathogens or those that spread through superficial contact may not work for those that spread through an exchange of bodily fluids.

Large-scale public understanding of the “best” behaviors in each case, for each region and population—added to the need for public understanding for the reasons behind medical recommendations; and then added to the need to obtain widespread compliance with these behaviors—requires a highly sophisticated, multi-channel communications effort. This “communication inoculation” must happen just as quickly as drug inoculation. Both kinds of inoculation can be critical for saving lives. Put another way, words and images can be as powerful in reducing death rates as drugs and doctors.

It is extremely difficult, however, to achieve this degree of mass behavioral change under the best of circumstances. The task becomes even more difficult in a world where “official” sources, including both governmental agencies and major media outlets, are distrusted by significant sectors of the global population, and where billions of people can access and amplify any unfounded opinion on the Internet.

The life-or-death importance of clear, trusted, scientifically reliable communication in the event of a pandemic was strongly emphasized by WHO scientists in their post-mortem report on how Singapore and the world handled the SARS outbreak in 2004. They recognized the critical human-behavior factor. According to WHO, “Human behaviors nearly always contribute to [the spread of a pandemic, therefore]…information to the public…

acquires the status of a control intervention with great potential to reduce or interrupt transmission and thus expedite containment.” To put it more plainly: Clear, credible communication of science-vetted messages to the public can make the difference between an epidemic that threatens a limited population confined to a relatively small geographic region and a pandemic that spreads across the planet and indiscriminately threatens hundreds of millions of lives—especially in urbanized, highly mobile societies.

In the face of these many challenges, a new and effective approach to crisis communication and management must be developed, tested, refined, and implemented. This approach cannot and must not wait for government agencies at every level to realize and act upon this need.

Civil society’s role

Before a potential or actual pandemic emerges, the resiliency of any society can always be strengthened. Every country has important, untapped assets in civil society that go beyond public employees and leaders, and these untapped assets can play a critical role in minimizing fatalities from pandemics.

Around the world, such assets include millions of scientists and tens of millions of qualified professionals in all major industries and sectors worldwide, especially in the fields of media and communication. The vast majority of these citizens and scientists are people of goodwill who would enthusiastically serve in a volunteer corps if invited to do so.

A global corps of qualified volunteer reservists could be created from civil society and funded privately to operate independently of any government to play a critical supporting role to national health ministries and local governments worldwide during a pandemic, by enabling prompt communication of clear, credible scientific information to the public.

Among other services, this independent global community would be fast and adept at creating public information materials—from Wikipedia pages to YouTube videos, texts, podcasts, radio spots, and more—that are precisely targeted for many disparate populations and demographic sectors. This includes grade-appropriate content for schoolchildren, multiple-language versions of urgently needed content for population slices at every education level from college graduates to the illiterate, regionally and culturally-targeted content, and materials for special populations such as the hearing- or vision-impaired.

More specifically, volunteer corps communications experts could create, market-test, refine, and stockpile a library of crisis media assets long in advance of certain kinds of pandemics or likely outbreaks. These assets would be ready-to-go in the event of well-understood threats such as SARS, anthrax, smallpox, virulent influenza, and other highly communicable diseases. To help ensure credibility, all media content would acknowledge that scientific knowledge of any unfolding emergency is necessarily uncertain and subject to continual revision.

Ideally, for internal communication among themselves, members of this global volunteer community would use affordable, existing technologies including, but not limited to, smartphones, texting, social media, and well-established global websites. For communication to the public and local agencies, the global volunteer corps would be expert at rapidly leveraging the social media platforms that billions of citizens around the world today already regularly turn to and use.

To be clear, this is not about giving scientists a direct line to the public through social media. And this proposal is not about trying to turn scientists into bloggers, YouTube video producers, and the like. That’s not a practical idea because so many scientists often find it challenging to translate their facts, findings, and ideas into language that the public clearly understands. Instead, volunteer communications amateurs and professionals around the world, working in close consultation with qualified volunteer scientists and governmental agencies, would craft media assets that both the public and front-line responders can easily understand, relate to, and find credible and compelling for use in a potential or actual pandemic or other asymmetric event. The communicators would create the media assets; the scientists would vet their content for accuracy. Separately, some of the scientists among the global volunteers would be available to do interviews on traditional and non-traditional media.

When communicators are identified as part of a civilian science volunteer organization rather than a governmental agency or media organization, their information is far more likely to be perceived by the public as free of political and financial self-interest, and therefore more credible than much of the emergency communication and guidance that comes from standard sources.

Finally, this proposal includes the suggestion that all of the volunteer scientists would be available to act as a grassroots network of local field agents. In this role they would perform non-communications, science-oriented tasks in the event of a crisis, in support of public agencies (police, fire, emergency medical technicians, and so on), as well as health ministries or international agencies.

These science-oriented tasks might include performing local testing of food and water sources, or basic, “on the ground” information gathering. Reliable data could then be passed on from the grassroots network to authorities. Other science-oriented tasks performed by volunteers could include limited, second-tier problem solving when local or national governments, health agencies, or international agencies are overburdened and unable to perform these tasks for themselves.

The size of this global volunteer corps would necessarily be a function of the scope of its mission. The organization needs distributed membership that is already in place.

Important note: the idea here is not that far-flung volunteers would act in perfect coordination worldwide, like a fast-food franchise simultaneously pushing the identical menu on every population in every quarter of the globe. Rather, a global volunteer corps at this scale ensures that in every major region, city, nation, and community, the organization will have local representatives ready and able to advise on—and adapt to—unique local conditions, including public attitudes, values, and communications requirements in case of an epidemic or pandemic.

Volunteers in each geographic region would act only when and as needed. For example, if a pandemic breaks out in three nations, then only the local volunteers in those three nations would need to respond. It would be extremely rare for the entire global volunteer corps to act simultaneously. Even if a massive pandemic required simultaneous, coordinated action across half the world, a widely distributed body of representatives makes it possible for volunteers to shape local communications by taking into account the dramatically varied cultural differences that drive public opinion and behavior.

In a time of crisis, the local volunteers’ input, recommendations, feedback, and experience in customizing health messages for individual communities would often make the difference between success and failure for any public service communications campaign or medical information-gathering effort. With these considerations in mind, the global volunteer corps would probably reach optimum size with between 1 million to 2 million members worldwide. This scale would ensure ready representation in every city of more than 10,000 people.

If this global community were assembled, trained, and tested before a crisis occurs, it would be able to establish credibility with general populations around the world, enabling the volunteers to make a very significant contribution to the containment of potential pandemics and the mitigation of actual pandemics.

When West Africa’s Ebola epidemic escalated into a pandemic in 2014, thousands of victims died across the subcontinent in a matter of months. And if Ebola had exploded in Lagos, Nigeria­—with its population of 21 million—casualties could have quickly reached hundreds of thousands just in that city. The spread would have been uncontrollable, and the entire economy of most African nations would likely have suffered enormous economic damage as global trade with Africa collapsed. Fortunately, Nigeria’s government, the CDC, and WHO held the number of cases in Lagos to just 20 infections, with only eight fatalities. Quick volunteer action was an important ingredient of this success. Volunteer media teams, led by private citizens including both media professionals and doctors, created a three-way partnership that made the difference.

The partnership included:

• An aggressive social media campaign called “Ebola Alert,” supported by Facebook in California and accessed mostly via mobile phones in Nigeria.
• An entertainment media effort called “Lens on Ebola” quickly created effective, entertaining videos featuring the most popular and trusted actors in Nigeria’s “Nollywood” entertainment industry. These CDC-approved videos gave the public a quick education in biodefense measures and personal prevention techniques. The videos, in five languages, were then widely distributed via Facebook, via DVDs (attached to popular movies), and over the public airwaves.
• A government-run contact tracing system was established, and a toll-free information hotline was staffed to answer questions from members of the public at any time.
• The Bill and Melinda Gates Foundation had a team of polio trackers in place in the northern reaches of the country; they were reassigned to track Ebola in Lagos and played a critical role in containing the outbreak.
• The CDC and WHO assisted locally and from afar. This partnership was responsible for Nigeria’s globally coordinated, locally customized, volunteer-led, and science-vetted public information campaign.

The campaign was pronounced a “spectacular success” by WHO. A major outbreak of Ebola was prevented from becoming an out-of-control mass killer and economy destroyer.

In November 2015, TEDMED and the Skoll Global Threats Fund convened a daylong discussion with 30 leaders from 24 educational, corporate, government, and nongovernmental organizations to discuss the growing threat of global pandemics and to explore strategies for prevention and response.

The thoughtful dialog that resulted from this gathering clearly revealed a growing consensus about the need and willingness to support a science-driven cooperative of qualified volunteers who can work with governments to help mitigate the next pandemic.

Key points of consensus included:

• Global agencies and initiatives are moving us in the right direction, but qualified volunteer support is critical to keeping them on track.
• A communications strategy is important. When people have facts, they are less likely to act in harmful or unproductive ways.
• Think globally, act locally. Successful crisis communication often involves listening to and engaging with the local community—not just expert-driven, top-down messages.
• Trust is key. Any agency head may be seen as serving a political agenda, unless they were highly visible long before a crisis and had built public familiarity and credibility. An independent expert could be more likely to be trusted.

Acting now to create a global volunteer corps of qualified scientists, communicators, and other experts from civil society will significantly strengthen the world’s “firewall” against mass-scale deaths from pandemics and their aftermaths. And it will strengthen the underlying economies of all nations. In addition, the capabilities of this global volunteer corps could alter the calculus of transnational terrorists who today see very few sources of deterrence and resilience in our otherwise ill-prepared societies.

Foresight, imagination, and willingness to act are our most effective tools to prevent outbreaks and their consequences, and to contain and mitigate those that cannot be prevented. Both the responsive and deterrent capabilities of the proposed corps of global volunteers could ultimately save lives and reduce casualties—quite possibly in the many millions.