The FRONTLINE Interviews
Britta Jewell and Nicholas P. Jewell
Britta Jewell is an infectious disease epidemiologist at the MRC Centre for Global Infectious Disease Analysis at the Imperial College London.
Nicholas Jewell is an infectious disease epidemiological statistician at the London School of Hygiene and Tropical Medicine.
Following is the transcript of an interview that was conducted via Skype by FRONTLINE filmmaker Martin Smith on March 31, 2020. It has been edited for clarity and length.
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Britta Jewell and Nicholas P. Jewell
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All right.Well, thank you both for taking the time to do this.This work that you do is quite interesting.I guess, you've spent a lot of time thinking, both of you, about diseases and the way in which they spread and threaten us all.Maybe you could comment in the beginning, just about the kind of world we now live in with so many more of us, so many more of us pushing into and living in areas where there are these threats.How much of a factor is that?
Britta: I think this really is an unprecedented event in terms of world history, because of the population being so much bigger.A lot of people have said that the question of whether or not there would be a pandemic is not really a question of if, but of when.And Bill Gates has been saying that for a long time, and plenty of scientists have been raising the alarm. So there's just a lot more opportunities for spill over to happen from the animal population, which is where a lot of novel diseases come from.And having closer interaction both between humans and animals, and between humans and other humans through international travel, domestic travel, really means that this was always a bomb that was just waiting to go off.That would be my response.
Nick?
Nicholas: I don't have too much to add to that.I think these pandemics, as we all know, have been with humans from the very beginning of our existence.And they happen a lot, and they've happened through time, and major ones have happened.So it's, coming from California, it's a bit like the big one, the earthquake.You know it's coming, you have to prepare for it.And sometimes we're prepared, and sometimes we aren't.And this is a certain way, a once-in-a-century, a pandemic.The last one that I can think that even resembles this is the 1918/1919 influenza epidemic, which ended up infecting close to a third of the world.And now it's our turn a century later.
And unfortunately, we weren't very prepared.In part because of what Britta said, that we're so connected now in a modern world.But If you think that the 1918/1919 epidemic, that was in a year where, of course, there was a world war going on, but there was no air travel for the public.There was very little in connectivity, but still it spread throughout the world, partly because of the war going on.So, now it spread extremely quickly by those standards, because of the air travel.
A lot of people have been saying that this was an inevitability, that this was going to happen, it was just a matter of when.And you've spent a lot of time modeling these kinds of things, but yet we were caught so unprepared.How do you, Britta, how do you account for that?
Britta: I think it's always a surprise when it happens, in a sense.Like, you can assume that it will happen at some point, but you never expect it to be actually today that it arrives.I think also, there's been a lot of defunding of pandemic preparedness, or people seeing that it's not an important thing to fund, because of course, we're always blind to when that day will actually arrive.And also, it's just very hard to get funding for a disease that doesn't yet exist.You know?It's much easier for people to find a — work on malaria, or HIV, or TB, which are problems that we know we need to fight right now.I think it had been seen as something that was harder to invest in when we don't know if that threat would arrive today, or in 20 years.
At the same time, we spend an enormous amount of money — a huge part of the federal budget in the U.S. is spent on weapons, bombs, and very sophisticated weapons systems.Tons of money goes into developing ever newer kinds of weapons so that we're prepared for some eventuality that is also, in some real sense, very abstract.We don't really have any knowledge of when we're going to really have to deploy some of these weapons.But something about healthcare, something about public healthcare seems elusive to us.Abstract.Nick?
Nicholas: Yes, I think that's true.You mentioned about the worldwide and U.S. domestic spending on the military budget, and how it completely dwarfs what we spend on a public health preparedness.And some are calling this the greatest intelligence failure of the United States ever, because here's an enemy, if you wish to use that metaphor, that's come here and we are completely unprepared.We don't have the weapons, the equipment, the army, to deal with it, in the way that we think we're so prepared for a military confrontation.
And this is also reflected in a smaller scale within our healthcare budget.Almost the entirety of the U.S. healthcare budget goes to curing us once we're sick.So, it's training doctors, building hospitals, developing very fancy diagnostic and treatment, equipment, and pharmaceuticals.Almost nothing has gone to the public health sector.It's the sort of orphaned child of the healthcare system, because, as Britta pointed out, no one really cares until it's upon you.No one really wants to put money into public health prevention measures, largely because people, I think, humans get fooled into thinking, "If it's not happening, it will never happen.So, why are we spending money on building defenses or preparing for something we've never seen before in our lives?"And unfortunately that means when it does happen, as now, we find ourselves woefully unprepared.
...It's funny, I remember in the early ‘60s, people built bomb shelters in their yards, and in their basements, and stocked them with canned goods.And I mean, this was common that people took those kinds of preparations, fearing that a nuclear war was upon us.
Nicholas: I think it was more common, too, in earlier centuries, for people to be acutely aware and scared of infectious disease outbreaks, because it was in their immediate DNA.It was in their immediate memories that they'd lost families or children, or villages had been quarantined, and the like.And modern Americans just simply hadn't experienced that, even during the two world wars, modern Americans never really felt the presence of that war in the homeland, in the sense of being attacked, or bombed, the way that many cities, of course, in Europe and Asia, did feel the immediate impact of the war.
And so, we just don't have that in our consciousness, that this is something that will happen regularly and we need to be prepared for, not only at the government level, but in the individual level.And I think, even in this case, even when the epidemic was growing in China, which was evident really in early January that there was now human-to-human transmission, and it was spreading, and it was likely to go out of control in China, which is what my friends and colleagues, and Britta and I were discussing at the time.There was still a remarkable lack of urgency in the western world — that this was actually almost inevitably going to reach their shores, and that it was going to be a potentially catastrophic, unless we took major steps.So, there's no question in my mind that we lost the time that we had gained from the early warning coming out of China about this epidemic.And that has, unfortunately, put us in a much harder place today than we might have been.
As Britta said, as scientists were doing, sounding the alarm, and had politicians and the governments around the western world spent enormous sums of money, and nothing happened, in the sense that it never had come to the United States, there would have been an enormous amount of criticism.So, you're kind of damned if you do and damned if you don't in this environment.If you make the preparations and you block things from arriving, people said, "See, it never arrived.What were you worried about?"When in fact it's these simple public health measures that ultimately can protect populations, and save literally thousands and thousands of lives.
… Britta, when did you first hear of the virus, or what was then a SARS-like pneumonia coming out of China?When did you first take note of that, and what did you think at that time?Without the benefit of hindsight, I'm curious how you thought about it.
Britta: I think I first heard about it very early January, and at that point there hadn't been a status human-to-human transmission yet.So it seemed like something to be aware of, but not necessarily to overreact to, and assume that it would become a worldwide pandemic.I think even for experts in field, it would be hard to say that anybody predicted that it would happen exactly as it did happen.I know for me, I had assumed that governments were more on top of it as well, that they were monitoring what was happening, and the UK government and U.S. government would be taking the precautionary measures to prepare the countries in case it turned into an epidemic.I think really, once it became bigger than SARS, once more than 8,000 people were infected, and it was clearly not at the end of the epidemic, that's when I felt like I was starting to get scared, and realize that it was going to get out of control, and it was going to arrive in the UK, it was going to arrive in the U.S., it was going to arrive in every country.
... Even when we have test kits, and we have more of them now, of course, we have a dearth of people that are prepared to actually use them, or know how to use them.I was on the phone this morning with a health official in Korea, and certainly MERS was instructive to them.And it's remarkable that with just four known cases, they decided to roll out a massive testing program.So, they were way ahead of anybody else in that regard, it seems.
By December 31st at least they seemed to know, and there was a lot of chatter, and there was a lot of WeChat conversations about this being a respiratory illness that could be transmitted human to human.But it took the government something like several weeks to make that announcement, and the [World Health Organization] WHO in China to make that announcement.You saw that, did you not, Britta?How long it took for them to come forward and admit that this was growing, and was transmissible?
Britta: Yeah, it did take a long time.I think partly that's due to needing to figure out if something is, in fact, novel.We do already have coronaviruses, and once you see the presentation of similar symptoms, even if there is some deviation, maybe it takes a while for doctors to be able to actually identify that that is a novel pathogen, and sequence the genome, which happened quite early on, as well.But I think there was also definitely some attempts to hope to contain it before it became such a big problem that it needed to be disclosed to the world.
… So, the virus was spreading and you talk about exponential growth.I don't think it's very clear to a lot of people just what that is.What is exponential growth?
Britta: So, exponential growth means that you start with a certain number of cases, or anything you like, and that number will grow to double over a certain period of time.You could have that doubling over a week, say, so that you start out with one case, and a week later it's two cases, and then a week later it's four cases, and so on.Or, you could also have the doubling be on a shorter time scale, like we've seen with COVID-19, that in some places the cases are doubling every two or three days.
I think, intuitively, it's very hard for people to understand how you can go for several weeks with having cases in the single or double digits, and then you check in again a month later and you've got tens of thousands, hundreds of thousands, cases.It's just not a very intuitive pattern, I think, for humans to grasp, because you tend to anchor on those very early initial numbers where it seems like there's not a lot of spread happening.
And it's just very slow. It takes over so rapidly that you don't realize how quickly it can grow.Even though, I mean, we learn about exponential growth as children.You know, it's not a foreign concept, but I think in practice it's something that's hard to wrap your head around…Nicholas: I think humans have a great ability to think linearly.Meaning, if I tell you that if you save $1,000.00 a year for your retirement fund, any one of us knows that in ten years, we do the calculation in our heads and we say, "That's going to be $10,000.00."What we don't pay attention to, though we learn through financial advice the power of compound interest thing, that if you put money away and it accumulates with interest, that is actually exponential growth.But unfortunately, none of us have bank accounts which double every seven days.
I was going to say.Interest rates do not produce the kind of exponential growth that you're talking about.
Nicholas: … We don't see, in real life, very many examples of the kind of doubling that Britta is referring to.And it's just stunning, because early on, even when you're experiencing exponential growth, which the United States was in the early part of late-February, early-March, and there were pronouncements being made: "Well, we only have a few cases, and they all came from travel.There may have been a little spread to family members, but the numbers are all very small: in the 10s, 15, 20, 30."
And it seems like, even though exponential growth is actually happening at that moment, partly because we're not counting them very effectively early on, with the absence of testing and the like.But partly the numbers are small.If I tell you there's 30 cases in the United States, that's not going to scare you.That's not going to cause you to shut down your cities.If I tell you there's 60 cases in the United States, you still feel very comfortable.120, 240, and so on, you don't feel the power of exponential growth until it's absolutely stunning.
So, when you say, "Oh, if there are 10,000 cases in the United States," then we ought to pay attention.The trouble is, in two or three days, now it's 20,000.So the month or two that it took a government, and individuals, and community members to become concerned enough to take steps, within a few days that whole month-and-a-half of growth has been repeated again, and in two or three days it's now four times what it was when you started to get concerned.Within another two or three days, it's 16 times.
So, within a very brief —It takes a long time to ramp up exponential growth, but once it takes effect, once it gets your attention, it's stunning in its speed.You're really then caught not being able to keep up with the spread at all.Which is what I think New York experienced and has been repeated — what Italy experienced, what many countries and regions have experienced firsthand, in maybe a way they never have before.
There were all sorts of warnings here.So, is that a failure of our public health establishment, not to have sounded a bigger alarm?Or is it the politicians just not listening?How do we sort that out?Britta?
Britta: I mean, part of what I would say is, I feel like because all of the emerging infections in the last 50 years have been in places that have not been in the West particularly, other than H1N1, which is a form of flu, so it's not necessarily the same as an emerging infection in the sense that COVID is.I think there was a sense of arrogance that these infections were things that happened elsewhere, and that they would not touch us.
You know, like if you go to — I work a lot in sub-Saharan Africa.If you got to, if you go to Uganda or somewhere you have to get lots of different kinds of vaccinations for yellow fever, or malaria.You have to take anti-malarials to go there.There's, I think, this attachment of that place being in a different location, an "other," where these things happen, and there's some failure to recognize that that was not a barrier for a disease like this that was not environmental.It was transmitted as a respiratory infection, the same as a cold or the flu.
… But we have a public health establishment.We spend some money on public health.We have Dr. Fauci at the Centers for Disease Control for decades, and yet we're caught unprepared…I know that things were not being heard at the top, but on the other hand — Well, I mean, which points to the failure of our political leadership, I guess.
Nicholas: I think to some extent the question you're asking is getting at, within the infectious disease community, people like Britta and I, and epidemiologists and maybe some clinicians, to what extent were they sounding the alarm in early January?
And I think there was a fairly substantial group of people who were beginning to sound the alarm in both Europe and the United States with seeing what was coming out of China…But we are a pretty small voice in the whole medical care complex political access, and those alarms were really not treated that seriously, for the reasons we've discussed.So, I think actually, fundamentally, it was a failure of the political leadership to listen, and to have in place the power of a public health voice.As you pointed out earlier, it was removed from the White House.The group that were dealing with pandemic preparedness had been removed, as it happened, many times in the past.When we're in the time of "peace" it doesn't seem worth it to invest in that kind of effort.
… Why Iran?Why did Iran become the second biggest outbreak?
Nicholas: I think there's an unawareness, in the U.S. in particular, how much China has grown its economy over the years, and how much of a presence the Chinese workforce plays in other parts of the world.And one of those places is in the Middle East.In Iran, there's a fairly significant Chinese workforce that is there in Iran, and that moves back and forth.
Early on, and when I say early on I'm talking about mid- to late-February, there was a great concern in the London School of Hygiene and Tropical Medicine that there is a similarly large Chinese workforce in Africa that has grown over the last decade or so, in a way that we don't have in America.
… Why Italy?Do you, do you have any, I mean, it surprised us all.First Iran and then Italy, and an enormously high death rate in Italy.
Britta: I mean, my reaction, and this is maybe only one factor, but it's partly bad luck.It's not like this virus was being distributed evenly around the world and I think Italy is one of the only European countries, if not the only one, to ban travel from China quite early on.And that may have given them a false sense of security in terms of not doing testing, not assuming that it was going to arrive, although of course there were multiple sources besides China at that point.
But in some ways it's like it's just a spark that happens to fall in one place and if it happens to be in the right place, it can explode.That could have also been somewhere besides Italy.
The other things I think about Italy is that there's a lot of intergenerational living there that maybe doesn't exist so much in other countries in Europe.So you only really start to see it taking hold once it gets into the older populations because that's where you're going to start seeing deaths, and Italy's unlucky in the sense that it also just has an older age structure in general.That's part of the reason that we see so much more death.
… Britta, you've done some interesting, I mean you both have done a lot of very interesting sort of modeling and statistical work on this.One thing that struck me was the graph that you composed showing the power of just one case averted sooner than later.Maybe you could describe that work.This is kind of the inverse of exponential growth.Explain what that graph shows.
Britta: All right, so I have this idea that if you look at exponential growth you will always be the negative side of it.And maybe you could flip that on its head and see the power of intervening early with exponential growth.So the graph shows that if you took the number of cases that were in the U.S., I think on March 12th, and if you just removed one of the infections that would happen tomorrow and monitored how many infections, assuming it just continues to grow at a 30% rate every single day for a month, how many infections you would end up with at the end of the month.And then what would happen if you didn't avert that one infection tomorrow but instead waited a week to avert the one infection.And what you see at the end of the month is that you averted about four times as many infections by averting it a week earlier.
So the point there really being that with exponential growth you need to intervene early if you want to have the biggest effect.Because of course also when we're looking at these exponential growth curves, no infectious disease is going to continue to grow exponentially forever.Eventually it's going to reach inflection point where you start seeing a reduction in cases.
So if you really want to have the biggest effect, you have to do it sooner rather than later.You know, if any of these countries had worked to shut down transmission when there were only a handful of cases, we would never have seen this exponential growth.But therein lies kind of the Catch-22, because if you intervene and shut down the entire economy when there's 50 cases in your country, that seems almost politically infeasible.But you would have seen a much greater effect in terms of the number of potential infections that had been averted.
… Were you surprised by that graph when you plotted it out, what it showed?
Britta: Yeah, in a way.I mean like as I was saying, even for someone who works in exponential growth, it's still sort of hard to wrap your head around how much even one tiny change can perturb the system.So yeah, I think it's very powerful for me to see the effect that one person could have by changing their behavior at the very least in a very simplified form.
Nicholas: … But we're still learning that lesson in the United States today.There are still many states in the U.S. today that have not imposed any real social distancing policies in terms of an edict because they have very few cases and they think, "Well, we don't have to do that now the way that New York has had to do, or California or Washington state."And we're still learning that.And I'm so frustrated.I want to stand up at the daily press conference and say, "Look, it may have been too late for New York.We're going to have to deal with a big crisis right.But down there in Mississippi, you have a chance, you could still get out of the building now if you'd only pay attention.I know it's low."So in a sense, that lesson is still to be learned in, in the U.S. even now, well into the epidemic.
… There is this tension between those who warn that, well as the president put it, the cure could be worse than the problem.Now he's backed off of that and now he's talking about as many as 100,000 to 200,000 deaths from this.Is that what you think we're going to see?Does that seem optimistic or pessimistic?
Britta: I mean, I'm going to go out on a limb and say, I think that's optimistic to see that level of death.I think that's, if we do things right, we'll end up there.
Two hundred thousand deaths, you think is optimistic?
Britta: Yes.I know that the modeling that people have done, I was not involved in this, but people at Imperial College, where I work, forecasted 2.2 million deaths if you do nothing.Obviously we're not doing nothing.So I wouldn't expect to see it reach anywhere near that level.But it doesn't seem like this is a virus where you have a lot of room to play.If you don't do things right and you don't do things early, it gets out of control very quickly.And I think part of the issue in the U.S. is that each state is essentially going to have its own epidemic.And as of right now, there isn't any formal limitation that I'm aware of on transit in between states.So my guess right now is that you're going to see epidemic taking off at different points in time unless you enact this major social distancing and keep it in place.
And the thing is locking down our country, that's not the solution.That's just buying yourself time to get to a point where you actually could do something effective and buying yourself time to develop all the testing infrastructure that you need or to get healthcare workers the protective equipment they need.Without a vaccine, we're not going to be able to just have one wave of this epidemic and just let people go back to their regular lives.So if you want to stop doing these social distancing measures, you're going to have to be able to test people.
The head of your department, Britta, came out with a study that said there could be 2.2 million deaths in the United States.Now I've heard that's been revised.Is that true?
Britta: It's been, I don't think that actual model has been revised, but it's been revised in light of the fact that the U.S. has actually enacted measures now.So 2.2 million was the estimate if we had an unmitigated epidemic, so nothing was done, people carried on with their lives as normal.Of course that isn't the case.Almost regardless of whether or not states have even enacted things, some people are choosing to change their behavior at this point and we're seeing lots of shelter in place measures including in New York and California.So also the difficulty with models is that if you release a number, like 2.2 million which is incredibly scary, then of course that does prompt change and therefore renders that number inaccurate for the future.
You guys can't get a break.You're always wrong.
Britta: Exactly.But I think that the basic tenet of modeling is that all models are wrong, but some are useful.And I feel like that is something that we should bear in mind, that we shouldn't be looking at these models to predict the future.We should be looking to them to guide us in our behavior now.
… There's one more question that I want to bring up here…That is this distrust in science, this misinformation, the power of the internet, the failure of our education system to teach us about the value of the scientific method and empirical reasoning.At the same time, the internet, which empowers people who spread misinformation.So what is your analysis of the impact of this on our situation?
Britta: Well, and I was going to mention that earlier, that I feel like both, at least in the UK and in the U.S., there has been a trend in populism the last few years to distrust experts or to view your own opinion as equally valid to that of an expert.And I do think it has had an effect in terms of individuals thinking that they can judge the situation just as well as an epidemiologist.I've witnessed that myself, and just on a larger scale of people thinking that it's not something you need to worry about until it's too late.And of course, experts know it's too late.They know when it's the right time.
… Nick?
Nicholas: Yes.I think we do live in a slightly unusual time with the effect of social media that everyone is an expert.And everyone is an expert on the economy.Everyone is an expert on politics.Everyone is an expert on climate change.And now, everyone is an expert on what we should do in the event of an epidemic.But there are people who are deeply trained and understand and study these phenomena, and I do think there has been a dilution of their impact through this.
And I think the distrust of experts amongst the public is a very, very serious issue.But almost more deeply and more insidious is the distrust of experts within the highest levels of our government…And I personally find it very hard to understand.If I'm going to have cancer surgery, I don't want to listen to you, I’m afraid, as to what you think should be done… I want to listen to my surgeon, the person who's trained and I know has done this operation successfully many times in the past.
Why it is when we move to something that's far more influential than my personal health, in other words, affecting the health of everyone in the world, we refuse to listen to the people who we've trained to deal with this is beyond my comprehension.It's an absolute disaster and it has been a disaster to date, and it will continue to be so until someone stands up at the highest level of the government and says, "We're not going to be driven by an election year.We're not going to be driven by the economy.We can solve that issue separately.We're going to listen to the experts."And there's little glimmers of hope now and then where that happens, but, boy, it's costing us a lot of lives until people are starting to pay attention and listen to the experts.
… Do you want to add anything, Britta?
Britta: Well, just kind of going back to your first question, it seems like it's too soon to be saying this in some ways, but this may be a big one, but it's not the big one.There will be other epidemics, and they could be even deadlier than this one.So I think it really does bear weight to be prepared for the future, as well, for other threats, and for people to not see this as just — people keep saying that it's a once-in-a-century thing.And it is because the last time this happened it was a century ago.But it seems very likely to me that it will be less than a century before something like this happens again.
So investing in public health and investing in preparedness is essential, even beyond the 18 months that has been proposed to get the vaccine for this.At that point, people say, "Oh, what I'll do when coronavirus is over."Yes, it might be over at some point in the future, but there will be another thing waiting right around the corner.So I think this really is a wake-up call that all countries need to be more prepared for this.
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