'COVID-19: Pathway to Pandemic?' Panel

Panel date: March 12, 2020

Panelists included:

The discussion was moderated by Brandeis Professor Allyala Krishna Nandakumar, the director of the Institute for Global Health and Development.

Visit Brandeis University’s website for COVID-19 for information, travel restrictions and resources regarding the disease.

The panel was co-sponsored by International Global Studies; East Asian Studies; Health: Science, Society and Policy; the MS in Global Health Policy and Management; and the Asia Pacific Center.

Note: This panel was filmed without the audience present due to the COVID-19 pandemic. Questions from the audience watching the live stream were fielded by Associate Professor Rosenberger. Panel member Uretsky, Moderator Nandakumar and Rosenberger are shown seated together panel-style. Remaining panel members joined individually via webcam.

Watch a recording of the livestream on BrandeisNOW.

Panel transcript

All right, good afternoon everyone. My name is Elanah Uretsky.

I am an Assistant Professor here at Brandeis in International and Global Studies in the Department of Anthropology.  I'm also trained as a medical anthropologist of China and welcome to our discussion today, "COVID-19: Pathway to Pandemic?" A couple of hours ago, I think that title was good.

This is obviously a very fluid situation. I can take the question mark away now. Two hours ago, the WHO declared that COVID-19 is a global pandemic.

I was a teacher course here at Brandeis called global pandemics, history, science and policy. I teach it in the fall. And so this is a wonderful conversation for me to engage in as an anthropologist of China who teaches about global pandemics. I started thinking about this panel sometime in late January when this really was a Chinese issue and I thought this is an issue that I need to speak to the public about.

I need to speak to Brandeis about because SARS was in the back of my mind.

I was a graduate student when SARS occurred and was about to go out to do my field work on the HIV epidemic in China when SARS hit and was waiting for the epidemic to end so I could go to the field. And if it hadn't ended by the time it ended, I would've had to delay my research for my PhD.

 So, I called some of the people who I knew were the best experts to engage with on this topic. Kate Mason at Brown University who wrote a book called "Infectious Changes" and she had been living in Guang Jo during the SARS epidemic teaching English. I called Jennifer Bouey, who's an epidemiologist who has deep experience in China, is now at the Rand Corporation. And I called my friend Debbie Seligsohn, who's a political scientist at Villanova, who at the time of SARS was the science and technology officer at the US embassy.

And I knew that we could have a great conversation and great discussion.

At that time we didn't know how far this would go and we thought this was really purely a Chinese, a discussion about China. Until yesterday we planned to have this discussion here at Brandeis in a large auditorium, at which point we knew we could no longer have a large gathering and so we moved it to purely be a live streamed event.

So, I wanna just before we get started, I wanna thank the people who had, the programs and people who have made this possible.

The International and Global Studies Program here at Brandeis, the East Asian Studies Program, the Health Science Society and Policy Program, the MS Program in global health policy and management and the Asia Pacific Center for Economics and Business at Brandeis International Business School.

One more thing before we get started. I know there are probably a lot of maybe Brandeis students, Brandeis alum out there who are waiting to see what Brandeis may do in the wake of the epidemic and develops about the epidemic. So, I wanna read a brief statement on behalf of the panel.

We understand there are fears and anxieties and concerns over whether the university is taking the correct measures to respond to the epidemic. From what we know, the university's conferring with leading medical experts in Boston to make the most informed decisions possible. While we understand these concerns, our role during this panel is to discuss what are primarily academic questions that will help us understand the trajectory of the epidemic and the response to the epidemic primarily in China, but also extending to what is now going on in the US.

We're confident that Brandeis has our health and wellbeing at the top of its priorities and will apprise us of any new decisions and policies to protect the campus community in a timely and safe manner. Trying to act quickly but also be thoughtful so they can release policies that are in the best interest of our community. And I've been asked by the administration to let us know. I've been asked by the administration to tell everyone that the university will be issuing additional guidance later today, possibly by the end of this panel.

So, with that, I'd like to turn this over to Professor Nandakumar, who is the Director of the MS Program in Global Health Policy and Management here at Brandeis.

Nandakumar: Good afternoon everyone.

I am Nandakumar. I'm the Director of the MS Program in Global Health Policy Management. I'm a health economist by training.

I direct the Institute for Global Health and Development and I also have an appointment at the state department as the chief economist at the office of the global AIDS coordinator. And I am really delighted to have such an outstanding panel today discussing this very important issue.

The last time the WHO declared a pandemic was in 2009 for the H1N1. After that, this is the first time they have done so. We have over close to 90 countries that have been impacted. There are over 120,000 cases worldwide that we know of. There are close to over 3,300 fatalities rising out of this.

And as an economist, what this has done is it has really led to a lot of volatility in the global markets which have wiped out a lot of gains, created disruptions, possible disruptions to the supply chain and are probably impacting the small business sector quite adversely in the US.

So, we have an outstanding panel of experts to discuss the issue. And I will now request Dr. Jennifer Bouey to make her remarks.

Bouey: Great, thank you for including me. Can you hear me well? Okay, great.

Thanks again for your time. And I have to apologize that I may have to leave early today as Elanah mentioned. Months ago when we are planning for this session, I thought this is a great time to review what coronavirus epidemic would be. But today we're actually really at the day that pandemic was announced. So it's a very interesting timing. So I have given two testimony to the Congress House hearings.

The first one I gave the testimony was on China's management of coronavirus and that was on February 5th. And yesterday I gave the second hearing to the Committee of Small Business. And this one was focused more on the how coronavirus impact the small and medium sized business in China and what US can learn from that.

So between these two testimonies, I've done some writing, did some research, and given my background as epidemiologist, I'm really interested in how this, just looking at how this epidemic unfold and how different countries are managing it.

So as Elanah mentioned that many of us are thinking about SARS. 17 years ago, that we have seen this pneumonia clusters that emerged in Southern China in November, and then it was not until January that has been reported to the central CDC.  And then they sent a team to investigate.

But at the time that the investigation didn't produce anything to the public because they thought this is just a viral pneumonia. And it's not until March when at the time, the Chinese, many people in the Southern China noticed that there's a circulating of a flu. So there's a panic in Guang Jo and then that create this frenzy of people going to the pharmacies and buying flu or cold medicine.

And then the Guang Jo governments announced that there is about 300 clusters of pneumonia. And then they reported to WHO, but at the time, no one really had a technology to isolate this virus. So when there's a outbreak in Hong Kong and Vietnam, no one really linked those cases to the Chinese cases until all the way to the March.

So to me it's amazing to see that from the beginning of the new pneumonia cluster showed up the index case until the WHO announced that there is a emergency. There's about three and half months of time.

So fast forward to 2019.

Again, we heard about this pneumonia clusters in Wuhan, China in late December. Apparently, the local government has notice of this clusters, but because of China's political system, no one can really announce there's a pandemic or epidemic situation unless it's been announced by the central government. So, at a time there were circulations about SARS-like pneumonia in the ERs, and that actually prompted the local government again to say, well don't panic.

We know of this clusters, but they are all related to the seafood market and things are under control. But between end of December to January 19th, the central CDC sent in three investigation groups. The first to look at the cases and still insist on the epidemiologic case definition as cases with these syndromes, but then also link to the seafood market. So that actually limit the case counting because they only counting the cases that's linking to the market.

It's not until January 20th that the third team confirmed that there's person to person transmission. And at that time, Chinese government to put this outbreak onto their level two infectious disease list and which requires mandatory case reporting.

So, from then on, we see the cases start grow every day in China and we realize that Wuhan is a epicenter of the COVID-19. And before that, actually the Chinese scientists did a really good job in isolating the virus and identified virus as a new coronavirus. This was the seventh in the line. And they also share that genomic data with the world. So that technology has helped the world to link the cases outside China to those cases in China. So, I see that as the biggest difference between the COVID-19 and SARS. But otherwise, China's government has really implemented unprecedented quarantine policy, try to contain the COVID-19.

So, on January 23rd, two days before the Chinese New Year that we see the Wuhan announced the lockdown of the city and onto January 28th, 16 other cities in the same province has been under locked down. And on January 29th, all 31 provinces in China has announced the public housing emergency in the province. So, this really enabled the government at different levels to implement quarantine.

So, during the Chinese New Year, we see that pretty much the whole China has been locked down. The air, rail, highway transportation are all being greatly reduced. People are advised not to attend any big events and they should stay home to basically do self-quarantine. This continued until February 4th when basically the official holiday season has been extended to February, 4th. So, I think even till this day, we see most of the cities are still under severe policy of quarantine. For example, Beijing still implement 14-day quarantine for anyone who's coming in from outside Beijing basically.

And now they are also using technology to help with the tracing during the case tracing and also help with identify people at risk. Actually, this morning I heard one of my friends from China told me that the WeChat now actually has an app that can record everyone's movement and they can also send a code and telling each person basically how much risk they have. And this risk is calculated based on their travel history. So, we do see quite a lot of new innovation. And very interesting policy that's been implemented to try to contain this one.

But certainly, now we all know that coronavirus, COVID-19 is a highly contagious disease of a new virus. No one has the immunity to it and it can cost a disease, mostly mild, 80% are mild cases, but 15% or 20% of the patients can experience, can be advanced to more serious clinical symptoms. The case fatality is varying from place to place now from the different report, which I think is reasonable because we are still at the beginning of a pandemic.

So, at the beginning of the epidemic, we tend to overestimate the case fatality because we don't capture all the patients who will have mild diseases. So, the denominator is really well known now. So, but in general, I think there's a consensus that the fatality is lower than SARS and the MERS, which is actually 9% and 32% respectively. So, the current estimate is maybe one to 2%. The highest report was 3%. 5% by WHO.

We also see that now China, certainly is not the only epicenter of the COVID-19. Unfortunately, we see the clusters emerging from the Western Europe clusters led by Italy, Germany and France and we also see an East Asian cluster that has Korea and Japan. We also see that there's a Middle East cluster emerging. And in the US, we have a witness that in the last few days there's increasing case reporting.

But I think it should be important to note that even though places are reporting, countries are reporting cases, it doesn't mean those countries are not reporting cases are not having an epidemic. Because the case reporting really depends on the public health system and depends on the testing capacity. So, what we see now again, I think is still in the middle of a pandemic.

So back to China since China has implemented the mass quarantine policy in end of January, and that has continued to at least at to mid-February. I think it's from February 15th, different provinces started to lower their emergency levels.

So now we also see how this has really hurt the economy in China almost completely for a couple of weeks and now it's gradually very slowly coming back. And yesterday at the Congress committee, I talked about how the small and medium business has been hurt in this epidemic and these quarantine policies especially for retail services, hospitality, tourism, entertainment.

These industries are usually relying on Chinese New Year as one of the most revenues are coming from these holiday seasons. So, they have been hurt most. There was an estimate of a loss from the service industry from that week of Chinese New Year has amounted to about 1% of GDP of in China. So, it's a tremendous loss for many of the business in China. And it also hurts the manufacturing industry sectors.

So now the question is whether the supply chain and the global logistic line can be interrupted. So, I think that's also part of the worries of the Chinese government of its impact on the economy. So, the government has made several policies, try to reopen the business and also helping the small and medium size business to stay afloat.

Because many of these companies, several surveys in February showed that small companies, two third of them in the survey mentioned that they can only stay open for one or two months and without an income, without the market reopening, they have to lay off workers and they have to close. So, the government provide several helps.

One is the central government provide a large loan to the market to make current funds available for loans and to ease some of the borrowing costs. The central government also encouraged commercial banks to defer some of the fees and the interest of the loans from these businesses. And I think they want them to postpone the interest to June. They also cut the interest rate by a quarter point. So now it's about 2%. 5% interest for commercial borrowing.

The local government also have some certain policies. Try to help the small business like the deferring the rent for two months, reduce some of the tax and fees. But even with all these policies support, until last week, we still see only about 30% of the small business just opened and by talking to many people are looking at a survey results, I summarize the challenges that's faced by small business including at least five. So, one is the public house requirement for the reopening. So, in China, in order to reopen a business, the local government will have to review their applications and make sure that all the business fit into the requirement for disease prevention. So, some of the small business are not being able to fulfill these. These usually include there's enough room for a person. There's not a very crowded situation that can promote the transmission, that provides certain PPEs, personnel protections, and also checking temperature regularly and so on. Some business cannot do that on day to day basis.

The second barrier is the 14-day quarantine requirement. So, in many cities, so they are still reinforcing this. If you travel from another place, if you are on a flight with one person on that flight with a temperature higher than a certain degree, then everyone in that flight should be self-quarantined for 14 days. But we know that there's lots of these services industry are supported by the migrant population. Most of these migrants went back home during the Chinese New Year, but then when they come back, they're thinking of 14 days they cannot work and who will pay them for the rent and that. So, the 14-day quarantine can be a problem.

And then they're also facing a down market. Lots of people are still not going out and not using services. So, the market is down. And then also the chain is fractured now. And finally, many of these businesses already have very low cash reserve. So those are the five reasons that many small businesses are still trying not opening yet.

So, given that, I think that's sort of the situation now in China. I think the government is trying to balance how to prevent more transmissions in China. They're very cautious about that at the same time, how to reopen the business. So, I think that will be a dilemma faced by many governments in the world.

So, should I just stop there and I'm happy to answer questions.

Nandakumar: Thank you. Thank you Dr. Bouey.

[to Uretsky] You want everyone to finish this thing so we would take your questions at the end of it? If there are any questions for Jennifer.

Uretsky: Let's see if there are any. Jennifer needs to exit at four o'clock.

Rosenberger: Hi everyone. It's a Chandler Rosenberger here. Hi, I'm the Chair of International Global Studies and I am your designated question taker today. So, let's see if any questions have come in. If not, I suppose we can move on. We've got at least one, okay. Here we go.

Jennifer, I'm not sure this is a question specifically for you, but perhaps you can address it. We have a questioner asking what distinguishes a virus from being or not being a pandemic? Why did it take the WHO such a long time to formally declare COVID-19 as a pandemic? And I think really anyone who thinks they can answer that, we should probably open the floor. But Jennifer, I don't know if that's something that you feel like you can address particularly.

Bouey: I can say quickly. In terms of a virus and the definition of pandemic, the pandemic is usually considered as an epidemic that spread to multiple continents. We definitely see that coronavirus or COVID-19 fit to that definition. When we see now we actually have more than 100 countries reporting the cases and we can see sustained community transmission has been reported in multiple countries on multiple continents. So why this virus is so contagious? I think part of it is we know this is one of the seven coronavirus and the four of the coronavirus we know exist among people, among human are basic causing common colds and the three we know now can cause severe symptoms and deaths.

So, these three are SARS, MERS, and COVID-19. So, I see COVID-19 as more dangerous than any of these because they share some of the common characteristic of all of them. So, one of them is 'cause most of the cases are mild. 80% of our cases are mild. So, we see lots of people can still move around when they first got the disease and they can spread, but they are not really as sick as SARS or MERS cases. So, I see that COVID-19 has a potential for pandemic.

Nandakumar: Is there another question? There's a question here from Dan Murphy. The question to summarize, it says that there was a downturn in the US-China relations and has that impacted and affected the efficiency or the efficacy of the response both of the Chinese side and the US side in terms of because of the lack of cooperation?

Bouey: If I can say a few words, I'm sure we have other experts on this.

One of the hearings I talked about the US-China collaborations after SARS. SARS showed China that they do have a gap in their public health system. And after SARS that China really opened up to the international communities, including US and US has signed a multiple MOUs with China CDC and really helped China to build the surveillance system for influenza. And we have seen that China CDC and the US CDC has worked shoulder by shoulder in many of the epidemics during these 17 years.

But it's just really last couple, three or four years that maybe part of it's a US CDC budget cut, part of it is the US-China relationship problems. So, we see lots of the offices are closed and certainly the collaboration is not as close as before.

Seligsohn: Can I add to that?

Bouey: Please, please.

Seligsohn: So, I was the environment science technology and health counselor during SARS and the Bush administration made an intensive and from the top decision to really try to help China to improve across the board. So, in the wake of SARS, the then CDC director, Julie Gerberding came out to China. After that we had the first visit ever, I believe, by an NIH director. We also had the then HHS Secretary, Tommy Thompson out and there was a huge agreement.

We created the health attaché position at the HHS level within the embassy. CDC had already set up. They had had this flu program for a very long time, we should say. They had been collecting samples from China for a lot of years because as everybody knows, a lot of flus come from China. What I was told by another epidemiologist the other day is actually flus come from elsewhere in Asia, as well as China, but we often don't know about those because our surveillance from this 20-year prior to SARS cooperation with China had really helped already.

So, after that we set up a field epidemiology training program to help the Chinese with their epidemiology. And we set up something called the Global Disease Detection Program, which CDC became aware with SARS not just of the problem in China, but that they had to be more active everywhere. And they set up over 40 offices around the world.

In the defunding, the reduced funding since the Trump administration came in, as Laurie Garrett has documented in foreign policy, three quarters of these posts around the world had been left vacant or have been reduced and the China one has been radically reduced.

And I had an op ed on that as well because we're down from 10 to 12 US CDC assignees in China to maybe three positions left but not all filled. And we went from over 40 local hire specialist staff to a very few. They've left their offices out in the China CDC and their standalone offices, and there are a few of them in the US embassy, which is anybody who spent time in US embassy in the last 20 years knows means that you have a lot less access than when you're out in the community.

So, the cooperation has been radically hurt and I think more by inattention and a failure on the part of the current leadership to really take seriously these issues of global disease than by anything sort of relative to the US-China relationship. Although there's become this attitude that I think is a huge problem, that science cooperation between the US and China is somehow only about helping China.

And it's also in enormous ways about helping the United States. And the fact that we had our umbrella agreement for US-China signed some technology cooperation expire and take two years to be resigned, which was just done this past fall. All kinds of agreements in many areas have fallen apart. I think the immediate damage is obvious in terms of disease, but there's damage across the board in terms of our science relationship as we look at China more with suspicion than with cooperation and as we emphasize sort of one important aspect of the relationship, trade matters. But a lot of other things do too and they've been ignored.

Nandakumar: Thank you. I will now request Dr. Elanah Uretsky to give her comments. And then we'll open it up for questions.

Uretsky: We can probably go through the rest of the panel…

Nandakumar: Go through the panel, then open it up for questions.

Uretsky: …then I wanted to take some questions.

Nandakumar: Wonderful.

Uretsky: Can we get the PowerPoint back?

[Text on screen: Going Viral – The Role of Social Media in Spreading an Epidemic. Elanah Uretsky, Brandeis University Assistant Professor International and Global Studies and anthropology]

All right, so I'm an anthropologist. I'm gonna take this discussion in a slightly different direction. Myself and Kate Mason will probably take us in a more social, cultural direction. And I wanna talk about the effect that social media has had on this epidemic, particularly social media in China.

So in 2014, our eyes were on West Africa as the world watched and braced for pandemic outbreak of Ebola. With memories of SARS as perhaps the most recent global pandemic outbreak in mind many including myself, started to question why Guinea, Liberia, and Sierra Leone couldn't just quarantine people.

After all, China imposed mass quarantines and canceled a major national holiday to prevent millions of people from traveling in 2003 after they finally admitted to what was happening in their country. And it worked. China brought SARS under control in a matter of weeks. And in a matter of months it was declared over.

China after being criticized by the global community was then hailed, they were praised for their efforts in ending the first pandemic of the 21st century. So why couldn't that be a good solution for West Africa as well? Why couldn't it work there as well? They tried quarantine, but it didn't work.

The authoritarian system that exists in China doesn't exist in West Africa and it was difficult for the government to exert control over people's daily actions and daily movements. So, where an authoritarian government was able to threaten people with punishment for violating quarantine orders or passing around false rumors, the governments in West Africa were powerless and they faced riots after trying to impose quarantines.

That SARS was able to spread so far without check was surprising. China had a very weak health system at the time that had been allowed to deteriorate over several decades when SARS finally broke out. They learned their lesson through the renewed commitment to health and their health system after SARS partially influenced from the world of global health but the international health regulations were modified so that new emerging pathogens that are now a threat to global health can be caught in time and prevent a global pandemic outbreak.

[Image of Kate Mason’s Book, “Infectious Change: Reinventing Chinese Public Health after an Epidemic” replaces the slide that introduced Uretsky]

China too did its part as Kate Mason may talk about. But as she's talked about in her book "Infectious Changes," China professionalizes its public health resource and its public health system after SARS replacing people who were previously seen as experts to a traditionally worked for the public health system with true public health professionals who came with degrees in epidemiology and other scientific fields from prestigious universities at home and abroad.

We can today still I think, feel safe that China's public health response to the current epidemic has been in good hands because of the professional track record of people who are working for the Chinese CDC today. Under this renewed public health system, China built a strong surveillance system and emergency preparedness structure with new laboratories and nationwide infectious disease reporting system to detect and respond to an epidemic outbreak as well as new laws of infectious disease and public health emergencies.

Today they have a surveillance system that runs from the local level up to Beijing to track what's going on, to track the number of cases of coronavirus that are reported. It's an extensive surveillance system connecting every level of municipal government.

It was effective in controlling outbreaks of H1N1, aiding influenza and gave the confidence, gave the Chinese CDC the confidence to say that SARS would not return. Yet we see that somehow China was not prepared to respond to the novel coronavirus that broke out in Wuhan in late 2019.

So, Lori Garrett, who was singing China's praises after SARS has more recently written about how China's incompetence is endangering the world. There are many reasons we could ascribe to the lack of preparedness in China. This was yet another novel virus and we've yet to figure out how it behaves despite months at this point of epidemiologic investigation.

There's also the feasibility of always being in ready mode, keeping up the level of preparedness required to react to something like this is taxing on a health system and even in the most resourced countries and cities. How well prepared could we have expected China to be if this didn't emerge in a second-tier city, but yet emerged in Beijing, Shanghai or Guan Jo cities with very strong academic public health infrastructures.

And then of course there's the question of local preparedness and the impact of state local communication on preparedness in place like Wuhan. The national surveillance system is really only as strong as local public health officials allow it to be. And the response locally can only be as strong as local officials allow. Coordination with central level CDC with its access to a wealth of world-class epidemiologist is essential for getting a handle on this epidemic and Wu Han is prepared and was prepared with infrastructure.

[Slide changes to show cover of Lakoff’s Book]

But preparedness as Andrew Lakoff lets us know in his book, "Unprepared: Global Health in a Time of Emergency" is about more than just having the tools. It's about knowing how to use them and when to use them and keeping in touch with the population so they know what's happening too. A country needs warning systems, scenario-based exercises, stockpiling of essential supplies and the capacity for crisis communication in order to truly be prepared for series emergency outbreak like the current epidemic outbreak. China's a master at creating five-year economic plans, but contingency planning may not be in its bailiwick.

In 2003, when Chinese citizens in the world found out about SARS and were quarantine in their homes, they spoke out through their phones, which at the time had a capability of text messaging, basically messages that could be sent from point to point with the possibility for a slightly wider range of distribution.

Rumors did ensue and people did flee Beijing, but it was all but effectively shut down. The government shut down fairly quickly with orders that declared rumormongering a crime. My main source of information at the time of what was going on in Beijing came from a close friend who was a nurse on the front lines in the wards that were treating the first SARS patients. Her daughter at the time was in middle school and she would email me about what was going on. She was home from school, and what they were seeing. They seemed fairly calm at the time considering what they were living through.

Outside maybe something else was going on. This was a friend of mine and she's admittedly quite guarded in her communication with people. There were all sorts of things happening over text messages that people were sending over their phones.

 In the wake of the government cover ups that had sent them into quarantine, they used their anonymous mobile devices to voice the opinions that they were not allowed to voice in public in silent protest of a government that had gotten to them to this point. In classic adherence to a form of resistance that James Scott refers to as weapons of the weak, they spoke out in an uncoordinated fashion with little planning through forms of what Scott calls everyday forms of peasant resistance.

Distributed through the informal networks, constructed through the contact lists on their phones. These forms of resistance were anonymous and didn't ruffle party feathers because they were distributed on a small enough scale to avoid attention and they lacked systematic organization. So, they essentially went under the radar covering the tracks of those who disseminated the messages.

A perfect way to do this, argues Scott, is through hidden transcripts, discourse that takes place off stage and under the radar of those in power who would otherwise take offense to such sentiments. Perfect forms of hidden transcripts and include things like rumor, gossip, folktales, jokes, songs, rituals and euphemisms.

For China, jokes became the perfect medium for people to covertly air their sentiments of resistance. And the text message was the perfect portal for transmission.

And so, SARS opened up a window for people to practice resistance, which was prohibited, but practice it in sort of an underhanded way. Jokes in China have always been useful for making merry amongst the bitter. The Chinese people are wonderful at coming up with creative jokes to express what to them is bitterness and take that bitterness and turn it into something that can make light of a situation, but in a positive way. It's something that they did in what was referred to as the age of reverence right after the Chinese revolution in 1911.

And what we saw during the SARS epidemic was that people were doing this again. They were making jokes. They were making light of the situation through text messages through their phones. They couldn't get together, maybe in person. So, they were sending their sentiments and airing their concerns through text messages, but through really, really creative jokes that were making light, not only the situation that was going on but making light of the situation that they had lived in for a long time.

And a lot of these jokes used SARS as a way to target government corruption and criticize government corruption. But they could do it anonymously because they were doing it through their phones, over text message.

So here are a couple of jokes that were going around in text messages during the SARS epidemic.

They mocked what was then called the Three Represents. Jiang Zemin's Three Represents, joking that his three represents,

Another one targeted this sort of old government masters, the old bureaucratic masters, the old leaders of modern China,

And finally, one that really resonated with me at the time because of what I was studying, so during SARS I mentioned I was about to go out and do fieldwork my dissertation. And I went out to do field work about how the networking practices that businessmen and government officials use in China make them vulnerable to the HIV epidemic. I spent a year and a half looking at people who were sort of banqueting carousing, exchanging cigarettes and alcohol and commercial sex with each other. And so, this one really resonated with me. It was called "What the Party Has Failed to Do SARS Has Succeeded in Doing.”

Here we are in 2020 and we're experiencing this again.

There is great public reaction and public outcry to the next coronavirus pandemic that emerged in China. But the public reaction is drastically different now than it was in 2003. The weapons of the weak that was shrouded inherit hidden transcripts of text messages have been transformed into what I see more as daggers pointed directly at the government and the government seems to have little defense against them at this point.

The text messages that created broad critique of the government through satire are now graphic messages of individuals suffering that appeal to people's emotions. The response to this epidemic in China has been extremely, extremely emotional. As people are able to write down their experiences and transmit those across the world within seconds, and those emotions have played a big part in transmitting information, transmitting the way people respond to the epidemic, and I think affecting the way the government can respond to the epidemic in China.

In 2003 we heard about a whistleblower doctor who blew the cover on SARS and we were able to react with shock and horror. We heard about it maybe a day later, a couple hours later.

[Two images appear on screen, a photo of a man in a hospital bed on a ventilator and a sketch of the man wearing a labcoat and a medical mask] In 2020, we see the image of a whistle blower moments after he's destroyed by the virus and the government bureaucracy that led to his untimely death. The reaction to this, I think is much more visceral because these images went around the world within seconds. All of us in the United States knew about this within seconds of his death, probably within 60 seconds of his death. And the Chinese government then reacted by saying, oh, he's actually alive. We're keeping him alive on life support.

It was a very, very emotional part of this whole epidemic that reached around the world within minutes. The messages that we see going across social media in China are also heart wrenching. The messages that go across, WeChat and WeiBlog. There's one WeChat group alone that as of February 27th had received four billion hits. So that was two weeks ago. And I'm just gonna share a couple of messages from some of those platforms.

 "This is real, real incidents and real thing. Please help my mother. My mother cannot live without an oxygen tank so we can leave for home. There's no bed available and we cannot even get a kit for testing.

The community officials said that they could not report the case to the hospital until she's confirmed positive for coronavirus. I really do not know what to do.”

Another one says,

"the only thing I have left is desperation. All my families are waiting to be dead. At this moment, my grandfather has trouble breathing and today he was diagnosed with coronavirus, but no hospital has capacity to take him. Yesterday he already witnessed his wife die. My aunt's lung got infected as well. We've all tried all we could do. WeChat apps, social media posts and local journals.

Nothing has worked. I see the National Health Commission announce that hospitals are opening up more space in the news. We called every day. They either did not pick up the phone or told us there was actually no bed available to take new patients. This is a dead circle and finally, can you imagine? The community did not record my cousin's case and neither did they report to the hospital.

They always told us that you guys have to get tested first and then we can report the case to the hospital and that is it. No one offered us the testing kit. Are you even human? Since the CT she did on January 26th, she's been going to hospital back and forth. She had to wait in line to get some saline injection. She's only 28.”

There are countless numbers of posts like this that are being archived and recorded from patients, from doctors, from community members, from other healthcare workers. This is the perception that we get of the new pandemic outbreak in China in 2020. And it's been hugely, hugely emotional. I don't see that this type of social media response in the United States. We're much more concerned about what we see on the news. But it's still fairly emotional. It's just not as personal as this.

So, I'm not trying to say that the governments should be able to silence people. These are very, very important stories that I think will become a large part of the history of this epidemic. But I think it's difficult for the epidemiologists and the clinicians to accomplish their jobs objectively and do the objective work of investigating this epidemic to bring it under control either in China, Iran, Italy, or the United States in the face of such vitriolic emotion and sentiments, in the face of emotionally charged information that circulates even quicker than the virus itself perhaps and creates panic and fear that puts a wall up in front of the efforts needed to bring the virus under control.

Nandakumar: Thank you. That was a good sentence to finish with.

I think the challenge of trying to balance a measured response and panic.

How do you bridge this? We'll come back to this maybe more in the question and answer session and what, given your experience that you described the social media rule across two epidemics and pandemics. What would your recommendations be? That's great.

I will now request Dr. Katherine Mason to offer her remarks.

Mason: Thanks. I'll ask you to bear with another anthropological take on this that I hope will complement Elanah's and not get too repetitive. Elanah mentioned that I was in Guang Jo during the SARS epidemic. I was also in the same area during the H1N1 pandemic which I'll speak to you briefly because it adds sort of an interesting counterpoint and sort of different from both now and then. So I'm gonna try to bridge all of these things a little bit with a little more context.

 So anthropologists like to tell stories.  So I'm gonna start off my comments with a story. Just over 17 years ago, on April 12th, 2003, I was evacuated from my post teaching English at University in Guang Jo. I packed my belongings into two suitcases and a duffle back, got on a bus, crossed the border into Hong Kong and flew with my A95 mask on back to the United States. It was the height of China's outbreak of SARS.

Interestingly, at the time of my evacuation, this was before the whistle blower in Beijing, I should note, SARS had actually produced impressively little panic among those I knew in Guang Jo. To my friends and colleagues there, it was simply another virus one that was competing with scores of other microbes to kill, really, a tiny minority of Guang Jo's millions of citizens. And that point, the only action that ordinary people were taking was to open the windows and repeatedly wash the floors with vinegar. This relatively muted response contrasted sharply with responses I was met with back in the US.

My sponsor, an American program demanded my evacuation leaving me five days to wrap up two years of a life I had built in Guang Jo. During that five-day period, my family became so worked up convinced that I was gonna be a patient zero for an American outbreak of SARS that they attempted upon my return to quarantine me in my sister's apartment in Philadelphia.

And being sort of young and stupid, I broke that quarantine and went to really the worst place you could go if you might have a deadly epidemic, which was Manhattan. So I did not have SARS and I was not patient zero.

Something to keep in mind here and thinking about this, which is now sort of shocking to people in a different way than it used to be when I told this story is that even at the height of SARS, there were no blanket travel bans or quarantines being instituted for travelers returning to the US from China. The US CDC was actually recommending against quarantine for those who had no risk factors other than travel. And so I had a lot of really very animated arguments with my father who is a physician telling him he should know better because CDC was actually saying this is not what they should be doing.

I didn't have any symptoms. I had no fever, cough, I had no contact with SARS patients and this was a different disease. So in 2003, that was enough to put me on the clear.

So I didn't have SARS as I said, and I did not see the new plague in New York, but the message that SARS was a cause for panic was received not just by my parents, but as others have noted eventually by the Chinese people and the Chinese government as well. So things changed quite a lot after I left. So I'll just give a little bit of a view from how I was sort of viewing this from where I was at the time. So in Guang Jo, we started hearing about a strange new virus around the end of 2002 but no one paid much attention until February, 2003, which was when a physician crossed into Hong Kong and spread the virus to over a dozen hotel guests, one of the so called super spreaders.

And then they then carried it around the world. And in an unprecedented move at that time, the WHO then issued a global health alert and urge the cessation of all non-urgent travel to mainland China and Hong Kong and later to other cities including Toronto.

After initially denying the scope of SARS within China and China's central government finally admitted error following the whistleblower's report, Chinese leaders purged the minister of health and the mayor of Beijing promise to cooperate with all international disease control efforts and began aggressively instituting control measures that are quite familiar now, including quarantining entire hospital, city blocks in universities in villages.

They did not quarantine whole cities the way they are now setting up neighborhood watch systems to breed up potential carriers of disease and building new hospitals in a matter of days, which again, they did again this time around. And as I think others have noted, the WHO did praise China's control efforts and credited them in part with the success of the global containment effort.

So all of this led me to think a lot about what had happened to me and led to my going into graduate school to try to figure out what was going on here and what lessons had really been learned in 2003. And so I went back to China in 2008 to connect an ethnographic field project and the development of public health after SARS. And that resulted in the publication of my book that Elanah mentioned.

For this fieldwork, I spent a lot of time embedded with local public health institutions, including local CDCs in the cities of the Pearl River delta region. And what I found was that SARS had just been enormous impact on China's public health system. In part this was because of serendipitous timing.

So Elanah mentioned that after Mao's death in the 70s, China's public health infrastructure was deteriorating over a few decades. But the government finally did begin rebuilding the system before SARS hit in that early 2000s, just prior to their arrival of SARS.

So beginning in a couple of years leading up to then, the central government began replacing thousands of crumbling, what were then anti epidemic stations that form the backbone of Mao's grassroots public health infrastructure with thousands of centers for disease control and prevention or CDC.

So that's when they established, not only the National Chinese CDC that others have referred to, but also thousands of local CDCs all the way down to the district level and cities and the county level and outside of cities. And the name CDC was an explicit reference to the US CDC in Atlanta.

So Deborah mentioned a lot of cooperation there and there was really great enthusiasm while I was there at the local level to emulate what the CDC was doing in terms of disease control and research, et cetera. But until SARS hit the call to build the CDC system remained an unfunded and unclear mandate.

And their arrival of SARS made this mandate much clearer, preventing and other SARS became the number one priority of China's public health system, even at the local level, especially in big cities over and above any more mundane domestic health priority, public health priorities. So there was a cost to this.

A huge amount of money on resources from the central government, local government and foreign sources poured in to help. And as Elanah mentioned, over the next several years, thousands of young scientists were hired at all levels of government to carry out this new mission. And a very sophisticated surveillance and reporting system was developed that all local health officials were supposed to utilize for exactly this kind of scenario.

And so what I usually get asked at this point is, well, how did this happen then? And so the sort of anthropologists cop out to that is always, it's complicated, but I think that I can start to address some of that based again on my experience doing research I witnessed repeatedly, the discomfort and reluctance to actually use the system the way it was intended to be used. So the image that a lot of people have of the central Chinese government's authoritarian powers when it comes to obtaining or disseminating information is highly overblown. Essential government relies heavily on local systems to collect and pass on disease surveillance information. And actually in practice, has very little power to enforce the surveillance system that was put in place after SARS. 

China's system can best be described, I think is what political scientist, Kenneth Lieberthal has referred to as fragmented authoritarianism. So it operates as a collection of thousands of little fiefdoms at the local level with very little ability on the part of the central government to compel ongoing action in any one of these fiefdoms. And sometimes this people get confused by this because you can see that the central government does have immense power when it comes to an emergency like we're experiencing now.

But when you're looking at sort of the everyday of the system working, it really is quite powerless, particularly in the realm of public health. So what this means in practice is that the central government does not have a lot of power to make local officials report what they're seeing when they don't want to or feel unable to do so. And there are just so many reasons not to report. So proper reporting requires at an individual low-level doctor or public health worker report to their immediate boss that they're seeing something new and alarming. And then that those bosses report upwards to their bosses and so on. And frankly, particularly at the level of local officials.

So the leaders of hospitals or the leaders at the local CDCs, no one wants to do this. Doing so has very little benefit to the person at the local level and may have immediate repercussions for them professionally and personally, which we did see in the cases of some of the whistle blowers because no low level official wants their institution or city to be the source of a major outbreak, which may embarrass them and cause economic and political repercussions for their local area, which of course is eventually what happened anyway in Wuhan.

As to many of the people who are on the immediate front lines of this, see upwards of 100 patients a day, even when there isn't an epidemic. So, we have to remember that the Chinese hospital system is heavily overburdened even in the best of times. And in this kind of environment in the middle of winter, it is very hard to distinguish a new virus from the many other respiratory viruses that are circulating.

 And finally, as we saw with Li Wenliang who Elanah mentioned who's now become something of a martyr individual doctors do not have the rate and China trip where cases of a novel disease directly outside sources. New viruses are still categorized as state secrets and that is the term that was used to me when I was doing my research. And you can't talk about this because it's a state secret. And only a provincial government sometimes or the central government has the power to report on them to the outside world.

 So, the other important lesson learned from SARS pertains to the containment response, both domestically in China and I would suggest globally. One of the big takeaways that the Chinese government got from SARS was that draconian actions are necessary to control a new virus if it does occur. That China is particularly good at taking such actions and that China will be praised by the international community if it does take such actions, but only if it does so within its own borders. And so I'll get back to that in a moment.

So, during SARS, China implemented a lot of containment actions domestically that would not be possible anywhere else in which we're now seeing again in more exaggerated form. Now I know that things have changed recently and that a lot of containment measures that feel really extreme to us are rapidly being implemented here, but even Italy's lock down, does not really equate to what China has been doing for going on two months now.

So, to get a sense of what China's drastic actions have meant for those who are living in them, I invite you to engage in a brief thought exercise. Imagine what would happen if the US government decided to entirely seal off and strictly confine to their homes the entire population of the Northeastern US from Washington D C through Maine. This is roughly the population that has been under the strictest lockdown in the province since January.

Then imagine if local governments further put checkpoints on interstate highways across the whole country, shut down public transportation in all major US cities and made laws about when people in the strictest lockdown zones were allowed to leave their homes even to purchase food.

Suppose they then kept all these measures in place for an indefinite period of time with no indication of when restrictions might be lifted. And then imagine what US citizens reactions might be if the entire world started shutting down its borders with the US and air lifting their citizens out of our major cities. Again, things have been changing very rapidly, but this is sort of the view from China for quite a while.

So as a point of comparison, in 2009, we had another novel pandemic, as was mentioned, the last pandemic that was declared by the WHO and that was H1N1 one influenza. We should remember that that flu pandemic did eventually kill approximately 200,000 people worldwide, which is still 50 times the number of people killed so far by COVID-19. Of course, H1N1 very likely had a lower overall fatality rate than COVID-19, although it also seemed to have be more dangerous than COVID-19 is among young people in children, which scared a lot of people at the time. It was particularly virulent among the young. And other important difference I would suggest is that that outbreak began in North America. So again, we have to remember, not all viruses start in China.

In 2009 I was conducting research for my book in Southeastern China and at the time, local public health professionals there were expecting the US to lock down its borders in a similar manner to what China did with COVID-19 precisely to buy time for China and other countries to develop a response, much as China apparently did buy us some time this time around although it's sometimes hard to understand what we did with that time, but that's another question.

The US CDC at the time, however, in 2009, dismissed such a suggestion as an overreaction and when Chinese authorities attempted to quarantine some foreign citizens and prevent others entering the country during H1N1 national community, they were overreacting…

[sound cuts out briefly]…Because after years of preparation and declarations of global solidarity and the prevention of pandemics, their American colleagues seem to them to be standing by and doing nothing and allowing their disease to invade China. To many of the public health professionals I knew, this really felt like a betrayal to them.

So, since SARS, a number of scholars have argued that as members of an authoritarian society, the people of China simply find it more acceptable to be subject to coercive containment practices than people of democratic societies which could partially explain the differences in the response to this two pandemics. Current circumstances are challenging whether this is really gonna continue holding true.

So for one thing, we are about to find out whether coercive China-like containment policies are able to work in a democratic society. What is going to happen in Italy or here in the US if Trump were to try to shut down entire regions of the US for example, is really anyone's guess, but pretty much everyone expects it to get very ugly if that were to happen. On the other hand, and we have yet to see what the longterm impact is gonna be in China, economically, epidemiologically or politically.

What we do know is that the effort to make appears to have slowed at least temporarily in China, and we also know, as Elanah pointed out, that people are very upset and very angry. They're angry that they can't say what they want to say. They're angry that the Chinese authorities have not been forthcoming with them and most of all, they're angry that their government let this happen to them.

People happened to be complying with draconian measures so far out of fear. The message that has been received loud and clear according to a lot of my friends in China is that leaving their apartments means certain death and so people are willing to comply with even the most draconian of control measures to avoid that fate, at least for a time.

Elanah mentioned that one of the things that might change this calculus is social media, so I won't get into that too much myself. But for a long while, the Western media, which is really always dying to finally find the thing that's going to take down the Chinese government was presenting social media and the anger being expressed there as a thing that might take down Xi Jing Ping and maybe the whole Chinese communist party. But I have to say that recently the tide has been turning somewhat in terms of public sentiment, at least outside of Hu Bay where people are still pretty upset.

The government is spinning the tale of China’s slowing epidemic as a huge win for Chinese autocracy in a moment of nationalist pride. And a lot of people are buying it for at least for right now.

So, I would just finish by saying we still don't know how this story ends. What will happen when the dust settles and the restrictions are lifted? Will the epidemic cumbering back in China? Will the economy recover? Will people feel it was all worth it in the end, which is certainly how the Chinese press is spinning it right now or will the spell that the party has held over the Chinese people for so many years finally be broken? And I just want to say it in conclusion that while China has been praised for its bold efforts to buy the world's and extra time to prepare for what is now a pandemic, I think it's very important that as we head down our own path of containment, we acknowledge the very large collateral damage of China's bold efforts.

Tens of millions of migrant workers are stuck in their home provinces without a way to get back to work so they can feed their families. Small businesses all over the country are going bankrupt. People who have been stuck for nearly two months in what was intended to be a one-week holiday can't get home to take care of elderly parents or disabled relatives and we heard cases of these people dying alone in their apartments. People who are sick with chronic ailments cannot get their medications, or go in to see their doctors.

I have a good friend who had the misfortune of having a baby in the middle of all of this and she can't even bring her newborn to the doctor for a checkup or to get his vaccinations, not because of a crush of coronavirus cases, because in her vocation, there are not that many cases but rather because of all the hospitals in her city have shut down those services to focus on preventing an outbreak there. And her relatives cannot come to help her with the baby because they're not allowed to leave their homes in other parts of China.

So, I don't pretend to have any answers here. I don't think any of us have any answers here, but I do think we have to keep our eyes wide open to the fact that quarantining tens of millions of people for weeks or months on end is not just an inconvenience. It is catastrophic. And when we think about the risks and benefits of epidemic control measures, we need to recognize it as such.

So, I'll stop there.

Nandakumar: That was again, extremely powerful and I think you're once again, the fallout of actions and what are the ramifications of actions have to be taught through.

You touched briefly, I just want to leave this thought with you so that you can answer it in a question and answer session. You talked briefly about the political structure in China and its impact on the credibility of the country to deal with the pandemic.

It would be very nice for you to talk about the differences in the political systems within the US and China, and from your own experience as an anthropologist, what would some of the lessons or recommendations you would make to the US as the US deals with its own problems?

Rosenberger: And if I may, I'd just like to point out that there are a lot of questions coming in online along those lines.

Nandakumar: Excellent.

Rosenberger: And that's where I think it will be a very interesting central point of our discussion when we get going.

Nandakumar: Wonderful. So, I'll now request to Dr. Deborah Seligsohn to give her comments, please.

Seligsohn: Thanks. So, it turns out, I guess I'm the only one on this panel who was in China for all of SARS as well as the H5N1, the H5N3 and the H1N1.

So, I thought I'd step back to a little bit of what it was like back in those days and then talk a little bit about my views as a political scientist, since I think I've already shared my views as a former diplomat about the nature of the relationship.

So, one of the things that was interesting in Beijing is as expats, we were very much aware by certainly early March, probably earlier that there was this problem in Guangdong that the government wasn't really tracking where the disease was spreading, and we started taking a lot of precautions. There were precautions in our workplaces, there were precautions in all the international schools.

 At the same time, our Chinese colleagues were like, we don't get it. Why are you so worried? The government says everything's fine. There was even a view in Beijing at that time that the whole thing was probably an American disease because the term that they were using at the time, atypical pneumonia was the same thing they used to describe Legionnaire's disease, which was an American disease. So, there was a lot of confusion.

I will never, I guess in my life forget the date, April 20th, 2003, because that's the date the Chinese national government acknowledged the SARS epidemic and acknowledged that it had come to Beijing. And what we saw overnight in Beijing was just a transformation among all our Chinese friends and colleagues. They were suddenly extremely scared, very cautious, putting on masks, not wanting to be near anyone. As someone who never wore a mask walking down the street, people would sort of jump out of your way because you looked like you might be more dangerous 'cause you didn't have a mask on. But at the same time, these measures were never as extreme as has been the case for COVID-19.

There were school closures, there were a lot of people sent home from work, there were organizations put on kind of rotating schedules. Certain number of villages, especially around Beijing decided to quarantine themselves to protect themselves from dangerous city dwellers that might be carrying disease. And some of them even dug up the roads around their villages to keep any Beijing people out of them.

But the kind of rules that have existed in Wuhan now for well over a month well, almost two months now did not exist for anyone around SARS. So, I think it's worth realizing how very different this situation is. And it's interesting because one of my recollections from SARS was that once everybody realized that given that exposure, really had a couple of foot radius. Your safest spot was probably outdoors in the sun and it was already springtime.

All the children were outside, the schools were closed, and so they were riding their bicycles, flying kites. I had never seen so many Chinese children having a good time in all of my 18 years living in China. And it was actually weirdly kind of enjoyable to see all that. And that seems very, very different from the experience people are having right now during COVID-19. So, I think that's worth realizing just how many differences there are.

What I saw with the Chinese CDC, which I worked with very closely in those days, was that they transformed this reporting system and it worked incredibly well for H5N1 and H5N3 the avian influenza epidemics that occurred in the subsequent couple of years. In fact, they were so good that human beings were the sentinels for the chickens, which is the exact opposite of what you want to have happen. What you wanna do is catch bird flu in the birds and protect the people.

And instead, because China had a very poor system of compensating farmers for forced calls, when you kill off all your animals to protect on the larger area from disease, the Ministry of Agriculture, especially all the lower level parts of the agriculture system, were busy sort of facilitating farmer coverups and so they were only catching the disease when it occurred in people, which before you have sustained human to human transmission is actually very difficult epidemiologically 'cause you're just catching unique one off cases all over the place. And yet they were doing that time after time.

So, the system was actually certainly in the years, immediately after SARS working very well and local governments seemed quite motivated to notify us, which is a little bit different than what happened in the Wu Han situation. But the other thing I really want to say as a political scientist is I often find that people always wanna attribute everything to the type of political system, especially when an autocracy is involved. So, autocracy on the one hand and democracy on the other hand.

It would be like if we, in political science, we often like to differentiate presidential from parliamentary systems, and yet we know there are many problems in the world that are not affected by whether you have a presidential or parliamentary system. It's also the case that autocracy is not necessarily the causal factor for whatever mistakes happen in one society or another.

And what was interesting and where I think H5N1 is quite instructive is if you look at the four countries that were affected most strongly, China, Thailand, Vietnam and Indonesia. China and Indonesia both did pretty badly in terms of dealing with their animal problems. And Vietnam and Thailand did quite well and Vietnam and China, after all had the most similar political systems. So, I think it's a good lesson that we can't extrapolate too much from political system alone.

And when I look at what's been happening with COVID-19, certainly there were failures, there were coverups in Wu Han maybe for two weeks, maybe for a month. It's a little unclear, but it seems that at the end of a month, they not only had started reporting, but they had also done the genome, reported that to the world. They move far, far more quickly than they had during SARS. And I think they had much better tools to do so.

And by the way, they're so good at doing this rapid DNA because they were originally involved in the human genome project way back when. Another plug for international scientific cooperation.

But look at what's going on in the US right now. We have community infection all over the place, which means we don't know where the cases are coming from, even though we already knew what the disease was and already knew the genome before it even got here.

Similar in Italy, we're now seeing stories out of Lombardy that are the same as those tweets that Elanah read from China. And doctors saying we're having to triage and decide who lives and who dies and a tremendous problem developing there. We're certainly seeing tweets in the US about people unable to get tests that they really want to see. And so, I think when we look at these problems, autocracy causes a lot of problems for people. It causes a great deal of political problems. It causes human rights problems. But when we're looking at a disease question, I think we have to look beyond that simple dichotomy because the problem is more complex and managing it requires a large number of skills the governments of all types find to be very challenging. So, thank you all in there.

Nandakumar: Thank you. Deborah, in your role as a diplomat, you are very engaged in the trade negotiations. And a question that I would like you to ponder about and answer is the dependence of the global community on China's manufacturing sector. And in your view, what impact would this pandemic have in recalibrating that dependence and what implications it might have for the US and for China?

Seligsohn: Do you want me to answer that now or later?

Nandakumar: At this point, I think I wanted to thank every member of the panel for their remarks and we open it to the question and answer session and maybe Deborah, you can start with the question that was just posed to you.

Seligsohn: So, it seems like a lot of companies are gonna be thinking about diversifying their supply chains. A friend of mine just tweeted that he thought the most likely scenario was that companies are gonna be thinking China plus one, that you need to have some other source besides China. But despite what Commerce Secretary, Wilbur Ross gleefully said about a month ago and really upset people, that's not likely to be the United States.

 I think Vietnam is an obvious and likely beneficiary of a lot of diversification. We'll see other places in Asia probably. I mean we've seen this already with the trade war that looking at Mexico again, and for more different solutions is also gonna be part of this story. But you're not going to move highly labor intensive, low cost manufacturing from China to the United States.

But I do think you're gonna see people looking at more diversification. How long the lesson lasts, I would be surprised if it lasted more than five years. I, at one point in my career worked on international debt issues and it's amazing how rapidly the banks suddenly decide that there is no such thing as country risk anymore. So, I'm guessing that these lessons they don't last that long.

But for the moment I think we'll see changes and besides, China is becoming much more of a value-added economy. They're moving up the value chain. So, I think there are a lot of reasons to see change happening and this whole epidemic accelerating it. I think the larger problem is that we're facing a huge impact on the global economy. A month ago, everybody thought this was a China story. This isn't a China story anymore.

And the problem with all of our sort of service sector dependent economies is while you might delay the purchase of a manufactured product, whatever services you choose not to partake of now because you're hiding in your house, you're not going to make up for later. Those are movies you will never watch and restaurant meals you will never eat and probably trips you will never take. And so, this economic slowdown is gonna be different than other recent slowdowns.

 It's, I think an open question how well equipped any of our governments are to really understand them and find the optimal means to address them.

Rosenberger: That's really interesting.

Nandakumar: Very interesting.

Rosenberger: All right, I've been reading through questions that we've been getting online and I think it's probably best for me to try to summarize some of them and put them to the panel as a whole because as some of them are quite similar.

I think one of the things that viewers are obviously very interested in is, what are the effective means for containing an outbreak? Setting aside cultural differences, setting aside predilections of countries or governments to do one thing or the other, what do we know works? And so, can we draw anything, any lessons from China's reaction or from the United States' reaction and even down to the individual level? Do masks work? What works to help contribute to the containment of an outbreak? And I think maybe I should just pose that to anybody on the panel who wants to answer it.

Uretsky: I'll start. I mean, I think China has shown us through SARS and through COVID-19 that quarantine does work. The measures were much more drastic this time than they were in 2003. And it's difficult to impose those measures in a country like this. We'll see what happens with Italy.

 More drastic measures have been taken in New Rochelle, New York at this point. So maybe that's sort of a pilot for us to see what will happen. But even there, it's not a full quarantine.

I think one of the issues that we have as Americans is difficulty putting the benefit of society, prioritizing the benefit of society over our own individual needs and wants and desires. That's what I see from people sort of pushing back.

[imitating a person pushing back] Well, yeah, people should be self-isolating. But can I still go on my trip? 'cause I had a trip scheduled.

I think until we realize that this is an issue where we really need to think about the good of society over our own individual needs and wants and desires, that we're gonna have a hard time tackling this issue.

Rosenberger: Kate, can I ask you maybe to follow up on some of the points that you were making at the end about the dangers of overdoing it. Because I thought that was really striking.

Mason: I wanted to speak a little to what Elanah said. In one sense, sure I agree.

Obviously we need to think of society, but I think it's not quite that simple, because as we've all been reading a lot in the news, there are a lot of things we don't have in place in the US in particular to support people's ability to put society first, because we don't put society first all along.

So, for example, the lack of sick leave, the lack of paid leave of any kind, the lack of any sort of social safety net for a large proportion of the population. And so, it's all well and good to tell people they need to stay home and not do things.

But if they're hourly workers and they don't have childcare and they're not gonna eat if they don't go to work, until we put in some serious safety net policies to support that, that people believe are actually going to come to them, like not just a premise of it, it's gonna be very difficult. And I think the difference in China is not so much…so, a number of things…

One is that they do have higher health insurance coverage in terms of the population, but it's not so much that people aren't suffering because as I noted, the vulnerable members of society are not being helped as much as they need to be helped. There's a lot of talk of supply chains and not nearly enough talk I think of all the people who work in the supply chain and how they're putting food on the table right now. But it's more that they don't have a choice.

So in China, you're not gonna break your quarantine or you're much less likely to break your quarantine because people have been trained very well to do what the government tells them to do, particularly when the government is being very, very serious about it as they are now. And fear has done a lot in China to kind of keep people doing what they're supposed to be doing. So it's very complex.

I think quarantine does work. It's working for now. Whether that will hold once quarantines are lifted is an open question.

A lot of epidemiologists are quite concerned that as things start to return to normal in China, that there'll be an explosion of cases again and that we're just kind of postponing the inevitable.

That said, epidemiologists also stress that it's really important to do social distancing activities at least of some sort so that we can at least spread out the cases and not overwhelm the hospitals. So, it's a really delicate balancing act.

I think in terms of masks, the data is very clear that masks help if you are sick but not if you're not. And hoarding masks can be a real problem because then healthcare workers can't get what they need.

So I think the guidance to not start buying masks is a good one right now in our context because it's probably not gonna do much good and it's a really bad idea to buy masks unless you really, really need them because others are gonna need them who are in much more seriously in need of them.

Rosenberger: Deborah, do you have anything to add on that particular question?

Seligsohn: So, I think it's been interesting 'cause some things have really changed. So, Kate was talking about the US and travel restrictions.

What was interesting all the way back to during SARS, Julie Gerberding who was the head of US CDC spoke out against travel restrictions and the US position and this was clear during the Ebola epidemic in West Africa was that travel restrictions often cause people to lie about where they've been and then lead to difficulties in contact tracing.

So, if you think you can handle an epidemic through sort of classic epidemiology of detection and contact tracing, then things like travel restrictions actually can be an impediment.

But in the last month, you've seen the discussion in the US about travel restrictions really change a lot with this whole sort of, China's bought us a lot of time and the cutting down on travel has been very helpful. I think part of the problem has been unlike SARS or Ebola, this particular disease, you have this problem that people are transmitting when they're not symptomatic. So, it makes the sort of detection and contact tracing much more difficult. But it also means that a classic quarantine where you quarantine the people who are sick doesn't do it either.

So that's where the Chinese came up with this much more draconian quarantine where they're quarantining everyone, both the sick and the well. And the big issue with that, which I think Kate was just alluding to is how long can you do that for? So, people are estimating it's probably 18 months till we get a vaccine. I mean, and that's hoping that we do, but talking to one of the scientists who was actually in one Guan Yi's lab in Hong Kong during SARS is now in Singapore. He was pretty optimistic that they already have a vaccine for MERS, for camels, not for people. They had done a ton of work on SARS and so we may long have it. But we need to somehow figure out how to get to 18 months. And even in Wuhan, they're not gonna keep people in their houses for 18 months.

So some sort of more realistic thoughts about longterm social distancing where we try to figure out how to reduce the rate of transmission, 'cause the other thing is it's not just about overloading the hospitals, which is so, so important, but it's also what this guy was saying, is there many more potential treatments out there than there were during SARS. That anti viral medication has improved.

So, the longer we can delay, the more medications get tested and the better treatment people who get sick are going to receive. So, we wanna slow this down and flatten the curve and everybody's Facebook page is full of that diagram of flattening the curve. And it makes a lot of sense. But I think, yeah.

I mean the National Guard is now patrolling the streets of New Rochelle. But it's a small town. What are we gonna do with the whole country? I don't know. So, I think we have to do a lot of habit changing. And my proposal to the world is let's stop shaking hands now and let's never ever go back. [folds hands in prayer]


Rosenberg: Well, let me follow up on that idea of flattening the curve just to address the question being asked on all those Facebook posts. Because we have one viewer who wrote in to ask that it seems that the most dangerous situation with regard to COVID-19 is the failure of an entire health system such as has presumably happened or starting to happen in a Wuhan or Lombardy. Is there such a risk here in the United States? Could the health system be overwhelmed by COVID-19?

Mason: Yes.


Nandakumar: Having studied health systems across the world and everywhere, I do not think that we should jump to the conclusion that what happened in Wuhan was due to a complete failure of the healthcare system. If you want to look at a silver lining, when these viruses hit developed countries with a lot of manpower, infrastructure and resources, the ability to mobilize to deal with them is much better. 'Cause I've lived through the Ebola, I think when I was at USAID and it hit the Congo and other places, Liberia had very fragile health system.

 We have extremely resilient health systems. So, I think to some extent, the fact that the health system was strengthened with this collaboration with CDC and the Chinese have invested heavily in their health system and the fact that we have a very strong health system in the US, positions as much better to deal with this.

Now, having said that, every health system has pressure points and weaknesses. And what this has shown in both cases is where the weaknesses within the health system exist and then we have, can we remedy those things and how do we do it? So, I do not think we should make a presumption that the health system was weak and before this happened.

Rosenberger: No, okay. That's very helpful. I think the more the concern was are we in danger that our health system weak or strong, will be overwhelmed by it. I think that was what he was referring to, that the Wuhan system, whatever its weaknesses going into it somehow has been swapped by it and we are in danger of that. Is that one of our weak points?

Nandakumar: That is one of our weak points for a couple of reasons. And that is why I think some of the proactive actions that we're taking before let's say Massachusetts becomes a full blown problem, Is helping us kind of preempt that happening.

For example, you have the flu season. So, during the flu season, you have the health system already being stretched because a lot of people with the flu are going in the ER, they are occupying the ICU beds.

Now, if you start overlaying uncontrolled number of cases coming in with COVID-19, yes, even the best health systems will start fraying. I think what you see the US trying to do, especially in Massachusetts, is yes, we know we have a problem.

Let's be proactive about it and take measures that are reasonable, not draconian, that will help us contain it or push this out enough so that we are able to allow the health system to cope with it.

Rosenberger: So there's a way of flattening the curve that doesn't require a draconian response.

Nandakumar: Yes.

Rosenberger: We continue to earn income the way Kate was suggesting. That has to be taken into account for a sort of enduring a response.

Nandakumar: And that is because we have been fortunate in having the time to plan for it. [Rosenberger nods] I think what happens in other places is that it becomes a huge public health problem. I mean, I'm trying to cope with it. Here we've have had the luxury of at least putting in place some measures that give us the flexibility to try to deal with it more proactively.

Rosenberger: Perfect. Any other thoughts on that? Yes, Deborah.

Seligsohn: I mean generally in the US, there are not a large number of excess hospital beds and that's a worry. I was just in Singapore where after SARS, they put in place a plan to build an infectious disease hospital that they would generally only have at 25% capacity so that they had enormous surge capacity. And that was completed last year. So I don't think there's any place in the world that's as well set up. And it was also impressive that the public health messaging was so good.

You didn't see a lot of people walking around with masks because the government has done a ton of propaganda telling people, save the mask for the healthcare workers. Don't hoard, that kind of thing. So, I think like getting information out, and I think in the United States, especially in our age of fragmented information, a lot of people don't have a lot of good information and what they're getting is from their Facebook friends.

I saw some rather educated people today circulating fake news from a fake Stanford professor. And yeah, including if you hold your breath, you can tell whether you have COVID-19 or not. So, it's alarming and I think this is one of the big challenges of the moment that people are getting their information all over the place.

And so I would say for universities, for employers, for anyone that can put together good information for their students and their employees, they should be doing more, they should be more proactive. And also creating venues where, especially for the students, they can do more Q&A's and get their questions answered. 'Cause I think there's a lot of anxiety out there without a lot of sources of information.

Mason: I would totally agree with that and just add that we also need to acknowledge that not all of the social distancing, proactive measures that are being taken now are being taken purely as the most rational, next step response to flatten that curve.

That there's a lot of peer pressure kind of among institutions happening right now, particularly among universities that will have so and so closes we need to close too. And even in the public schools, a lot of pressure from parents to either close or not close.So, the fear and the worry and also just the deep concern that institutions have that they're gonna be seen as not doing enough is also driving a lot of actions people are taking.

And so, it's very hard to sort out, I think for the average person what is actually necessary, what is actually recommended by public health experts and what is being done for legal concerns, political concerns or just peer pressure kind of among institutions.

Rosenberger: I think that's a very interesting point because it gets to this point about endurance. As you said, I think Kate they're not going to keep people in their apartments in Wuhan for 18 months. Even if you flatten the curve or especially if you're flattening the curve, you have to do it in a way that allows society to sustain and level of social distancing over the long term that slows the disease's transmission, but it doesn't cripple the society or isn't so unsustainable that people will flip back very quickly to needing to be back in circulation.

Uretsky: I would just add a little bit to that. I think one of the challenges we have today with COVID-19 is the uncertainty around it. We've heard a lot of information since this started. There are 41 million cases of the flu in this country right now. 29,000 people have died of the flu this year. And we keep on saying, but this isn't as serious. It's a little over 100,000 cases in the world right now. So we're a little over 3000 deaths.

The case fatality rate is not what SARS was, but yet as much as I think epidemiologists have tried to get our focus on to those huge numbers of flu, we focus on that there is fatality from this disease. [Rosenberger nods] And it's because of the uncertainty [Rosenberger nods again] and what's happening around institutions and public schools and universities that again, that's because of the uncertainty. We don't know.

Is the virus transmitted when you're asymptomatic or is it not? How fatal is this disease? No one's really sure. And I think that uncertainty sort of heightens our sensitivity to this and makes it that combined with how fast information can travel at this point.

Rosenberger: And misinformation.

Uretsky: Information and misinformation. So, at the end of this session, we'll have been sitting here for two hours. Who knows what will have happened in the news?

Rosenberger: I haven't checked my Facebook in these 2 hours. [laughter] Who knows?

Uretsky: And that makes it so difficult to gauge sort of a measured response.

Rosenberger: Mmm-hmm. Excellent.

There was actually another very interesting question here about the nature of the disease and this may go to the issue of the things that we don't know yet about the disease. But someone has asked, what do we know or predict about those who have recovered? Do they have immunity? Are they still able to transmit the disease if they come into contact with someone contagious? Do we know that yet? Do we know anything about how people recover from it whether they're still infectious? And when we're scaling up or designing our social distancing systems, presumably we have to take into account what we think the likely contagious period for anyone is in order to slow that transmission.

So, can anyone speak to any of the medicine yet on contagion of either people who have recovered or suspected cases or even hidden cases?

Mason: So, it's too bad we lost our epidemiologist. (laughter) But my understanding in talking with a lot of epidemiologists and virologists and whatnot is that there's a lot of uncertainty about that right now. So, it seems like there is some immunity but maybe not for very long. It seems like symptoms can leave and come back. And no one's quite sure if that's because someone caught it again or because it sort of can come in cycles.

So, I think that's adding to the difficulty is that it's really unclear the answers to all of those questions, whether someone can catch it again, whether they stay infectious, whether it sort of can get worse and better and worse again. I think it's really unclear.

Uretsky: So, the person who I turn to and respect the most in Chinese epidemiology is a man named Wu Zunyou who I know from his work in AIDS and he was the head of NC AIDS in China. The CDC’s, the Chinese CDC's response to AIDS and he's now the chief epidemiologist of the CDC in China. And I'm sure he's really busy at this point.

I heard a podcast with him a couple of weeks ago in which he sort of said, "Yeah, we don't know. We don't know if there's immunity built up.” So, we can see someone who looks like they're recovering and then a day or two later they're dead.


Seligsohn: But there also have been people who are recovered and then test negative. So, there are people who are definitely sort of cleared to be non-infectious to other, but they're also having cases where people appear to be better and then still test positive. So, I mean I think they're learning as they go 'cause it's a new disease and we'll have to say.

Nandakumar: So, for the lay person, I think what's very interesting is and you made a very interesting point. They say, look at the flu, look at this, look at the few number of cases and then you have Angela Merkel today saying that 70% of the German population is going to contract this virus.

So then if that's happening in Germany, then people who are sitting here saying, is it gonna be 20% 30% 40% 70% of the US population? So, you have this two very different messaging coming out. One is saying the flu is there, this is not so bad, don't panic. And then someone else very responsible says 70% of Germany's going to have this virus. So that uncertainty always causes overreaction because you want to be safe rather than sorry. And I think this uncertainty, making decisions as we are learning becomes problematic. So, we're learning as we are going and sometimes that leads to some overreaction.

Uretsky: And I think even the best epidemiologists in the world are uncertain and aren't willing to give us sort of clear-cut answers. So, Mark Lipschitz at Harvard who's the mathematic modeler, who's been sort of propagating the information about how many people are gonna be infected says somewhere between 20 and 80%.

Seligsohn: So, either of those numbers is huge. And in terms of the need for social distancing and everything, either number would mean we should be doing a lot. Because the thing about the flu is we're not all epidemiologically naive. Immunologically naive.

Many of us have been exposed to other flus and therefore carry some immunity. We also all have the opportunity to get a flu shot. And especially dealing with elderly relatives, we make sure they get their flu shot every year. And this is a good time to remind people that that's still a really good idea. I mean, mostly for next year now, but we wouldn't have so many people get the flu if everybody got their flu shot. But with people who are at risk for getting a bad case of COVID-19, we have nothing to offer them right now. And so that's the other reason that people are more scared because the people who are the obedient public health people and go get all their immunizations, there's nothing to offer them.

Mason: Although we do have to remember too that the flu vaccine this year was particularly poor and only protected like 30 or 40% of people from the flu.

Seligsohn: They said that it actually was likely that if you'd had a flu vaccine, your probability of winding up in the hospital was substantially lower. I think for COVID-19 I'd take that. Not having a vaccine makes people a lot more scared.

[crosstalk] Sorry, go ahead.

Rosenberger: No, if I could, we were a little bit limited on time and so I have one more question that I really like that it may be from one of our students. And I think points to a possible way that people can get involved in helping to deal with these issues. We have a student who asks for students with biology or health training, should or can we do anything to help? And I am prompted to think about this question of uncertainty.

We've been just talking about how dangerous the uncertainty itself is. And I don't even know if it's possible for people to get involved in mass epidemiology efforts or if it's possible for people to do any kind of effort to contribute to the better knowledge of what's actually going on on the ground, or if there are other things that students with this training can do.

Does anyone know if there's anything our students can do to help out?

Uretsky: My thought is that our hospitals and our doctors are going to be extremely burdened at this point. And so, there's gonna be more need in the hospital system—

Rosenberger: Just, volunteering in a hospital?

Uretsky: Yeah, for resources. Either to help with this or—

Rosenberger: Or something else.

Uretsky: Right. To help with things that can't be supported.

Seligsohn: So I think people are gonna have to ask, because my understanding talking to someone in the hospital system this morning is hospitals are also figuring out how to sort of keep out unnecessary people to reduce the risk of infection, et cetera, et cetera.

I think maybe something else that Kate was talking about earlier and doesn't require a biology degree is for poor people, for the homeless, there's gonna be a lot of food insecurity when schools are closed, kids on school lunches don't get hot meals every day.

There's a lot of opportunity, especially for young people who are not immunocompromised and therefore in this disease are at notably low risk, they think to think about maybe sort of helping the poor in this situation.

Mason: Yeah, I would definitely second that. That I think that's where the need is really going to be and there's gonna be a lot of it. Childcare, food insecurity. I got an email today from Harvard Alumni Association. I did my PhD at Harvard asking for people to volunteer to put up students, low income students who had nowhere to go when they were being sent away from the Harvard campus.

They have days to get out of there and they don't necessarily have anywhere to go. And so, they're asking for volunteers to house students to hold onto their belongings, to drive them places. So, things like that that kind of volunteer work can be very, very valuable.

Nandakumar: I think getting more involved in the local community and figuring out from your city or town what the specific needs around these kinds of assistance might be and then finding a way to support that would be very good.

Just as someone who is trying very hard to find out the right information. As a matter of fact, the US government has got a website called coronavirus.gov and I found the information there to be extremely well organized and very easy to understand and they have some really practical things.

If you say, what should schools be doing or what should I be doing? They have some very simple steps that one can follow, and I found that information to be very helpful. So, because we are being inundated with all kinds of information. I found that to be very well laid out.

Rosenberger: Terrific. All right. [he looks at Uretsky]

Uretsky: I wanna thank everyone who's worked on this for weeks. Our panelists, this is my first foray into the virtual world that I think we're gonna live in for a little while at this point. We were all supposed to gather together here today in Waltham, Massachusetts.

The three people you see in front of this camera right now, those are the three of us who are in Waltham, Massachusetts. We live here, we teach here, we work here and we went down the East coast from there. To Providence, Rhode Island, Philadelphia and Washington DC.

I guess those are stops on the train. (laughter) So I wanna thank all of you. Chandler, thank you for sponsoring this...

Rosenberger: Of course, to all of the organizations.

Uretsky: ...for championing this idea for all of our sponsors. Brandeis University came together to sponsor this. We have sponsors from all across the university including the International Business School, the Heller School and the School of Arts and Sciences.

Organization for this was done by Winnie Huie, who did a wonderful job at jumping at every obstacle we had to face. And there's a team of people behind the screen who are sitting here filming this, live streaming it. This was not a simple operation.

COVID-19 made this discussion very, very difficult and challenging and we were able to have the discussion. So thank you.

Rosenberger: And thank you for all of you who are watching either on the campus or off. And if you have any further comments, please feel free to send me an email at crosen@brandeis.edu and we're very grateful to have your participation.

Mason: Thank you, Elanah for organizing this.

Nandakumar: Thank you.

Seligsohn: Thank you.