Transcript

Robert Wiblin: Hi listeners, this is the 80,000 Hours Podcast, the show about the world’s most pressing problems and how you can use your career to solve them. I’m Rob Wiblin, Director of Research at 80,000 Hours.

Today’s guest is at the top of the health security field. Last year his centre received a $16 million grant from the Open Philanthropy Project to expand its work on global health security, and the global catastrophic risks posed by pathogens.

This is the third in our series of episodes about controlling new diseases. The first is episode 4 with Howie Lempel and the second is episode 12 with Beth Cameron of the Nuclear Threat Initiative.

If you haven’t heard about why pandemic control is a big deal, the first hour of the interview with Howie offers a thorough introduction – we try not to spend too long setting the scene here.

Instead I aimed to get to the bottom of uncertainties that listeners trying to pursue a career in health security still have. As a result we go quite into the weeds.

Despite that, I expect most subscribers will still find the conversation engaging and learn some general lessons that apply to their own work, even if that has nothing to do with health security.

And without further ado I bring you Dr Tom Inglesby.

Robert Wiblin: Today I’m speaking with Dr. Tom Inglesby. Tom is Director of the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health, which is dedicated to protecting people’s health from the consequences of epidemics. He’s also a professor in the School of Public Health there. He is Chair of the Board of Scientific Counselors of the Office for Public Health Preparedness and Response at the US Centers for Disease Control or Prevention or the CDC. He’s also served on committees at the Defense Science Board and the National Academies of Sciences, and in an advisory capacity to the Department of Human Services and DARPA. Over the last 15 years Dr. Inglesby has authored and co-authored more than 115 publications including peer reviewed research, reports, and commentaries on issues related to health security. Thanks so much for coming on the podcast, Tom.

Tom Inglesby: Good to be here, Rob.

Robert Wiblin: We’ve already got two pretty lengthy podcasts on biosecurity with Howie Lempel and Dr. Beth Cameron, which I think make a pretty good case for working on pandemic preparedness. I’m going to try to dig in to some of the questions that I still have about finding the very top priorities within this area. First though, do you think more people in medicine should work on health security or more people in security should focus on threats to health? Do you want to make the case for that?

Tom Inglesby: Sure. I think both of those things are true. I think that if you define medicine broadly to include public health, I do think that there is a bit of a unnecessary divide between public health and issues of security. I do think that’s changing a little bit as people begin to see the larger consequences of epidemics and public health disasters, and see that they can influence national issues including security issues, governance, politics. I do think that on the security side there is more of a recognition of the importance of public health disasters and the importance of resilience in public health emergencies and how those things can affect the security of nations.

So I do think that there is a divide between the two. I do think that people who choose to work on security issues who were in public health are going to be in the minority and I think there should be more of them. Similarly, I do think that people who have interest in public health issues who are more classic national security trained are also gonna be in the minority and they will be quite valuable. So my hope is that there be more crossover and more cross-fertilization.

Robert Wiblin: What are the health risks that worry you the most in terms of their expected, potential damage that is timing that the harm of the event with its likelihood?

Tom Inglesby: In term of health risks over, we’ll kind of confine this discussion to epidemic or pandemic risks for now ’cause they’re obviously, the world of health risks is huge. We won’t talk about all the things that fall outside that ’cause there are many, many, many important global health risks. For epidemic risks, I think everybody typically starts with the risk of influenza because they are so, so expected. Influenza arrives on an annual basis and is always surprising. Even annual influenza events are surprising in the sense of when they’ll peak, how high they’ll peak, where they will be most severe. It’s difficult to predict in the United States, for example, which hospitals will be most severely impacted, how busy the intensive care units, which months, how badly will kids be affected, what’s the effectiveness of the vaccine. All these things that you might think that are sorted out well in the year 2018 — there are still many annual uncertainties about influenza and the way it operates.

If you think about all the annual uncertainties and then add to that the uncertainties that come with bird flus, flus that don’t primarily infect humans but could move into human populations and become efficient person to person spreading epidemics, there’s a whole other world of uncertainty and concern. If you think about, for example, the H7N9 bird flu in China that’s infected somewhat approaching 1600 people, it does not spread person to person efficiently although it had spread in small numbers in close family units and in people who are in close proximity. If you look at the case fatality rate of H7N9 in China, that has been something on the order of 40%. 40% of the people who have been infected have died from that influenza.

If you compare that to the case fatality rate of seasonal flu, that’s somewhere in the order of one in 10,000. So 40 out of 100 in H7N9, 1 in 10,000 in annual flu. Even annual flu, you can look at the United States experience currently and see how disruptive and how concerned people are because even annual flu does kill previously health people. It does disrupt workplaces. It does cause overflow in hospitals and intensive care units. Your question about what concerns you most, I think on everyone’s list, anyone who studies epidemics and pandemics would always include influenza as something very high on the list because it’s unpredictable and it can do, even in normal years, can do a lot of damage, but certainly in extraordinary events like 1918 or if a strain like H5N1 or H7N9 became pandemic, efficient person to person spreaders it could do severe damage around the world.

Kind of switching categories, just going up a bit to the big categories of biological concerns, we have the whole world of natural events which would include influenza at the top of the list. The world of deliberate events, which could include something on a very sophisticated scale if it had the resources of sophisticated science and government programs behind it all the way down to more of a individual or small group effort. Then the third category, third big category of biological concerns would be in the realm of inadvertent or accidental, something that happens in a laboratory or in a facility that’s making a product that goes awry and has consequences well outside that laboratory. Generally speaking, if you’re talking about the world of pandemic or epidemic threats, I think people would lump them into those large bins: natural, deliberate, accidental.

Robert Wiblin: Yeah, in previous episodes we’ve slightly lumped those together and haven’t been very careful about distinguishing them. In this interview I was hoping to pull them apart a little bit more.

Tom Inglesby: Yeah.

Robert Wiblin: Are you more worried about the natural pandemics or kind of the human caused ones?

Tom Inglesby: I’m worried about both. I think in terms of probability, at this point the probability is certainly in nature’s favor because we see natural events happening around the world all the time. I think that that calculation will be changing as biotechnology becomes more accessible and more de-skilled, things become more feasible at lower levels of laboratory sophistication. So things that would have earned you a PhD or even a large prize years ago are now kind of moving down to early college or high school level because of the ability to make things into kits and make them approachable for younger and less sophisticated people.

Over time we’re going to see much more power in the hands of much less skilled people. I think our calculation or risk assessment for how probable or feasible either accidents or deliberate misuse of biotechnology will be, those calculations are gonna have to change. I mean what we’re worried about for pandemics, it’s a subset of what people will be able to do in biotechnology. So people who are interested in doing harm could do things that are small scale. They could do things with non-contagious pathogens and just cause illness in a specific area. Or, on the higher end, could conceivably create pathogens that have the ability to spread person to person, and perhaps efficiently without easy control. Those kinds of possibilities, they exist now and will continue to exist into the future. There’s nothing that’s going to reverse that trend.

Robert Wiblin: Do you have a sense of which of these two problems is more neglected?

Tom Inglesby: At this point I would say that there are comparatively few people working on the deliberate misuse of biotechnology. There certainly are people thinking about those things. For example, there’s the Biological Weapons Convention community which is the group of people who are thinking about state misuse of biotechnology. Often those people reside in either the State Department or Ministries of External Affairs in other countries in the world. There is a community of non-governmental organizations that pay attention to the Biological Weapons Convention, that attend the expert meetings in the summertime, and the meetings of state parties in December in Geneva.

So there is a world that focuses on these issues but as compared to the world of experts, public health officials, scientists, focused broadly on natural epidemics, I would say the natural side, there’s much more going on. There’s much more funding. There are many more institutions, many more universities attending to those problems.

That said, for any particular global health problem or particular disease, or neglected global health issue, or a disease of regional epidemic importance like Dengue for example. Dengue causes terrible disease in many places in the world and appears in epidemics. It’s also endemic at a low level, circulating all the time in many places in the world. That disease has a good number of scientists and public health officials worrying about it but it’s a very tiny subset of the world of global health.

So any particular disease is still relatively small community around it but if you take the sum of those communities working on naturally occurring diseases, that’s a pretty large community as compared to the group of people who are thinking about, and trying to do risk assessment, and think about prevention strategies, and response strategies around deliberate misuse of biotechnology. I would say an even smaller group, a much smaller group at this point, is thinking about the accidental misuse of biotechnology of high consequence. There are many people who think about laboratory safety in a holistic, general way and kind of work on biosafety practices in labs around the world. But if you focus in on the dedicated effort to think about laboratory accidents that could have epidemic consequence or pandemic consequence, that’s a small group of people at this point.

Robert Wiblin: So the basic picture is, for now natural pandemics is still the greater risk in any given year but the risks from human behavior are kind of growing each year. Perhaps because it’s a newer risk, you don’t have all of these institutions that have been thought up over time to deal with it. It’s a new problem and it demands new approaches to solve the issue.

Tom Inglesby: Yes. I agree. That’s a very fair statement of what’s going on.

Robert Wiblin: So I’ve kind of an amateur interest in this area and there’s so many different terms that people use to refer to it like pandemic preparedness, health security, public health, biorisk, biosecurity. Can you do anything to disentangle all of these different terms and explain what they refer to?

Tom Inglesby: I’ll try. I think what people use, let’s start at the broad level. Health security is encompassing of the public health prevention and response activities for public health emergencies broadly described, so not just epidemics but also the public health implications of hurricanes, and mudslides, and nuclear events, and chemical spills, the kind of emergencies that really could have large scale public impact.

For example our center, it’s called the Center for Health Security, we focus a lot of our time on epidemic response, both prevention, response, planning, but we also have projects that relate to the impact of hurricanes, and the impact of a nuclear detonation, and the impact of chemical spills. We do some work that’s outside of that epidemic response.

When people talk about biosecurity, at least in the United States, they’re often referring to the policies, actions, programs related to preventing and responding to biological threats. What we would say is that that includes natural, deliberate, and accidental. The word biosecurity is used differently elsewhere in the world. In some places biosecurity is used only to represent animal biosecurity. In some places in the world it means really prevention of incoming pests or incoming non-native species. So that term changes culturally depending on where you go in the world, but right now, at least in the US experience, biosecurity typically is fairly encompassing.

In fact, in the US there is now a US Biodefense Strategy which is being developed. Actually it’s in its final stages, hopefully to come out some time soon. That’s been winding its way through the entire government for about a year. By law, this is the first time this has happened in the US, but by law, the biodefense strategy in the US is inclusive of natural, deliberate, and accidental, international and domestic, and human, animal, and plant. It’s supposed to look at all of those biological threats, so both on the natural side, deliberate side, et cetera, and bring them together so that agencies and the government understand what their goals are, understand what they’re responsible for, ultimately what kind of budget’s going to be behind those efforts.

Why that’s potentially important, depending on how the strategy comes out, is that right now in the US government there’s a plan for X and over here in a different agency or in a different president there was a plan for Y developed. They don’t all come together. They were developed at different times with different organization. So the hope is that a biodefense strategy now will tie these things together in a way that people understand their responsibilities, they can see across the government, know who’s doing what. Those outside the government can say, “Oh, this is how I plug in. This is how our university system can help with this particular facet.” Hopefully, for people who are interested in the field, when this strategy comes out they can get a better sense of the breadth of it and see whether there’s a place that is particular appealing for them, what kind of work in that strategy would be most exciting for them.

Robert Wiblin: Let’s talk for a minute about the Center for Health Security where you’re a director. What does CHS focus on and how are you guys hoping to make a difference?

Tom Inglesby: So our mission, you started off with our mission earlier. Our mission in a phrase is to diminish the consequences of epidemics and disasters and try and build resilience in communities. What we’re doing as a group is try and find issues where prevention activities, response activities can make the most difference. Where can we as a group, often through changes in policy or through changes in some of the big national programs or even international programs, where can we make the most difference in improving the likelihood of prevention or the possibility of response. So our group, we typically work in teams. We have a multidisciplinary group. We have a number of people who have clinical backgrounds, so doctors and nurses. We have a lawyer, a social scientist, a number of people from public health, some former government people. One of the reasons why we’re so avidly multidisciplinary is because many of the problems in biosecurity and health security are at the seams between disciplines.

If you approach pandemic planning, or let’s say influenza planning, purely from a clinical point of view you’ll be able to make a contribution clinically but a lot of the problems of influenza are in the health system. They’re not necessarily how to treat the patient but they’re how does the health system respond. They’re also around the public health response. How do you communicate to the public about influenza? They’re also about making medicines and vaccines, which is very far away from clinical care. So many of the problems that we take on at the center and many of the problems in health security and biosecurity are multidisciplinary. They are kind of at the edges between different fields. So if you’re willing to work in that edge between fields you can often make a difference where it would have been harder to make a difference if you’re coming at it straight from a clinical standpoint, for example.

We work in teams. We have somewhere between 15 and 20 big projects going at the center at any time. We also try and serve as a resource to the government. We serve on advisory committees when those things arise. We try to serve as a resource to the press to try and help explain things when new problems arise. When new epidemics occur we develop our own thinking about the response to that epidemic and we try to work with the government or with other governments to provide advice or outside thinking. If we see something that’s happening that seems like it’s not getting enough attention we’ll try to help shine a light on that particular problem or provide some guidance. In the past we’ve provided our own sense of what clinical guidance should be or our own sense of a public health response to a particular facet of a problem.

We work on policy at the center. We work on communication to professional communities, to the people who are involved in this work in biotech and clinical work and government. We also work on educating the rising generation of people who are interested in this. We work in the School of Public Health here teaching students who are rising through graduate school. We also have an emerging leaders fellowship program which we run every year which tries to get more early and mid-career people from other fields together to try and learn more about the field and how they can develop their own networks and rise to make a difference. Basically, kind of in summary, we do our own independent research and analysis aimed often at national policy or international policy, national programs. We do communication. We do education.

Robert Wiblin: I’ve heard that it’s difficult to do interdisciplinary research in academia. Is it hard for you to get taken seriously?

Tom Inglesby: No, I don’t think it’s hard for us to get taken seriously. Funding isn’t organized necessarily in that way. So it isn’t necessarily easy to get funding for multidisciplinary teams. For federal government funding, typically sometimes that’s more of a particular field like working with CDC. You go after certain problems and have to make an argument that a multidisciplinary team is necessary. The government is trying to encourage more multidisciplinary work with certain types of grants in the United States but that’s still not as easy as necessarily as being a very deep, highly skilled, monoculture type of field. There are often more opportunities there for funding. But with outside foundation funding, like in the past with the Sloan Foundation, with Open Philanthropy Foundation, with other public health oriented foundations it’s often possible to get funding for multidisciplinary work that bears on the problem.

Robert Wiblin: How do you prioritize among the different kind of health threats that you could work on tackling?

Tom Inglesby: We spend a lot of time as a group thinking about trade offs and thinking about return on investment. If a problem is very well characterized already and a particular project would kind of only refine it to another decimal point or two, kind of a bit more clarity but something is already relatively well worked out, then that’s less appealing to us. We are interested in problems that seem to be either not getting traction and hopefully, as much as is possible, if project is delivered major change could be a result. We like to look for projects where there’s a vehicle in government, either in US government or the international stage where the deliverable of the project could fit into something that is already a possibility.

For example, if there’s legislation that’s making its way through the US Congress and we can deliver a project that has a proposal for what to put into that legislation with the evidence that supports that and the means by which they would make those changes, we’d be excited about that. If there’s a project which could deliver something in time for the next World Health Assembly where we could change the way people think about biosafety in laboratories, we’d be excited about that. So we’re looking for projects that could have big impact in the world related to pandemic preparedness, at least in the realm of biosecurity.

Robert Wiblin: I mean I guess at 80,000 Hours we try to prioritize it across different problems but I think about it in terms of scale, neglectedness, and tractability. So it’s how big is the problem, how many people are already working on it, and how easy does it seem to solve. Does that kind of match how you would prioritize within the course area?

Tom Inglesby: Yes. It definitely does. Yes, is it tractable, and how big is it, and is it neglected? I think those are all key questions for anything that we’re doing.

Robert Wiblin: Do you ever try to calculate it out mathematically or is it more of a qualitative kind of judgment call about how large the scale is or how easy it is to solve?

Tom Inglesby: Typically it’s more qualitative for us, only because they’re really, I mean as compared to other kinds of problems where there’s lots of engineering data for a particular problem. Nuclear power plant, what’s the safety of this particular plan or these conditions? For many of these problems we don’t have quantitative data. We can do modeling around the impact of natural epidemics based on historic epidemics. So we can know that this particular problem has never caused impact that compares to this particular problem and make judgements that way. In terms of the very specific probabilities it’s difficult to do so, it’s often more judgments about what we think will make the most difference. When we can do quantitative calculations, when we can think through in a numeric way what impact something would make we would or we do, but that’s not as easy as it is in many cases to use kind of a more qualitative analysis.

Robert Wiblin: I guess ’cause you’re dealing with events that often aren’t expected to be that frequent anyway. You don’t have a sufficient sample of history and, of course, the situation’s constantly changing so you can never really anticipate the annual probability going forward.

Tom Inglesby: That is one of the problems, that things are changing and especially when you introduce the element of deliberate misuse of biotechnology. You can look at what’s happened up until now but what you can’t do is understand the intentions or necessarily the skills of potential adversaries or, even if they’re not adversaries, hackers, people who stumble into something. You can understand the skills that are required and make some kinds of quantitative judgments about how many people in the world might possess those skills but beyond that, trying to get into the minds of other who might intentionally do harm and on what scales, that’s difficult to do.

Robert Wiblin: So let’s talk about some of the uncertainties that I have about setting priorities within this area. At 80,000 Hours, as you probably know, we tend to focus a lot on the very worst case scenarios where billions of people die or potentially most people die because that’s the kind of event that will have really big ripple effects on future generations that could last basically forever. Whereas pandemics that kill a few thousand people or even millions of people probably wouldn’t have that kind of long term effect.

I saw that in the Journal of Health Security, where I think you’re an editor, there was recently a special issue about global catastrophic biological risks, which is another term for this kind of really worst case pandemic scenario. The Center for Health Security was trying to establish a kind of formal definition for these most extreme risks because they thought they were kind of a special category that deserved a, I think the term was a special category of biological threats that deserve careful study and action to counter them, because of the extraordinary consequences they would have for humanity and because they are potentially tractable.

So does that suggest that you or the Center for Health Security kind of share our belief that that it’s the worst case outcomes that should be the top priority or at least somewhere that we should be shifting more resources relative to other things?

Tom Inglesby: At a high level, certainly we absolutely agree that there should be more resources and study dedicated to this problem and that it is a worst case scenario which we think is possible. It’s difficult to predict the likelihood but we certainly think it’s possible. For that reason we think that there should be dedicated effort to studying it, and to thinking about prevention, and if prevention fails, thinking about how to diminish the consequences and diminish the potential reactions of governments that could themselves cause terrible harm, a lot like the immune system causing terrible harm when you get an influenza or pneumonia.

I think, in terms of shifting resources, it’s kind of like what you just said a moment ago about the fellowship program. We should get more money to include more fellows. I don’t think it’s a good approach to think about it as zero sum with other epidemic problems and here’s why: I think in many cases it’s going to be similar communities that are thinking about these problems. I don’t think it’s likely, even if we really decided to get very serious as a world, I don’t think it’s likely that there will be a community solely dedicated. I don’t wanna say never, ’cause it could happen, but I don’t think it’s likely that there will be a robust enduring community of professionals that would only, solely be dedicated to global catastrophic risk, biological risks alone.

The reason I think that is because to understand global catastrophic risks you really need to understand the fundamentals of normal epidemics. Catastrophic risks, at least in the natural world, are going to arise out of this frothy ocean of continual infectious diseases happening in the world and that meets conditions, ultimately, of breaking free of the normal froth and becoming an epidemic or a pandemic of terrible proportions. It’s true that on the deliberate side or the accidental side we could see things that have absolutely no precedent and seem completely different from all things that have come before but ultimately, the principles that we use to try and control epidemics are going to be similar. People are going to be in hospitals. They’re going to be spreading disease. The things that we do, they’re going to need medicines, they’re going to need vaccines, they’re going to need diagnosis. Those communities are going to overlap very heavily, no matter how you slice it, with the communities that worry about much smaller events.

I do think the way my view, at this point, it could evolve, but my view at this point is that what we should try to do is to open the aperture further of the people who work on these things to gather more people into the field who care a lot about global catastrophic events. But bring them into the larger field as opposed to creating a separate field that, in some ways, is kind of feels like it has to be zero sum with people who focus on more limited or more common events.

Robert Wiblin: I guess that brings me to my next question which was how much does a focus on extinction or near extinction events kind of imply quite different activities than what conventional biosecurity typically concerns itself with. It sounds like you’re saying there’s significant overlap or at least the people who train in conventional things can then switch over into the others.

Tom Inglesby: You mean train in conventional global health response, pandemic response could then switch over to thinking about global catastrophic risks?

Robert Wiblin: Right, or at least there’s significant overlap in what you do to deal with each kind of different problem.

Tom Inglesby: Yes. I think there’s very significant overlap. I think that the systems that we use both in public health, and in clinical medicine, and in biotech pharma, making of medicines and vaccines, those are the same systems that we’d rely on if there were a huge, terrible, catastrophic event that could conceivably kill hundreds of millions or billions. I think in the GCBR world, on the catastrophic side, we wanna do everything we possible can to prevent that from happening. There are activities that aren’t a perfect fit for the community that works on natural epidemics. Those kinds of activities would relate to biological weapons convention, or codes of conduct for scientists, dual use science thinking regulatory frameworks perhaps for certain very, very specific kinds of science.

So there are definitely things within the realm of deliberate misuse or accidental misuse that are not bread and butter, daily, natural public health or global health priorities. But, I still do think that it serves, in some ways we could raise all boats if we are a community that allows for the possibility of continuous endemic infectious disease burden in the world but also allows for the possibility of extraordinary, very, very high end events. Because if we don’t include the folks who care deeply about natural events and the epidemics that are happening all the time, then I think the people who are working on global catastrophic events, first of all they will not get the credibility that they need from a larger science community. They might even get push back if people who feel like, look, that discussion threatens the day to day work that we need to do for these diseases that are killing people right now in front of us.

I don’t think that’s necessary. There are many problems in the world. I think I’d rather have this community working on both ends of the scale than to, for example, have another $1.5 trillion dollar tax cut. I don’t think we need to necessarily think that they’re the only two problems that have to square off against each other. Some people will naturally gravitate and say that my calling is to work at the extraordinary level and that’s really what I want to spend my day and my expertise. Others will be on the other side. Hopefully their expertise cross fertilizes and there will be some people who are working on both. Some people who may say look, my real professional concern is events that could really threaten humanity as a whole. That’s okay, and I think they should try and then draw on the expertise that they need from the relevant communities around them and say, look, we all acknowledge each other’s role here but what we’re working on is really the high end of the spectrum.

Robert Wiblin: Yeah. One thing I’ve noticed is the more senior the person I’m talking to the more reluctant they are to say things just like A is more important than B within this field and A should cannibalize the resources that B is getting, which is what I’m always trying to goad people into saying basically. I’m trying to encourage people to just be very explicit about priorities. I wonder is this a phenomenon or it’s like perhaps people have gained wisdom over time, that they’ve realized that in fact there’s so many synergies or so many complementarities between different research areas that it’s not possible for one to be much more important than the other. Or perhaps they’ve realized that the politics of it is such that one research project trying to cannibalize the resources from another is just a terrible idea because it sets you up for conflict within the field. Or is there something else going on?

Tom Inglesby: Well I think both of those things are true. What was your first one? I remember the second one you just said-

Robert Wiblin: That there’s a lot of kind of complementarities between related areas so it’s not possible for one to be vastly more important.

Tom Inglesby: Yes. I think both of those explanations are true. The third one I’d add is that if you spend time in this field, you see that there are some programs that are stood up for very specific purposes, that only really that the intention of a particular program is only for this very specific scenario A or scenario B. And the founders of that program have no interest in relevance to other programs around it. What happens with those programs, when scenario A does not occur, those programs have a hard time being sustained. Both the people who are behind them, they move on and the funders who supported it, they move on, and the program itself rusts away.

Robert Wiblin: Because it’s not connected to a broader program.

Tom Inglesby: It’s not connected and so it has no natural constituents. It has no secondary purpose of value if that scenario A never happens. Let’s say we all decided to only focus on a particular scenario, extraordinary scenario and nothing else, and we didn’t really have any interest in whether or not the work that we did broadly had any benefit beyond that specific scenario. My worry is that, first of all, if you build parallel systems of response, at least on the response side –and those systems are never exercised in any way, they’re never part of a real training, or a real exercise, or a real day to day operation, they’re never used for anything else, then those things typically don’t work. There’s enough evidence out there in the world that, at least in the world of response, you need to exercise your programs by some surrogate means.

My worry is that if we only focused on that and we said look, it has no connection to anything else. It’s only about this particular scenario. I’m worried that it may not be sustainable for a long time. I think for something to be useful we need to find a path for people to be able to talk about and understand it. That’s concern number three. Concern number four is that, so we talked about complementarities, we talked about the politics of it, we talked about now kind of-

Robert Wiblin: The need to be part of a broader community.

Tom Inglesby: The value of being part of a broader community and the sustainability of that and its value for other purposes beyond only the primary purpose. The fourth is that you also could engender like an antibody response from the system that doesn’t serve anyone’s purposes. If you came out super strong and said look, my only interest here is to get extraordinary amounts of funding and dedication for this particular problems and I have no interest in these other problems over here, then that community which might have been for you, even if they’re a little bit puzzled or it took them a while to understand the value of your argument, they may start right at the beginning saying, “Why are you at this extreme? What are you doing over there? Why are you acting like that? Why are you focused on the worst case scenario?” et cetera. You can answer those questions but you’ve now provoked this kind of … what could have been allies are now potentially opponents. For something like this to work for the long run, for us to be able to focus on it and kind of …

For example, another example that hopefully that proves part of the case, if we’re gonna focus together as a community on avoiding deliberate or accidental misuse of biotechnology in a way that leads to an extraordinary or catastrophic event, the people who are on the leading edge of science are those same people that are going to be guardians of science. They’re going to be kind of aware of what’s happening in the world in other laboratories. They’re aware of what their colleagues are thinking about before anything is published or even proposed to new funders. So they’re all aware of what’s happening, where the leading edge is. It’s not a separate community of people that you’re going to be trying to reach out to to talk about extraordinary risks. It is the leading biology community where all of the solutions are and potentially where the risks are.

So if you alienate that community early on and it becomes adversarial and you say, “Well we’re worried about the risks that are coming out of your community. We mostly see downside and we don’t really see that your community also has the potential to create the solutions, and to self monitor, and to be responsible, and to be good custodians and guardians.” If you set up a relationship like that that’s not going to serve the broader purposes of prevention and response. I think trying to have discussions and thinking about it that’s inclusive of where the science is going, where prevention is going, I think that would be to all of our benefits. It’s not always gonna be possible. There may be contentious discussions that have to happen, there certainly will. I think if we all kind of start generally agreeing that yes, it is a reasonable goal to avoid huge catastrophes, then let’s think about how those might occur or what are the pathways to try and prevent those. I think that’s a hopefully more sustainable path. Does that make sense?

Robert Wiblin: Yeah. I think it does. I hadn’t really thought about this quite enough before I think.

Tom Inglesby: That may be why people aren’t necessarily-

Robert Wiblin: Are reluctant to say that their colleagues’ work is effectively useless.

Tom Inglesby: Yes, well-

Robert Wiblin: Or relatively useless.

Tom Inglesby: Yes, and I think also probably as you go on, as you spend time in the field and you see all these predictions happen, you see people say there will be a 50% chance of a biological attack by the year 2010. Then it doesn’t happen. Then someone else says another probability of this and it doesn’t happen. In some ways I think the more time you spend, the more cautious you get about making quantitative probability estimates or saying, “I am 85% sure of this being more important than this,” because you see all of the mistakes that have come before. It doesn’t mean you should stop making predictions, it just means you are more humble about the capacity to predict.

Robert Wiblin: I was gonna say just another reason might be that people become more uncertain about what actually is most important.

Tom Inglesby: Yes, you can have a lot of confidence that avoiding billions of illnesses and deaths is a very, very high priority and should be a priority for everyone but you can have uncertainty about the likelihood of that occurring and comparing that to the probabilities of a variety of scenarios, which are much less consequential but still could be hugely consequential to governments. They could cause extraordinary harm but they wouldn’t necessarily threaten humanity at an existential level. But they could threaten the existence of countries for example. Certainly it could topple particular governments. We’ve been close to that with relatively small outbreaks in the past. The governments of West Africa during Ebola were not stable during the time of the Ebola response. A little bit of consequence to the left or the right could have brought down governments.

Now that’s not to say that a government like the United States or the UK would be threatened like that, but at a certain scale you can imagine that there would be no more confidence in the government response. That scale would not need to be hundreds of millions of deaths. You can see, for example, that in the Ebola response in the United States there were only a couple of cases of Ebola and we probably were one or two Ebola cases away from people calling for the head of the CDC director. It happened around the time of elections so it got into the election discussion: Who’s stronger against Ebola? That happened in 2009 for the H1N1 pandemic. The governors around the United States were trying to outdo each other in terms of who was going to be tougher on influenza and were instituting different types of programs that eventually, if you keep going down that scale, you would have curtailment of civil liberties, actions that government could take that would cause a lot of harm in society.

That’s a long way of saying that yes, I think you’re right that sometimes people pull back from predictions when they see it’s difficult to judge the probability or likelihood of one versus the other. I think government doesn’t usually work that way anyway. I think government right now in most places in the world, certainly in the US, is committed to the urgent, and what is really present, the problems that exist in the world. It’s somewhat committed to the prospect of biological attack in the United States and the things that we would need to do to prevent that. To get it to go to a larger scale and say, “We know you have all those things going on and we know that you will continue to think those things are important and now we want you to focus on the prevention and response activities for global catastrophic risk,” that’s going to take time, and a coalition of people, and persuasive arguments, and ideas that are tractable.

We don’t just want to talk about it. We think you should do these three things and this is why we think these things will work. So I think as people begin to make those arguments, “Look, we want you to add this on to the program of work in the US or the UK or elsewhere in the world,” we need to come with evidence, we need to build a coalition that argues for it. When biodefense came along in 2000, 2001, 2002, around the time where the Anthrax letters were mailed to the various offices in the media and the government, there was a pretty serious immune reaction to that in the United States. It changed after 9/11 and the Anthrax mailings, but in the years before that when people started to say, “Look, we do need to prepare for deliberate misuse of smallpox, deliberate misuse of Anthrax, deliberate misuse of botulism.” There were a fairly substantial pushback from public health, from portions of public health and other parts of the government.

Over time, a coalition of people in public health, in defense, in foreign policy, in homeland security, have come to an agreement that it makes sense to include that. To think that there would be something called a National Biodefense Strategy that was required by Congress, to think about that back 15, 18 years ago, that would have been kind of, people would have thought that was ridiculous. But now it seems very logical. It seems like that’s quite obvious that’s what we should be doing, that we should have integration between domestic/international. We should have integration between accidental/natural/deliberate. But it wasn’t always that way. My hope is that we will continue to evolve what is logical and is expected from governments and international organizations and we should evolve to expect the WHO and national governments and others to think about catastrophes that are way beyond our limits now, but that we could aspire to prevent or respond to.

But it’s going to take time to do that. It took organizations like the Open Philanthropy Project to call it out by name and to say, “We’ve noticed that people aren’t attending to this and we need to attend to this.” It’s taken time to get to that deliberate moment. I think my own sense of strategy as we go forward is to make the case, to talk about the scientific plausibility, to talk about the tractability of it. If people feel like this is a problem that is so vast that it’s like a meteor hitting planet earth and there’s nothing we can do, then people will check out, governments will check out. They’ll feel like it’s not in their term of office, that they will hope it will pass before they ever have to react to it.

So as a community of people thinking about these issues we’re gonna have to fit it into the language people already understand. We’re gonna have to provide possible solutions because if we just provide the problem and say, “This is the size of the problem,” even if people believe the problem they’ll still check out. They’ll still feel like this is useless and hopeless because there’s nothing we can do about it. So anyway, that’s a long answer to your relatively short, specific question. Not easy to answer short and specifically.

Robert Wiblin: So obviously we’re trying to provide kind of career advice to people who are trying to solve this problem. In the course of researching this problem area one kind of view that I’ve encountered that I’m not sure what to make of is that if you’re focused on the catastrophic risks then the human caused risks vastly outweigh the natural risks, or at least they will in the short to medium term. That the best ways of tackling human caused pandemics, either through error or malicious intent, are quite different than what would be best to target the natural pandemics.

That as a result, when I’m coaching someone I shouldn’t just advise them to go into public health in general or into epidemiology in general, I should be advising them to focus on like very targeted stuff that is about regulation of scientific experiments and how do we control who can do gain of function research with viruses and things like that, which otherwise just might not really be on the agenda for health security. What do you make of that general perspective? I’m just not sure what to think.

Tom Inglesby: Sure. Well I understand the argument. I don’t fully agree with the argument. I think the argument would be something like we have a long historical record with natural events, and we’ve seen what’s happened over the years, and we’ve seen what kind of epidemics emerge naturally. That is all true. We certainly know that nothing has pushed humanity close to the brink of extinction. Although events like the plague in the Middle Ages was, for some communities it was like End of Times but for planet earth it was not. If your focus really is only on is really at the level of extinction then you can see why people would say we haven’t become extinct yet so we should think about the kinds of things that could inadvertently or deliberately push us closer.

What I would say to that is that those things are true but the world is also changing and we have conditions that are different than have existed before in humanity. We have cities, countless cities that are 20 and 30 million people large and getting bigger, with incredible poverty, and incredibly deplorable conditions in terms of the basic access to sanitation and to food and water. That’s one set of conditions that’s changed.

Condition two that’s changed is the ability for things to move in the world. Up until 30, 40 years ago it took a while to get around the world. Things are getting faster all the time now, to the point where you can get anywhere basically in 24 to 36 hours and things move around much more efficiently and would, in the event of a respiratory transmissible epidemic that arises like the next influenza, or coronavirus, or some other respiratory transmissible virus.

The third thing that’s changed is that the huge numbers of farmed animals in the world and the huge encroachment on previously pristine natural environments. So we’re cutting down forests, we’re moving into places where animals used to live by themselves and now people are moving into them and either eating the animals or living in close proximity to the animals. So all of those things combined, I would argue, have changed the deal and make the possibility of extraordinarily substantial epidemics greater than they’ve been before. We also, in many places of the world-

Robert Wiblin: Or at least the risk is unknown. The historical record doesn’t decisively say-

Tom Inglesby: The historical risk is not decisive. I think that’s, exactly. So that’s unknown. We do have some things in our favor in that in many places of the world health systems are stronger, we could conceivably come up with medicines and vaccines, we know a lot more about science and public health. So there are things that are also tip in the other direction but I do think that there’s a lot of uncertainty about whether we can judge the future based on the past in terms of the historical record.

Switching to the part of your question which was more about: if you believe that the risk is more on the deliberate side, should you focus more on the deliberate side? There certainly needs to be good thinking and smart people who are thinking about the proper role of the regulatory environment, regulatory agencies in the world. I still think that that’s going to be a relatively small number of people compared to the larger community. There already are people thinking about how to address gain of function, potential pandemic pathogens. There aren’t enough places in the world that are thinking about it or at least thinking about it publicly and out loud at this point. I think having people move into positions in government where they can think about those matters and come up with the right balance that doesn’t block science off, doesn’t block us from moving ahead and understanding diseases, but does help address some of those concerns that are now emerging about potential pandemic pathogens, I think that’s a great idea.

I think the field could also use more people thinking about the biotechnology solutions and what could be done in terms of medicines and vaccines, new platforms, new approaches to scaling manufacturing, to distributive manufacturing so that all the vaccine isn’t, for example, made in only two countries in the world when there’s the next pandemic, but that it could be made in multiple places concurrently in the world using the same formulas or approaches. I think, even if you decided that your real interest was thinking about deliberate misuse, I think that could take the form of working in diplomacy and foreign service, people who really are thinking about the international agreements that we adhere to. That could take the form, for some people, of working in intelligence, trying to make sure that you’re understanding what autonomous groups, what terrorist groups might ever have an interest in doing those things. It could take the form of working on, as you said before, on new countermeasure solutions for either medicine or vaccines or diagnostics for early warning, or rather, for early diagnosis. It could conceivably take the form of public health and surveillance, although that does move more towards natural events, looking for diseases that are occurring kind of on a natural basis.

Even, for example, the World Health Organization is now moving ahead with the creation of a new office that will be focused on the interface between natural events and deliberate events. On the world health stage, presuming that office is established and becomes a going concern, and is sustained and successful, there could be a place for, there will be a place for smart people working there and reaching out to other governments and setting norms. The establishment of norms in the world isn’t only going to come through regulatory agencies but it will also come through governments, and through the treaty system, and through professional societies like the National Academies of Sciences in the US working with the Royal Academy in the UK and the other national academies to say, “We do not approve of the following. We do think X is an acceptable alternative. We do think that the review process for this work, on a peer review level, should look like this.”

So there are lots of things that we can do that are outside of hard regulation. There’s a role for hard regulation if we do it right, but we could also do it wrong and really screw things up. But then beyond that role of the regulatory world there is all of the diplomacy, norm setting, peer review, scientific leadership saying what they believe. In the world of science, young people often look up to their role models, the ones who’ve really made a difference in the world. Obviously not always the case but if you have scientific leaders stepping up and saying, “We believe that this bad outcome is possible over here and for that reason we believe we should all think about taking this course of action,” that could be very powerful. So I think you do need people in the different realms of biosecurity to be thinking about these matters and working on these matters. I think if some people want to gravitate towards regulatory action, I think that can make sense for them. I think others, there’s plenty of roles for other people in the kind of the large ecosystem of what’s going on.

Robert Wiblin: So another kind of division that I face or that I observe among the people that I’m talking to is between those people who think that kind of the problem, both of natural pandemics and of human caused pandemics, like the sources of the main risks are well understood and the solutions are reasonably well understood as well, and what we have to do is just implement the things that we know are going to make a big difference. And other people who think that we don’t really know what the biggest risks are or how best to tackle them, and so what we need is more kind of risk scoping and disentangling of the different problems that we face by people who have good judgment and a big picture understanding of epidemiology and risks from pandemics in general. Where do you think you fall on that kind of spectrum?

Tom Inglesby: Well I do think that there are many things that, many problems that we well understand that we should act on even if we don’t have any further stimulus. Those things include improving the public health system in the United States and elsewhere in the world, include accelerating the medicine and vaccine development and manufacturing process, especially for things that are unusual or novel. They include better discussions of the BWC and potential pandemic pathogens. There’s a whole set of activities that are independent of any particular pathogen or scenario, so I definitely believe that those things are true and could be done or could be pursued. They’re not all perfectly clear how to make breakthrough X or breakthrough Y, but we know the general aim points and directions we should have for many things, many general areas of infrastructure or workforce or science.

At the same time, there is an area of, I would call it almost irreducible uncertainty about the kinds of things that could emerge from nature. We have been surprised by many things. We know some things are always true. We always will have influenza threats. We have had multiple pandemics. We will have new influenza pandemics. But it was quite a surprise at the time, although maybe it shouldn’t have been in hindsight, that we had an Ebola outbreak that moved from the country and spilled into cities and became an absolute crisis for West Africa. Ebola had never acted that way. We knew about Ebola but we didn’t understand its potential impact in cities in the new world. We didn’t understand that people now, because they can travel and understand that they might get their lives saved in cities, would take themselves from the countryside into cities, and that cities would become then kind of the incubator of the disease and it would spread around major urban areas.

We don’t know, necessarily, exactly what virus will appear in what way but we do know that respiratory transmissible viruses that have high virulence are very high on the list. So we can do more to study those things. We can do more risk thinking but at some point there is going to be some irreducible uncertainty, both on the natural side and there will be uncertainty on, definitely there will remain uncertainty on the deliberate side because of the role of human agency. We can and we should study what is possible, and what is possible at what levels of skill. We can and should know what is going on in science programs around the world. For the most part, science is very public. People are publishing their efforts. They can’t move along in their careers in less they do so for the most part we can understand what’s happening in science. But what is very difficult to know is in that ocean of science what are the actions or motivation or intentions of those who would be interested in misusing biotechnology for either small harm or very large scale harm.

I’m kind of, depending on the portion of your question, I’m both on the side of the camp which says there’s a lot of things that we already know and we can press ahead and then there is a portion of the problem that is going to remain uncertain and we’re gonna have to think about the system’s response that can operate without real fine understanding of what’s going to happen next.

Robert Wiblin: So there potentially are niches both for people who just want to implement what we know is going to be useful and for people who want to do.

Tom Inglesby: Absolutely. Yes.

Robert Wiblin: Much more research to see what the new threats and unanticipated threats are gonna bed.

Tom Inglesby: Absolutely. Yeah. On the latter side, if your real serious interest is risk assessment and thinking about the new threats, there are fewer organizations that focus on that right now. There are more coming into existence or more scientists who are thinking about that or more, we’ll call them risk experts. Partly because of Open Philanthropy Project’s emphasis on better understanding risks but also there are organizations like the Department of Homeland Security or intelligence agencies or NGOs that have an interest in risk assessment. Even some of the ones that do assessments around insurance think about likelihoods of pandemics. But those organizations would be a little different from those who are more focused on workforce or bio pharma or surveillance tools for new epidemics.

Robert Wiblin: Let’s just talk about policy for a minute. About I think five months ago you published an article in Foreign Affairs called Ready For A Global Pandemic, where you talked about the approach of the new White House to things like the Global Health Security Agenda, the Biological Weapons Convention, and the National Biodefense Strategy. Do you want to just describe those for a minute and maybe give us an update on how the US government is performing as a whole?

Tom Inglesby: Sure. Maybe we’ll start with the Global Health Security Agenda. So the Global Health Security Agenda is an initiative launched in 2014. It’s an effort made by many countries, in collaboration with the World Health Organization, to improve the capacities of mostly low and middle income countries to prevent, detect, and respond to epidemics. It was started because it was becoming clear that many countries were stalled out in their efforts to try and get better at preventing and responding to epidemics. All countries, if you go back to 2005, all countries at that time, all countries in the world at that time signed onto the International Health Regulations, what was called the Revised International Health Regulations. That was basically a commitment by every country to do a lot better in preventing, detecting, and responding to epidemics. They all signed up for it. In 2014 when the countries were surveyed how well they were doing, are they meeting the capacities that they committed too, it became clear that only a third of the countries in the world were reporting that they were capable of doing the things that they had committed to regarding epidemics.

So the Global Health Security Agenda, in many ways, was an attempt to provide some new fuel and new technical assistance and fire power to that overall effort that was started by the International Health Regulations 13 years ago. At the time it was nine years ago. What happened was that countries came together. They agreed that doing this work was important. Many countries decided to start technical assistance programs or provide funding to do work in those countries elsewhere in the world to shore up those capacities. The US was one of them. The US committed –the US Congress with the administration working together — committed a billion dollars over five years to do work in what ultimately became 39 countries in the world. Some were small programs, some were much larger. They worked with those countries to develop a plan: , let’s scan, let’s do a needs assessment, how strong are you on detecting, how strong are you on preventing and responding, let’s figure what your top priorities are, and then let’s work on them together.

For example, they did things like helped to establish laboratories where you could diagnose influenza. They helped to set up surveillance programs for multi-drug resistant tuberculous, which is in many countries a terrible disease and a sign of whether you can actually do surveillance for disease. They helped strengthen vaccination programs, so mass vaccination programs in the event that there’s an outbreak and there needs to be a large vaccination effort. What would we do and how do we know how you’re doing in terms of your day to day measles vaccination programs? So all sorts of activities going on run by both the US CDC and the US AID, Agency for International Development in the State Department.

There’s a whole issue of a journal, I don’t know if you know the journal. The journal Emerging Infectious Disease, which I would actually recommend to your audience because every issue has got very interesting descriptions of outbreak response and what’s going on in the world. But there’s one particular issue that came out recently which describes, in detail, the kinds of accomplishments that the CDC alone has made in the GHSA. That doesn’t even begin to count the efforts of USAID. It doesn’t count all the other national efforts that are going on in the world, all the other countries that have committed money and time and people to this.

In general in the world of global health and at national levels, the Global Health Security Agenda has been considered a great success and there’s no one against it, at least there hasn’t been anyone against it. This administration we’ve seen Secretary of State Tillerson, former Secretary of Health Tom Price before he resigned, both came out strongly in favor of the GHSA and said that the US will continue to support it. Then we’ve had White House officials also say they support the GHSA. The CDC director said she was in favor of continuing the GHSA. So all those things are good. There’s no one substantively opposed to it. The only question right now is whether or not it will be in the budget of the administration in this year going forward.

Robert Wiblin: So it’s a question of money.

Tom Inglesby: Yes. It’s a question of money, not a question of agreeing with the principles of it.

Robert Wiblin: Yes.

Tom Inglesby: And so there’s been a pretty broad conversation. It’s basically been all sorts of NGOs, universities, public health groups have all been strongly arguing how important it is. We’ll see how the administration decides, but it’s undecided at this point.

Robert Wiblin: Right.

Tom Inglesby: So that’s the GHSA. Go ahead.

Robert Wiblin: I was just gonna say are there any … if funding is in question for some of these programs, are there any particular programs that people like you and me ought to be particularly concerned with protecting and potentially calling up their members of Congress or their members in the Senate?

Tom Inglesby: Well yeah, I think GHSA is one of them. I think, I mean the way that the US budget process works, you probably know this already but this is the time of year when the administration comes out with its proposed budget and then the rest of the year, up until the Fall, are the deliberations that go on in the Congress where they decide on funding levels and particular programs and how it’s gonna work. So at this point the action will shift to Congress who will decide whether to agree with a particular proposal or to change it or augment it or diminish it.

For example, last year the administration proposed to cut a lot of the basic bread and butter preparedness programs for hospitals and public health agencies. It was not in their initial budget. But the Congress basically restored the funding for all those programs so the funding looked like the year before. This year it’s different because the Global Health Security Agenda wasn’t really in an annual budget before. Global Health Security Agenda was an emergency ask back in 2014 and that ask is now over so the Congress is going to have to decide. First of all, we’ll have to see what the administration decided to do. If there’s no money in it the Congress will then have to decide do they think it should be in the budget somewhere and if so, how are they going to organize it? What are they going to do about it?

So that is, I think for people who are concerned about, on the US side about the budget process, I think one is the GHSA. The second is that right now Congress is already beginning to deliberate whether or not to create what people have been calling a public health emergency response fund. On the disaster relief side, we have a disaster relief fund that FEMA operates, funds that are immediately available if there’s a hurricane that rips through the south, that they have funds that they can access to start giving people loans and getting people back on their feet. But for epidemic response in the US it can be a very long time by the time that all of the things are sorted out and all the issues are understood enough for Congress to pass emergency funding.

What’s been argued, and this argument has gotten developed and now there’s a coalition, a large, pretty broad coalition behind it, is that public health emergencies should have the same kind of emergency response fund that natural disasters have and we shouldn’t have to think. For Zika, it took more than 200 days for Congress to pass any money to respond to the Zika epidemic that was happening in Florida, in Texas, and that we feared would happen elsewhere.

Robert Wiblin: And it’s too late by then.

Tom Inglesby: It’s very late, yes. You either have to take people off the jobs they do on normal days, you have to try and engage the bio pharma industry, you have to prepare hospitals. So it’s very late. So we’re arguing for that. The third thing that people could argue about is the continued support of funding for hospital preparedness. What do hospitals do if there’s contagious disease emergency? If there is a large outbreak in America and we have to put people in intensive care units in isolation? We have relatively few beds. We have relatively limited hospital capacities for mass casualty events.

So there is a budget line in that, in the budget for hospital preparedness but it’s constantly threatened. So speaking up in favor of a healthcare system that is prepared for disasters and to take care of patients in mass casualty events, that would be beneficial. The same for our public health system. The public health officials now that are, the same people in public health agencies in America are dealing with the opioid epidemic. They’re dealing with issues of epidemic response, like normal influenza response and vaccination programs. They’re dealing with TB and STD programs that in some cities are rampant, nutrition programs. These very same people who are all maxed out on a normal day are supposed to be the ones who would help shepard our way through a nasty epidemic of the future. There’s constant downward budget pressure on public health in America because if your job is prevention then your success is when nothing happens-

Robert Wiblin: And then you look redundant.

Tom Inglesby: And you’re preparing for things. The system doesn’t seem like it’s actually crucial but these are the people that are, they’re basically thankless on a normal day. They’re thanklessly doing the work to try and prevent people from getting infected at a population level as opposed to an individual clinic level and so it’s relatively thankless. But they are also the people, when epidemics happen in a city, hospitals pick up the phone and say “What is the guidance? What is it we should be doing? How should we be operating now that there is an epidemic underway and we’re gonna need public health? So those are a few things that are, I think, quite crucial that people could let their Congressmen know are important to them.

Robert Wiblin: Yeah. You mentioned earlier that the government tends to just focus on what’s urgent. Which government agencies, if any, are kind of empowered to think about and plan for the sorts of low probability, high magnitude risks that might become a bigger problem over the next few decades?

Tom Inglesby: It’s not really in the lane of any agency I would say at this point. I don’t think that they are excluded from doing it per se but there isn’t … I would say at this point there’s not really any concerted budget for that set of problems, for this set of problems that we’re talking about today. They have responsibilities that are clear and present immediately in front of them. I think if any agency on the health side were responsible, there’s two agencies that have missions that are generally in the same lane but they have kind of urgent, smaller crises to attend to all the time. Those are the CDC, Center for Disease Control. Then another part of HHS, the US Department of Health and Human Services which is our big, it’s the equivalent of the Ministry of Health at the federal level. Within that, the CDC sits within that agency and is a large agency of its own obviously. Also within HHS is an office called the Assistant Secretary for Preparedness and Response, ASPR. They have also very substantial responsibilities for preparedness for all emergencies, so hurricanes, fires, epidemics, biological attack, all those things also fall into their lane.

What I would say is that there is not a called out responsibility in government at this point for preparing for extraordinarily large events. I think what people would say if asked about that would be we have so much trouble just thinking about the day in, day out problems in front of us, we don’t have any time or people or money to think about things that are bigger than that. So our job, if you’re not in that actual job of trying to run that agency, our job outside of that agency is to build an argument for that work and to talk about tractable things that could be done in that space and to generate kind of momentum around those things.

It may seem like well that seems like a remote, that seems too hard, that seems too hard to do from the outside but that’s, if you look at how things have changed in the past, I think there are a couple of interesting examples in the past. Example of, in the 70s when people began to think, and then the 80s began to think about nuclear Winter, it was really a lot of discussion that was happening almost entirely out of government that created pressure in society and in government to take that problem seriously. It’s not like we’ve solved that problem, but certainly it cause a lot of discussion and a lot of thinking about nuclear arms control and influence government thinking hugely.

I think if you think about, even the way that we prepare for pandemic influenza, if you go back into the 90s and the beginning of the 2000s we didn’t really have substantial programs around pandemic influenza. Even that one particular very clear, concrete case which no one doubts will occur, those programs really kind of, they were not really called out in budgets. There were relatively few scientists working or thinking about that problem. Now we have a much more dedicated program. We have a large program at CDC. People are talking about it at the international level. Partly that’s because of the discussions that people had, partly it was events in the world of course with bird flu, H5N1, but also the interaction between government and civil society and universities and NGOs.

So while on the one hand I think it’s true that we don’t have a lot of discussion about catastrophic events within the government right now and the government isn’t really positioned well for it, I don’t think that that necessarily needs to be the case for the long run. It is the case for now because everything else that’s in front of them is quite urgent. There are no budget lines for that. There’s no one from the Hill asking about that problem when they pick up the phone and call CDC. If there is an effort outside of government to work through these problems, to explain them, to break them down into components, to make it begin to feel tractable, then I think we could definitely make progress within the government too.

Robert Wiblin: So what kind of expertise is most needed for pandemic preparedness work? I guess my dream would be to hook up one of our listeners with a job at the Center for Health Security or somewhere else similar. What kind of listeners should think about applying to work with you?

Tom Inglesby: Let’s see. I want to talk generally and then I’ll talk about the center in specific. I think in general, first of all, there isn’t really an easy divide between natural pandemics and deliberate pandemics at this point. There’s not a clear separate track for those who are only interested in the deliberate misuse of biotechnology. I think you can find programs that ultimately, particular jobs or opportunities where that’s the focus but in terms of training it’s a little difficult to find those programs. I think good science training or health or medicine training gives you a particular way into the field that is very valuable. It’s certainly not the only way into the field but those kinds of avenues in are potentially very useful.

In terms of particular organizations, certainly our center always looking for bright excited people who want to work on these issues. We have a bandwidth. We only have a certain size of our organization at any one time but there are people who come and then move on, move into government or other pursuits and so there’s always a flux in our organization. So for us when we hire new people we’re looking for people who are, first of all, excited about the mission — I presume your listeners are excited about this mission. Excited to work on teams typically with other people, different skill sets. Happy to work both nationally and internationally with government. There’s a lot of work with government because government is where a lot of the resources are in the world. So comfort in working with organizations like Department of Defense, Center for Disease Control, Health and Human Services, Department of Homeland Security. A lot of this work is ultimately international and has international dimensions even if it’s a domestic problem, so people who are interested in understanding the international dimensions of a problem, willing to travel and interact with other Ministries of Health, CDCs, Ministries of External Affairs. There definitely is, in some realms of public health, there is less interest in thinking about deliberate misuse of technology. That’s relatively new in the world of pubic health, new in the last 15 years, and it’s not for everybody.

Many people who come to the world of public health or global health are drawn to problems that are in the world and immediate and pressing and urgent like malaria or bed nets or clean water and those problems are hugely important but they typically don’t run into the areas of deliberate misuse. They really are in the realm of building systems and science and public health programs/interventions. In our center we care a lot about those natural programs and systems buildings but we also care about the trends that will make it more likely that biotechnology could be misused, the trajectory of biotechnology, what kinds of entities in the world might ultimately misuse biotechnology. So there’s a facet of our work that’s a little bit adjacent to traditional global health and public health. We’re also interested in accidents that have high consequence, so that also isn’t necessarily directly in the center of global health issues. So generally what we’d say to people who are thinking about our center or thinking about this work is to see if they have an appetite for those things.

If you don’t that’s okay too. There are plenty of places to work on epidemic response that are really purely about natural epidemic response. For example, much of the work of the World Health Organization is around those issues. There are many important NGOs that have programs around the world working on on the ground epidemic response like UNICEF, Médecins Sans Frontières, The Red Cross. There are many organizations that have global footprints, global impact, but they are very much focused on natural events, natural crises, humanitarian crises. Our center is very interested in those matters but also interested particularly in those matters that have pandemic consequence and things that are much more in the realm of deliberate misuse.

Robert Wiblin: Yes. So do you know if you have any vacancies at the moment that people could apply for?

Tom Inglesby: So we probably will be hiring analyst positions. If you go on our website you can see the analysts that are here now and their backgrounds. These are people who are typically Masters level although, we’ve had exceptions either way, both less than Masters and more than Masters in the past. They are obviously excited about the field, smart, and usually part of a variety of different projects at the center. So the way our center is organized is we typically have what we call senior scholars as the leads of projects. Senior scholars typically develop a project idea from the first place, pitch it to our group, get our group to believe in it, be behind it. Then they will seek external funding for it, or find a means of funding it, and then develop a team in the center around executing that project. Typically, the analysts who we hire are part of multiple different projects. They sometimes will develop their own projects but it takes a while in the field to get a sense of what’s been done before, what’s been tried, what’s failed, what can get funding, what’s tractable.

So analysts are some of the people who are newer to the field that can be very well trained but newer to the field and game to be part of a variety or projects. For example, one of the projects that we’re working on now is the development of a global health security index. We’re working on this project with NTI and Beth Cameron, who I know you’ve spoken to, and with The Economist Intelligence Unit. That project, the aim of that project is to develop a country by country index of capabilities that countries need to prevent, detect, and respond to epidemics of international importance. So we are now in the pilot phase of that. We’ve developed a framework. We’ve developed indicators. We’ve gone out and collected data for a small subset of countries. We’re testing to see if that data is collectable and what it looks like. Ultimately, our aspiration is to build an index that covers the whole world and is done every two years.

So Jen Nuzzo in our center is the lead on that project. A number of our analysts are working with her to help develop the framework, and help to analyze the data that’s being collected, to think about the communication strategy, to think about the way that the data will be displayed. So that’s a big project. It’s collaborative with other organizations. But that’s an example of one project and at this point we have, I think, approaching 20 projects of different sizes but all of substantial analytic efforts or program efforts that are run in that way. So we have an analyst or two that are probably leaving this summer and so we’re now in the process of looking at CVs for new folks.

Robert Wiblin: So those would be for people who have like Masters in a relevant area and perhaps some work experience already?

Tom Inglesby: That would be great. That would be ideal.

Robert Wiblin: What kind of Masters would be most applicable?

Tom Inglesby: Well I think Masters in, certainly Masters in Public Health, Masters in a science related to biotechnology, perhaps a Masters in a clinical field if a person has a burning interest to do analysis in health systems, evaluation, technology evaluation, so nursing or clinical work. Physicians are typically further along in their career than this position would be appropriate for but certainly we have other clinicians that are working at different jobs at the center. It’s possible that someone with a background in foreign policy, some kind of Masters degree in either global affairs, foreign policy would be a good fit. It would depend on that person’s background and interests and the work that they’ve been doing before.

Then we’re open to other ideas. The center didn’t start the way it is now. It’s evolved over time. Many of our good ideas have come from our new people and new perspectives. So I wouldn’t exclude other kinds of Masters training if a particular candidate could make an argument for relevance. But mostly I’m relaying the kinds of experiences that we’ve had so far in those positions.

Robert Wiblin: You mentioned the Emerging Leaders in Biosecurity Fellowship earlier.

Tom Inglesby: Yeah.

Robert Wiblin: That’s being funded by the Open Philanthropy Project now isn’t it?

Tom Inglesby: Yes it is.

Robert Wiblin: And is it a new project or a new program?

Tom Inglesby: No. It started six years ago. It started by the US Department of Defense. It also has evolved into its current form. The way that it started was with the observation of a senior official in the Department of Defense that there were a number of programs in the US that focused on developing the rising generation of nuclear experts but nothing as far as the eye could see that focused on biosecurity broadly. There’s a CDC program for epidemiologist and there are science fellows programs for people who want to work in government on particular matters. But if you wanted to get a broad understanding of biosecurity, you wanted to build a network, you wanted to engage with the current leadership structure in and out of government in biosecurity, there was no program that did that.

Robert Wiblin: So there was kind of a chasm between people who were doing a Masters in the relevant area and then you needed people to run government departments that were focused on it and there was nothing in between or not enough.

Tom Inglesby: Exactly, exactly, exactly. So people were beating their own paths through various ways but there was no real tried and true pathway, no connection between people who currently ran program and the people who were trying to get in the field. So this was meant to be the beginnings of a program that would build over time, would create an alumni network, that would expose relatively early career professionals, sometimes as much as mid-career professionals from different fields, to each other and to existing leadership and to programs.

For example, a CEO of a biotech company that wants to make products for the US government to deal with pandemics who might have very significant expertise in that field but not understand at all how the government operates, or how decisions are made, or the regulatory interaction, or the international programs where our government reaches out to other programs to talk about these matters. That person would be, and has been, a great fit for the program because they come in and get to experience it, and the government benefits, and the others in the program benefits because they now are interacting with a leader of a biotech company who’s got incredible experience herself or himself and can help them understand the difficulties, the opportunities that are happening in biotech in a way that, kind of a, something from a distance wouldn’t do.

Robert Wiblin: So this is probably a pretty good fit for the kind of audience that we have. Do you wanna make a pitch for people to apply for that and tell everyone what exact kind of people you’re looking for?

Tom Inglesby: Sure. So this program, it’s an annual program in the sense that we pick fellows every year. Usually that occurs in November and the applications are open for about four weeks, maybe five weeks. We’re looking for people who are interested in leadership in the biosecurity community, interested in learning about leadership, interested in seeing what the field looks like. Typically we are excited to have people who’ve already begun to do something in this world. It doesn’t necessarily mean they’ve had a major career in it, obviously we’re looking for early career people, but that they’ve done something that indicates their career interest, this isn’t the very first thing that they’ve ever considered in biosecurity. Maybe they’ve taken a fellowship somewhere, they focused on this in their training, they’ve clearly shown an interest and aspired to do more in biosecurity. We’re looking for people from a variety of skill sets.

In this year’s class we have people from academia, we have people from government, we have people from biotech. We have, in the past, had people from the media. We’ve had people from the regulatory agencies. We have a particular, this year I think we’re quite fortunate to have a number of very talented bio engineers and bio scientists in our group, which is great. We’re very excited about the cross fertilization between people who are in the government trying to scan for problems and respond to them, and those who are outside the government who are actively working on biotechnology solutions and thinking kind of at the leading edge. That’s a great combination in our mind if we can get that together in a given year.

The way the program was set up, and now it’s still constituted this way, is that we have a majority of the fellows are from the US, but also two fellows each from the UK and Canada. This is kind of the original setup of the program that the Department of Defense was excited about because we have a lot of close collaborations between the governments on biosecurity issues, biotechnology issues. The idea was the program would continue that outside the government and continue to enrich government interactions and continue to build the community outside the government. We’ve continued that because it’s been very rewarding for the program to have the different perspectives. If there are listeners of this program who are from UK or Canada they should know that every year there are a couple of spots in the program for them as well.

Robert Wiblin: Great. Okay. Well I’ll stick up links to any vacancies that you have and to the biosecurity fellowship. How many people does it take each year?

Tom Inglesby: It takes 28 people a year.

Robert Wiblin: Okay, so quite a few. Is it really competitive-

Tom Inglesby: Quite a few.

Robert Wiblin: Or is it something that people might actually-

Tom Inglesby: It is. It is really competitive.

Robert Wiblin: Okay.

Tom Inglesby: Every year we think we may have exhausted the level of interest in the field but every year it seems like there are more people applying. In terms of statistics, it’s about a 100, 110 people a year apply and we take 28. So it’s pretty competitive. Not everyone is equally competitive in that pool but it’s usually very, very challenging to ultimately make decisions because there are so many good people.

Robert Wiblin: Okay. Well I guess that’s a good sign, that a lot of people are interested in taking these roles.

Tom Inglesby: And I should tell people that the way that it works, the fellowship works, it’s a part time fellowship. It’s not a full time position. We ask or we invite the fellows to come to Washington for the first session, typically in March. We spend three days together. At least what we’re doing this year and what we’ve done in the past is we interact with the White House National Security Council Staff. Then we have a day of discussions led by, mostly by people from agencies of relevance. We’re fortunate this year to have leaders from DARPA who work on biotechnology, the Defense Advanced Research Projects Agency. We have leaders from the Synthetic Biology World including, this year we have Kevin Esvelt from the Media Lab who is in Boston, who is one of the world’s experts on gene drives. We have people from IARPA or we’ve had people from IARPA in the past. This year we have the director from IARPA, Jason Matheny, speaking at our dinner.

The first session in Washington is a lot of interaction with government and the official Washington community who work on biosecurity and biodefense. We’re also going to Congress and spending a couple hours with congressional staffers to understand that process a bit better. Then we have, in between that and the second session which occurs in the summertime, we typically have a dinner. We have informal discussions or happy hours together in Washington to kind of build the network. We have typically a webinar or two. Then in the summertime we have a research symposium where we invite the current and past emerging leader fellows to make brief presentations on their own work. Then we have discussions around that so that’s a place for people to talk about their own work. Not everyone has to do that. That’s not mandatory but last year we had a strong minority of fellows did decide to submit their work. It’s kind of a very loose competition in the sense that we probably can’t take everyone if everyone wanted to present but we encourage a lot of participation for that.

Then we have a third week, usually in the Fall, probably September, where we go away from Washington and much more into the community somewhere. We did that in Boston last year and interacted with Harvard, MIT, and some of the biotech companies. We’ve done that in San Francisco and at US CDC at various times. This year we’re gonna most likely do that in Oxford, in the UK. The purpose of that session is to understand more from the outside what’s happening in biotech, interact with more of the universities, the NGOs. Sometimes other government officials like, for example, if we do go to Oxford this year we’ll invite officials from the UK government to come speak about their programs. So it’s basically three intense personal interactions at various times of the year. Then during the rest of the year dinners, alumni events.

The center also has, as the normal course of its work, a series of events in Washington usually over the course of the year on different topics. Once someone’s a fellow in our program they’re pretty much on our list forever in terms of invitations to these kinds of events. So we might have an event on healthcare system preparedness. We’re having one of those, an event like that in 10 days and we’ve invited all of the alumni from the fellowship program in the past to attend if they choose. So hopefully what we’re doing is we’re having an intense experience for a year, we’re connecting them to a network that’s now about 130 people. The network is very active. It’s an exciting group of people. They enjoy being, many of them enjoy being with each other because it’s a very skilled group of people. They can help open doors for each other in addition to the things that we might be able to do for them or the others that they meet along the way in the program.

Robert Wiblin: Great. Well it sounds like an excellent program to apply for. I guess if you’re having to turn away good applicants then maybe people should just give you some more money so that you can expand the program. Wink, wink, to any funders listening into this show. Let’s maybe push on. I’ll stick up links to any of these opportunities and some others in the show notes for people who are interested in finding things to apply for to advance their career.

Tom Inglesby: Great. Great.

Robert Wiblin: I’d like to now talk to you about like in the big picture how can listeners make a difference. I guess particularly with a focus on accidental or deliberate misuse of biotechnology ’cause that’s something where there’s relatively few resources that people can look at. Are there any technology breakthroughs in bio that worry you in particular, where you think there’s the greatest risk of them potentially causing harm?

Tom Inglesby: Yeah. I think it’s difficult to isolate particular technologies too much in terms of this particular thing versus this particular thing. I think the tools are generally becoming more powerful as the leading edge of biotech moves along. The tools, like any tools, they can be used for good or they could be used for not good. I think if you focus too much on one tool then by the time that you get there the tools will have evolved. The thing that people are talking a lot about this year are the gene editing technologies and how precise and how simplified they’re becoming. Obviously in the last year CRISPR-Cas9 has been in the popular press. CRISPR-Cas9 market alone I think is in the hundreds of millions or maybe billions of dollars at this point globally for its applications.

Most of these technologies are being powered by very strong market forces around the world. Just as a kind of operating assumption, it’s very difficult to imagine any effort from the outside swooping in and being able to turn off a technology driver that is that powerful. They’re not being developed in one place. It’s different from, for example, the other end of the spectrum, in World War 2, when nuclear weapons were being developed on a mesa in the American Southwest where it really was a controllable set of technologies and could remain classified, could remain in some government space, could be slow to diffuse in the world.

Biology is the opposite. The tools are being developed in universities here and there around the world. They’re picked up. They’re published. They move quickly around the world. Oftentimes they’re developed internationally so they’re born international, born basically unable to be controlled. I’m not saying this to sound like there’s nothing that can be done but just to get the assumptions right from the beginning, the idea of controlling technologies, it’s a tall order, especially when they are very very powerfully used for the good.

Robert Wiblin: So what kind of levers are actually available to reduce the chance that biotechnology goes on to cause harm?

Tom Inglesby: There are a couple different categories. The first is the levers that were kind of analogous levers to what happened in the 70s around Asilomar when recombinant DNA first became visible and people started thinking about its impact in the world. It’s not a perfect analogy, and the world was different back then, and it wasn’t a perfect solution. But one thing that did happen was that many of the leading scientists in that field spoke up about what they saw as the potential downsides, and themselves decided to really think through the norms that would be the right balance between the application, the technology, and the potential misuse or accidental use of the technology that could cause great harm.

So norms themselves, the development of scientific norms, the development of expectations of behavior can be a powerful tool. Over time we have agreed as scientific communities not to do certain kinds of things in science, or to do certain things under certain kinds of conditions like clinical trials are performed in very specific ways. Human subjects research is performed in a very particular way. Research related to radiation is performed in particular ways. So we have agreed as a community to follow certain sets of guidelines when it comes to certain kinds of experiments.

At this point, we haven’t really had good national and global scientific dialogues and discussions about what to do about new technologies that substantially change pandemic risks. So we’re still talking about those risks in the same way we talk about the risks that we’ve had up until now, biosafety risks or other kinds of laboratory risks. In my view, what we should be moving towards and we’ve had some of these discussions in the community, is: what is the appropriate scientific community reaction to experiments that could increase pandemic risks? So one category of valuable work would be to engage in the science world, possibly in the world of practice that uses these tools. There are plenty of examples of people who are very powerful users of these tools who themselves have put their hands up and said, “I think we should be having different kinds of discussions about this. I think we should be managing these technologies in a special way.”

So I think that’s a kind of effort that has more self-governance, scientific communities helping to describe their own rules of the road, that don’t slow science down but do acknowledge that there are new kinds of risks that need to be dealt with. So there’s the scientific community itself and working in those fields where there are powerful tools and taking responsibility for trying to develop norms and governance systems that are not necessarily imposed or regulated. So there’s that realm.

Then there are technology companies like the gene synthesis companies who’ve created a system like this where they have gotten together and agreed on a process for screening orders for oligonucleotides. They screen them against databases to try and understand if people might be trying to synthesize certain pathogens. They’ve done this consortium building work on their own without regulation. It’s international. It includes most of the genomic synthesis companies in the world or a great majority of them. It’s not a foolproof system and it’s not a perfect system because it doesn’t include all synthesis companies, it doesn’t include all permutations that might necessarily come in and that could conceivably spoof a system. But it’s a big step and it was self governed by companies themselves. So that’s an example of that realm. So if you’re a person who’s working in the genome synthesis space and that’s an interest of yours then I t